Every finding on record at Focused Care of Gilmer

Based on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 4 residents (Resident #1) reviewed for resident rights in that: The facility failed to ensure CNA A provided linen change in a respectful and dignified manner on 7/19/2026. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth. Findings included:1.Record review of a face sheet for Resident #1 dated 7/22/2026, indicated Resident #1 was a [AGE] year-old female who was admitted on [DATE] with the diagnoses of chronic respiratory failure (a serious condition that occurs when the body cannot get enough oxygen or remove carbon dioxide effectively), Chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe, primarily cause by long-term exposure to irritants like cigarette smoke or air pollution), type II diabetes (a condition that affects how the body uses insulin and sugar), and morbid obesity (a complex, multifactorial disease caused by an imbalance between calories consumed and calories expended, leading to excess fat storage). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #1 was rarely or never understood and BIMS score was 6 indicating she was severely cognitively impaired. Resident #1 required maximum assistance with bathing and dressing lower body. Record review of a care plan undated indicated Resident #1 was at risk for increased falls with interventions to anticipate needs, provide prompt assistance, assure lighting is adequate and areas are free of clutter, encouraged to ask for assistance of staff, and ensure call light was answered promptly. There was not a care plan for activities of daily living. Review of a video recording dated 7/19/2026 at unknown time, observed Resident #1 lying in bed receiving care from CNA A, CNA B, and Hospitality Aide C. CNA B was observed tucking the sheet and bed pad under Resident #1's bottom and then turning Resident #1 towards her on Resident #1's right side. Hospitality Aide C assisted with lifting Resident #1's left leg as she was turned on her right side. CNA A was gathering the soiled sheets, pulling them away from Resident #1 starting at the lower in of the bed, then pulled the top part of the fitted shirt at the top right side of the bed. CNA A picked up a gray round stuffed pillow and sat it down to the right corner of the bed and continued to gather the soiled sheets. CNA A then placed the soiled sheets near the foot of the bed out of view of camera. CNA A then grabbed a package of wipes, sat them on the bed and started to attempt to roll the fitted sheet and bed pad out from under Resident #1. The gray round pillow was located at the top right corner of the bed. CNA A picked up the round gray pillow and tossed it over where it landed near Resident #1's head as she was pulling the right corner of the fitted sheet on the bed. CNA B was observed placing the round gray pillow behind Resident #1's upper back as CNA A continued to attempt to get the sheet on the right corner of the mattress. CNA B was talking to CNA A and then CNA A started removing her PPE and gloves and exited Resident #1's room. Hospitality Aide C walked over to the left side of Resident #1's bed and was attempting to get the fitted sheet to the right corner of the mattress. During an observation and interview on 7/21/2026 at 2:57 PM, Resident #1 was sitting up in bed and had visitors. Resident #1 was clean and well-groomed with no signs of untimely care. Resident #1 denied any concerns with her care. During an interview on 7/21/2026 at 2:57 PM, Anonymous 1 and Anonymous 2 said CNA A threw a pillow at Resident #1's head. Anonymous 1 provided a review of video footage of 2 female CNAs and 1 male Hospitality aide on the video footage. Anonymous 1 said the CNA A did not need to be working at the facility and thought she had been let go. During an interview on 7/22/2026 at 12:15 PM, CNA A said she had quit after the incident on 7/19/2026. CNA A said CNA B and Hospitality Aide C were coming to assist from another hall because she needed help. CNA A said CNA B asked her why she was changing Resident #1's sheets. CNA B said it did not make sense because she had changed Resident #1's sheets earlier. CNA A said CNA B then asked her how long she had been a CNA in front of Resident #1. CNA A said she told CNA B that she had started in February. CNA A said CNA B told her she was messing things up. CNA A said she was trying to pull the sheet over and stated it was too much at once. CNA A said she then walked off. CNA A said she realized she was not professional. CNA A said everyone was talking at the desk and saying how she could not do anything right and they saw what happened on the camera. CNA A said she was advised to talk with the nurse on Monday. CNA A said she was only trying to move the pillow and CNA B had moved it out of the way. During an interview on 7/22/2026 at 3:08 PM, CNA B said she was making rounds and CNA A told her Resident #1's bed needed to be changed. CNA B said CNA A wanted a fitted sheet as the draw sheet and then got aggravated. CNA B said she rolled Resident #1 toward her as she was trying to pull the sheet and draw sheet. CNA B said CNA A tossed the pillow. CNA B said she could not recall the conversation. CNA B said she set the pillow aside and told CNA A that she did not have to be so rough. CNA B said she observed how aggravated CNA A was. CNA B said she should not have told her not to be rough in front of Resident #1. CNA B said CNA A took off her gown and walked out. CNA B said Resident #1 was fine. CNA B said she kept apologizing to Resident #1 and asked her if she was okay. CNA B said CNA A was her CNA for the night. CNA B said CNA A struggled at times and she was helping her out. CNA B said she had reported to LVN D. CNA B said she had been in-serviced on abuse, neglect and exploitation. CNA B said she was still learning how to handle things and had done construction prior to being a CNA. CNA B said if a resident was not treated with dignity and respect, it could cause the residents to be fearful of staff. CNA B said she was responsible for ensuring care was provided with dignity and respect. During an interview on 7/22/2026 at 3:19 PM, LVN D said CNA B came out and was upset reporting they were providing care and changing Resident #1 and CNA A was rough. LVN D said CNA B told CNA A to not be rough with Resident #1. LVN D said she thought CNA A had left but she was in the break room. LVN D told CNA A she had to leave and CNA A told her she was not coming back and she quit. LVN D said that was the second time she had worked with CNA A. LVN D said she reviewed the video and the care looked a little rough. LVN D said she heard the audio of CNA B telling CNA A It's ok, don't be so rough. LVN D said the next thing she saw, CNA A was removing her gown and gloves. LVN D said she saw CNA A toss the pillow up at Resident #1's head. LVN D said she had been in-serviced on abuse, neglect and exploitation. LVN D said she makes sure all staff treat residents like they are family. LVN D said if a resident was not treated with dignity and respect, it could cause a resident to not want to eat, refuse care and it could affect their trust with staff. During an interview on 7/22/2026 at 3:32 PM, the Dietary Manager said she was sitting outside smoking and she was informed by CNA B and Hospitality Aide C that CNA A had left. The Dietary Manager said she watched the video and said CNA A tossed the pillow and CNA B told her she did not have to be so rough. The Dietary Manager said she reported it to the ADM and did not get a response, then called the DON immediately. The Dietary Manager said there was no harm to Resident #1. The Dietary Manager said she had been in-serviced on abuse, neglect and exploitation and the ADM was the abuse coordinator. The Dietary Manager said all staff were responsible for ensuring care was provided to the residents in a dignified manner. During an interview on 7/22/2026 at 3:59 PM, the DON said she was made aware of the incident with CNA A being rough with Resident #1 by the manager on duty. The DON said she was able to contact the ADM. The DON said CNA A was sent home. The DON said she came to the facility and spoke with Resident #1 and the RP. The DON said Resident #1 was doing good and RP shared the video for review. The DON said she thought the care was unprofessional and did not feel it was abuse. The DON said she felt it was a customer service concern. The DON said she did a customer service in-service and CNA A did not return to the facility and did not provide care to any additional residents after the incident. The DON said everyone was responsible for treating residents with dignity and respect. The DON said it could negatively affect the residents' emotional well-being. The DON said she could not hear the conversation on the video recording due to background noise and the television being on during the recording. The DON said she expected the staff to step away and not discuss concerns of care in front of the residents. During an interview on 7/22/2026 at 4:18 PM, the ADM said she watched the video recording for Resident #1. The ADM said it was hard to hear because the television was on during the recording. The ADM said she felt CNA A was unprofessional. The ADM said it did not appear to her CNA A was throwing the pillow at Resident #1. The ADM said the staff had been in-serviced on abuse, neglect and exploitation, and customer service. The ADM said CNA A quit on her own. The ADM said she expected the staff to treat residents with dignity and respect. The ADM said she was the abuse coordinator. The ADM said all staff were responsible for ensuring residents were treated with dignity and respect. The ADM said if a resident was not treated with dignity and respect, it could cause psychosocial harm. The ADM said Resident #1 had not experienced any psychosocial harm and the SW had arranged counseling as a standard after an incident. Review of a policy revised December 2016 titled Resident Rights indicated .Policy Statement.Employees shall treat all residents with kindness, respect, and dignity.Policy Interpretation and Implementation.Federal and state laws guarantee certain basic rights to all residents of this facility.These rights include the resident's right to: a. a dignified existence.b. be treated with respect, kindness, and dignity.

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 3 of 3 residents (Resident #1, Resident #2, and Resident #4) reviewed for infection control. The facility failed to ensure CNA B and CNA D followed enhanced barrier precautions when providing care to Resident #1 on 06/16/2026. The facility failed to ensure the ADON and the Treatment Nurse provided proper wound care to Resident #1 on 06/16/2026. The facility failed to ensure Resident #2 had proper signage to indicate he required the use of contact precautions. The facility failed to ensure RN F followed contact precautions when providing wound care to Resident #2 on 06/13/2026. The facility failed to ensure LVN N followed enhanced barrier precautions when providing care to Resident #4 on 06/16/2026. These failures could place residents at risk for cross contamination and the spread of infection.Findings included: 1. Record review of Resident #1's face sheet dated 06/18/2026 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis of the arms, trunk, and legs resulting from damage to the brain and/or spinal cord), neuromuscular dysfunction of the bladder (problems due to disease or injury of the central nervous system or nerves involved in the control of urination), and type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar). Record review of Resident #1's Quarterly MDS assessment dated [DATE] indicated he was understood by others and understood others. The MDS assessment indicated Resident #1 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #1 was dependent on staff for toileting, had an indwelling catheter, was always incontinent of bowel, and had unhealed pressure ulcers Record review of Resident #1's Order Summary Report dated 06/17/2026 indicated:Right hip, cleanse with Theraworx (wound cleanser), pat dry, pack with Dakin's (wound cleaning solution) soaked gauze, and cover with dry dressing with an order date of 06/16/2026.Sacral (lower back/buttocks area) wound, cleanse with Theraworx, apply honey and calcium alginate to wound bed and cover with dry dressing with an order date of 06/09/2026. Left lateral (side) foot, cleanse with Theraworx, apply xeroform and calcium alginate and cover with dressing with an order date of 06/09/2026. There were no orders for EBP. Record review of Resident #1's care plan with a target date of 07/20/2026 indicated he was on EBP due to a chronic wound or skin opening requiring dressing changes and an indwelling catheter. Resident #1's care plan indicated staff would maintain EBP during high contact resident care activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or toileting, and when they performed any type of device care such as but not limited to the following urinary catheter care and wound care. Resident #1's care plan indicated he had pressure wounds to perform treatments per the doctor's orders. He required assistance with his ADLs related to quadriplegia, and he required assistance by staff for toileting and transfers. During an observation on 06/17/2026 at 9:17 AM, CNA B and CNA D entered Resident #1's room to provide incontinent care. CNA D grabbed Resident #1's catheter bag and tubing without any gloves or a gown on to see if it needed to be emptied. CNA B put on gloves and emptied Resident #1's foley catheter bad. CNA B did not wear a gown. CNA B had the same gloves on that she emptied the foley catheter bag and CNA D put on some gloves, and they took off Resident #1's blanket to change his brief. CNA B and CNA D still did not wear a gown. They realized the wound dressing on Resident #1's right hip needed to be changed and stopped to go get the nurse. During an observation on 06/17/2026 starting at 9:34 AM, CNA B entered Resident #1's room to provide incontinent care. CNA B unfastened Resident #1's brief and cleansed his front perineal area. CNA B turned Resident #1 on his side and wiped Resident #1's buttocks multiple times with the same wipe, grabbed another wipe and repeated the same action. The stool from Resident #1's dirty brief got on the draw sheet (white folded blanket often used to reposition the resident in the bed) underneath him. CNA B removed the dirty brief and took off her gloves. CNA B did not perform hand hygiene after she removed her gloves. Resident #1 remained on his side for wound care to his buttocks. The ADON entered the room and put on gloves and a gown to provide wound care. The ADON removed the dirty dressing to Resident #1's buttocks, removed and discarded her gloves, and applied new ones. The ADON did not perform hand hygiene after glove removal. Resident #1's open wound was directly on the dirty draw sheet. The ADON cleansed Resident #1's wound, changed gloves, and applied new gloves. The ADON did not perform hand hygiene after glove removal. The ADON applied the dressing, removed her gloves, applied new ones. The ADON did not perform hand hygiene after glove removal. The ADON removed the dirty dressing to Resident #1's right hip, cleaned the wound, removed her gloves, and applied new gloves. The ADON did not remove her gloves after removing the dirty dressing and did not perform hand hygiene after removing her gloves. The ADON completed the wound care, removed her gloves, and performed hand hygiene. The Treatment Nurse entered the room to provide wound care to Resident #1's left foot and put on a gown and gloves. The Treatment Nurse removed the dirty dressing, changed gloves, and grabbed gauze to cleanse the wound. The Treatment Nurse wiped multiple times back and forth when cleaning the wound, set the gauze on the bed to reposition Resident #1's foot, picked the gauze back up and wiped across the wound multiple times with the same gauze. The Treatment Nurse completed the wound treatment, removed her gloves and performed hand hygiene. During an interview on 06/17/2026 at 10:51 AM, CNA D said residents with foley catheters and wounds required EBP when changing them. CNA D said she should have worn a gown and gloves when she checked Resident #1's foley catheter bag. CNA D said not wearing a gown and gloves could result in the spread of bacteria. During an interview on 06/17/2026 at 4:58 PM, CNA B said Resident #1 required EBP and she should have put on a gown and gloves when she provided direct care to him. CNA B said hand hygiene should be performed before she went into the resident's room, before she put gloves on, and after she provided care. CNA B said during incontinent care she should wipe once and discard the wipe and get a new one to prevent UTIs. CNA B said she should have removed the dirty draw sheet when she finished cleaning up Resident #1. She said leaving the dirty draw sheet could result in a wound infection. CNA B said EBP were required to prevent the residents from getting more infected and to keep them from getting what the residents had. 2. Record review of Resident #2's face sheet dated 06/17/2026, indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia mild without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life without any behaviors or disturbances), atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow), and methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere (a type of bacteria that causes skin infections and is resistant to many antibiotics). Record review of Resident #2's Quarterly MDS assessment dated [DATE] indicated he was rarely/never understood by others and rarely/never understood others. The MDS assessment indicated Resident #2 had a short-term and long-term memory problem. The MDS assessment indicated Resident #2 was dependent on staff for all ADLs. Resident #2 had a total of 2 venous and arterial ulcers present. Record review of Resident #2's Order Summary Report dated 06/17/2026 indicated:Right first metatarsal, cleanse with Theraworx, apply gentamycin 0.1% (antibiotic) cream to wound bed and secure with dry dressing three times a day for wound healing for 14 days with an order date of 06/11/2026. There were no orders for contact precautions. Record review of Resident #2's care plan with a target date of 08/03/2026 indicated he was on EBP due to a chronic wound or skin opening that required a dressing change. Resident #2's care plan indicated staff would maintain EBP while performing wound care. During an observation of a video dated 06/13/2026 timed 11:52 AM, RN F entered Resident #2's room and provided wound care to his right foot. RN F failed to put on a gown. During an observation of a video dated 06/13/2026 timed 3:31 PM, RN F entered Resident #2's room and provided wound care to his right foot. RN F failed to put on a gown. During an observation on 06/16/2026 at 12:55 PM, there was a sign for EBP outside of Resident #2's room on the doorframe. There was no sign to indicate he required contact precautions. During an observation on 06/17/2026 at 8:59 AM, Resident #2 had a sign on his doorframe that indicated he required EBP. There was no sign to indicate he required contact precautions. During an interview on 06/17/2026 at 4:16 PM, RN F said she provided Resident #2's wound care treatments on 06/13/2026. RN F said she did not wear a gown when providing Resident #2's wound care because she did not realize he required contact precautions. RN F said Resident #2 did not have a sign on his door that indicated he was on contact precautions. RN F said any of the nurses who knew he required contact precautions could have placed a sign on Resident #2's door to alert staff and visitors to put on the appropriate PPE. RN F said she should have applied a gown and gloves when providing care to Resident #2. RN F said not following the proper PPE precautions during wound care and not posting a sign with the required precautions could result in the spread of infection. 3. Record review of Resident #4's MDS assessment dated [DATE] indicated she admitted to the facility on [DATE]. Resident #4 had diagnoses which included spinal stenosis in the lumbar region with neurogenic claudication (narrowing of the spinal canal that compresses nerve roots and causes weakness and pain, numbness, or tingling in one or both legs) and infection following a procedure deep incisional surgical site (infection to an incision (cut) made for a surgical procedure). Resident #4 understood others and was understood by others. Resident #4 had a BIMs score of 14, which indicated her cognition was intact. Resident #4 required substantial/maximal assistance with toileting and bathing and required partial/moderate assistance with personal hygiene. Resident #4 had a surgical wound and received wound care. Record review of Resident #4's Order Summary Report dated 06/16/2026 indicated:Lower back wound cleanse with Theraworx apply foam to wound bed cover with drape and apply wound vac (vacuum-assisted closure; machine used to apply suction to the wound for wound healing) at 125 mmhg as needed for dislodgement of drape or foam with an order date of 05/30/2026. There were no orders for EBP. Record review of Resident #4's care plan with a target date of 08/20/2026 did not address the use of EBP. During an observation on 06/16/2026 at 1:28 PM, LVN N entered Resident #4's room to reconnect Resident #4's wound vac. LVN N did not put on a gown or gloves. LVN N grabbed Resident #4's wound vac and the tube on the wound vac with her ungloved hands and wiped off the tip of the wound vac tubing with an alcohol swab to reconnect it. LVN N grabbed Resident #4's linens, uncovered her, and attempted to locate the other end of the tube on Resident #4's back with her ungloved hands. LVN N was unable to reach the other end of the tube without turning Resident #4 on her side. LVN N said she was going to talk to the wound care doctor and exited the room. During an interview on 06/16/2026 at 5:59 PM, LVN N said EBP was required when a resident had wounds and a gown and gloves should be worn with any personal care, contact with clothes or any type of close contact, wound care, and incontinent care. LVN N said she forgot to put on a gown and gloves with Resident #4. LVN N said not following EBP could result in the spread of infection. During an interview on 06/17/2026 at 5:48 PM, the ADON said EBP should be followed when a resident had wounds, indwelling devices such as foley catheters. She said any time the staff provided care for those residents they should wear gloves and a gown. The ADON said when handling the foley catheter bag and tubing, the residents' linens, and a wound vac gloves and a gown should be worn. The ADON said hand hygiene should be performed before and after providing care and after glove removal. The ADON said when providing incontinent care, the staff should wipe once and discard the wipe and get a new one. She said proper incontinent care was required to prevent infections. The ADON said when she provided wound care to Resident #1, she should have rolled him over more for there to be less of a chance of the wound touching the bed. She said she should not have performed the wound care over the dirty draw sheet. The ADON said she forgot to perform hand hygiene in between glove changes, and she should have removed her gloves and applied new ones before the dressing was changed. The ADON said Resident #2 required the use of contact precautions because he had ESBL and MRSA in his wound. The ADON said she was responsible for putting up the signs to alert staff and visitors of the required precautions. The ADON said she had placed a sign on the door when they received the order to place him on contact precautions. The ADON said the residents should have orders for the precautions they required, and she did not know why they did not. The ADON said not performing adequate hand hygiene could result in a wound infection. The ADON said not following EBP could result in the spread of bacteria. The ADON said the Treatment Nurse, DON, and herself were responsible for ensuring the staff followed proper infection control practices. The ADON said she conducted random checks to see if the staff were following proper infection control practices. The ADON said not following contact precautions could result in the staff getting the bacteria on them and taking it to the residents. During an interview on 06/18/2026 at 1:32 PM, the Regional [NAME] President said the facility administrator had been terminated on 06/08/2026. He said he expected the staff to adhere to common perineal care practices, follow contact and enhanced barrier precautions, use sterile technique for wound care, and proper hand hygiene. He said the Interim DCO was responsible for monitoring the staff. He said he was not clinical and was not able to determine the risks and outcomes associated with not following proper infection control practices. During an interview on 06/18/2026 at 3:11 PM, the Director of Resident Support Services said the Interim DCO was not available for interview. Record review of the facility's policy titled, Perineal Care, effective 10/01/2021, indicated, To provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Wash and dry your hands thoroughly. Put on gloves. For a male resident: a. Use wipe and apply skin cleansing agent. b. Wash perineal area starting with urethra and working outward. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches.) (1) Retract foreskin of the uncircumcised male. (2) Cleanse the urethral area using a circular motion. (3) Continue to wash the perineal area including the penis, scrotum and inner thighs. Do not reuse the same side of the disposable wipe, change the surface position of the disposable [NAME] and/or obtain a clean wipe to clean the urethra. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. Record review of the facility's policy titled, Transmission-Based Precautions for Infections, revised 10/24/2022, indicated, Contact- In addition to standard precautions, use Contact precautions (gown, gloves, mask or faceshield if splashing could occur) for residents known or suspected to be infected with microorganisms that can be easily transmitted by direct or indirect contact, such and handling environmental surfaces or resident care items. In some instances, residents colonized with these organisms may also require contact precautions for example, when a draining wound cannot be contained, when a resident exhibits noncompliant behavior with stool or other body fluids, or when a resident has very poor personal hygiene, etc. The above includes epidemiologically important organisms (Multidrug-resistant organisms) such as methicillin-resistant Staphylococcus aureus (MRSA). Hand hygiene- Hand hygiene, with alcohol-based hand rub or soap & water is recognized as the most important way to prevent the transmission of infection. All employees are required to perform hand hygiene prior to any resident contact, after unprotected contact with blood or other potentially infectious materials and after removing gloves. Hand hygiene with alcohol-based hand rub is preferred method, unless the hands are visibly soiled, before and after use of restroom, performing invasive procedures. 5. Transmission-based precaution signage for door of each resident room a. Signage should have Contact Nurse Prior to Entering b. All needed PPE should be listed on the signage. 8. Physician order is required to begin transmission-based precaution and to end transmission-based precaution. Record review of the facility's policy titled, Enhanced Barrier Precautions, effective 04/01/2024, indicated, Enhanced Barrier Precautions (EBP) are a CDC guidance to reduce the transmission of multi-drug resistant organisms (MDRO) in health care settings, including nursing homes. EBP require team members to wear a gown and gloves while performing high-contact care activities with residents who are infected or colonized with a targeted MDRO, or who have open wound or indwelling medical device.Determine if a resident has any wounds.chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds. Determine if any of the following indwelling medical devices are in use: urinary catheter.EBP will be implemented if any of the above wounds or invasive medical devices are present. 4. High contact resident care activities: Dressing Bathing/Showering Transferring Providing hygiene Changing linens Changing briefs or assisting with toileting. Device care or use Wound care: any skin opening requiring a dressing.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free from pests in 3 of 3 halls reviewed for pest control. The facility did not maintain an effective pest control program to ensure the facility was free of flies. This failure could place residents at risk for an unsanitary environment and a decreased quality of life. Findings included: During a walk through the facility on 06/16/2026 starting at 11:41 AM, there were multiple flies observed on halls 100, 200, and 300. During an observation and interview on 06/17/2026 at 9:15 AM, there were multiple flies in Resident #1's room. He was observed shaking his head trying to get them away. He said this had been an ongoing issue but was not able to provide a timeframe. During an interview on 06/17/2026 at 6:16 PM, the ADON said the residents complained to her about the flies in the facility and in their rooms, and she had reported it to the previous maintenance director. She said she could not remember how long ago it had been. The ADON said it was important for their not to be any flies in the facility because it was unsanitary and it was a hazard to the residents. During an interview on 06/18/2026 at 10:55 AM, LVN A said several of the residents complained to her about the flies in the facility and their rooms and it had been at least a month since they had been complaining. LVN A said all the management staff had been notified and were aware that there were too many flies in the facility. LVN A said she had not logged it in the pest control book because she did not know she was supposed to. LVN A said it was important for the facility to be free of flies for the residents' comfort, for safety, and for general human living conditions. During an interview on 06/18/2026 at 11:08 AM, a representative with the facility's pest control company said they serviced the facility monthly, but their routine services did not cover flies and gnats. They said they were able to provide those services, but the facility had to contact them to request those services. They said the facility had not reached out to them to request services for flies and gnats. During an interview on 06/18/2026 at 11:32 AM, Maintenance Director L said he was helping at the facility until the facility hired a maintenance director. He said it had been a week since the previous maintenance director left. He said if there was an issue with flies and gnats the staff should report it to the maintenance director, and the maintenance director notified the pest control company and the pest control company would address the issue. He said the staff had not reported any issues with flies or gnats to him and he was not even aware of the last time the pest control company was at the facility. Maintenance Director L said it was important for there not to be flies and gnats in the facility for the residents' health. During an interview on 06/18/2026 at 1:43 PM, the Regional [NAME] President said if there were flies in the facility the staff should log it in the pest control book, and it was reviewed so that the specific issue was treated. He said the maintenance director was responsible for ensuring the facility was treated for flies. He said the flies could be annoying. Record review of the facility's pest control log dated from 10/06/2025-06/01/2026 did not indicate any issues with flies or services provided for flies. Record review of the facility's policy titled, Pest Control, revised May 2008, indicated, Our facility shall maintain an effective pest control program. This facility maintains an on-going pest control program to ensure that the building is kept free of insects.

Based on interview and record review, the facility failed to provide sufficient number of nursing staff on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans and the facility assessment for 1 of 1 facility reviewed for care and services. The facility failed to provide sufficient CNAs according to the facility assessment on 05/18/2026, 05/21/2026, 05/22/2026, 05/23/2026, 05/24/2026, 05/30/2026, 05/31/2026, 06/06/2026, 06/09/2026, 06/13/2026, 06/14/2026, 06/15/2026 This failure placed residents at risk of inadequate supervision, an unsafe environment, falls, serious harm and injury, exacerbations of disease processes, and a decreased quality of life.Findings included: During an interview on 06/16/2026 at 12:30 PM, Resident #6 said it took the staff a long time to answer the call lights, and sometimes he had to call the nurses' station on the phone to have them provide incontinent care. Resident #6 said in the past he had waited for his call light to be answered or to be provided incontinent care from one and a half hours to five hours. During an interview on 06/16/2026 at 1:46 PM, Resident #5 said the staff took a long time to answer the call light and she had to wait a long time to be changed. Resident #5 was unable to provide exact times. During an observation and interview on 06/16/2026 at 2:02 PM, Resident #3 said she was not receiving her baths as scheduled. Resident #3's hair appeared oily and disheveled. She said she should have received a bath yesterday (06/15/2026), but she did not. She said when she asks the staff about her baths they tell her they do not have time and they are short staffed. Resident #3 said it took the staff a long time for them to respond to the call light. During an interview on 06/16/2026 at 5:03 PM, the Ombudsman said the facility had a lot of staff who left over the past 2 weeks. The Ombudsman said the residents complained to her about the lack of staff and call lights not being answered. During a confidential interview Anonymous Person #1 said they often did not have enough staff to fulfill all the residents' needs. They said when there was not enough staff the residents did not get their showers and they did not even have time to pass out water to the residents. Anonymous Person #1 said the residents reported to her not getting showers, not getting changed and the call lights not getting answered in a timely manner. They said when they were short staffed nurse management did not step in and help them. They said the residents had to wait for extended amounts of time to get changed. They said they reported it to the previous DON and the ADON. They said this placed the residents at risk for worsening wounds, dehydration, and UTIs. During a confidential interview Anonymous Person #2 said the residents reported to her they were not getting changed and the call lights were not answered in a timely manner. They said there were times when they were short-staffed and could not pass out ice and water and they missed giving baths. They said staff call off and they were not replaced. They said they reported not having enough staff to fulfill the residents' needs to the ADON and previous DON. They said not having enough staff placed the residents at risk of getting sick, injuries, dehydration, and more skin problems. During a confidential interview Anonymous Person #3 said sometimes they were short and did not have enough staff. Anonymous Person #3 said when they were short, they were not able to accomplish all their tasks and the residents did not get their showers, they were unable to change people in a timely manner, and call lights were not answered timely. They said residents have reported to him not being changed during the night and not being helped out of bed because of the lack of staff. They said they reported these things to the charge nurse. They said not providing required care to the residents placed them at risk for neglect, UTIs, and skin breakdown. During a confidential interview Anonymous Person #4 said they did not have enough staff to change the residents in a timely manner and give them their showers. They said they reported this to the ADON and charge nurse. They said not providing care to the residents could be considered neglect. They said due to not having enough staff the residents could feel they were stressed or they could get talked to wrong, the residents may not want to ask for help because they knew they were short, or they could get wounds. During a confidential interview Anonymous Person #5 said the residents reported to her not getting changed and the call lights not getting answered in a timely manner, and they noticed it had been when they were short staffed. They said they reported it to the ADON. They said not having enough staff could affect the residents' care and they could be neglected. During a confidential interview Anonymous Person #6 said sometimes they did not have enough staff, and she missed some of the showers. They said the residents reported to them not getting changed due to being short staffed. They said they reported this to the charge nurse. They said not having enough staff could cause the residents emotional damage and they could be more prone to getting sick more often. During a confidential interview Anonymous Person #7 said sometimes they did not have enough CNAs, and it was a struggle. They said a lot of the residents required 2 staff to assist them with transfers, so it made it difficult to assist them in a timely manner. They said the residents reported to them the call lights not being answered. They said sometimes the showers were missed due to not having time to complete them. Anonymous Person #7 said if they did not have enough staff the residents could get wounds, fall, and life-threatening things could happen to them. During an interview on 06/17/2026 at 5:52 PM, the ADON said the staff had reported to her they were not able to accomplish all of their tasks, and she had discussed time management with them because they were taking too many breaks. The ADON said the staff reported to her that they were short-handed. She said the facility had a staffing ratio she followed when she did the scheduling, and the staffing ratio was 5 CNAs for the day shift (6 AM- 6 PM) and 3 CNAs for the night shift (6 PM- 6 AM). The ADON said if there were any call ins she found somebody to fill in or she worked on the floor. During an interview on 06/18/2026 at 1:48 PM, the Regional [NAME] President said staffing was volatile and as far as being shorthanded they might have to work harder that the day before, but his expectations were for the residents to be taken care of. He said to his knowledge the facility was adequately staffed. He said if there was a call in there was an on-call phone and the individual with the phone was responsible for finding coverage or working. He said they should have 5 CNAs on the day shift and 4 CNAs on the night shift. He said if they were not adequately staffed he assumed the responsibilities would not be completed timely. During an interview on 06/18/2026 at 3:11 PM, the Director of Resident Support Services said the Interim DCO was not available for interview. Record review of the Facility assessment dated [DATE] indicated, 5 CNAs for the 6 AM- 6 PM shift and 3 CNAs for the 6 PM- 6 AM shift. Record review of the timecards dated 05/18/2026-06/15/2026 indicated the facility did not have 5 CNAs for the 6 AM- 6 PM shift on: 05/18/2026- 4 CNAs05/21/2026- 3CNAs05/22/2026- 4 CNAs05/23/2026- 4 CNAs05/24/2026- 4 CNAs05/30/2026- 4 CNAs05/31/2026- 3 CNAs06/06/2026- 4 CNAs06/09/2026- 3 CNAs06/13/2026- 3 CNAs06/14/2026- 2 CNAs06/15/2026- 3 CNAs Record review of the timecards dated 05/18/2026-06/15/2026 indicated the facility did not have 3 CNAs for the 6 PM- 6 AM shift on: 05/21/2026- 2 CNAs05/23/2026- 2 CNAs06/13/2026- 2 CNAs06/14/2026- 2 CNAs06/15/2026- 2 CNAs Record review of the facility's policy, Staffing, revised 10/2017, indicated, Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment.

Based on observation, interview, and record review the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside, for 1 of 1 facility reviewed for call lights. The facility failed to ensure the call light system was functioning properly. This failure could place residents at risk of injury, falls, and unmet needs.The findings included: During an interview on 06/16/2026 at 2:02 PM, Resident #3 said it was taking a long time for the staff to answer the call light. She said she had reported it to the nurses and they told her they were short. During an interview on 06/16/2026 at 7:22 PM, LVN P said some of the residents reported to her that the call lights were not being answered in a timely manner. She said they were having issues with the call lights because if 4 or more call lights went off on the 100 hall the call light system stopped working and all the call lights turned off. She said when they realized it had stopped working they would reset the board and it would start working again. LVN P said she had reported this to the previous DON and the ADON. LVN P said if the call lights were not functioning it could cause falls or the residents could have an emergency and not get the help they needed. During an interview on 06/17/2026 at 6:58 AM, LVN E said she had been working at the facility for 4 months. LVN E said the residents reported to her their call lights were not being answered in a timely manner. LVN E said if there were 5 or more call lights going off on the 100 hall the call lights would go off and stop working. She said if she was at the nurses' station and noticed the call light system turned off, she would reset it, but if she was not at the nurses' station, she would not know it stopped functioning. LVN E said the call light system had been doing this since she started working at the facility. She said she had reported it to the previous DON. LVN E said it was important for the call lights to properly function so the residents' needs could be met. During an observation and interview on 06/17/2026 at 8:27 AM, Maintenance Director L said the previous maintenance director left on 06/04/2026. He said he had not heard anything about the call system malfunctioning. Maintenance Director L and the Dietary Manager went down the 100 hall and activated multiple call lights. Surveyor stayed at the end of the hall by the nurses' station to observe. There were call lights on the other halls that were activated by residents. After multiple call lights were activated on the 100 hall. All of the call lights turned off and the call system board turned off. Maintenance Director L said he was not aware this was happening. He said he did not know how to print the maintenance log from their system, but he would try to see if he could figure it out (maintenance log was not provided upon exit of the facility). During an interview on 06/17/2026 at 8:28 AM, the Dietary Manager said she was aware the call light system was not functioning properly because one day over a month ago she was shocked that there were no call lights on. She said she started pushing buttons on the call light system's main board until it reset and the call lights came back on. The Dietary Manager said she reported it to the previous Maintenance Director, and it had not been fixed. The Dietary Manager said if the call lights were not functioning properly they could not provide the care that the residents' needed and if it were an emergency they would be delayed in finding out. During an interview on 06/17/2026 at 5:48 PM, the ADON said she had randomly been told by the residents that their call lights were not answered. The ADON said there was an issue down the 100 hall because there was a short in the circuit and if a couple of lights went off all the lights went completely off. The ADON said she had been aware of this for about two and a half months, and the previous maintenance director said he would contact the company that installed the call light system. The ADON said if the call light system was not functioning properly the residents could not receive the care they needed and they could not alert them when they needed something. During an interview on 06/18/2026 at 1:38 PM, the Regional [NAME] President said if the call light system was malfunctioning, he expected for it to be brought up in the morning meetings and for it to be placed in the maintenance log. He said he was not aware of the issue with the call light system that nobody had reported it to him. He said the call light system malfunctioning could impede the residents' ability to ask for help. Record review of the facility's policy, Maintenance Service, effective 02/01/2017, indicated, Maintenance service shall be provided to all areas of the building, grounds, and equipment. 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include but are not limited to: a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. A policy specific to the call light system was requested from the Director of Resident Support Services and not received upon exit of the facility.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 of 4 residents (Resident #2) reviewed for resident neglect. The facility failed to ensure Resident #2 was given lunch and dinner on 06/13/2026. The facility failed to ensure Resident #2 was provided with incontinent care and turning and repositioning every 2 hours on 06/13/2026. These failures could result in pressure injuries, weight loss, infections, psychosocial harm, and a decreased quality of life. Findings included: Record review of Resident #2's face sheet dated 06/17/2026, indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia mild without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life without any behaviors or disturbances), atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow), and methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere (a type of bacteria that causes skin infections and is resistant to many antibiotics). Record review of Resident #2's Quarterly MDS assessment dated [DATE] indicated he was rarely/never understood by others and rarely/never understood others. The BIMS interview could not be completed due to Resident #2 rarely/never understood by others and rarely/never understood others. The MDS assessment indicated Resident #2 had a short-term and long-term memory problem. The MDS assessment indicated Resident #2 was dependent on staff for all ADLs. Record review of Resident #2's care plan with a target date of 08/03/2026 indicated he required assistance with his ADLs. Resident #2 required assistance by staff for dressing, eating, personal hygiene, transfers, and toilet use. Resident #2 was at risk for skin breakdown with interventions to monitor nutritional status and serve diet as ordered. Resident #2 was at risk for deficient fluid volume and for altered nutritional status with interventions to encourage 6-8 glasses of fluid intake and to offer fluids he liked as much as possible. Resident #2 was incontinent and was at risk for skin breakdown and needed to be monitored for incontinence every 2 hours and as needed. During an observation of video footage dated 06/13/2026 from 10:51 AM- 11:02 PM revealed:10:51 AM, CNA C and CNA K provided incontinent care to Resident #2, changed his shirt (shirt was changed to a white shirt), and positioned him on his left side. No fluids were offered and none observed on his overbed table.12:59 PM, CNA G was observed entering Resident #2's room, she set his meal tray down on his over-bed table, which was located out of Resident #2's reach, and walked out of the room. No attempts were made to assist him, offer him fluids, or reposition him. 3:51 PM, CNA C entered Resident #2's room, looked at his covered lunch tray, and said, Did she not try to feed him?. She took the cover off the plate, looked at it, covered it back up, and walked out of the room. CNA C could be heard talking to someone in the hallway but the audio was inaudible due to Resident #2's TV playing loudly. No attempts were made to assist him with his meal, offer him fluids, or reposition him. Resident #2 was still on his left side.4:10 PM, CNA K provided incontinent care to Resident #2 and transferred him to his wheelchair with assistance of CNA C. Fluids were not offered and Resident #2 was still lying towards his left side prior to being transferred. 6:18 PM, CNA M gave him a drink. 11:02 PM, Resident #2's resident representative entered the room and provided him with a meal. Resident #2's dinner tray was not observed delivered to his room and there were no attempts to give him a dinner meal. During an interview on 06/16/2026 at 11:06 AM, Resident #2's family member said on Saturday evening, 06/13/2026, they reviewed the video footage for the day and realized Resident #2 was not given his lunch or dinner meal and was not provided with incontinent care, repositioned, or given fluids for long periods of time. They said this was reported to the ADON via phone call before she arrived. They said she expected for them to try to give him something to eat when they were made aware of the situation, but nobody attempted to give him any food. They said when they arrived to the facility at around 10:45 PM all the staff were sitting at the front desk. They said they reported everything to the ADON, and the ADON told them maybe the camera glitched and did not catch when CNA M gave him his dinner. They said they asked CNA M if she had given Resident #2 his dinner and she said no. They said that was unacceptable and it was neglect. They said prior to this incident they had made other complaints about Resident #2 not being taken care of to the nurses and she had also reported it to the Interim DCO. During an interview on 06/16/2026 at 7:22 PM, LVN P said on Saturday, 06/13/2026, Resident #2's resident representative went to the facility around midnight and said Resident #2 did not get a lunch or dinner tray. She said Resident #2's family member assisted him with a meal. LVN P said Resident #2 required assistance with his meals. LVN P said she was not aware Resident #2 was not assisted with his lunch and dinner meals. LVN P said she was not present for lunch, but she thought the ADON assisted Resident #2 with his meal because the ADON passed out the dinner trays on his hall. LVN P said they were short Saturday (06/13/2026) and she had to help pass out the dinner trays on a different hall and then give medications. LVN P said she did not know if the ADON had delegated the task to someone else. LVN P said the CNA working the residents' hall should make sure the residents received their meals. LVN P said prior to Resident #2's family member's arrival, a different family member called and notified the ADON Resident #2 was not assisted with his lunch meal and was not given a dinner tray. LVN P said not assisting the residents with their meals could affect their mental and psychosocial well-being, they would not have the proper nutrition, could get UTIs, low blood sugars, depression and could be considered neglect. During an attempted interview on 06/17/2026 at 8:59 AM, Resident #2 was not interviewable. He did not respond to questions asked. During an interview on 06/17/2026 at 4:16 PM, RN F said on Saturday, 06/13/2026, she was the RN Supervisor and they were shorthanded. She said everybody was answering call lights and it was a rough weekend. She said she notified the ADON staff had called in and the ADON told them she was working on it, and a staff member came in at 2 PM. RN F said being short resulted in a delay in the care provided to the residents. RN F said she did not remember who passed the hall trays on 06/13/2026. She said the CNAs were responsible for ensuring the residents got their tray and notifying the nurse if a resident refused their meal or if they needed assistance with giving the residents their meals. RN F said she was not aware of any of the residents not being assisted with their meals. RN F said not assisting the residents with their meals could lead to them being hungry, and if they missed their meal it resulted in them missing calories and nutrients and placed them at risk for weight loss. During an interview on 06/17/2026 at 5:14 PM, CNA C said she worked on Saturday, 06/13/2026, and they were not short staffed. She said they had 4 CNAs for the day shift, and she was able to handle all of her duties. CNA C said she was not assigned to care for Resident #2 on 06/13/2026. CNA C said Resident #2 required assistance with his meals. She said she did not know the name of the CNA who was responsible for giving him his lunch. CNA C said at 3 PM she went to pick up Resident #2's tray. She said she noticed the tray was in the corner of the room, had not been touched, and the silverware was unused, so she reported it to the charge nurse. CNA C said she took Resident #2's tray to heat it up in the microwave to try to give it to him, but he refused to eat. CNA C said the dinner trays came out of the kitchen at 5:45 PM and she passed them out to the residents on the hall she was assigned. CNA C said she believed the ADON was passing out the dinner trays on Resident #2's hall. CNA C said if a resident did not receive their meal, they could go hungry and it could be considered neglect. During an interview on 06/17/2026 at 5:26 PM, LVN A said she provided care to Resident #2 and was the charge nurse for Resident #2 on Saturday, 06/13/2026. LVN A said CNA G placed Resident #2's tray on his over-bed table, and CNA C picked up Resident #2's tray. LVN A said they were short on 06/13/2026, and she had notified the ADON and she told her she could not find replacements. LVN A said CNA G left early in the shift and they were left with 3 CNAs, CNA H, CNA C, and CNA K. LVN A said the video showed that the CNAs did not attempt to assist Resident #2 with his lunch meal. LVN A said she did not know who gave the residents their dinner trays because she left at 5:40 PM and the dinner trays were not ready to be passed out at that time. LVN A said CNA C did not report to her that Resident #2 was not assisted with his meal or that he refused lunch. LVN A said she was not aware Resident #2 was not given his lunch meal. LVN A said the CNAs should be checking on the residents to see if they needed to be changed and repositioning them every 2 hours. LVN A said the CNAs should offer the residents fluids when they were doing their rounds at least every 2 hours. LVN A said Resident #2 went without being changed and repositioned and without fluids and food for too long and it was bad for his skin and could be considered neglect. During an interview on 06/17/2026 at 6:18 PM, the ADON said on Saturday, 06/13/2026, she worked as a CNA for the 6 PM-6 AM shift. The ADON said it was around midnight one of Resident #2's family members arrived to the facility and stated Resident #2 had not been fed lunch or dinner and was not provided care for extended lengths of time. The ADON said this allegation could be considered neglect. She said she did not know who she should report to because she thought the Interim DCO, who was currently the Abuse Coordinator, was not available. The ADON said CNA M was responsible for giving Resident #2 his dinner, so she asked CNA M if she had given Resident #2 his dinner and she told her she had. The ADON said she did not pass out any dinner trays. The ADON said she thought CNA M gave Resident #2 his dinner. The ADON said she did not check to see if Resident #2 had lunch, and she did not further look into what happened. The ADON said when Resident #2's family member notified her of him not receiving his lunch Resident #2's family member had already given Resident #2 some beans. The ADON said the CNAs should be checking and turning the residents and offering them fluids during their rounds at least every 2 hours. The ADON said the residents not being assisted with their meals could result in weight loss and cause issues with wound healing. During an interview on 06/17/2026 at 6:48 PM, the Interim DCO said he was not aware of Resident #2 not receiving lunch and dinner, and Resident #2's representative had not brought any concerns to him. He said the ADON should have investigated when Resident #2's representative reported to her he had not been given lunch or dinner and there were complaints regarding the lack of care he received. The Interim DCO said the ADON should have notified him of the allegation made. He said the previous DON's last day was 05/26/2026 and the previous administrator's last day was 06/05/2026. He said the process that should have been followed by the ADON was if a resident representative reported to her the resident was not fed that should have prompted somebody to take it seriously, and the staff involved should have been suspended pending investigation and it should have been reported according to the guidelines. He said he expected the staff to check on the residents, reposition them, and offer fluids every time they went into the residents' rooms. He said Resident #2 was denied his nutritional requirements for the day and was at risk for dehydration, low blood sugar, and the ADON not reporting had the potential to harm every resident because they deprived the resident of the determination of what happened. During an interview on 06/17/2026 at 7:18 PM, CNA G said they were short staffed on Saturday, 06/13/2026, and she initially started working on Resident #2's hall but then was switched to a different hall and CNA C was supposed to provide care to Resident #2. CNA G said she gave Resident #2 his breakfast, and then for lunch she passed his tray but did not go back to feed him. She said it was wacky and there was a lot going on and she got switched halls. CNA G said she was switched halls way before lunch, and CNA C was responsible for Resident #2's hall. CNA G said she got off around 3 PM, so she was not present for dinner. CNA C said they were supposed to round on the residents every 2 hours, check them to see if they needed to be changed, offer them fluids, and reposition them. CNA C said Resident #2 could be dehydrated or have malnutrition. CNA G said not providing care and not assisting the residents with their meals could be considered neglect. During an interview on 06/18/2026 at 10:40 AM, CNA M said Saturday, 06/13/2026, she worked all over the building on the 6 PM-6 AM shift. She said it was just her and the ADON as CNAs that night. She said she did not assist any residents with their meals. She said she thought she saw the ADON passing out meal trays on Resident #2's hall. CNA M said she was not aware Resident #2 did not receive his dinner tray. CNA M said not providing meals to the residents could be considered neglect. During an interview on 06/18/2026 at 11:17 AM, CNA K said on 06/13/2026, CNA G was assigned to Resident #2's hall. CNA K said CNA G left at 2 PM and she and CNA C were assigned to care for Resident #2. CNA K said CNA G gave Resident #2 his lunch tray, so she was responsible for assisting him with his meal. CNA K said CNA C picked up Resident #2's tray but she was not aware he did not eat. CNA K said she did not know who gave the residents their dinner trays because she was leaving when they started passing out the dinner trays. CNA K said CNA M and the ADON were the ones who worked the night shift on 06/13/2026, and they gave out the dinner trays. CNA K said not giving the residents their meals could be considered neglect and the residents could get sick. During an interview on 06/18/2026 at 11:49 AM, CNA H said on Saturday, 06/13/2026, she did not provide care to Resident #2. CNA H said during her shift the lunch meal was served, but she was gone when the dinner meal was served. CNA H said CNA G was responsible for giving Resident #2 his lunch. During an interview on 06/18/2026 at 1:53 PM, the Regional [NAME] President said he expected for the residents to be assisted with their meals. He said the staff should be checking when they are rounding to ensure the residents have fluids within reach or offer them fluids when rounding routinely. He said he was not aware Resident #2 did not receive his lunch or dinner meal or that he was not repositioned or offered fluids for extended periods of time. He said that was unacceptable and it was considered incompetency. He said when the ADON received the complaint from Resident #2's representative she should have notified him or the Interim DCO so they could resolve the issue. He said this could affect the residents and cause dehydration and malnutrition. Record review of the facility's policy, Abuse, revised 01/01/2023, indicated, The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect.Each employee receives the standards of conduct which includes the standard for prohibiting abuse or neglect of a resident, and the reporting of any suspected abuse or neglect of a resident.

Based on observation, interview, and record review the facility failed to ensure based on the comprehensive assessment of a resident, the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 3 (Resident #1) residents reviewed for quality of care. The facility failed to ensure a skin assessment was conducted on Resident #1 after CNA B observed a new open wound on his front perineal area on 06/17/2026. This failure could place residents at risk for not receiving appropriate care and treatment, a decreased quality of life, and worsening pressure ulcers. Findings included: Record review of Resident #1's face sheet dated 06/18/2026 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis of the arms, trunk, and legs resulting from damage to the brain and/or spinal cord), neuromuscular dysfunction of the bladder (problems due to disease or injury of the central nervous system or nerves involved in the control of urination), and type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar). Record review of Resident #1's Quarterly MDS assessment dated [DATE] indicated he was understood by others and understood others. The MDS assessment indicated Resident #1 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #1 was dependent on staff for toileting, had an indwelling catheter, was always incontinent of bowel, and had unhealed pressure ulcers. Resident #1 was at risk of developing pressure ulcers/injuries. Record review of Resident #1's Order Summary Report dated 06/17/2026 did not indicate any orders for his front perineal area. Record review of Resident #1's Skin Assessment completed by the Treatment Nurse dated 06/16/2026 did not indicate he had a wound to his front perineal area. Record review of Resident #1's Skin Assessment completed by the Treatment Nurse dated 06/18/2026 indicated he had a wound to his posterior left perineal area that measured 3 cm (length), 1.6 cm (width), 0.1 cm (depth). The wound was open and pink, red with light amount of pink exudate (drainage). The current wound treatment indicated cleanse wound with Theraworx (wound cleanser), pat dry, apply collagen powder (powder used to promote wound healing), and cover with border gauze daily and as needed. The Skin Assessment indicated the wound was a new wound. Record review of Resident #1's Progress Notes dated 06/01/2026-06/18/2026 indicated:06/18/2026 at 9:41 AM, spoke to the NP about new open area to posterior left upper thigh new order given to cleanse area with Theraworx pat dry apply collagen, and cover with border gauze daily completed by the Treatment Nurse. There were no other notes regarding Resident #1's wound to his front perineal area. Record review of Resident #1's care plan with a target date of 07/20/2026 indicated he had a pressure injury to his right hip to monitor/document/report as needed any changes in skin status. Resident #1's care plan indicated to check all his body for breaks in his skin and treat promptly as ordered by the doctor and to assess his skin weekly and record findings in his clinical record. Resident #1's care plan did not indicate any wounds to his front perineal area. During an interview and observation of incontinent care with CNA B on 06/17/2026 starting at 9:34 AM, surveyor observed an open wound on Resident #1's front perineal area. The wound was located in his left lower groin area to the side of his scrotal sac. The wound was open, appeared light pink and had edges, it was approximately 1.5 inch long and 1 inch wide. CNA B said she had not seen this wound before. Resident #1 said he was not aware of having a wound in that area, but it felt sore. CNA B said she would notify the nurse. During an interview on 06/17/2026 at 4:58 PM, CNA B said she was not aware Resident #1 had the open area on the left side of his front perineal area, but she reported it to the Treatment Nurse when she finished providing care to him (06/17/2026). CNA B said it was important for wounds to be reported and assessed promptly so they did not worsen and for them to be treated quicker. During an interview on 06/18/2026 at 8:56 AM, the Treatment Nurse said she conducted a skin sweep earlier in the morning (06/18/2026) to check the residents' skin and identified a new wound on Resident #1 in his front perineal area and was awaiting new orders from the NP. The Treatment Nurse said CNA B did not report to her Resident #1 had a wound on his front perineal area. The Treatment Nurse said if a new wound was observed by the CNAs, they should report it to the charge nurses or if she was in the building they could report it to her. The Treatment Nurse said when a new wound was reported she conducted a skin assessment and notified the doctor for new orders. She said when she conducted his skin assessment on 06/16/2026 she did not notice he had an open area to his front perineal area. The Treatment Nurse said the open wound on Resident #1's front perineal area likely had been there for days because it was not something that happened overnight. She said it was probably caused from friction when they were applying his brief. The Treatment Nurse said it was important for new wounds to be reported and assessed promptly so they did not worsen. During an interview on 06/18/2026 at 10:55 AM, LVN A said she was not aware Resident #1 had an open area to his front perineal area. LVN A said there was a lack of communication and the CNAs should be reporting to her any new findings on the residents' skin. LVN A said she did not conduct skin assessments on him that the Treatment Nurse did, but if the CNA noticed a new area the CNA should notify her. LVN A said the CNAs should report any new wounds to the charge nurses and the charge nurses would assess the area, notify the Treatment Nurse, and doctor for orders. LVN A said it was important for new wounds to be identified and assessed to ensure the proper treatment was in place. LVN A said not promptly addressing new wounds could result in the wound worsening. During an interview on 06/18/2026 at 1:44 PM, the Regional [NAME] President said he expected the CNAs to notify the Treatment Nurse of new wounds. He said he expected the Treatment Nurse to notify the family and doctor of new wounds and get an order for treatment. The Regional [NAME] President said he was not clinical and he could not determine what could happen if wounds were not assessed and treated promptly. During an interview on 06/18/2026 at 3:11 PM, the Director of Resident Support Services said the Interim DCO was not available for interview. Record review of the facility's policy titled, Skin Management: Prevention and Treatment of Wounds, revised 10/06/2022, indicated, The purpose of this procedure is for prevention and treatment of skin breakdown such as pressure injuries, diabetic ulcers, arterial ulcers, and skin wounds. Resident Care Providers will complete a Stop and Watch form in Point of Care from the resident's chart, which alerts on the nurse's clinical dashboard. A licensed nurse will address the alert after completing an assessment of the resident's skin area and complete the e-INTERACT Change in Condition form for newly identified wounds. A licensed nurse will notify resident's physician, responsible party, and hospice nurse if on services, with new onset of wounds or deterioration in wound status. A licensed nurse will obtain orders from physician for new skin wounds and transcribe onto resident's treatment record for follow up.

Based on observation, interview, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 2 of 2 medication carts (100/300/400 Hall Medication Cart and the 200 Hall Medication Cart) reviewed for drugs and biologicals. The facility failed to ensure LVN O secured the 100/300/400 Hall Medication Cart and the 200 Hall Medication Cart, when they were not in use on 06/17/2026. This failure could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion. Findings included: During an observation on 06/17/2026 starting at 6:34 PM, the 200 Hall Medication Cart was observed unlocked and unattended stationed against the wall leading to the kitchen. LVN O was observed standing in front of the 100/300/400 Hall Medication Cart with her back to the 200 Hall Medication Cart on her computer. LVN O walked down the hall and went into a room. LVN O left the 100/300/400 Hall Medication Cart unlocked. Staff and residents were observed around the unlocked medication carts. LVN O returned to the nurses' station and both Medication Carts remained unlocked. Surveyor intervened and LVN O locked the medication carts. LVN O said the medication carts should be locked whenever she walked away from them. She said it was a mistake she left them unlocked because she was working between the two medication carts. She said they should be locked to ensure nobody stole the medications or nobody walked away with any of the medications or the residents did not get into the medication. During an interview on 06/18/2026 at 1:46 PM, the Regional [NAME] President said medication carts should be locked at all times, unless they were in use. The Regional [NAME] President said the Interim DON was responsible for ensuring the staff were locking the medication carts. He said an unlocked medication cart placed the residents at risk for potential exposure to medications. During an interview on 06/18/2026 at 3:06 PM, the ADON said medication carts should be locked anytime it was not within the staff's sight and when they walked away from it. The ADON said the nurse responsible for the medication cart should ensure it was locked when not in use. The ADON said if the medication cart was left unlocked the residents could get the medications or anybody could take medications from it. Record review of the facility's policy, Storage of Medications, revised 08/2020, indicated, Medications and biologicals are stored safely, securely, and properly.Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #1) reviewed for indwelling urinary catheters. The facility failed to ensure Resident #1's urinary catheter was secured to his leg on 06/17/2026. This failure could place residents at risk for damage to the bladder, penis, or urethra (a hollow tube that lets urine leave your body), dislodging of the catheter, and urinary tract infections. Findings included: Record review of Resident #1's face sheet dated 06/18/2026 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis of the arms, trunk, and legs resulting from damage to the brain and/or spinal cord), neuromuscular dysfunction of the bladder (problems due to disease or injury of the central nervous system or nerves involved in the control of urination), and type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar). Record review of Resident #1's Quarterly MDS assessment dated [DATE] indicated he was understood by others and understood others. The MDS assessment indicated Resident #1 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #1 was dependent on staff for toileting and had an indwelling catheter. Record review of Resident #1's Order Summary Report dated 06/17/2026 did not indicate orders for Resident #1's urinary catheter. Record review of Resident #1's care plan with a target date of 07/20/2026 did not address securing his foley catheter. During an observation and interview on 06/17/2026 at 9:17 AM, Resident #1's foley catheter was not secured to his leg. Resident #1 said he was not aware it was not secured to his leg. During an interview on 06/17/2026 at 4:58 PM, CNA B said she did not know for how long Resident #1's foley catheter had not been secured to his leg. CNA B said she notified the nurse after providing care to him that he needed his foley catheter secured to his leg. CNA B said it was important for the foley catheters to be secured properly to prevent them from getting pulled and prevent injuries to the resident's penis. During an interview on 06/17/2026 at 6:14 PM, the ADON said if the CNA noticed a residents foley catheter was not secured they should let the nurse know. The ADON said she did not know why Resident #1 did not have orders for his foley catheter. The ADON said the MDS Coordinator was responsible for the orders for the foley catheters and for ensuring the staff were properly securing them. The ADON said if foley catheters were not properly secured they could pull and result in an injury. During an interview on 06/18/2026 at 10:55 AM, LVN A said she was not notified Resident #1 did not have his foley catheter secured. LVN A said the CNAs were responsible for ensuring it remained secured and that the CNAs should report to the charge nurses when they noticed the foley catheters were not secured. She said she was not aware Resident #1 did not have orders for his foley catheter. She said the ADON and DON reviewed the residents' orders to ensure they had the necessary orders in place. She said foley catheters needed to be secured to ensure they did not pull and to ensure the foley catheter did not irritate the penis. During an interview on 06/18/2026 at 2:57 PM, the MDS Coordinator said she was not responsible for the foley catheter orders or for ensuring the staff were properly securing them. The MDS Coordinator said the charge nurses were responsible for ensuring the residents had orders for their foley catheters and the charge nurses and CNAs should be ensuring the foley catheters were properly secured. The MDS Coordinator said securing the foley catheter kept it from getting pulled and causing trauma. She said if it was not secured it could cause infections. During an interview on 06/18/2026 at 1:42 PM, the Regional [NAME] President said foley catheters should be strapped to the residents' legs. He said the Interim DCO was responsible for ensuring this happened. He said he did not know what could happen if it was not strapped because he was not clinical. During an interview on 06/18/2026 at 3:11 PM, the Director of Resident Support Services said the Interim DCO was not available for interview. Record review of the facility's policy, Catheters-Insertion and Care: Indwelling, Straight, Supra-Pubic, and External, effective 04/2021, indicated, It is the policy of this community that the resident with a urinary catheter will be provided services in a safe and appropriate manner to minimize the risks of urinary tract complications. Physician order is required for all catheters. Order should contain the following: Type of catheter, size of catheter and size of bulb, Frequency to change catheter, Frequency to change drainage bag.Attach catheter strap to leg to assist in securing tubing.

Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents. The facility failed to ensure CNA B and CNA D performed a proper transfer with the mechanical lift when they caused Resident #1's wheelchair to tip backward and failed to guide the bar of the mechanical lift so it would not make contact with Resident #1's head on 06/17/2026. This failure could place residents at an increased risk of falls and injuries. Findings included: Record review of Resident #1's face sheet dated 06/18/2026 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis of the arms, trunk, and legs resulting from damage to the brain and/or spinal cord), neuromuscular dysfunction of the bladder (problems due to disease or injury of the central nervous system or nerves involved in the control of urination), and type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar). Record review of Resident #1's Quarterly MDS assessment dated [DATE] indicated he was understood by others and understood others. The MDS assessment indicated Resident #1 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #1 was dependent on staff for toileting, had an indwelling catheter, was always incontinent of bowel, and had unhealed pressure ulcers Record review of Resident #1's Order Summary Report dated 06/17/2026 did not indicate the use of a mechanical lift for transfers. Record review of Resident #1's care plan with a target date of 07/20/2026 indicated he required assistance with his ADLs related to quadriplegia and required assistance by staff for transfers. The care plan did not specifically address the use of a mechanical lift. During an observation on 06/17/2026 at 10:07 AM, CNA B and CNA D transferred Resident #1 from his bed to his wheelchair with the use of a mechanical lift. CNA B lifted Resident #1 with the mechanical lift. Resident #1's wheelchair was positioned sideways to the mechanical lift rather than directly facing the lift. CNA B rolled the mechanical lift towards the sideways positioned wheelchair and opened the legs to where one leg of the lift was positioned towards the back wheels, and the other leg was positioned in front of the front wheels. CNA B and CNA D rotated Resident #1 to lower him into the wheelchair. As they were lowering Resident #1 into the wheelchair the leg of the mechanical lift got stuck on the front wheels, and Resident #1's wheelchair tipped slightly back. CNA D was attempting to hold it with her body weight to keep it from falling back, and she told CNA B the wheelchair was stuck. They stopped and were attempting to reposition the wheelchair to dislodge the bottom of the lift leg from the front wheels. The bar of the mechanical lift went towards Resident #1's head and he hollered Oh, oh, and CNA D was able to grab the bar before it struck his head. The bar brushed Resident #1's head but did not strike him directly. CNA B and CNA D dislodged the lift leg and prevented the wheelchair from tipping back and completed the transfer. During an interview on 06/17/2026 at 4:58 PM, CNA B said when using the mechanical lift for transfers they should pay attention to the bar of the mechanical lift and hold it away from the resident's head. CNA B said some of the wheelchairs required using the mechanical lift from the side. CNA B said when they transferred Resident #1 with the mechanical lift, they should have placed his wheelchair facing the mechanical lift. CNA B said during the transfer Resident #1's wheelchair started tipping back because it got stuck on the leg of the lift, and this could have caused Resident #1 to fall and get injured. CNA B said she was not paying attention to the bar and did not notice it was going to hit Resident #1's head. CNA B said she felt like she did not have the appropriate training when she started at the facility. CNA B said a competency check was completed, but she felt like she required more hands-on training. During an interview on 06/17/2026 at 10:51 AM, CNA D said when transferring Resident #1 they should have changed the direction the wheelchair was facing the mechanical lift to prevent his wheelchair from tipping back. CNA D said she was concentrating on ensuring Resident #1's arm and shoulder did not catch on the mechanical lift, so she was not paying attention to the bar of the mechanical lift. She said they should have guided the bar during the transfer to prevent injuries to Resident #1's head. CNA D said there was a big miscommunication between CNA B and herself during the transfer. She said the improper transfer could have resulted in Resident #1 falling or getting hurt. During an interview on 06/17/2026 at 6:11 PM, the ADON said during a transfer with a mechanical lift the staff should drive the mechanical lift towards the wheelchair so the legs of the lift were on each side of the wheelchair. She said the front of the mechanical lift should face the front of the wheelchair. The ADON said if it was not positioned in this manner it could result in the wheelchair tipping over and the residents falling and injuring themselves. The ADON said the staff member who was behind the resident during the transfer should guide the bar of the lift and hold it out of the way to prevent it from hitting the resident. She said competency checks were conducted when the CNAs were hired, and after that she conducted random check-ins to ensure they were transferring the residents properly. During an interview on 06/18/2026 at 1:37 PM, the Regional [NAME] President said he expected the staff to follow the guidelines while performing a transfer by mechanical lift to ensure the safety of the residents. He said the Interim DCO was responsible for ensuring the staff had knowledge on safe transfer practices. During an interview on 06/18/2026 at 3:11 PM, the Director of Resident Support Services said the Interim DCO was not available for interview. Record review of the facility's policy titled, Safe Lifting and Movement of Residents, revised July 2017, indicated, In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to life and move residents.12. Safe lifting and movement of residents is part of an overall facility employee health and safety program, which: a. Involves employees in identifying problem areas and implementing workplace safety and injury-prevention strategies.Provides training on safety, ergonomics and proper use of equipment.

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 3 residents (Resident #3) reviewed for ADLs. The facility failed to ensure Resident #3 received bathing as scheduled for the months of May 2026 and June 2026. This failure could place residents at risk of not receiving needed services and care, decreased self-esteem, and a decreased quality of life. Findings included: Record review of Resident #3's face sheet dated 06/18/2026 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs) and muscle weakness. Record review of Resident #3's Quarterly MDS assessment dated [DATE] indicated she understood others and others usually understood her. Resident #3's BIMS was a 13, which indicated her cognition was intact. Resident #3 required substantial/maximal assistance with showering/bathing. Record review of Resident #3's care plan with a target date of 07/20/2026 indicated she required assistance by staff with showering. Record review of Resident #3's Shower Sheets dated 05/01/2026-06/17/2026 indicated she had a bath on 05/01/2026, 05/06/2026, 05/29/2026 and she refused a shower on 05/11/2026. There were no other shower sheets provided for the month of May 2026 and no shower sheets provided for the month of June 2026. Record review of Resident #3's Documentation Survey Report for the Month of May 2026 indicated bathing on Monday, Wednesday, and Friday on the 6 AM-6 PM shift. Resident #3 did not receive a bath on 05/08/2026, 05/15/2026, 05/18/2026, 05/22/2026, and 05/27/2026. Record review of Resident #3's Documentation Survey Report for the Month of June 2026 indicated bathing on Monday, Wednesday, and Friday on the 6 AM-6 PM shift. Resident #3 did not receive a bath on 06/03/2026, 06/05/2026, 06/10/2026, and 06/15/2026. During an observation and interview on 06/16/2026 at 2:02 PM, Resident #3 said she was not receiving her baths as scheduled. She said she was supposed to get them on Monday, Wednesday, and Friday, but she had not received one since last Friday (06/12/2026). She said she should have received a bath yesterday (06/15/2026), but she did not. She said when she asked the staff about her baths they told her they do not have time and they were short staffed. Resident #3's hair appeared oily and disheveled. During an interview on 06/16/2026 at 6:26 PM, CNA B said Resident #3 reported to her she had not been getting her showers as scheduled. CNA B said if she had time, she would give her a shower but sometimes she did not have time to give it to her. CNA B said being short staffed made it hard to give the residents showers. CNA B said if she missed a shower she tried to give it to them the next day. CNA B said she reported to the charge nurse and to the ADON when she did not have time to give showers. CNA B said it was important for the residents to get their showers for their hygiene, and they could get sick if they were not clean. During an interview on 06/17/2026 at 5:14 PM, CNA C said Resident #3 reported to her that she was not getting her showers, and she reported it to the charge nurses. CNA C said when she provided care to Resident #3, she gave her showers and had not missed giving any showers. CNA C said it was important for the residents to receive their showers so they would be clean and feel good. During an interview on 06/17/2026 at 5:26 PM, LVN A said she was aware residents were not receiving showers/baths as scheduled. LVN A said when they did not have enough staff, they did not get all the showers completed. LVN A said she reported this to the ADON. LVN A said it was important for the residents to receive their showers/baths for their hygiene and to prevent infections. During an interview on 06/17/2026 at 5:52 PM, the ADON said to her knowledge the showers were being done. The ADON said the Treatment Nurse was responsible for monitoring to ensure the residents were getting their baths. The ADON said if it was reported in the morning meeting that a resident did not receive their bath the CNA was notified for them to give a bath the same day. The ADON said if showers were not done it could affect the residents' mood and it could affect their skin. During an interview on 06/18/2026 at 8:50 AM, the Treatment Nurse said she used the shower sheets to monitor to ensure the showers were completed. The Treatment Nurse said some of the staff were not completing the shower sheets, but they also documented bathing in the resident's clinical record. The Treatment Nurse said she was not aware of any residents not receiving their showers/baths. The Treatment Nurse said it was important for the residents to get their baths for cleanliness, infection control, and the health of their skin. During an interview on 06/18/2026 at 1:47 PM, the Regional [NAME] President said the residents should receive their showers/bathing according to their schedule, and if they requested a shower outside of their schedule the staff should accommodate for them. He said the Interim DCO was responsible for ensuring the residents received their baths. He said it was important for hygiene issues. During an interview on 06/18/2026 at 3:11 PM, the Director of Resident Support Services said the Interim DCO was not available for interview. Record review of the facility's policy, Shower/Tub Bath, revised 10/2010, indicated, The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The following information should be recorded on the resident's ADL record and/or in the resident's medical record: The date and time the shower/tub bath was performed. The name and title of the individual(s) who assisted the resident with the shoer/tub bath.

Based on interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible, and each resident received adequate supervision to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and hazards in that: 1. On 03/23/26, the facility failed to ensure that Resident #1 did not lay on the floor for approximately 2 hours and 20 minutes after falling out of bed. 2. The facility failed to ensure that RN A, LVN B, and CNA C appropriately transferred Resident #1 back to bed post fall. 3. The facility failed to ensure that RN A and CNA C monitored Resident #1 every 2 hours. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 04/07/26 at 10:18AM. While the IJ was removed on 04/07/26 at 04:07PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.These deficient practices could place the residents at risk for serious harm, serious injury, or death.Findings included: Record review of Resident #1's face sheet, dated 04/06/26, reflected he was an [AGE] year-old male, admitted to the facility initially on 01/27/24, and most recently readmitted on [DATE]. His diagnoses included dementia (a term for several diseases that affect memory, thinking, and the ability to perform daily activities), muscle wasting and atrophy of both arms (the loss of muscle mass caused by inactivity, malnutrition, aging, or nerve damage), and chronic lymphocytic leukemia (a slow-growing cancer of the blood and bone marrow, most common in older adults). Record review of Resident #1's quarterly MDS assessment, dated 02/06/26, reflected he was rarely/never understood, and rarely/never understood others. A BIMS score was not obtained because he was rarely/never understood. His cognitive skills for daily decision making were severely impaired. He had a functional limitation in range of motion for all four extremities. He required substantial assistance from staff for rolling left and right in bed. He was completely dependent on staff for eating, oral hygiene, toileting, bathing, dressing, sit to lying, bed to chair transfer, and shower transfer. Record review of Resident #1's Order Summary Report, dated 04/06/26, reflected he had this order:*Eliquis (blood thinner medication) oral tablet 5mg, Give 1 tablet two times a day. The start date was 02/02/26. Record review of Resident #1's care plan, dated with admission date 02/02/26, reflected a focus of I have a history of falls and at risk for increased falls and fractures as evidenced by history of falls, cognitive impairment dementia, and physical impairment left leg fracture. Interventions included may have fall mat, anticipate needs, provide prompt assistance, encourage resident to ask for assistance of staff, and ensure call light is in reach and answer promptly. The care plan further reflected a focus of self-care deficit, needed assistance with activities of daily living related to disease processes. Interventions included bed mobility: the resident requires assistance by staff to turn and reposition in bed and as necessary. May use assist bar to have some independence with bed mobility, and transfer: the resident requires assistance by staff to move between surfaces. Another focus reflected Resident #1 had an actual fall with no injury, 03/23/26 - fall from bed to floor mat. Interventions included Bolster mattress to assist with decrease in falls, for no apparent acute injury, determine and address causative factors of the fall, monitor/document/report as needed for 72 hours to doctor for signs or symptoms of pain, bruises, change in mental status, new onset confusion, sleepiness, inability to maintain posture, agitation, neurological checks, and send to emergency room for evaluation per family request. Record review of a video recording provided to this surveyor by Family Member D, dated 03/23/26 at 08:05PM, this surveyor observed the following:*Resident #1 was lying in bed. His head and left shoulder and left arm were lying off the side of the bed. His legs were lying towards the other side of the bed towards the wall. His left hand was touching the floor mat beside the bed on the floor. Resident #1 raised his left hand and arm, picked up his head and reached towards the bedside dresser next to his bed. His head and shoulders slid further off the bed. His torso began to slide off the bed and his right hand reached towards the floor. His legs followed and he fell to the floor on the floor mat. After this he was lying on his left side on top of the fall mat. The left side of his head and face were touching the floor mat. After this he moved his right arm and head around. The video ended at 08:06PM. Record review of a video recording provided to this surveyor by Family Member D, dated 03/23/26 at 10:25PM, this surveyor observed the following:*Resident #1 was lying on top of the floor mat on the floor next to his bed. He was lying on his left side. LVN B and RN A entered the room. LVN B said We're going to need a [mechanical] lift. RN A then left the room. LVN B had a mechanical lift sling in her hand and crouched near Resident #1. LVN B asked Resident #1 are you hurting?. LVN B attempted to adjust Resident #1's positioning on the floor mat. RN A and CNA C entered the room. RN A then picked up the mechanical lift sling and crouched on the floor near Resident #1. The video ended at 10:28PM. Record review of a video recording provided to this surveyor by Family Member D, dated 03/23/26 at 10:28PM, this surveyor observed the following:*Resident #1 was lying on the top of the floor mat on the floor next to his bed. RN A, LVN B, and CNA C were in his room. RN A was crouched down on the floor next to Resident #1. LVN B was standing by Resident #1's head leaning over him. CNA C was standing at Resident #1's feet. The three staff members moved Resident #1 and assisted him to sit up on his bottom on top of the floor mat. LVN B stood by Resident #1's left side and held under his left arm. CNA C stood on Resident #1's right side and held under his right arm. RN A stood by Resident #1's legs and stabilized Resident #1 as he was sitting up. At this moment all three staff members changed their grip on Resident #1. CNA C put her left hand and arm under Resident #1's right arm. CNA C also put her right hand under Resident #1's left leg. LVN B grabbed under Resident #1's left arm. RN A grabbed Resident #1's left side of his torso and Resident #1's left leg. After this the staff members all counted out loud and lifted Resident #1 back into bed. Record review of a grievance regarding Resident #1's fall on 03/23/26, dated 03/27/26, reflected .Resident laying on fall mat on left side beside bed. No injuries assessed.Nurse (AM) asked why the ambulance was at the facility upon arrival [and] was told by night nurse [Resident #1] rolled out of bed [family member] asked AM nurse to walk [with] her and showed video.Resident experienced fall from bed. family request resident to be sent to ER. ER evaluation no fractures. Monitoring for delayed injuries in place. The grievance was marked that it was not resolved to the satisfaction of all concerned.family upset due to length of time resident laid on floor. [sic] Record review of Resident #1's progress notes, reflected the following notes:*dated 03/24/26 12:30AM, Author: RN A, [Resident #1] was found on the floor by [housekeeper] while he was cleaning the floors on [Resident #1's hall]. [Resident #1] was on the floor next to his bed, fall mats were in place. No injuries noted and family members notified.*dated 03/24/26 06:16AM, Author: LVN C, [Family member] entered facility to check on resident and request that resident be sent to the ER to be checked out post fall. No delayed injuries observed by this nurse. Vitals (121/77 [blood pressure], 91 [heart rate], 98% RA [oxygen saturation on room air], 18 [respirations]). No pain or discomfort noted. No signs of distress noted. EMS called by this nurse. Awaiting arrival. Daughter in residents room and aware of EMS call.*dated 03/24/26 02:12PM, Author: Treatment Nurse, Resident returned from ED. Skin assessment completed.Resident has a small scratch to right buttock.*dated 03/24/26 02:21PM, Author: LVN E, Resident back in facility from hospital, transported by EMS [company] on stretcher, no paperwork on resident from hospital, nurse stated did get IM injection of Rocephin [antibiotic] for elevated WBC and no injuries noted from fall for reason went out to er. No issues noted, cna tried to feed resident lunch but only [took] ensure [protein drink] at this time.*dated 03/25/26 04:16AM, Author: RN A, Resident is sleeping in bed with no sign of pain or distress. Vitals are WNL. Resident is day 2/3 from a fall from his bed. [Neurological] check was started this evening. Monitor groin for redness and abrasion on the right [buttock]. No needs at this time. Record review of Resident #1's skin assessment, dated 03/20/26 at 11:29AM, reflected he did not have any bruise, skin tear, abrasion, laceration, rash, or moisture associated skin damage. He did have an other skin issue identified as a pressure, venous, arterial, diabetic, or surgical wound. The note said See wound assessment - being followed by [wound care company] The assessment was signed by the ADON. Record review of Resident #1's skin assessment, dated 03/24/26 at 02:27PM, reflected he did not have any bruise, skin tear, abrasion, laceration, rash, or moisture associated skin damage. He did have an other skin issue identified as a pressure, venous, arterial, diabetic, or surgical wound. The note said Unstageable pressure wound to right heel 2.5cm x 2cm. ulceration to right metatarsal 2cm x 2cm. self-inflicted scratch to right buttock. Record review of Resident #1's hospital records, dated 03/24/26, reflected: .HPI.this 86 [years] old male presents to ED via EMS.with complaints of fall injury.Patient presents from nursing home after a fall from bed. Per video reviewed bedside with patient's [family member] it appears patient was leaning over the bed to reach something when he fell striking his head on the floor. He fell primarily onto the left side. Patient has a history of cognitive decline and is minimally verbal. He [does not have] any discrete complaints but per EMS [appears] to have pain with manipulation of the shoulders and hips. Per video review by the [family member] the patient was on the floor for about 2 hours. He does take Eliquis.Imaging Report.Exam date: 03/24/26.Exam: [Upper Extremity-Shoulder 2 view bilateral].Impression:1. Elevation of the right humeral head suggesting massive rotator cuff tear. 2. Flattening of the superior lateral aspect of the right humeral head that could represent fracture.3. Elevation of the left humeral head suggesting massive rotator cuff tear. During an interview on 04/06/26 at 09:40AM, Family Member D said Resident #1 was moved to another hall due to the facility treating his room for pests. She said Resident #1 fell after this move and he was found by the housekeeper sweeping. She said she asked the staff about it and the story did not match the camera. She said Resident #1 laid on the floor for almost 3 hours. She said he fell around 8:00PM. She said the staff called her mom around 12AM to report that Resident #1 had rolled out of bed. She said Resident #1's head hit the dresser. She said he had a bruise on his forehead and a red mark on his shoulder. She said he also had a bruise on the side of his head. She said he had a scratch on his back. During an interview on 04/06/26 at 09:57AM, Family Member G said she received a phone call from the nurse after Resident #1 fell. She said the facility staff told her that Resident #1 did not hit his head. She said he did not have a brain bleed, but he did have some bruising, a bruise on his head, and a scratch on his back. She said they pulled him up from the floor and did not check his vital signs, or neurological checks. She said when they called her, they assured her he was okay and he did not hit his head. She said she was not called until around 12:00AM. During an interview on 04/06/26 at 10:23AM, the Administrator said RN A did not do neurological checks or vital signs on Resident #1 after the fall. She said she had not seen the video regarding how the staff members transferred Resident #1 back to bed. She said the DON did see the video. During an interview on 04/06/26 at 11:35AM, the DON said RN A said he had worked in long term care and the hospital before coming to this facility. She said at this point he should have known better regarding not assessing the resident and the improper transfer, and known what to do after a resident fall. During an interview on 04/06/26 at 11:46AM, RN A said on the night Resident #1 fell they did not have a medication aide that night, and there were only two CNAs working as well. He said he was on another hall passing medications when the floor custodian working down Resident #1's hall came and told him that Resident #1 was on the floor. He said Resident #1 was lying on the fall mat and did not appear to be hurting. He said he grabbed the other nurse and they did an assessment. He said they transferred Resident #1 back in bed. He said they did not notice any scrapes, cuts, or bruises. He said he did not think Resident #1 hit his head. He said he left to go get the vital sign machine and he was told another resident was falling out of bed. He said he did not make it back down to check Resident #1's vital signs. He said he went back in and checked on him about every 30 mins. He said he called the family. He said the daughter came in about 4:30am. He said he worked the next night and everything was ok at the hospital. He said he did the neurological checks the next night. He said the family said his cheek bone was puffy. He said him and the DON thought it was how the resident was holding his head. He said the ER did clear him of any injuries. He said he did not do vital signs after his fall. He said he also did not do neurological checks after his fall. He said Resident #1 was taking a blood thinner. He said he was not aware Resident #1 was taking a blood thinner at the time of the fall. He said he had only worked at this facility about one week when Resident #1 fell. He said he felt like it was important to get vital signs and neurological checks on an unwitnessed fall. He said he did not think the resident was having a stroke. He said the risk of not getting vital signs or neurological checks was that the resident could have had a change in status and they may not have caught it. He also said they did not use the mechanical lift to transfer the resident back to bed. He said the resident was contracted on his right side and they were unable to get a mechanical lift down that low to the floor. He said Resident #1 could sit up with assistance and they felt that it was safe to transfer him. He said he felt like they transferred him properly because they transferred him by putting the weight on his back. During an interview on 04/06/26 at 12:15PM, LVN B said she recalled Resident #1's fall. She said RN A called for help and she went to go help him. She said she went in the room and Resident #1 was lying on his right side on his right shoulder, with his back towards the bed. She said his head was by the bedside table. She said she asked if he was hurting and he did not respond. She said she felt on his shoulders to see if he was hurting and he did not grimace. She said she thought RN A already checked vital signs and got his physical assessment. She had RN A go get CNA C and they assisted Resident #1 back to bed. She said while she was in the room she did not see RN A get a set of vital signs, do an assessment, or neurological checks. She said she only saw him do a set of vitals when the family had come up to the facility and had RN A sent the resident out to the hospital. She said she thought it was very important for RN A to do vital signs, an assessment, and neurological checks. She said Resident #1 should have been sent out at the time of the fall. She said they manually transferred Resident #1 back to bed by lifting him. She said they had a hand under each arm, and one person grabbed his legs. She said they did not use a mechanical lift because they could not get him moved away from the bed because they could not move the mat or the bed. She said she felt that was the safest way to transfer him. During an interview on 04/06/26 at 12:55PM, CNA C said the nurses asked her to come help after Resident #1 fell. She said when she entered the room Resident #1 was lying on the floor. She said it took 3 of them to pick him up. She said she did not see him fall. She said they changed his brief. She said when they put him back in bed they made sure to position him in the center of the bed so he would not fall. She said she did not see either of the nurses do vital signs. She said RN A was checking Resident #1's skin while they changed his brief. She said they did turn him to his side and they did look at his back. She said she was assigned that hall that night. She said she usually rounds every 2 hours. She said she had not checked on him before he had fallen. She said she had not checked on him until around 10:30 when they found him on the floor. She said they only had 2 aides that evening. She said she had a lot going on and others needed changing. She said if she had checked on him at 8PM she may have found him on the floor and he may not have laid on the floor for two hours. She said she came on shift about 6PM. During an interview on 04/06/26 at 01:47PM, the DON said she was notified of Resident #1's fall and she was told by LVN B that the resident had fallen. She said she received a call the next morning that the family was upset and wanted Resident #1 to be sent out to the hospital. She said she asked if there was any injury and they said no. They sent him to the ER per the family's request. She said she was told by the ADON that the family had come back and was upset because he had laid on the floor for a long time. She said she reviewed the records, and the neurological checks and vital sign checks were not completed. She said she called RN A and asked him about it and notified him that the policy was for vital signs and neurological checks to be completed after a fall. She said she had him come in prior to his next shift and did a one on one regarding this situation and what was expected. She said RN A told her that he did go in and he did do an assessment but did not check vital signs or neurological checks. She said he did not document any of this. She said when the resident returned from the hospital he did not have any new injuries. She said she told RN A to start the neurological checks once Resident #1 had returned to the facility. She said she did a fall in-service with all the nurses immediately. She said she watched the videos. She said she expected the nurse to do vital signs and neurological checks after a fall. She said she expected the nurse and CNA to check on each resident every 2 hours. She said she watched the video of Resident #1's transfer back to bed, and the staff thought that was the best way to get the resident back into bed. She said she did not think that transfer was proper. She said she thought they should have used the mechanical lift or a lift sheet to transfer the resident back to bed. She said the transfer was not addressed in the in-service. She said there was a risk of harm to the resident, he was taking a blood thinner and could have had a brain bleed. She said the risk regarding the transfer was hurting his shoulders and arms and/or dropping him. During an interview on 04/06/26 at 02:02PM, the Administrator said she heard about Resident #1's fall. She said she heard the family wanted to send the resident out to the hospital to be checked out. She said they did in-services and safe surveys. She said RN A failed to do neurological checks and vital signs. She said they wrote him up for this. She said RN A told them he was going to check Resident #1's vital signs but another resident was about to fall. She said it threw him off and he did not return to get neurological checks or vital signs. She said when Resident #1 got back from the hospital, he did not have any new injuries. She said she expected RN A to have done vital signs and neurological checks after the fall. She said she was not clinical staff and was unsure about how the transfer should have been done, so she did not want to comment on the transfer. She said Resident #1 was on a blood thinner, so she thought it was important to check vital signs and neurological checks. She said she expected the staff to check on the residents every 2 hours. She said if the CNA or nurse had done rounds around 8 then they may have found the resident and he may not have laid on the floor for over 2 hours. She said the risk of not doing vital signs or neurological checks, could be they may have missed an out of parameter vital sign or a change in condition. During an interview on 04/06/26 at 02:24PM, the Treatment Nurse said she did Resident #1's skin assessment after his return from the hospital. She said the changes from the previous assessment prior to his fall were a scratch to his buttocks of 3cm x 0.5cm, and the arterial wound on his foot was missing the scab. She said the scratch looked like a fingernail scratch, and the resident was known to scratch himself like that sometimes. During an interview on 04/06/26 at 03:00PM, the Administrator said the nurse that received the resident back from the hospital was responsible for ensuring that the resident returned with his medical records from the hospital. During an interview on 04/06/26 at 03:06PM, the DON said the nurse receiving the resident back from the hospital was responsible for ensuring that they also have the medical records from the hospital. She said the nurse should have followed up and/or passed it on to the next shift or notified the DON that she was unable to get the hospital records. During an interview on 04/06/26 at 03:10PM, LVN E said she was assigned to Resident #1 when he came back from the hospital on [DATE]. She said he did not return with hospital records. She said she did call, and the hospital told her that they provided the medical records to the family. She said she asked the hospital to fax them to the facility, and she did not receive them. She said when Resident #1 came back from the hospital he did not seem to be in pain. She said when he was moved to bed he made a grimaced face, but that is normal for him. She said she had offered a pain pill, and his family was present and turned it down. She said she did not think he was in any pain, and he did not look to be out of the ordinary. She said the hospital did not call report to her. She said she attempted to call the hospital and get report and left her phone number. She said the nurse did not call her back. She said the Resident's family member came to the facility shortly after he came back from the hospital. She then said the hospital did call her back because they told her that Resident #1 received an antibiotic shot while he was in the ER. She said the hospital nurse did not notify her of an abnormal diagnostic scan. She said they told her everything was clear. She said she thought it was possible the improper transfer could cause a bilateral rotator cuff tear. During an interview on 04/06/26 at 4:10PM, the DON said she looked at the mechanical lift and she said it would likely not be possible for the staff to use the lift to get the resident off the floor. She said the legs of the lift would be in the way and it would not get close enough to the ground. During an interview on 04/06/26 at 04:19PM, The Director of Rehabilitation watched the video of RN A, LVN B, and CNA C transferring Resident #1 back to bed after his fall on 03/23/26. She said it was an inappropriate transfer. She said they should have used a mechanical lift or a gait belt. She said she did not know if it was possible for the inappropriate transfer to have caused a rotator cuff tear. She said they should have used a gait at least when they transferred Resident #1 back to bed. During an interview on 04/06/26 at 04:25PM, the Facility's Nurse Practitioner was present in the facility. She said the staff just notified her of the finding in the hospital paperwork for Resident #1 that was missed. She said she was going to order a follow up MRI. She said she expected the facility staff to have gotten the hospital paperwork when he came back from the hospital. She said if she were told of the significant finding in Resident #1's diagnostic scans when he returned to the facility, she would have ordered a follow up scan and an orthopedic appointment. During an interview on 04/07/26 at 07:27AM, Family Member D said Resident #1 did not have a history of any rotator cuff tears. She said she was not aware the x-ray at the hospital suggested he may have 2 rotator cuff tears and a fracture. She said the hospital did not mention that to her, and they only asked if he had any history of shoulder injury or surgery. She said he did not. She said he has not exhibited signs of increased pain since the fall. She said he grimaced when he was moved but that is normal for him. During an interview on 04/07/26 at 07:57AM, RN A said on the night of Resident #1's fall, his shift started around 6PM and he did not check on Resident #1 prior to his fall. He said the first time he saw Resident #1 that shift was when he was already on the floor. He said it would have been later than that if he hadn't been made aware that the resident was on the floor. He said he was busy passing medications. He said they did not have a medication aide that evening. He said there were two nurses and two aides working. He said the last time he had to work like that without a medication aide it took him until 1AM to finish passing medications to his residents. During an interview on 04/07/26 at 09:20AM, RN A said he did not contact the doctor after Resident #1 fell or when he was sent out to the hospital. During an interview on 04/07/26 at 10:30AM, Family Member D said if she would have been aware of the abnormal finding of the x-ray regarding a possible fracture and torn rotator cuffs for Resident #1, she would have had the facility send him back to the hospital, or set up a follow up appointment, or get follow up imaging done. During an interview on 04/07/26 at 11:21AM, Family Member F said she was a family member of Resident #1's. She said she thought that Resident #1 may have had a little decreased range of motion in his arms since the fall. She also said Resident #1 hides his pain well, but she thought he had an increase in pain since his fall. She mentioned that he has a facial grimace he makes when he is transferred. She said she was not present when the other family members came up to the facility and had him sent to the hospital. During an interview on 04/07/26 at 03:30PM, LVN B said she did not call the family after Resident #1's fall. She said she may have notified the Nurse Practitioner, but she was not sure. She said RN A called the family. Record review of the facility's policy, Safe Lifting and Movement of Residents, last revised July 2017, reflected: .2. Manual lifting of residents shall be eliminated when feasible .5. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary The Administrator was notified of an IJ on 04/07/26 at 10:18AM and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 04/07/26 at 01:36PM and included the following: [Facility name] [Facility address] April 7, 2026 Attention: Program Manager Re: Plan of Removal of Immediate Jeopardy - F689 This letter serves as the Plan of Removal for the Immediate Jeopardy identified at [Facility name] ( the Facility) on April 7, 2026, at 10:25am. The corrective actions outlined below have been implemented to address the alleged deficient practices. Resident #1 was discharged from the Facility to an Acute Care Facility on March 24, 2026 following the fall on March 23, 2026. On April 7,2026 Resident #1's physician and family were notified of the Acute Care Facility's findings from the March 24, 2026 visit by the Director of Clinical Operations (DCO). On April 7, 2026, at 11am, re-education for Executive Director of Operations (EDO) and DCO on Incident/Accident investigations and review during the routine Clinical Systems meeting conducted by Regional [NAME] President of Operations. Re-education provided for all Clinical Staff was initiated at 11:00am on April 7, 2026 by the EDO and/or designee regarding 2-hour routine rounding on assigned halls, Titled Routine Rounding. DCO re-educated all floor nurses on post fall assessment protocols including proper notifications to families and physicians. Assessment criteria outlines vitals assessments and Neuro checks post fall. Re-education titled: Post Fall Assessment. Re-education completed on April 7, 2026. RN A, LVN B, and CNA C were provided 1:1 transfer re-education from the Rehab Director on April 7, 2026. On April 7, 2026, All Clinical Team members were re-educated on resident transfer procedures, validating and utilizing appropriate mechanics that align with the resident's plan of care to ensure the safety of all, and the importance of Gait Belt Utilization. Education for resident transfers including proper utilization of equipment, [mechanical] lift, when a resident is on the floor. Education will be on going and no employee will be permitted to start his/her next shift until re-education is completed. Re-education audience is all clinical team members and emphasized proper response to resident who has experienced a fall, required assessment protocols, and immediate investigation and reporting of all falls to the DCO and/or designee. Staff demonstrated competency through verbal questioning related to the in-service topic at the time of re-education. On April 7, 2026, at 11:00am Incident/Accident audit was initiated and completed by DCO to validate accuracy and investigation into the incidents and accidents. No concerns notated. The Medical Director was notified of the Immediate Jeopardy on April 7, 2026, and participated in development of this plan through an abbreviated Quality Assurance process. The next scheduled QA meeting is set for April 24, 2026, at 12:00 p.m. This Plan of Removal was implemented on April 7, 2026, and compliance will be monitored through direct observation by the Executive Director of Operations and the Director of Clinical Services. Sincerely, [Facility name][Facility address] The surveyor's verification of the Plan of Removal on 04/07/26 was as follows:Record review of an undated checklist reflected the facility had initiated and completed an incident/accident audit to validate accuracy and investigation into the incidents and accidents. Items verified included whether vital signs where checked, neurological checks were completed, responsible party notified, physician notified, and whether hospital records were received if the resident went to the hospital. Record review of an undated monitoring sheet, reflected the facility had initiated a monitoring form for review of resident falls and included checks for vital signs, neurological checks, responsible party notified, physician notified, 24-hour report updated, post fall interventions implemented, ER visit required, record received from the ER, and whether the nurse had reviewed the records. Record review of an undated QAPI Project document, Improving Post-Fall Assessment Completion & Documentation, reflected that the facility had initiated a QAPI plan regarding post-fall assessment and documentation.During interviews on 04/07/26 from 01:52PM through 04:03PM the following staff were interviewed:LVN E, MA H, LVN K, CNA L, CNA M, the MDS Coordinator, CNA N, CNA O, the Treatment Nurse, CNA P, LVN Q, LVN, R, LVN S, LVN B, LVN T, RN A, LVN U, CNA V, CNA W, CNA X, CNA Y, CNA Z, CNA AA, CNA BB, CNA CC, CNA DD, CNA EE, MA FF, MA GG, RN HH, RN KK, the DON, the ADON, and the Administrator

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents (Resident #1) reviewed for quality of care. 1. The facility failed to ensure RN A assessed Resident #1's vital signs and neurological status after his fall on 03/23/26. Vital signs were not checked until the next morning when the family requested the Resident to be sent to the emergency room. Resident #1 took Eliquis (anticoagulant medication). 2. The facility failed to obtain, review, and follow-up on Resident #1's hospital records after his return from the emergency room on [DATE]. These hospital records were not obtained until surveyor intervention. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 04/07/26 at 10:18AM. While the IJ was removed on 04/07/26 at 04:07PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could place the residents at risk for decreased quality of care, missed diagnostic results, and harm.Findings included: Record review of Resident #1's face sheet, dated 04/06/26, reflected he was an [AGE] year-old male, admitted to the facility initially on 01/27/24, and most recently readmitted on [DATE]. His diagnoses included dementia (a term for several diseases that affect memory, thinking, and the ability to perform daily activities), muscle wasting and atrophy of both arms (the loss of muscle mass caused by inactivity, malnutrition, aging, or nerve damage), and chronic lymphocytic leukemia (a slow-growing cancer of the blood and bone marrow, most common in older adults). Record review of Resident #1's quarterly MDS assessment, dated 02/06/26, reflected he was rarely/never understood, and rarely/never understood others. A BIMS score was not obtained because he was rarely/never understood. His cognitive skills for daily decision making were severely impaired. He had a functional limitation in range of motion for all four extremities. He required substantial assistance from staff for rolling left and right in bed. He was completely dependent on staff for eating, oral hygiene, toileting, bathing, dressing, sit to lying, bed to chair transfer, and shower transfer. Record review of Resident #1's Order Summary Report, dated 04/06/26, reflected he had this order:*Eliquis (blood thinner medication) oral tablet 5mg, Give 1 tablet two times a day. The start date was 02/02/26. Record review of Resident #1's care plan, dated with admission date 02/02/26, reflected a focus of I have a history of falls and at risk for increased falls and fractures as evidenced by history of falls, cognitive impairment dementia, and physical impairment left leg fracture. Interventions included may have fall mat, anticipate needs, provide prompt assistance, encourage resident to ask for assistance of staff, and ensure call light is in reach and answer promptly. The care plan further reflected a focus of self-care deficit, needed assistance with activities of daily living related to disease processes. Interventions included bed mobility: the resident requires assistance by staff to turn and reposition in bed and as necessary. May use assist bar to have some independence with bed mobility, and transfer: the resident requires assistance by staff to move between surfaces. Another focus reflected Resident #1 had an actual fall with no injury, 03/23/26 - fall from bed to floor mat. Interventions included Bolster mattress to assist with decrease in falls, for no apparent acute injury, determine and address causative factors of the fall, monitor/document/report as needed for 72 hours to doctor for signs or symptoms of pain, bruises, change in mental status, new onset confusion, sleepiness, inability to maintain posture, agitation, neurological checks, and send to emergency room for evaluation per family request. Record review of a video recording provided to this surveyor by Family Member D, dated 03/23/26 at 08:05PM, this surveyor observed the following:*Resident #1 was lying in bed. His head and left shoulder and left arm were lying off the side of the bed. His legs were lying towards the other side of the bed towards the wall. His left hand was touching the floor mat beside the bed on the floor. Resident #1 raised his left hand and arm, picked up his head and reached towards the bedside dresser next to his bed. His head and shoulders slid further off the bed. His torso began to slide off the bed and his right hand reached towards the floor. His legs followed and he fell to the floor on the floor mat. After this he was lying on his left side on top of the fall mat. The left side of his head and face were touching the floor mat. After this he moved his right arm and head around. The video ended at 08:06PM. Record review of a video recording provided to this surveyor by Family Member D, dated 03/23/26 at 10:25PM, this surveyor observed the following:*Resident #1 was lying on top of the floor mat on the floor next to his bed. He was lying on his left side. LVN B and RN A entered the room. LVN B said We're going to need a [mechanical] lift. RN A then left the room. LVN B had a mechanical lift sling in her hand and crouched near Resident #1. LVN B asked Resident #1 are you hurting?. LVN B attempted to adjust Resident #1's positioning on the floor mat. RN A and CNA C entered the room. RN A then picked up the mechanical lift sling and crouched on the floor near Resident #1. The video ended at 10:28PM. Record review of a video recording provided to this surveyor by Family Member D, dated 03/23/26 at 10:28PM, this surveyor observed the following:*Resident #1 was lying on the top of the floor mat on the floor next to his bed. RN A, LVN B, and CNA C were in his room. RN A was crouched down on the floor next to Resident #1. LVN B was standing by Resident #1's head leaning over him. CNA C was standing at Resident #1's feet. The three staff members moved Resident #1 and assisted him to sit up on his bottom on top of the floor mat. LVN B stood by Resident #1's left side and held under his left arm. CNA C stood on Resident #1's right side and held under his right arm. RN A stood by Resident #1's legs and stabilized Resident #1 as he was sitting up. At this moment all three staff members changed their grip on Resident #1. CNA C put her left hand and arm under Resident #1's right arm. CNA C also put her right hand under Resident #1's left leg. LVN B grabbed under Resident #1's left arm. RN A grabbed Resident #1's left side of his torso and Resident #1's left leg. After this the staff members all counted out loud and lifted Resident #1 back into bed. Record review of a grievance regarding Resident #1's fall on 03/23/26, dated 03/27/26, reflected .Resident laying on fall mat on left side beside bed. No injuries assessed.Nurse (AM) asked why the ambulance was at the facility upon arrival [and] was told by night nurse [Resident #1] rolled out of bed [family member] asked AM nurse to walk [with] her and showed video.Resident experienced fall from bed. family request resident to be sent to ER. ER evaluation no fractures. Monitoring for delayed injuries in place. The grievance was marked that it was not resolved to the satisfaction of all concerned.family upset due to length of time resident laid on floor. [sic] Record review of Resident #1's progress notes, reflected the following notes:*dated 03/24/26 12:30AM, Author: RN A, [Resident #1] was found on the floor by [housekeeper] while he was cleaning the floors on [Resident #1's hall]. [Resident #1] was on the floor next to his bed, fall mats were in place. No injuries noted and family members notified.*dated 03/24/26 06:16AM, Author: LVN C, [Family member] entered facility to check on resident and request that resident be sent to the ER to be checked out post fall. No delayed injuries observed by this nurse. Vitals (121/77 [blood pressure], 91 [heart rate], 98% RA [oxygen saturation on room air], 18 [respirations]). No pain or discomfort noted. No signs of distress noted. EMS called by this nurse. Awaiting arrival. Daughter in residents room and aware of EMS call.*dated 03/24/26 02:12PM, Author: Treatment Nurse, Resident returned from ED. Skin assessment completed.Resident has a small scratch to right buttock.*dated 03/24/26 02:21PM, Author: LVN E, Resident back in facility from hospital, transported by EMS [company] on stretcher, no paperwork on resident from hospital, nurse stated did get IM injection of Rocephin [antibiotic] for elevated WBC and no injuries noted from fall for reason went out to er. No issues noted, cna tried to feed resident lunch but only [took] ensure [protein drink] at this time.*dated 03/25/26 04:16AM, Author: RN A, Resident is sleeping in bed with no sign of pain or distress. Vitals are WNL. Resident is day 2/3 from a fall from his bed. [Neurological] check was started this evening. Monitor groin for redness and abrasion on the right [buttock]. No needs at this time. Record review of Resident #1's skin assessment, dated 03/20/26 at 11:29AM, reflected he did not have any bruise, skin tear, abrasion, laceration, rash, or moisture associated skin damage. He did have an other skin issue identified as a pressure, venous, arterial, diabetic, or surgical wound. The note said See wound assessment - being followed by [wound care company] The assessment was signed by the ADON. Record review of Resident #1's skin assessment, dated 03/24/26 at 02:27PM, reflected he did not have any bruise, skin tear, abrasion, laceration, rash, or moisture associated skin damage. He did have an other skin issue identified as a pressure, venous, arterial, diabetic, or surgical wound. The note said Unstageable pressure wound to right heel 2.5cm x 2cm. ulceration to right metatarsal 2cm x 2cm. self-inflicted scratch to right buttock. Record review of Resident #1's hospital records, dated 03/24/26, reflected: .HPI.this 86 [years] old male presents to ED via EMS.with complaints of fall injury.Patient presents from nursing home after a fall from bed. Per video reviewed bedside with patient's [family member] it appears patient was leaning over the bed to reach something when he fell striking his head on the floor. He fell primarily onto the left side. Patient has a history of cognitive decline and is minimally verbal. He [does not have] any discrete complaints but per EMS [appears] to have pain with manipulation of the shoulders and hips. Per video review by the [family member] the patient was on the floor for about 2 hours. He does take Eliquis.Imaging Report.Exam date: 03/24/26.Exam: [Upper Extremity-Shoulder 2 view bilateral].Impression:1. Elevation of the right humeral head suggesting massive rotator cuff tear. 2. Flattening of the superior lateral aspect of the right humeral head that could represent fracture.3. Elevation of the left humeral head suggesting massive rotator cuff tear. During an interview on 04/06/26 at 09:40AM, Family Member D said Resident #1 was moved to another hall due to the facility treating his room for pests. She said Resident #1 fell after this move and he was found by the housekeeper sweeping. She said she asked the staff about it and the story did not match the camera. She said Resident #1 laid on the floor for almost 3 hours. She said he fell around 8:00PM. She said the staff called her mom around 12AM to report that Resident #1 had rolled out of bed. She said Resident #1's head hit the dresser. She said he had a bruise on his forehead and a red mark on his shoulder. She said he also had a bruise on the side of his head. She said he had a scratch on his back. During an interview on 04/06/26 at 09:57AM, Family Member G said she received a phone call from the nurse after Resident #1 fell. She said the facility staff told her that Resident #1 did not hit his head. She said he did not have a brain bleed, but he did have some bruising, a bruise on his head, and a scratch on his back. She said they pulled him up from the floor and did not check his vital signs, or neurological checks. She said when they called her, they assured her he was okay and he did not hit his head. She said she was not called until around 12:00AM. During an interview on 04/06/26 at 10:23AM, the Administrator said RN A did not do neurological checks or vital signs on Resident #1 after the fall. She said she had not seen the video regarding how the staff members transferred Resident #1 back to bed. She said the DON did see the video. During an interview on 04/06/26 at 11:35AM, the DON said RN A said he had worked in long term care and the hospital before coming to this facility. She said at this point he should have known better regarding not assessing the resident and the improper transfer, and known what to do after a resident fall. During an interview on 04/06/26 at 11:46AM, RN A said on the night Resident #1 fell they did not have a medication aide that night, and there were only two CNAs working as well. He said he was on another hall passing medications when the floor custodian working down Resident #1's hall came and told him that Resident #1 was on the floor. He said Resident #1 was lying on the fall mat and did not appear to be hurting. He said he grabbed the other nurse and they did an assessment. He said they transferred Resident #1 back in bed. He said they did not notice any scrapes, cuts, or bruises. He said he did not think Resident #1 hit his head. He said he left to go get the vital sign machine and he was told another resident was falling out of bed. He said he did not make it back down to check Resident #1's vital signs. He said he went back in and checked on him about every 30 mins. He said he called the family. He said the daughter came in about 4:30am. He said he worked the next night and everything was ok at the hospital. He said he did the neurological checks the next night. He said the family said his cheek bone was puffy. He said him and the DON thought it was how the resident was holding his head. He said the ER did clear him of any injuries. He said he did not do vital signs after his fall. He said he also did not do neurological checks after his fall. He said Resident #1 was taking a blood thinner. He said he was not aware Resident #1 was taking a blood thinner at the time of the fall. He said he had only worked at this facility about one week when Resident #1 fell. He said he felt like it was important to get vital signs and neurological checks on an unwitnessed fall. He said he did not think the resident was having a stroke. He said the risk of not getting vital signs or neurological checks was that the resident could have had a change in status and they may not have caught it. He also said they did not use the mechanical lift to transfer the resident back to bed. He said the resident was contracted on his right side and they were unable to get a mechanical lift down that low to the floor. He said Resident #1 could sit up with assistance and they felt that it was safe to transfer him. He said he felt like they transferred him properly because they transferred him by putting the weight on his back. During an interview on 04/06/26 at 12:15PM, LVN B said she recalled Resident #1's fall. She said RN A called for help and she went to go help him. She said she went in the room and Resident #1 was lying on his right side on his right shoulder, with his back towards the bed. She said his head was by the bedside table. She said she asked if he was hurting and he did not respond. She said she felt on his shoulders to see if he was hurting and he did not grimace. She said she thought RN A already checked vital signs and got his physical assessment. She had RN A go get CNA C and they assisted Resident #1 back to bed. She said while she was in the room she did not see RN A get a set of vital signs, do an assessment, or neurological checks. She said she only saw him do a set of vitals when the family had come up to the facility and had RN A sent the resident out to the hospital. She said she thought it was very important for RN A to do vital signs, an assessment, and neurological checks. She said Resident #1 should have been sent out at the time of the fall. She said they manually transferred Resident #1 back to bed by lifting him. She said they had a hand under each arm, and one person grabbed his legs. She said they did not use a mechanical lift because they could not get him moved away from the bed because they could not move the mat or the bed. She said she felt that was the safest way to transfer him. During an interview on 04/06/26 at 12:55PM, CNA C said the nurses asked her to come help after Resident #1 fell. She said when she entered the room Resident #1 was lying on the floor. She said it took 3 of them to pick him up. She said she did not see him fall. She said they changed his brief. She said when they put him back in bed they made sure to position him in the center of the bed so he would not fall. She said she did not see either of the nurses do vital signs. She said RN A was checking Resident #1's skin while they changed his brief. She said they did turn him to his side and they did look at his back. She said she was assigned that hall that night. She said she usually rounds every 2 hours. She said she had not checked on him before he had fallen. She said she had not checked on him until around 10:30 when they found him on the floor. She said they only had 2 aides that evening. She said she had a lot going on and others needed changing. She said if she had checked on him at 8PM she may have found him on the floor and he may not have laid on the floor for two hours. She said she came on shift about 6PM. During an interview on 04/06/26 at 01:47PM, the DON said she was notified of Resident #1's fall and she was told by LVN B that the resident had fallen. She said she received a call the next morning that the family was upset and wanted Resident #1 to be sent out to the hospital. She said she asked if there was any injury and they said no. They sent him to the ER per the family's request. She said she was told by the ADON that the family had come back and was upset because he had laid on the floor for a long time. She said she reviewed the records, and the neurological checks and vital sign checks were not completed. She said she called RN A and asked him about it and notified him that the policy was for vital signs and neurological checks to be completed after a fall. She said she had him come in prior to his next shift and did a one on one regarding this situation and what was expected. She said RN A told her that he did go in and he did do an assessment but did not check vital signs or neurological checks. She said he did not document any of this. She said when the resident returned from the hospital he did not have any new injuries. She said she told RN A to start the neurological checks once Resident #1 had returned to the facility. She said she did a fall in-service with all the nurses immediately. She said she watched the videos. She said she expected the nurse to do vital signs and neurological checks after a fall. She said she expected the nurse and CNA to check on each resident every 2 hours. She said she watched the video of Resident #1's transfer back to bed, and the staff thought that was the best way to get the resident back into bed. She said she did not think that transfer was proper. She said she thought they should have used the mechanical lift or a lift sheet to transfer the resident back to bed. She said the transfer was not addressed in the in-service. She said there was a risk of harm to the resident, he was taking a blood thinner and could have had a brain bleed. She said the risk regarding the transfer was hurting his shoulders and arms and/or dropping him. During an interview on 04/06/26 at 02:02PM, the Administrator said she heard about Resident #1's fall. She said she heard the family wanted to send the resident out to the hospital to be checked out. She said they did in-services and safe surveys. She said RN A failed to do neurological checks and vital signs. She said they wrote him up for this. She said RN A told them he was going to check Resident #1's vital signs but another resident was about to fall. She said it threw him off and he did not return to get neurological checks or vital signs. She said when Resident #1 got back from the hospital, he did not have any new injuries. She said she expected RN A to have done vital signs and neurological checks after the fall. She said she was not clinical staff and was unsure about how the transfer should have been done, so she did not want to comment on the transfer. She said Resident #1 was on a blood thinner, so she thought it was important to check vital signs and neurological checks. She said she expected the staff to check on the residents every 2 hours. She said if the CNA or nurse had done rounds around 8 then they may have found the resident and he may not have laid on the floor for over 2 hours. She said the risk of not doing vital signs or neurological checks, could be they may have missed an out of parameter vital sign or a change in condition. During an interview on 04/06/26 at 02:24PM, the Treatment Nurse said she did Resident #1's skin assessment after his return from the hospital. She said the changes from the previous assessment prior to his fall were a scratch to his buttocks of 3cm x 0.5cm, and the arterial wound on his foot was missing the scab. She said the scratch looked like a fingernail scratch, and the resident was known to scratch himself like that sometimes. During an interview on 04/06/26 at 03:00PM, the Administrator said the nurse that received the resident back from the hospital was responsible for ensuring that the resident returned with his medical records from the hospital. During an interview on 04/06/26 at 03:06PM, the DON said the nurse receiving the resident back from the hospital was responsible for ensuring that they also have the medical records from the hospital. She said the nurse should have followed up and/or passed it on to the next shift or notified the DON that she was unable to get the hospital records. During an interview on 04/06/26 at 03:10PM, LVN E said she was assigned to Resident #1 when he came back from the hospital on [DATE]. She said he did not return with hospital records. She said she did call, and the hospital told her that they provided the medical records to the family. She said she asked the hospital to fax them to the facility, and she did not receive them. She said when Resident #1 came back from the hospital he did not seem to be in pain. She said when he was moved to bed he made a grimaced face, but that is normal for him. She said she had offered a pain pill, and his family was present and turned it down. She said she did not think he was in any pain, and he did not look to be out of the ordinary. She said the hospital did not call report to her. She said she attempted to call the hospital and get report and left her phone number. She said the nurse did not call her back. She said the Resident's family member came to the facility shortly after he came back from the hospital. She then said the hospital did call her back because they told her that Resident #1 received an antibiotic shot while he was in the ER. She said the hospital nurse did not notify her of an abnormal diagnostic scan. She said they told her everything was clear. She said she thought it was possible the improper transfer could cause a bilateral rotator cuff tear. During an interview on 04/06/26 at 4:10PM, the DON said she looked at the mechanical lift and she said it would likely not be possible for the staff to use the lift to get the resident off the floor. She said the legs of the lift would be in the way and it would not get close enough to the ground. During an interview on 04/06/26 at 04:19PM, The Director of Rehabilitation watched the video of RN A, LVN B, and CNA C transferring Resident #1 back to bed after his fall on 03/23/26. She said it was an inappropriate transfer. She said they should have used a mechanical lift or a gait belt. She said she did not know if it was possible for the inappropriate transfer to have caused a rotator cuff tear. She said they should have used a gait at least when they transferred Resident #1 back to bed. During an interview on 04/06/26 at 04:25PM, the Facility's Nurse Practitioner was present in the facility. She said the staff just notified her of the finding in the hospital paperwork for Resident #1 that was missed. She said she was going to order a follow up MRI. She said she expected the facility staff to have gotten the hospital paperwork when he came back from the hospital. She said if she were told of the significant finding in Resident #1's diagnostic scans when he returned to the facility, she would have ordered a follow up scan and an orthopedic appointment. During an interview on 04/07/26 at 07:27AM, Family Member D said Resident #1 did not have a history of any rotator cuff tears. She said she was not aware the x-ray at the hospital suggested he may have 2 rotator cuff tears and a fracture. She said the hospital did not mention that to her, and they only asked if he had any history of shoulder injury or surgery. She said he did not. She said he has not exhibited signs of increased pain since the fall. She said he grimaced when he was moved but that is normal for him. During an interview on 04/07/26 at 07:57AM, RN A said on the night of Resident #1's fall, his shift started around 6PM and he did not check on Resident #1 prior to his fall. He said the first time he saw Resident #1 that shift was when he was already on the floor. He said it would have been later than that if he hadn't been made aware that the resident was on the floor. He said he was busy passing medications. He said they did not have a medication aide that evening. He said there were two nurses and two aides working. He said the last time he had to work like that without a medication aide it took him until 1AM to finish passing medications to his residents. During an interview on 04/07/26 at 09:20AM, RN A said he did not contact the doctor after Resident #1 fell or when he was sent out to the hospital. During an interview on 04/07/26 at 10:30AM, Family Member D said if she would have been aware of the abnormal finding of the x-ray regarding a possible fracture and torn rotator cuffs for Resident #1, she would have had the facility send him back to the hospital, or set up a follow up appointment, or get follow up imaging done. During an interview on 04/07/26 at 11:21AM, Family Member F said she was a family member of Resident #1's. She said she thought that Resident #1 may have had a little decreased range of motion in his arms since the fall. She also said Resident #1 hides his pain well, but she thought he had an increase in pain since his fall. She mentioned that he has a facial grimace he makes when he is transferred. She said she was not present when the other family members came up to the facility and had him sent to the hospital. During an interview on 04/07/26 at 03:30PM, LVN B said she did not call the family after Resident #1's fall. She said she may have notified the Nurse Practitioner, but she was not sure. She said RN A called the family. Record review of the Facility's policy, Risk Management, dated 03-01-17, reflected: .3. Licensed nurse will complete a fall investigation report after every fall to include vital signs, pain assessment, and environmental assessment. There may be instances where residents have multiple falls in a day and a new incident report will be completed with each fall. A head-to-toe assessment must be completed at the time of the incident. Resident will continue to be assessed every shift for 72 hours.4. Licensed nurse will notify physician and responsible party.13. A neurological check form is to be completed for any fall involving the head or any unwitnessed fall. Record review of the prescribing information for Eliquis (anticoagulant drug), revised April 2025, reflected the following: .5.2 BleedingELIQUIS increases the risk of bleeding and can cause serious, potentially fatal, bleeding Advise patients of signs and symptoms of blood loss and to report them immediately or go to an emergency room 17 PATIENT COUNSELING INFORMATION Advise patients of the following: That it might take longer than usual for bleeding to stop and they may bruise or bleed more easily when treated with ELIQUIS. Advise patients about how to recognize bleeding or symptoms of hypovolemia (low blood volume) and of the urgent need to report any unusual bleeding to their physician MEDICATION GUIDE How should I take ELIQUIS? Call your healthcare provider .right away if you fall or injure yourself, especially if you hit your head. Your healthcare provider .may need to check you The Administrator was notified of an IJ on 04/07/26 at 10:18AM and was given a copy of the IJ template and a Plan of Removal (POR) was requested. An updated IJ template was provided on 04/16/26 at 01:58PM. The Plan of Removal was accepted on 04/07/26 at 01:36PM and included the following: [Facility name] [Facility address] April 7, 2026 Attention: Program Manager Re: Plan of Removal of Immediate Jeopardy - F689 This letter serves as the Plan of Removal for the Immediate Jeopardy identified at [Facility name] ( the Facility) on April 7, 2026, at 10:25am. The corrective actions outlined below have been implemented to address the alleged deficient practices. Resident #1 was discharged from the Facility to an Acute Care Facility on March 24, 2026 following the fall on March 23, 2026. On April 7,2026 Resident #1's physician and family were notified of the Acute Care Facility's findings from the March 24, 2026 visit by the Director of Clinical Operations (DCO). On April 7, 2026, at 11am, re-education for Executive Director of Operations (EDO) and DCO on Incident/Accident investigations and review during the routine Clinical Systems meeting conducted by Regional [NAME] President of Operations. Re-education provided for all Clinical Staff was initiated at 11:00am on April 7, 2026 by the EDO and/or designee regarding 2-hour routine rounding on assigned halls, Titled Routine Rounding. DCO re-educated all floor nurses on post fall assessment protocols including proper notifications to families and physicians. Assessment criteria outlines vitals assessments and Neuro checks post fall. Re-education titled: Post Fall Assessment. Re-education completed on April 7, 2026.Education will be on going and no employee will be permitted to start his/her next shift until re-education is completed. Re-education audience is all clinical team members and emphasized proper response to resident who has experienced a fall, required assessment protocols, and immediate investigation and reporting of all falls to the DCO and/or designee. Staff demonstrated competency through verbal questioning related to the in-service topic at the time of re-education. On April 7, 2026, at 11:00am Incident/Accident audit was initiated and completed by DCO to validate accuracy and investigation into the incidents and accidents. No concerns notated. The Medical Director was notified of the Immediate Jeopardy on April 7, 2026, and participated in development of this plan through an abbreviated Quality Assurance process. The next scheduled QA meeting is set for April 24, 2026, at 12:00 p.m. This Plan of Removal was implemented on April 7, 2026, and compliance will be monitored through direct observation by the Executive Director of Operations and the Director of Clinical Services. Sincerely, [Facility name][Facility address] The surveyor's verification of the Plan of Removal on 04/07/26 was as follows:Record review of an undated checklist reflected the facility had initiated and completed an incident/accident audit to validate accuracy and investigation into the incidents and accidents. Items verified included whether vital signs where checked, neurological checks were completed, responsible party notified, physician notified, and whethe

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 kitchen sanitation in that:1. The facility failed to dispose of expired prepackaged green onions that were actively decomposing.2. The facility failed to label and date bread, butter, and baked items.These deficient practices could place residents who received meals from the kitchen at risk for food borne illness.The findings were:During an observation of the kitchen on 2/22/26 at 10:01 a.m. it was observed that bread was not dated or labeled sitting on top of a toaster. Bags of green onion were expired, dated 1/17/2026, and unlabeled. [NAME] onions were decomposing inside of the bag releasing black liquid. Blocks of margarine were undated and labeled with no expiration date listed on the packaging.During an interview on 2/25/26 at 9:13 a.m. with the Dietary Manager she stated that food should be labeled and dated. She said that food should be covered properly. She stated that food that was expired or actively decomposing in the refrigerator should have been thrown away. She said that all kitchen staff were responsible to ensure that all regulations were followed. She said that residents could be placed at risk for foodborne illness if they consumed expired food or food that was not stored properly.During an interview on 2/25/26 at 9:30 a.m. with the Director of Clinical Operations she said that she expected that kitchen staff follow regulations to prevent foodborne illness. She stated that residents could be placed at risk for foodborne illness if they ate food that was not properly handled. She said that residents in nursing homes could be more vulnerable to food that was not handled properly.During an interview on 2/25/26 at 10:00 a.m. the Executive Director of Operations said that she expects that food in the kitchen will be stored properly, labeled, dated, and expired food thrown away. She said that residents could have been placed at risk of foodborne illness if they ate food that was contaminated or not handled properly. Record review of a facility policy titled, Food Storage dated 2/2026 revealed the purpose of this policy was, Food should be stored in a safe and sanitary method to prevent contamination and food-borne illness. All food should be stored according to local, state, and federal regulations.Bulk items that have been opened should be stored in covered containers or sealed bags and should be labeled and dated. Items should be sealed, labeled and dated. Use the first-in, first-out rotation method. Date packages and new items should be placed behind existing ones, so that the older items are used first.

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments for 3 of 23 residents reviewed for storage of drugs and biologicals (Resident #9, Resident #32, and Resident #30) and 2 of 4 medication carts (Medication Cart #2 and Treatment Cart #4) reviewed for medication storage. The facility failed to securely store wound care chemicals for Resident #9.The facility failed to securely store fluticasone propionate nasal spray 50 micro grams (a corticosteroid used to relieve seasonal and year-round allergy symptoms, including nasal congestion, runny nose, itchy nose, sneezing, and watery eyes), fluticasone propionate and Salmeterol powder 250/50 micrograms (a combination prescription inhaler containing a corticosteroid and a long-acting beta-agonist), and povidone-iodine 10% solution (a fast-acting, broad-spectrum topical antiseptic used to prevent infections in minor cuts, scrapes, and burns, as well as for preoperative skin preparation) for Resident #32.The facility failed to keep over the counter supplements, Magnesium 200 mg, men's multivitamin secure for Resident #30.The facility failed to ensure Medication Cart #2 was locked when unattended.The facility failed to ensure Treatment Cart #4 was locked when unattended.This failure could place residents at risk for adverse reactions, risk of having access to unauthorized medication and/or lead to harm or drug diversions. Findings included: 1. Record review of Resident #9's face sheet, dated 11/23/23 revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses that included Paraplegia (impairment or loss of motor and sensory function in the lower extremities and sometimes the torso, resulting from spinal cord damage in the thoracic, lumbar, or sacral regions), Muscle Wasting and Atrophy (involve the loss of muscle tissue and strength, typically caused by inactivity, malnutrition, aging (sarcopenia), or diseases affecting nerves or muscles), and Depression (a serious, common mood disorder causing persistent sadness, loss of interest, and functional impairment, affecting how you think, feel, and behave). Record review of Resident #9's quarterly MDS assessment, dated 02/03/26, revealed Resident #9 had a BIMS score of 10, which indicated moderately impaired cognition. Shows that Resident #9 was dependent for activities of daily living. Record review of Resident #9's care plan dated 2/05/26 shows that Resident #9 had an activities for daily living self-care deficit. Resident #9 required assistance with most all of her activities of daily living. During an interview and observation on 2/22/26 at 10:30 a.m. a bottle of wound care cleanser was left at Resident #9 bedside table. Resident #9 said that she did not know what was in the green spray bottle the surveyor found. She said that someone must have left it in her room. During an interview on 2/22/2026 at 10:46 a.m. LVN H said that she did not know that there were chemical products being left in resident rooms. She said that she would go get the wound care treatment chemicals. She said that these types of chemicals should be in the treatment cart or stored on the medication cart. She said that residents could be placed at risk of harm if they misused a chemical. She said that they could go blind or burn their throats. 2. Record review of Resident #32's face sheet, dated 02/17/26 revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses that included Respiratory Failure with Hypoxia (Respiratory failure is a critical condition where the lungs cannot adequately oxygenate the blood), Venous Insufficiency (occurs when leg vein valves become weak or damaged, causing blood to pool (venous reflux) rather than flowing back to the heart), Acute Pulmonary Edema (a life-threatening, sudden buildup of fluid in the lungs' air sacs, usually caused by rapid heart failure (cardiogenic) or lung injury). Record review of Resident #32's quarterly MDS assessment, dated 01/15/26, revealed Resident #32 had a BIMS score of 13, which indicated Resident #32 was cognitively intact. Shows that Resident #32 was dependent for most of her activities of daily living. Record review of Resident #32's care plan dated 10/24/25 shows that Resident #32 had an activities for daily living self-care deficit. Resident #32 required assistance with most all of her activities of daily living related to her disease process. During an interview and observation on 2/22/26 at 11:18 a.m. with Resident #32 it was observed that she had two bottles of fluticasone propionate nasal spray 50 micro grams (a corticosteroid used to relieve seasonal and year-round allergy symptoms, including nasal congestion, runny nose, itchy nose, sneezing, and watery eyes), fluticasone propionate and Salmeterol powder 250/50 micrograms (a combination prescription inhaler containing a corticosteroid and a long-acting beta-agonist), and povidone-iodine 10% solution (a fast-acting, broad-spectrum topical antiseptic used to prevent infections in minor cuts, scrapes, and burns, as well as for preoperative skin preparation.) She said that they were her medications that staff left with her. During an interview on 2/25/26 at 9:30 a.m. the Director of Nurses said that every staff in the facility was responsible to ensure residents did not have prohibited items in their rooms such as over the counter medications, chemicals, or wound care chemicals. She said that these items should be removed and then reported to her. She said that residents could be placed at risk of harm if they misused one of these items. During an interview on 2/25/26 at 10:00 a.m. the Administrator said that she expected that medications and chemicals were not left in residents' rooms. She said that they should be stored properly in the medication cart or medication room. She said that everyone was responsible to ensure that these items were not in residents' rooms. She said that residents could be placed at risk of harm if they did not use a medication or chemical properly. During an observation and interview on 2/22/2026 at 9:40 AM, revealed Treatment Cart #4 was unlocked and unattended with no nurse or medication aide at cart for 2 minutes. RN F said she left the treatment cart unlocked while she went to get a drink. RN F said she should not have left it unlocked. Observed a housekeeper and another resident in hallway where unlocked treatment cart was left unattended. During an observation and interview on 2/22/2026 at 12:07 PM - Observed medication cart #2 located near nurses' station on hall 200 unlocked. No staff near or within eye site of the unlocked medication cart. The drawers pulled out. RN G said the medication cart should only be unlocked when she was at the cart. She said she went to administer noon medication to a resident. She said leaving her medication cart unlocked could be a danger. She said a resident could take wrong medications. She said she was away from her medication cart for approximately 3 minutes. She said normally the facility had MAs administering medications. She said the DCO; Treatment nurse and herself were responsible for ensuring medication carts were locked. Observed OTC medications in top drawer, Blister packets with resident medications in drawer 2. Side drawers observed liquid medications, narcotic box was securely locked inside medication cart #2. During an interview on 2/24/2026 at 10:19 AM, LVN E said a medication cart can be unlocked when in use and within sight. LVN E said the person who had access to the keys was responsible, nurses and medication aids. LVN E said medication carts were not shared during a shift. LVN E said someone could get in the medication cart such as a resident or visitor and take something not prescribed to them. She said it could make them sick. During an interview on 2/24/2026 at 1:59 PM CNA B said she would tell the charge nurse or the DCO if she observed a medication cart or the treatment cart unlocked. CNA said anyone could get in the medication or treatment cart. It could kill a resident or visitor if they took medication not prescribed. During an interview on 2/25/2026 9:49 AM CNA C said treatment carts and medication carts should not be unlocked. She said she had observed them unlocked but not all the time. CNA C said she had seen the wound care cart unlocked. CNA C said if a cart were unlocked, a resident who wanders could get in the medication cart, take the wrong medication. CNA C said anyone could get in the medications. She said it does not give them the right but gives them access. CNA C said the nurse who was assigned to the keys to the cart was responsible for ensuring it was locked. During an interview on 2/25/2026 at 10:09 AM LVN H said the nurses and MAs were responsible for ensuring the medication carts were locked. She said the medication carts should be locked when not at the medication cart. LVN H said a resident with dementia could get in the cart and take something that could harm them. LVN H said the treatment cart should be locked due to wound cleansers on the cart. During an interview on 2/25/2026 at 11:18 AM, the DCO said she expected the nursing staff and MAs to keep medication carts locked. She said the medication cart should only be unlocked when the nurses were directly in front of the medication or treatment cart. The DCO said a resident or visitor could take something out of the medication cart that could harm them. The DCO said a resident or visitor could take extra medications, or overdose. She said she did not think anyone could get to the narcotic box. The DCO said a resident could take medication that could cause side effects. She said the nurses and the treatment nurse were responsible for ensuring the medication carts were locked and secure. During an interview on 2/25/2026 at 11:57 AM, the EDO said she expected the medication and treatment carts to be locked. The EDO said it could only be unlocked when in use and getting medications for residents. The EDO said a resident or visitor could take medications that were not prescribed. The EDO said it could cause a person's blood pressure to drop, or adverse effect on the person. She said the person who had access to keys and who was assigned to the medication cart was responsible. Review of a facility policy titled Administering Medications last revised in April 2019 indicated .Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation.1. Only persons licensed or permitted by this state to prepare, administer and document.2. The Director of Nursing Services supervises and directs all personnel who administer medication.19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide.

Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care were provided with such care, consistent with professional standards of practices for 3 of 25 residents (Resident #14, Resident #35, and Resident #2) reviewed for respiratory care.The facility failed to ensure that oxygen filters were clean for Resident #14's oxygen concentrator.The facility failed to change the oxygen tubing for Resident #35's oxygen concentrator.The facility failed to ensure Resident #2's oxygen reservoir was changed weekly.These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.1. Record review of Resident #14's face sheet, dated 01/02/26 revealed a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included Chronic Obtrusive Pulmonary Disease (a progressive, irreversible lung disease causing chronic, long-term breathing problems, typically characterized by chronic bronchitis, emphysema, or both), Sepsis (a life-threatening, emergency response to infection where the immune system damages the body's own tissues and organs), and Urinary Tract Infection (a common bacterial infection in the bladder, kidneys, or urethra, often causing painful, burning urination, frequent urges, and cloudy or strong-smelling urine.) Record review of Resident #14's quarterly MDS assessment, dated 1/4/26, revealed Resident #14 had a BIMS score of 15, which indicated she was cognitively intact. Shows that Resident #14 required oxygen therapy. Record review of Resident #14's care plan dated 1/5/2026 indicated that, Ineffective Breathing Pattern related to: Chronic Obtrusive Pulmonary Disease. Resident will demonstrate an effective respiratory rate, depth, and pattern, and increased activity tolerance throughout the review date. Record review of an phyisidan's order for Resident #14, dated 1/2/26, shows that an order was placed for, Oxygen at 2 liters per nasal cannula to maintain peripheral capillary oxygen saturation greater than 90%. Record review of an physician's order for Resident #14, dated 1/2/26, shows that an order was placed for, Clean/change oxygen concentrator filters every night shift every Sunday. During an observation and interview on 2/22/26 at 10:14 a.m. Resident # 14 said that she did not know when her oxygen concentrator was cleaned by staff. It was observed that the oxygen concentrator filter was covered in dust and dirt. During an observation on 2/23/26 at 12:55 p.m. of Resident #14's oxygen concentrator, it was observed that the oxygen concentrator filter was still covered in dust and dirt. 2. Record review of Resident #35's face sheet, dated 12/28/24 revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included Acute and Chronic Respiratory Failure with Hypercapnia (occurs when a patient with underlying chronic respiratory insufficiency (e.g., COPD, pulmonary fibrosis) suffers a sudden, severe decline in lung function, often due to an infection or exacerbation), Acute Pulmonary Edema (a life-threatening, sudden buildup of fluid in the lungs' air sacs, usually caused by rapid heart failure (cardiogenic) or lung injury), Cognitive Communication Deficit (difficulties with verbal and non-verbal communication caused by underlying impairments in thinking skills—such as memory, attention, organization, and reasoning—rather than primary language disorders). Record review of Resident #35's quarterly MDS assessment, dated 1/27/26, revealed Resident #35 had a BIMS score of 03, which indicated severely impaired cognition. Shows that resident #35 required oxygen therapy on admission and while a resident. Record review of Resident #35's care plan dated 1/23/26 shows a lack of care planning regarding oxygen use. Care plan did not document oxygen therapy or oxygen usage. Record review of an order for Resident #35, dated 10/21/25, shows that an order was placed for, Oxygen at 2 liters per nasal cannula to maintain peripheral capillary oxygen saturation greater than 90% Record review of an order for Resident #35, dated 10/21/25, shows that an order was placed for, Oxygen tubing change every night shift every Sunday for tubing. During an observation on 2/22/26 at 10:46 a.m. Resident # 35 was asleep in her wheelchair. She had her oxygen concentrator turned on and providing oxygen via nasal. The label for the oxygen concentrator read 2/16/26. During an observation and interview on 2/23/26 at 9:10 a.m. Resident # 35 was sitting in her wheelchair watching TV. She had oxygen concentrator on and nasal cannula providing oxygen. The label for the oxygen concentrator read 2/16/26. She said she did not know if staff changed her oxygen tubing, but she does use it every day. During an observation on 2/23/26 at 1:00 p.m. Resident #35's The label for the oxygen concentrator still read 2/16/26. During an interview on 2/25/26 at 9:30 a.m. with the Director of Clinical Operations she said that nursing staff on Sundays were responsible to ensure that all oxygen tubing and filters were changed per doctor's orders. She said she expected her nursing staff to change residents' oxygen tubing and clean or replace their filters. She said that residents could be placed at risk of infection if they did not have their concentrator tubing and filters clean. During an interview on 2/25/26 at 10:00 a.m. the Executive Director of Operations said that she expected that nursing staff would keep residents' oxygen filters and tubing clean and replaced as ordered. She said that residents could be placed at risk for a respiratory infection if their oxygen tubing and filters were not clean. 3. Record review of Resident #2's face sheet dated 2/23/2026 indicated the resident was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of acute on chronic systolic congestive heart failure (a serious condition where the heart's ability to pump blood efficiently is impaired over time, affecting the left ventricle), Chronic obstructive pulmonary (a progressive lung disease that makes it difficult to breathe, primarily caused to irritants), Diabetes (a chronic condition that occurs when the body cannot properly use blood sugar) and morbid obesity (a complex chronic disease with BMI of 40 or higher). Record review of Resident #2's MDS assessment, dated 12/22/2025, indicated she understood and was understood by others. Resident #2 had a BIMS score of 7 indicating she had severe cognitive impairment. The MDS also indicated Resident #2 had shortness of breath while lying flat and required oxygen. Record review of Resident #2's Care Plan undated indicated the Resident #2 was on oxygen therapy related to Chronic Obstructive Pulmonary disease. The interventions included monitoring signs and symptoms of respiratory distress and report to MD as needed. The interventions also included oxygen via nasal cannula per MD orders. Record review of Resident #2's Medication administration record dated 2/1/2026-2/28/2026 indicated orders to change oxygen tubing weekly every night shift on Sunday. There was documentation the tubing was last changed on 2/15/2026. During an observation and interview on 2/22/2026 at 11:23 AM, Resident #2 was sitting up in bed with oxygen on 3 liters with oxygen concentrator water dated 2/5/2026. Resident #2 said she was treated with dignity and respect and had her call light within reach. Resident indicated the tubing was changed weekly. During an observation on 2/22/2026 at 1:46 PM, Resident #2's oxygen concentrator reservoir was dated 2/5/2026 and had not been changed out. During an interview on 2/24/2026 at 10:19 AM LVN E said the nurses were responsible for changing out the water on the concentrator and CNAs could notify the nurse if the water was out on the concentrator. LVN E said the nursing staff changed out the water routinely on Sundays. LVN E said the staff date and time the water on the concentrator. LVN E said the residents could have dryness of nasal passages and nose bleeds if the water was not changed. During an interview on 2/24/2026 at 1:59 PM, CNA B said the nurses were responsible for changing out the water in the concentrator and the tubing. She did not know how often it was changed out. During an interview on 2/25/2026 at 9:49 AM, CNA C said she assisted residents with taking their oxygen on and off during a transfer. She said they would take oxygen off and cover it with a bag to keep it clean. She said she would notify the nurse if the water was not bubbling. CNA C said she did not know when the water needed to be changed out. She said she had observed dates and labels on them. CNA C said the nurse was responsible for ensuring the water and tubing were changed. During an interview on 2/25/2026 at 10:09 AM LVN H said the water concentration was supposed to be changed when the water gets low or every 6-7 days. She said some residents used oxygen as needed so they had to watch it if it got low. She said the concentrator water dated 2/5/2026 would be over due to be changed if observed on 2/22/2026. She said the nurses were responsible for changing the water out. She said the water could get stale and not smell right. During an interview on 2/25/2026 at 11:18 AM, the DCO said the water should be changed one time a week. The DCO said the nurse on the night shift was responsible for changing out weekly. The DCO said she would expect the water to be changed if the date was 2/5/2026. She said it could place the residents at risk of infection with the water not being changed. During an interview on 2/25/2026 at 12:02 PM, the EDO said she expected the nurses to change out the water for the concentrator. She said she did not know when it was supposed to be changed out. She said she was not sure what could happen but felt it could be an infection control issue. The DCO said the nurse was responsible for changing out the water. Record review of facility policy titled, Oxygen Therapy dated 4/2021 revealed that the purpose of this policy was to, It is the policy of this community to ensure all oxygen administration is conducted in a safe manner.Change the reservoir, Oxygen Cannula and tubing every 7 days.Keep Oxygen cannula and tubing used PRN in a plastic bag when not in use.Wash filters from oxygen concentrators every 7 days in warm soapy water. Rinse and squeeze dry.

Based on observation, interview and record review the facility failed to provide care and services in accordance with activities of daily living for hygiene-bathing, dressing, grooming, and oral care for residents a during a confidential interview for 13 of 13 residents (Unidentified Resident #1, Unidentified Resident #2, Unidentified Resident #3, Unidentified Resident #4, Unidentified Resident #5, Unidentified Resident #6, Unidentified Resident #7, Unidentified Resident #8, Unidentified Resident #9, Unidentified Resident #10, Unidentified Resident #11, Unidentified Resident #12, Unidentified Resident #13)reviewed for ADLs. The facility failed to ensure the residents had a sufficient number of towels in the facility for ADL care. This failure could place residents at risk of no showers, hand hygiene, not receiving services/care and decreased quality of life. Findings include:A record review of the facility in-service binder, no in-services were noted related to the facility not having towels available for the resident's hygiene needs. A record review of the facility invoice indicated, washcloths and towels orders were made to distributor in November of 2025, but the towels were on back order. During an observation on 2/24/26 at 9:47 A.M., on Hall 200 linen cart, revealed there were no towels on the cart. During an observation on 2/24/26 at 9:49 A.M., on Hall 300 linen cart, revealed there were no towels on the cart. During an observation on 2/24/26 at 9:55 A.M., on Hall 400 linen cart, revealed there were no towels on the cart. During an observation on 2/24/26 at 11:06 A.M., on Hall 100 linen cart, revealed there was one bath towel on the cart. During an observation on 2/24/26 at 11:08 A.M., on Hall 200 linen cart, revealed there was one face towel and two bath towels on the cart. During an observation on 2/24/26 at 11:09 A.M., on Hall 300 linen cart, revealed there were two face towels and three bath towels on the cart. During an observation on 2/24/26 at 11:12 A.M., on Hall 400 linen cart, revealed there were no towels on the cart. During confidential interview 13 of 13 residents (Unidentified Resident #1, Unidentified Resident #2, Unidentified Resident #3, Unidentified Resident #4, Unidentified Resident #5, Unidentified Resident #6, Unidentified Resident #7, Unidentified Resident #8, Unidentified Resident #9, Unidentified Resident #10, Unidentified Resident #11, Unidentified Resident #12, Unidentified Resident #13) voiced the facility often did not have towels available and CNAs were not giving residents their showers due to a lack of washcloths and bath towels supplied by the facility. The residents said they complained about the issue, but the situation had not gotten better. During an interview on 2/24/26 at 9:35 A.M., CNA B said towels were hard to find every day and staff had to hunt for them in the facility. CNA B said the Director of Environmental Service was responsible for ordering the towels. She said a negative effect of not having towels available in the facility was that staff could not get the residents up for showers or bathe them and could not wash the residents' face and hands in the morning. During an interview on 2/24/26 at 9:35 A.M., Laundry Aide F said she thought there were not enough towels and washcloths in the facility, but her supervisor, the Director of Environmental Services, said a shipment would be on the next day. She said the facility had a shortage of towels and washcloths. She said the Director of Environmental Services was her supervisor and she was responsible for ensuring the facility had enough towels. She said a negative effect of not having an adequate number of towels was the aides were not able to give residents showers or wash their faces in the mornings and the aides could not provide the appropriate care, because they did not have what they need to perform their job. During an interview on 2/24/26 at 11:30 A.M., the Director of Environmental Services said since November she had taken over, and she had ordered towels every month. She said she put in an order for towels every month since November. She said she had not received any towels since November. She said the facility was supposed to get 75 towels and 120 washcloths today or tomorrow. She said she expected the residents to have towels. She said she told the Director of Plant Operations what she needed, and he ordered it for her, because she did not have access to ordering materials. She said a negative effect of the residents not having towels available was the residents were not getting the care they needed, because the aides did not have the linen supply. During an interview on 2/24/26 at 11:38 A.M., LVN E said the aides were supposed to have towels for the residents, often the aides did not have towels. She said laundry was responsible for ensuring the aides had towels washed and supplied. She said the risk of not having towels available was infection and residents not being able to take baths. During an interview on 2/24/26 at 3:00 P.M., LVN A said she expected the aides and residents to have towels. She said laundry and housekeeping were responsible for getting the laundry out. She said the risk of not having the appropriate supply of towels would be skin breakdown if the residents did not get their showers. During an interview on 2/25/26 at 9:54 AM, the Director of Plant Operations said he expected residents to have towels. He said the towels were on back order for several months now from the company the facility ordered. He said he was responsible for ordering the towels. He showed the state surveyor where the towels were on back order. He said the distributor gave them an option to get a different line of towels ordered. He said a risk was the residents would not have towels for hygiene care. He said the towels were ordered, and the facility should receive them today. During an interview on 2/25/26 at 10:33 A.M., the Director of Clinical Operations said she expected towels to be available for the residents. She said housekeeping and the Environmental Services Manager were responsible for ensuring the appropriate number of towels were available. She said the risk was residents missing showers and could cause skin issues. During an interview on 2/25/26 at 10:55 A.M., the Executive Director of Operations said she expected the staff to have an appropriate number of towels to take care of the residents. She said housekeeping management was responsible for ensuring the towels were in the facility. She said the negative effect was increased infection. Record review of the facility's policy and procedure Quality of Life- Accommodation of Needs, dated August 2009, indicated .Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being. The residents' individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #35) reviewed for care plans. The facility failed to implement the comprehensive person-centered care plan for Resident #35 by not documenting resident's need for oxygen therapy. This failure could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services Findings include:Record review of Resident #35's face sheet, dated 12/28/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #35 had diagnoses which included Acute and Chronic Respiratory Failure with Hypercapnia (occurs when a patient with underlying chronic respiratory insufficiency suffers a sudden, severe decline in lung function, often due to an infection or exacerbation), Acute Pulmonary Edema (a life-threatening, sudden buildup of fluid in the lungs' air sacs, usually caused by rapid heart failure [cardiogenic] or lung injury), and Cognitive Communication Deficit (difficulties with verbal and non-verbal communication caused by underlying impairments in thinking skills-such as memory, attention, organization, and reasoning-rather than primary language disorders).Record review of Resident #35's quarterly MDS assessment, dated 1/27/26, reflected Resident #35 had a BIMS of 03, which indicated severely impaired cognition. Resident #35 required oxygen therapy on admission and while a resident.Record review of Resident #35's care plan dated 1/23/26 reflected a lack of care planning regarding oxygen therapy. There was no information entered into the care plan regarding oxygen therapy. Record review of an order for Resident #35, dated 10/21/25, reflected an order was placed for, Oxygen at 2 liters per nasal cannula to maintain peripheral capillary oxygen saturation greater than 90%During an interview on 2/25/26 at 9:30 a.m. the Director of Nurses said oxygen therapy should be on a resident's care plan. She said she was responsible to ensure care plan's were accurate and all resident care was documented on their care plan. She said residents could be placed at risk of not receiving oxygen therapy if their oxygen order was not care planned. She said that a resident could not have oxygen therapy if it was not documented in their care plan.During an interview on 2/25/26 at 10:00 a.m., the Administrator said she expected care plans were accurate and reflected the needs of each resident. She said if a resident received oxygen therapy it should be documented on their care plan. She said residents could be placed at risk of not receiving their oxygen therapy if it was not properly care planned.Record review of the facility's policy titled, Resident Assessment, dated 1/20/2021, reflected, 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 plan 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. The resident's Care Plan will include participation from residents' representatives, external partners Preadmission Screening and Resident Review, Hospice, Therapy, Clinicians and not as all-inclusive.A Registered Nurse will complete the Baseline Care Plan in the RN's absence in the Clinical reimbursement role. An Registered Nurse initiates all Care Plans.

Based on interview and record review, the facility failed to ensure each resident had the right to be free from misappropriation of property and exploitation for 1 of 4 residents (Resident #3) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #3's Hydrocodone (Norco) (a combination medicine that is commonly taken for severe pain). This failure could place residents at risk for uncontrolled pain. Record review of Resident #3's face sheet, dated 2/24/2026, indicated Resident #3 was an [AGE] year-old male who was readmitted to the facility on [DATE]. Resident #3 had diagnoses which included chronic venous hypertension with ulcers to bilateral lower extremities (occurs when veins in the lower extremities fail to efficiently return blood to the heart ), Sepsis (a life-threatening condition caused by the body's extreme response to an infection), diabetes mellitus (a condition in which the body has trouble controlling blood sugar and using it for energy), and lymphedema (a condition characterized by swelling caused by an accumulation of protein-rich fluid in the body's tissues, primarily affecting the arms or legs).Record review of Resident #3's quarterly MDS, dated [DATE], indicated he was usually able to make self-understood and usually understood others. Resident #3 had a BIMS score of 6, which indicated he had severe cognitive impairment. Resident #3 was dependent on toileting and bathing, required moderate assistance with personal hygiene, and dressing lower body.Record review of Resident #3's, undated, care plan indicated Resident #3 had potential for pain and risk for injury from decrease in activities of daily living and was currently on hospice care. Interventions included:Assess characteristics of pain: location, severity, on a scale of 1-10, type and frequency.Discuss with resident factors precipitated pain and what may reduce it.Administer medication as ordered.Discuss with resident the need to request pain medications before pain becomes severe.Discuss with physician that maximum pain relief pain medication were best given around the clock, with PRNs for breakthrough pain.Monitor for potential side effects of pain medication.Record review of Resident #3's Medication Administration record, dated 2/1/2026-2/28/2026, indicated he was prescribed Hydrocodone-Acetaminophen 7.5-325 mg 1 tablet by mouth one tablet every 4 hours as needed for pain.Record review of the pharmacy narcotic sheet, dated 2/7/2026 at 2:47 AM, indicated Hydrocodone-Acetaminophen 7.5-325 mg was delivered with 55 tablets filled and received on 2/7/2026 at 1:39 AM. Resident #3 received Hydrocodone 7.5-325 mg on 2/2/2026 and 2/9/2026.Record review of Resident #3's pain assessment, dated 2/17/2026, indicated pain level 2 out of 10 related pain to right and left lower leg wounds. Resident #3 refused pain medication at the time of the assessment.Record review of the facility's Provider Investigation Report of the misappropriation of medication, dated 2/18/2026, the facility initiated an investigation into the missing medication for Resident #3. The investigation report indicated the facility assessed Resident #3 for pain, staff were in-serviced initiated on drug diversion, how to count narcotics, process of completion of narcotic and where sheets go and safe surveys initiated for drug diversion. The facility provided drug screens for 6 nurses who worked shifts and the SW assessed Resident #3 for mental distress and no distress noted. Provider post-investigation was Unconfirmed. Resident #3 was noted to be happy and received medications as requested and no doses were missed.During an interview on 2/22/2026 at 11:15 AM, Resident #3 said everything was going good. Resident #3 said he was treated with dignity and respect. The resident said he had pain and received his pain medication timely. The resident was unable to recall a time when he received medication and pain not relieved. Resident #3 had no concerns with his care.During an interview on 2/23/2026 at 8:11 AM, CMA J said she was responsible for administering medication on Halls 100,200, and 400. She said she completed narcotic counts at every shift change. CMA J said she observed counts being off count, but it was because the nurse did not sign off. She said the nursing staff counts the cards and one stands by the book to ensure the medication counts match. CMA J said the staff could not locate the narcotic card for Resident #3. CMA J said she did not know who was working at the time. CMA J said when a nurse or CMA received a narcotic, they placed the count sheet in the narcotic book and secured the narcotics in the locked box. CMA J said the narcotic count sheet was missing with the narcotics card for Resident #3 Hydrocodone. During an interview on 2/23/2026 at 9:35 AM, the DCO said she identified the narcotics were missing for Resident # 3 when she completed a medication review on Hall 200.She said she identified a narcotic count sheet with 55 tablets of Hydrocodone. She said one card had 8 tablets remaining. She said the staff were counting one card with 25 tablets and the other card with 30 tablets was missing the narcotic count sheet and it was not labeled 1 of 2. She said whoever took the medications had taken the narcotic count sheet as well. The DCO said she identified the missing medication on 2/17/2026 around 2:00 PM. She said she notified the police on 2/18/2026. The DCO said she wanted to have time to locate the missing medications. The DCO said she was not suspicious of anyone, she was just reviewing the medications. The DCO said she interviewed the nursing staff and reviewed the delivery of the medication sheet. The DCO said she called the pharmacy to make sure there was not an error. The DCO said the medication had come up missing from 2/6/2026-2/17/2026. The DCO suspended RN N. The DCO interviewed all the staff who handled the medication cart and drug tested them. She said 2 staff had not tested yet and all those tested currently were negative.During an interview on 2/23/2026 at 10:19 AM, LVN E said the DCO and LVN A were searching through papers for the missing medication. She said she did not know who could have taken the medication. LVN E said she counted her narcotics on the medication cart. LVN E said the facility made two copies for each medication card and they were numbered. LVN E said she did not have any concerns with anyone she worked with. LVN E said the nurse on the floor and CMA were the only ones who had access to the medication carts. She said she thought the DCO had an extra set of keys. LVN E said she did not recall a time when the narcotic counts on her medication cart were off. LVN E said she did not work the day the medications were identified as missing. LVN E said medication carts were not shared during a shift.During an interview on 2/23/2026 at 12:05 PM, RN D said she was made aware last week there were narcotics missing. RN D said she was PRN. She said all the nurses had taken a urine drug screen. RN D said she did not have any concerns with the nurses she worked with that would make her question them. She said when narcotics were delivered, the Pharmacy would bring a sheet with the counts and were verified with two nurses. RN D said the narcotic count sheet required two nurses at shift change to verify the number of cares, liquids and counts for each narcotic.During an interview on 2/24/2026 at 1:40 PM, the DCO said she took statements from the staff who were working on the unit at the time the medications came up missing.During an interview on 2/24/2026 at 1:59 PM, CNA B said she did not work with medications. She said she heard there were missing medications at the facility.During an attempted phone interview on 2/25/2026 at 9:09 AM, a message was left for RN N regarding Resident #3's missing medication. No return call was received by the end of the survey.During an attempted phone interview on 2/25/2026 at 9:12 AM, a message was left for LVN M regarding Resident #3's missing medication. Left a voice message for a return call.During an attempted phone interview on 2/25/2026 at 9:16 AM, a message was left for LVN O regarding Resident #3's missing medication. No return call was received by the end of the survey.During an attempted phone interview on 2/25/2026 at 9:22 AM, a voice message for LVN P was left regarding Resident #3's missing medication. No return call was received by the end of the survey.During an interview on 2/25/2026 at 11:18 AM, the DCO said the nurse who had access to the medication cart and had the keys was responsible for ensuring the narcotics were counted and secure. She said she expected the nurse with the keys to count the narcotics at every shift change and report immediately any issue with the counts. The DCO said there was nowhere else in the facility where the narcotics would be stored. The DCO said the Pharmacy consultant was coming on 2/26/2026 to do a review. The DCO said her cabinet was triple locked with a lock box inside the locked filing cabinet. She said she completed an in-service on the process to check medication in with 2 nurses signing the narcotics into the facility. The DCO said the nurses were to initiate card count sheet and stop making copies of the sheets. She said the facility used the count sheet the medications come in with. The DCO said she was responsible for all medications in the building.During an interview on 2/25/2026 at 12:03 PM, the EDO said the facility had not come to a conclusion with their investigation. She said 6 nurses had been drug tested and 4 were negative. She said 1 had to retest due to running a fever and the other nurse did not have transportation to the testing facility. The staff had not completed the drug test prior to end of survey. The EDO said the facility had in-services with staff regarding the counts, processes on completion of medications and where the sheets were to go. The EDO said she expected the narcotic counts to be accurate and medications were secured. She said she expected all the cards to be accounted for and reported immediately if any counts were off. The EDO said the nurses assigned to the medication cart with the keys were responsible for ensuring the medications were secured.During an interview following a return call on 2/25/2026 at 2:32 PM, LVN M said she worked the night shift and did not recall receiving the medication for Resident #3. She said she would administer Resident #3's Hydrocodone prior to performing his wound care. She said she did not recall if she received his medication when it came in. She said if the nurse for the resident was at the facility, she would have handed it off to the nurse who worked on Hall 200. She said the staff were in-serviced and they now had a process in place for two people to sign off when the medication was received. She said she never had narcotic counts off in the past.Record review of the facility's policy, revised 8-2020, titled Discrepancies, Loss, and/or Diversion of Medication indicated Policy.all discrepancies, suspected loss, and/or diversion of medications, irrespective of drug type or class, are immediately investigated and a report filed. Procedures.Immediately upon discovery or suspicion of a discrepancy, suspected loss of diversion, the ADM, DON and consultant pharmacist are notified and investigation conducted.I. Discrepancy on a drug count.The DON investigates the discrepancy and researches al the records related to medication administration and the supply.Medication reconciliation is made from the last known date and time of reconciliation.A thorough search is conducted in all drug storage areas, the resident room, and any locations where medications may have been used or placed during medication administration.If the discrepancy cannot be reconciled after a thorough investigation has be completed the remaining supply is documented with the current date and the accountability process restarted.The medication in question should be checked several times.Appropriate agencies required by state regulation will be notified. II Loss of supply of medication.The DON investigates the suspected loss and research all the records related to medication receipt, its use since receipt, and all persons involved with medication administration and supply of medication and identifies the last known point in time that medication was available. The pharmacy should be notified, and the pharmacy should verify the medication was dispensed.4. If the loss invoices a controlled substance, all the controlled drug accountability procedures and document should be reviewed and audited. If the audit reveals a particular individual or individuals who might be suspected of involvement of loss, appropriate disciplinary actions are taken and deferred to human resource policy.

Based on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 3 of 16 residents (Resident # 17, Resident #52, and Resident #69) reviewed for resident rights.1. The facility failed to ensure Resident #17 was able to access her bedroom furnishings.2. The facility failed to ensure Resident #69 was able to access her call light.This failure could place residents at risk for unmet needs and decreased quality of life.Findings include:1. Record review of Resident #17's face sheet, dated 08/21/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #17 had diagnoses which included Paraplegia (impairment or loss of motor and sensory function in the lower extremities and sometimes the torso, resulting from spinal cord damage in the thoracic, lumbar, or sacral regions), Muscle Wasting and Atrophy (involve the loss of muscle tissue and strength, typically caused by inactivity, malnutrition, aging [sarcopenia], or diseases affecting nerves or muscles), Needs for Assistance with Personal Care (mobility, hygiene, and daily living tasks to maintain dignity, safety, and independence at home).Record review of Resident #17's quarterly MDS assessment, dated 12/15/25, reflected Resident #17 had a BIMS of 09, which indicated moderately impaired cognition. Resident #17 was dependent for activities of daily living.Record review of Resident #17's care plan, dated 2/19/26, reflected Resident #17 had an activities for daily living self-care deficit. Resident #17 required assistance with most all of her activities of daily living.During an observation and interview on 02/22/26 at 10:30 a.m., Resident #17 said she stored a lot of her snacks in her bed because staff won't turn her bed the other direction so she could reach her nightstand. She said her nightstand was at the foot of her bed and she could not move herself that far. It was observed that Resident #17 had a trapeze bar to pull herself up as she had limited mobility. There were multiple jars of protein powder, peanut butter and other snack items laying in her bed. Her nightstand was at the foot of her bed and she was unable to reach. She said she used a hoyer lift to get out of bed. She said she asked staff multiple times to change the direction of her bed so she could make use of her nightstand, but they told her okay and then nothing happened.During an observation and interview on 02/23/2026 at 2:20 p.m., Resident #17's nightstand was not in a position to reach. She said the items on her nightstand, her snacks, were out of reach and she had to wait for the staff to come into her room to help her get them.During an interview on 2/25/26 at 9:30 a.m., the Director of Nurses said residents who were dependent for care should have their needs met which included being able to reach their bedside nightstands or bedside tables. She said if a resident's needs were not being met all staff should report to her so the issue could be fixed. She said a resident could suffer a lower quality of life if their needs were not met.During an interview on 2/25/26 at 10:00 a.m., the Administrator said she expected all staff to ensure residents' needs were being met. She said she expected that if a resident had a specific need that wasn't being met it should be reported so the residents did not have a lower quality of life. She said a resident could have a lower quality of life if they were unable to reach their bedside nightstand to store their belongings.2. Record review of Resident #69's face sheet, dated 02/25/2026, indicated Resident #69 was [AGE] year-old female who was admitted to the facility on [DATE]. Resident #69 had diagnoses which included Vascular dementia (a type of dementia that occurs when the brain's blood vessels are damaged or blocked, disrupting the supply of oxygen and nutrients to brain cells), Type II Diabetes (a chronic condition that occurs when the body cannot properly use blood sugar), morbid obesity (a complex chronic disease with BMI of 40 or higher) and bipolar disorder (a mental condition characterized by significant mood swings). Record review of Resident #69's MDS, dated [DATE], indicated Resident #69 was understood and understood others. The Resident #69 had a BIMS score of 11, which indicated moderate cognitive impairment. Resident #69 required substantial/maximal assistance with ADLs.Record review of Resident #69's, undated, care plan indicated Resident #69 was at risk of falling related to history of falls, Physical impairment, and Right Below the knee amputation. Interventions included anticipating needs, provide assistance and ensuring call light was in reach and answered promptly.During an observation and interview on 2/22/2026 at 10:23 AM, Resident #69 said she was sick to her stomach and needed some medication for nausea. The resident's call light was on the floor and out of the resident's reach and she was unable to reach staff for medication. The State Surveyor notified RN G of resident complaints of nausea.During an interview on 2/24/2026 at 10:19 AM, LVN G said call lights should be placed within reach so the residents could use it. LVN G said the resident would not be able to receive the care, if they needed help. LVN G said it was everyone's responsibility for ensuring call lights were within reach. She said 2-3 minutes was a reasonable time for a call light to be answered. LVN G said it was important to at least check in and notify the residents when you would be back in. LVN G said a resident may need a drink or need to go to the bathroom. She said a resident could fall or hurt themselves if they did not have access to their call light.During an interview on 2/24/2026 at 1:59 PM, CNA B said call lights should be placed next to the resident. She said the CNAs and all staff were responsible for ensuring the residents call lights were within reach. CNA B said the call light was the resident's lifeline. She said the residents would not be able to reach anyone for help or their needs may not be met. CNA B said the residents may need water or need their brief change and try to get up and fall.During an interview on 2/25/2026 at 9:46 AM, CNA C said the CNAs were responsible for ensuring the call lights were within reach. She said a resident could fall if they were unable to get up independently. She said the call light should be placed on the bed, wheelchair or on a pillowcase so the resident could reach it no matter where the resident was sitting.During an interview on 2/25/2026 at 10:09 AM, LVN H said the staff were responsible for ensuring the call lights were within resident's reach. She said the staff placed the call light where the resident could see and reach it. LVN H said it should not be draped over the light or anything else out of reach. LVN H said CNAs and Nurses made rounds and made sure the residents were doing okay and call lights were within reach. She said a resident could try to reach for the call light and fall out of bed. She said some residents had respiratory problems and they need to make sure the call light was within reach or a resident could fall resulting in an injury.During an interview on 2/25/2026 at 11:18 AM, the DCO said she expected the nurse and CNA, or any staff who got in the resident room to ensure the call light was within the reach of the residents and clipped to their bedsheet. She said it placed the residents at risk of not getting needs met if not in reach. The DCO said a resident could fall causing an injury.During an interview on 2/25/2026 at 11:55 AM, the EDO said she expected the resident call lights to be placed within the residents reach. The EDO said the nurse and care staff were responsible for ensuring call lights were within reach. The EDO said a resident may not be able to call for help and the staff may not meet their needs.Record review of the facility's policy and procedure Quality of Life- Accommodation of Needs dated August 2009, indicated . Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being. The residents' individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. A. providing access to assistive devices, such as grab bars in the bathroom; B. arranging furniture as the resident requests, providing the arrangement is safe, his or her roommate agrees and space allows.

Based on interview and record review the facility failed to ensure that residents were free from neglect 1 of 3 (Resident #1) residents reviewed for neglect. The facility failed to have an effective system in place for referrals resulting in Resident #1 not receiving a referral to the vascular specialist as ordered by his primary care physician and having an above the knee amputation to his right leg. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 4/04/23 at 3:00 p.m. While the IJ was removed on 4/06/23, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could result in residents not being seen by physicians when needed and lead to further decline in health status, harm, or death. Findings Include: 1. Record review of the face sheet dated 4/05/2023 indicated Resident #1 was admitted to the facility on [DATE] with diagnoses including COPD (a group of lungs diseases that block airflow and make it difficult to breathe), atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and difficulty walking. Record review of the physician orders dated 4/05/2023 indicated Resident #1 had an order for wound care to the right toes to cleanse with normal saline, pat dry, apply betadine moistened gauze, apply calcium alginate (a dressing used on moderate to heavy draining wounds during the transition from debridement to repair phase of wound healing) daily and as needed for wound care and infection prevention starting on 3/22/2023. Record review of the MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS of 11 and was moderately cognitively impaired. The MDS indicated Resident #1 did not reject evaluation or care. The MDS indicated Resident #1 required extensive assistance with bed mobility, transferring, toileting, personal hygiene, and dressing. Record review of an undated care plan indicated Resident #1 had impaired cognitive function or impaired thought process related to impaired decision-making abilities. Record review of the nursing progress note dated 2/28/2023 written by LVN F indicated nursing staff was having difficulty locating Resident #1's pedal pulse (foot pulse) to the right lower extremity. The nursing progress note indicated Resident #1's capillary refill was less than 3 seconds to right foot, excluding the second toe. The nursing progress note indicated a new order was received for Resident #1 to have a venous and arterial doppler to the right lower extremity. Record review of the right lower extremity arterial doppler (an ultrasound exam of the arteries on the legs that can help evaluate whether there are blockages caused by plaque in the arteries) report dated 3/01/2023 indicated Resident #1 had moderated atherosclerotic cardiovascular disease. Record review of the right lower extremity venous doppler (an ultrasound exam that evaluates blood as it flows through a blood vessel including the body's major arteries and veins) report dated 3/01/2023 indicated Resident #1 had superficial thrombophlebitis (an inflammatory disorder of superficial veins with coexistent venous thrombosis (blood clot)) of the greater saphenous vein and no deep vein thrombosis. Record review of the nursing progress note dated 3/02/2023 written by the Wound Care Nurse indicated Resident #1's doppler results were sent to the primary care physician. The nursing progress note indicated the primary care physician said Resident #1 needed a referral to a vascular specialist. The nursing progress note indicated the nurse on the floor was aware of the referral and would complete the task. Record review of the nursing progress note dated 3/03/2023 written by the Wound Care Nurse indicated the vascular specialist office was called to make an appointment for Resident #1. The nursing progress note indicated a voicemail was left at the vascular specialist's office and the facility was awaiting a phone call back. Record review of the nursing progress note dated 3/13/2023 written by the Wound Care Nurse indicated the facility had spoken with the vascular specialist's office on 3/09/23 regarding the previous voicemail left concerning Resident #1 getting an appointment. The nursing progress note indicated the vascular specialist's office would let the facility know by the end of the day or by the next day if a referral was received. The nursing progress note indicated the vascular specialist's office did not call back. The nursing progress note indicated the referral was discussed with the nurse practitioner on 3/10/2023. The nursing progress note indicated the nurse practitioner said the primary care physician's office did not do the referrals, but that it should be the facility's social worker who sends the referral. The nursing progress note indicated the social worker was not aware of what was needed for the referral. The nursing progress note indicated the nurse practitioner and the DCO were notified due to Resident #1's right lower extremity. The nursing progress note indicated the facility talked with the vascular specialist's office and the vascular specialist's office said they had not received a referral for Resident #1. The nursing progress note indicated the DCO was notified and will take care of it. Record review of the nursing progress note dated 3/28/2023 written by LVN F indicated Resident #1's right foot and toes were looking significantly worse. The nursing progress note indicated orders were received to transport Resident #1 to the emergency room for further evaluation and treatment. Record review of the hospital records dated 3/28/23 indicated the chief complaint for Resident #1's emergency room visit was wound check. The hospital records indicated the toenail on the 4th right toe came off and the facility staff noted a hole in the toe. The hospital records indicated Resident #1 had dressed wounds to Lt foot. The hospital records indicated Resident #1 had erythema (reddening) and significant discoloration of all toes on right foot with foul smell. The hospital records indicated Resident #1 had ulcers on the 3rd and 4th toes on right foot. The hospital records indicated Resident #1 had decreased sensation to right foot. Record review of the hospital records dated 3/30/23 indicated Resident #1 was admitted from the facility with necrotic right foot and toes. The hospital records indicated Resident #1 was scheduled for an above the knee amputation on 3/31/2023. During an interview on 3/31/23 at 2:25 pm the receptionist at the venous specialist's office said they had never seen Resident #1. The receptionist at the vascular specialist's office said they did not have Resident #1 in their computer system and had no record of a referral. During an interview on 3/31/23 at 2:29 pm, the nurse practitioner said the referral for Resident #1 to see a vascular specialist was regarding vascular issues and arterial blockages. The nurse practitioner said she was unsure how advanced Resident #1's arterial/venous damage was at that time. The nurse practitioner said she would not be comfortable saying whether seeing the vascular specialist would have prevented Resident #1 from such an advanced amputation to right leg. During an interview on 3/31/2023 at 2:55 p.m. the SW said she had called the vascular specialist's office approximately 2 weeks ago. The SW said the vascular specialist's office said they were booked and short-handed. During an interview on 3/31/2023 at 2:56 p.m. the ADCO said the facility had asked the primary care physician's office to send a referral to the vascular specialist. The ADCO said the vascular specialist's office had said the referral had to come from the primary care physician's office. The ADCO said she had called the vascular specialist's office to find out what information they needed for a referral and had not received a call back. The ADCO said Resident #1's right lower extremity had worsened over the past 2 weeks. The ADCO said Resident #1 was sent to the emergency room so they would be taken seriously. During an interview on 3/31/23 at 3:32 pm, the Wound Care Nurse said she did not know if a referral was sent to the vascular specialist's office for Resident #1. The Wound Care Nurse said the DCO was supposed to talk to the SW regarding the referral for Resident #1 to the vascular specialist. The Wound care nurse said the nurse practitioner said the physician's office did not send referrals and that the facility's SW needed to send the referral to the vascular specialist for Resident #1. The Wound Care Nurse said Resident #1's right leg had significantly worsened over the past month. The Wound Care Nurse said Resident #1 was placed on antibiotics for the wounds to his right toes versus being sent out to the hospital. The Wound Care Nurse said Resident #1 was seen by the wound care nurse practitioner every Thursday at the facility. The Wound Care Nurse said Resident #1 did not have any discoloration to his legs but had pitting edema to both legs. The Wound Care Nurse said Resident #1's toes had worsened over the past month. During an interview on 4/03/2023 at 3:47 p.m. the primary care physician said he was informed of the referral for Resident #1 not being sent to the vascular specialist on 3/28/2023. The primary care physician said there was no way to know if Resident #1 had gotten into the vascular specialist if it would have prevented such an advanced right leg amputation. The primary care physician said he was aware of the wounds on Resident #1's toes. The primary care physician said he felt Resident #1 needed a referral to the vascular specialist due to the wounds on his right toes. During an interview on 4/04/2023 at 1:45 p.m. the SW said she handled referrals to mobile optometry, podiatry, hearing, and dental services. The SW said she had never done a referral to a physician or specialist. The SW said she was told by the nursing staff referrals to a physician or specialist was supposed to come from the primary care physician. The SW said she sometimes made appointments/referred residents for optometry, podiatry, hearing, and dental services in the community. The SW said she had never been trained on sending a referral to a physician or specialist. During an interview on 4/04/23 at 1:52 p.m. the ADCO said the facility did not have a process for sending referral to physicians or specialists. The ADCO said the DCO had told her it was the primary care physician's responsibility to send referrals. During an interview on 04/04/23 at 1:54 p.m. the DCO said the physician/Medical Director told the facility they did not send referrals. The DCO said the facility cannot make referrals. The DCO said there was not a process in place for making/sending referrals. During an interview on 04/04/23 at 2:00 p.m. the EDO said for referrals, the charge nurse or SW would make the appointments. The EDO said the facility did not have a policy regarding referrals to outside physicians or specialists. The EDO said if the physician/Medical Director wrote an order for a resident to see an outside physician/specialist, the facility would call to start the process of getting the appointment made. The EDO was notified on 4/04/2023 at 3:20 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The EDO was provided the Immediate Jeopardy template on 4/04/2023 at 3:22 p.m. The facility's Plan of Removal was accepted on 4/06/2023 at 8:28 a.m. and included: In Response to the facility failure to have a referral system or policy in place, the Administrator immediately created and implemented a referral policy on 4-4-23 to ensure that no additional residents are affected by poor quality of care. To ensure no other residents were affected by the facility failure of not having a referral system in place, the Director of Clinical Operations or Assistant Director of Clinical Operations has completed a review all orders on 4-4-23, for any orders requiring physician and or specialist referrals to ensure referrals are handled in a timely manner. No additional missed referrals were found. In Response to the facility failure to follow up with physician, the Medical Director, Licensed Nurses, Social Worker and wound care specialist will be provided in-service education related to the referral process policy. Inservice: Physician referral process for sending residents to a specialist or outside physician services by obtaining the Medical Director's referral order beginning on 4-4-23 to be completed by 04-4-23, by the Administrator or Assistant Director of Nurse's which includes: Referral Policy: 1. Upon receiving directions or recommendations from a provider or nurse practitioner, whether a physician or nurse practitioner, the charge nurse is to contact the Medical Director immediately and enter an order in PCC. 2. The charge Nurse to notify the Director of Nurses and/or the Assistant Director of Nurses and the Social Worker of the referral. 3. Social Worker to call in referral order, confirm insurance, obtain doctor signature on forms if needed and make appointment with Specialist and arrange for appropriate transportation. 4. Administrator to be notified if referrals are refused or denied by physician or Medical Director immediately with the reason for the denial to determine if the resident needs to be sent out to hospital for further evaluation. If it has been found the resident does not need immediate referral, the Director of Nurses will continue to monitor during daily clinical meetings with charge nurses and treatment nurses for change of condition. If a change of condition is found the physician is to be immediately notified. 5. Newly hired nurses will receive in-service from the Assist Director of Nurses regarding physician referral during orientation process, and to be included in the nurse's information book or Brain Book at nurse's station. In response to the facility failure to send a referral to the vascular specialist, the Director of Nurses, Assistant Director of Nurses and Social Worker will be provided in service to obtain the necessary information from the specialist's office, including vascular specialist, for the referral requirements needed from the physician and obtain the required signature's or orders to accommodate the requirements for the specialist to ensure there are no delays in resident's delay in care. In-service provided to Director of Nurses, Assistant Director of Nurses, and Social Worker 04/04/23 by Administrator to be completed by 04/04/23. Validation/Monitoring Tools Director of Clinical Operations or Designee will validate staff knowledge base through random questioning. Director of Clinical Operations or designee will review any referral orders documented by reviewing orders in daily stand up meeting and clinical meetings to ensure appointments are being made, beginning 4-4-21. Director of Clinical Operations or designee has called to follow up with Resident affected by the Failure of Quality of Care 4-4-23. Information obtained was that the resident received an above knee amputation and is being discharged to another skilled nursing facility for rehab. On 4/06/2023 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the chart audits for residents who had been referred to outside providers in March 2023 was performed with no other issues noted. Record review of the facility's undated Referral Policy was performed. The Referral Policy indicated the facility's newly implemented steps in ensuring referrals were made to outside providers in a timely manner. Record review of the facility's Brain Book located at the nurse's station indicated the referral policy had been added into the book and was available to the nursing staff at all times for reference. Record review and signature verification was performed on in-services dated 3/30/23 through 4/13/23 regarding the facility's Referral Policy Interviews of staff on 4/04/2023 between 11:03 a.m. and 11:48 a.m. (LVN A, RN B, LV C, RN D, RN E, ADCO, LVN F, SW, MDS nurse, Wound Care Nurse, and DON) were performed. During the interviews staff were able to correctly identify the process for referrals per the facility's Referral Policy. Interview with the Medical Director and nurse practitioner on 4/04/23 between 11:38 a.m. and 11:41 a.m. regarding the facility's referral policy indicated they had received and agreed with facility's Referral Policy. Both the Medical Director and nurse practitioner said this policy would help ensure residents received appointments and were seen by outside providers and specialists. On 4/06/2023 at 11:51 a.m., the EDO was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 3 (Resident #1) residents reviewed for quality of care. 1. The Facility Failed to follow-up with the physician regarding referral ordered 3/02/23 to the vascular specialist in a timely manner resulting in Resident #1 not being seen by the vascular specialist and having an above the knee amputation of the right leg on 3/31/23. 2. The facility failed to send a referral to the vascular specialist resulting in Resident #1 not being seen by the vascular specialist and having an above the knee amputation of the right leg on 3/31/23. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 4/04/23 at 3:00 p.m. While the IJ was removed on 4/06/23, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of harm or death related to not receiving proper care or death by not being seen by a specialist or another physician as ordered by their primary physician. Findings Include: 1. Record review of the face sheet dated 4/05/2023 indicated Resident #1 was admitted to the facility on [DATE] with diagnoses including COPD (a group of lungs diseases that block airflow and make it difficult to breathe), atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and difficulty walking. Record review of the physician orders dated 4/05/2023 indicated Resident #1 had an order for wound care to the right toes to cleanse with normal saline, pat dry, apply betadine moistened gauze, apply calcium alginate (a dressing used on moderate to heavy draining wounds during the transition from debridement to repair phase of wound healing) daily and as needed for wound care and infection prevention starting on 3/22/2023. Record review of the MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS of 11 and was moderately cognitively impaired. The MDS indicated Resident #1 did not reject evaluation or care. The MDS indicated Resident #1 required extensive assistance with bed mobility, transferring, toileting, personal hygiene, and dressing. Record review of an undated care plan indicated Resident #1 had impaired cognitive function or impaired thought process related to impaired decision-making abilities. Record review of the nursing progress note dated 2/28/2023 written by LVN F indicated nursing staff was having difficulty locating Resident #1's pedal pulse (foot pulse) to the right lower extremity. The nursing progress note indicated Resident #1's capillary refill was less than 3 seconds to right foot, excluding the second toe. The nursing progress note indicated a new order was received for Resident #1 to have a venous and arterial doppler to the right lower extremity. Record review of the right lower extremity arterial doppler (an ultrasound exam of the arteries on the legs that can help evaluate whether there are blockages caused by plaque in the arteries) report dated 3/01/2023 indicated Resident #1 had moderated atherosclerotic cardiovascular disease. Record review of the right lower extremity venous doppler (an ultrasound exam that evaluates blood as it flows through a blood vessel including the body's major arteries and veins) report dated 3/01/2023 indicated Resident #1 had superficial thrombophlebitis (an inflammatory disorder of superficial veins with coexistent venous thrombosis (blood clot)) of the greater saphenous vein and no deep vein thrombosis Record review of the nursing progress note dated 3/02/2023 written by the Wound Care Nurse indicated Resident #1's doppler results were sent to the primary care physician. The nursing progress note indicated the primary care physician said Resident #1 needed a referral to a vascular specialist. The nursing progress note indicated the nurse on the floor was aware of the referral and would complete the task. Record review of the nursing progress note dated 3/03/2023 written by the Wound Care Nurse indicated the vascular specialist office was called to make an appointment for Resident #1, The nursing progress note indicated a voicemail was left at the vascular specialist's office and the facility was awaiting a phone call back. Record review of the nursing progress note dated 3/07/2023 written by RN B indicated Resident #'1 family reported the dressing to Resident #1's right foot was dirty and leaking pus. The nursing progress note indicated upon inspection Resident #1's dressing to his right foot was clean, dry, and intact. The nursing progress note indicated Resident #1's dressing to his right foot was freshly changed by the treatment nurse. The nursing progress noted indicated Resident #1 did not have any pus noted. Record review of the nursing progress note dated 3/10/2023 written by LVN A indicated a new order was received for the nurse practitioner for Resident #1 to start antibiotic therapy related to Resident #1's right foot being red and warm to the touch. Record review of the nursing progress note dated 3/13/2023 written by the Wound Care Nurse indicated the facility had spoken with the vascular specialist's office on 3/09/23 regarding the previous voicemail left concerning Resident #1 getting an appointment. The nursing progress note indicated the vascular specialist's office would let the facility know by the end of the day or by the next day if a referral was received. The nursing progress noted indicated the vascular specialist's office did not call back. The nursing progress note indicated the referral was discussed with the nurse practitioner on 3/10/2023. The nursing progress note indicated the nurse practitioner said the primary care physician's office did not do the referrals, but that it should be the facility's social worker who sends the referral. The nursing progress note indicated the social worker was not aware of what was needed for the referral. The nursing progress note indicated the nurse practitioner and the DCO were notified due to Resident #1's right lower extremity. The nursing progress note indicated the facility talked with the vascular specialist's office and the vascular specialist's office said they had not received a referral for Resident #1. The nursing progress note indicated the DCO was notified and will take care of it. Record review of the nursing progress note dated 3/18/2023 written by LVN G indicated Resident #1 was lying in bed, hanging his right leg off the bed. The nursing progress note indicated Resident #1 said he did not want his leg up. The nursing progress note indicated Resident #1 said his leg felt better hanging off the bed. The nursing progress note indicated Resident #1 was encouraged to elevate his right leg due to edema. The nursing progress note indicated Resident #1 chose not to elevate his leg. Record review of the nursing progress note dated 3/28/2023 written by LVN F indicated Resident #1's right foot and toes were looking significantly worse. The nursing progress note indicated orders were received to transport Resident #1 to the emergency room for further evaluation and treatment. Record review of the hospital records dated 3/28/23 indicated the chief complaint for Resident #1's emergency room visit was wound check. The hospital records indicated the toenail on the 4th right toe came off and the facility staff noted a hole in the toe. The hospital records indicated Resident #1 had dressed wounds to Lt foot. The hospital records indicated Resident #1 had erythema (reddening) and significant discoloration of all toes on right foot with foul smell. The hospital records indicated Resident #1 had ulcers on the 3rd and 4th toes on right foot. The hospital records indicated Resident #1 had decreased sensation to right foot. Record review of the hospital records dated 3/30/23 indicated Resident #1 was admitted from the facility with necrotic right foot and toes. The hospital records indicated Resident #1 was scheduled for an above the knee amputation on 3/31/2023. Record review of the hospital records last reviewed on 3/31/2023 indicated Resident #1's problem list included cellulitis and abscess of the toe on the right foot noted on 3/282023, peripheral vascular disease noted on 3/28/2023, skin ulcer of the bilateral feet noted on 3/28/2023, venous stasis (a condition in which veins have problems moving blood back to the heart) noted on 3/28/2023, and peripheral arterial disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) noted on 3/30/2023. During an interview on 3/31/23 at 2:25 pm the receptionist at the venous specialist's office said they had never seen Resident #1. The receptionist at the vascular specialist's office said they did not have Resident #1 in their computer system and had no record of a referral. During an interview on 3/31/23 at 2:29 pm the nurse practitioner said the referral for Resident #1 to see a vascular specialist was regarding vascular issues and arterial blockages. The nurse practitioner said she was unsure how advanced Resident #1's arterial/venous damage was at that time. The nurse practitioner said she would not be comfortable saying whether seeing the vascular specialist would have prevented Resident #1 from such an advanced amputation to right leg. During an interview on 3/31/2023 at 2:50 p.m. LVN F said she did not see Resident #1's feet often due to them being wrapped in wound dressing. LVN F said Resident #1 had edema to his bilateral feet. LVN F said the right foot was bluish in color at the beginning of March 2023. LVN F said Resident #1's family had asked his feet approximately 2 weeks prior. LVN F said she performed a dressing change on Resident #1's feet when the family had asked about his feet. LVN F said Resident #1's feet were a reddish/blue color and more swollen when she did the dressing changes approximately 2 weeks ago. During an interview on 3/31/2023 at 2:55 p.m. the SW said she had called the vascular specialist's office approximately 2 weeks ago. The SW said the vascular specialist's office said the were booked and short-handed. During an interview on 3/31/2023 at 2:56 p.m. the ADCO said the facility had asked the primary care physician's office to send a referral for Resident #1 to the vascular specialist. The ADCO said the vascular specialist's office had said the referral had to come from the primary care physician's office. The ADCO said she had called the vascular specialist's office to find out what information they needed for a referral and had not received a call back. The ADCO said Resident #1's right lower extremity had worsened over the past 2 weeks. The ADCO said Resident #1 was sent to the emergency room so they would be taken seriously. During an interview on 3/31/23 at 3:32 pm the Wound Care Nurse said she did not know if a referral was sent to the vascular specialist's office for Resident #1. The Wound Care Nurse said the DCO was supposed to talk to the SW regarding the referral for Resident #1 to the vascular specialist. The Wound care nurse said the nurse practitioner said the physician's office did not send referrals and that the facility's SW needed to send the referral to the vascular specialist for Resident #1. The Wound Care Nurse said Resident #1's right leg had significantly worsened over the past month. The Wound Care Nurse said Resident #1 was placed on antibiotics for the wounds to his right toes versus being sent out to the hospital. The Wound Care Nurse said Resident #1 was seen by the wound care nurse practitioner every Thursday at the facility. The Wound Care Nurse said Resident #1 did not have any discoloration to his legs but had pitting edema to both legs. The Wound Care Nurse said Resident #1's toes had worsened over the past month. During an interview on 4/03/2023 at 3:47 p.m. the primary care physician said he was informed of the referral for Resident #1 not being sent to the vascular specialist on 3/28/2023. The primary care physician said there was no way to know if Resident #1 had gotten into the vascular specialist if it would have prevented such an advanced right leg amputation. The primary care physician said he was aware of the wounds on Resident #1's toes. The primary care physician said he felt Resident #1 needed a referral to the vascular specialist due to the wounds on his right toes. During an interview on 4/03/2023 time unknown the wound care nurse practitioner said she had seen Resident #1 a week and half ago. The wound care nurse practitioner said she was not aware of any of the issues with Resident #1's right foot/toes at the time or the infections. The wound care nurse practitioner said she did not remember any redness or signs of infections to Resident #1's right toes. The wound care nurse practitioner said Resident #1's right foot did not have a pulse. The wound care nurse practitioner said she did not think Resident #1 needed to go to the hospital, but Resident #1 did need a vascular consult During an interview on 4/04/2023 at 1:45 p.m. the SW said she handled referrals to mobile optometry, podiatry, hearing, and dental services. The SW said she had never done a referral to a physician or specialist. The SW said she was told by the nursing staff referrals to a physician or specialist was supposed to come from the primary care physician. The SW said she sometimes made appointments/referred residents for optometry, podiatry, hearing, and dental services in the community. The SW said she had never been trained on sending a referral to a physician or specialist. During an interview on 4/04/23 at 1:52 p.m. the ADCO said the facility did not have a process for sending referral to physicians or specialists. The ADCO said the DCO had told her it was the primary care physician's responsibility to send referrals. During an interview on 04/04/23 at 1:54 p.m. the DCO said the physician/Medical Director told the facility they did not send referrals. The DCO said the facility cannot make referrals. The DCO said there was not a process in place for making/sending referrals. During an interview on 04/04/23 at 2:00 p.m. the EDO said for referrals the charge nurse or SW would make the appointments. The EDO said the facility did not have a policy regarding referrals to outside physicians or specialists. The EDO said if the physician/Medical Director wrote an order for a resident to see an outside physician/specialist the facility would call to start the process of getting the appointment made. Record review of the facility's Change in Condition or Status policy last revised May 2017 indicated, .The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): .significant change in the resident's physical/emotional/mental condition .need to transfer the resident to a hospital or treatment center . The EDO was notified on 4/04/2023 at 3:20 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The EDO was provided the Immediate Jeopardy template on 4/04/2023 at 3:22 p.m. The facility's Plan of Removal was accepted on 4/06/2023 at 8:28 a.m. and included: In Response to the facility failure to have a referral system or policy in place, the Administrator immediately created and implemented a referral policy on 4-4-23 to ensure that no additional residents are affected by poor quality of care. To ensure no other residents were affected by the facility failure of not having a referral system in place, the Director of Clinical Operations or Assistant Director of Clinical Operations has completed a review all orders on 4-4-23, for any orders requiring physician and or specialist referrals to ensure referrals are handled in a timely manner. No additional missed referrals were found. In Response to the facility failure to follow up with physician, the Medical Director, Licensed Nurses, Social Worker and wound care specialist will be provided in-service education related to the referral process policy. Inservice: Physician referral process for sending residents to a specialist or outside physician services by obtaining the Medical Director's referral order beginning on 4-4-23 to be completed by 04-4-23, by the Administrator or Assistant Director of Nurse's which includes: Referral Policy: 1. Upon receiving directions or recommendations from a provider or nurse practitioner, whether a physician or nurse practitioner, the charge nurse is to contact the Medical Director immediately and enter an order in PCC. 2. The charge Nurse to notify the Director of Nurses and/or the Assistant Director of Nurses and the Social Worker of the referral. 3. Social Worker to call in referral order, confirm insurance, obtain doctor signature on forms if needed and make appointment with Specialist and arrange for appropriate transportation. 4. Administrator to be notified if referrals are refused or denied by physician or Medical Director immediately with the reason for the denial to determine if the resident needs to be sent out to hospital for further evaluation. If it has been found the resident does not need immediate referral, the Director of Nurses will continue to monitor during daily clinical meetings with charge nurses and treatment nurses for change of condition. If a change of condition is found the physician is to be immediately notified. 5. Newly hired nurses will receive in-service from the Assist Director of Nurses regarding physician referral during orientation process, and to be included in the nurse's information book or Brain Book at nurse's station. In response to the facility failure to send a referral to the vascular specialist, the Director of Nurses, Assistant Director of Nurses and Social Worker will be provided in service to obtain the necessary information from the specialist's office, including vascular specialist, for the referral requirements needed from the physician and obtain the required signature's or orders to accommodate the requirements for the specialist to ensure there are no delays in resident's delay in care. In-service provided to Director of Nurses, Assistant Director of Nurses, and Social Worker 04/04/23 by Administrator to be completed by 04/04/23. Validation/Monitoring Tools Director of Clinical Operations or Designee will validate staff knowledge base through random questioning. Director of Clinical Operations or designee will review any referral orders documented by reviewing orders in daily stand up meeting and clinical meetings to ensure appointments are being made, beginning 4-4-21. Director of Clinical Operations or designee has called to follow up with Resident affected by the Failure of Quality of Care 4-4-23. Information obtained was that the resident received an above knee amputation and is being discharged to another skilled nursing facility for rehab. On 4/06/2023 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the chart audits for residents who had been referred to outside providers in March 2023 was performed with no other issues noted. Record review of the facility's undated Referral Policy was performed. The Referral Policy indicated the facility's newly implemented steps in ensuring referrals were made to outside providers in a timely manner. Record review of the facility's Brain Book located at the nurse's station indicated the referral policy had been added into the book and was available to the nursing staff at all times for reference. Record review and signature verification was performed on in-services dated 3/30/23 through 4/13/23 regarding the facility's Referral Policy Interviews of staff on 4/04/2023 between 11:03 a.m. and 11:48 a.m. (LVN A, RN B, LVN C, RN D, RN E, ADCO, LVN F, SW, MDS nurse, Wound Care Nurse, and DON) were performed. During the interviews staff were able to correctly identify the process for referrals per the facility's Referral Policy. Interview with the Medical Director and nurse practitioner on 4/04/23 between 11:38 a.m. and 11:41 a.m. regarding the facility's referral policy indicated they had received and agreed with facility's Referral Policy. Both the Medical Director and nurse practitioner said this policy would help ensure residents received appointments and were seen by outside providers and specialists On 4/06/2023 at 11:51 a.m., the EDO was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to immediately inform the physician when there was a significant change in the resident's physical and mental status for 1 of 6 residents whose records were reviewed for change in condition. (Resident #1) 1. The facility failed to notify the physician Resident #1 was not receiving her indefinitely prescribed antibiotic related to vertebral [CONDITION(S)]. 2. The facility failed to notify the physician Resident #1 did not receive her vertebral x-ray that was ordered related to her complaints of severe back pain. 3. The facility failed to notify the physician Resident #1 had pressure wounds to her feet and a surgical wound over her lumbar spine, upon her admission to the facility. An Immediate Jeopardy (IJ) situation was identified on 11/04/22 at 12:50 p.m. While the IJ was removed on 11/06/22 at 2:50 p.m., the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures resulted in the resident not receiving urgent medical care and resulted in death. Findings included: Record review of Resident #1's face sheet, with a print date of 11/07/22, indicated she was [AGE] years old, admitted on [DATE], readmitted on [DATE] and discharged on [DATE]. She had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's hospital history and physical, with an admitted [DATE], indicated she had lumbar surgery in May 2022, but did not give the exact date. Her wound became infected, and she was readmitted to the hospital in July 2022 for removal of hardware in her spine. Blood cultures were positive for [CONDITION(S)] (a bacteria that is resistant to most antibiotics and causes hard to treat infections) and she was placed on antibiotics. After a few more re-hospitalization s, she was diagnosed with [CONDITION(S)] and underwent another surgery to stabilize her spine. An active drug list sent to the facility from the hospital on 09/23/22, indicated she was on [MEDICATION(S)] 100mg and was to receive it long term. The orders did not indicate she was to follow up with any physician and did not address wound care or monitoring of wounds. Record review of Resident #1's baseline care plan, completed on 09/27/22 by the interim-DON indicated she had no wounds or skin alterations. Record review of Resident #1's admission MDS, dated [DATE], indicated she had adequate hearing and vision, could understand and was understood by others, and had intact cognition. She exhibited behavioral symptoms not directed at others from 1 to 3 days of the look back period and she disrupted the living environment of others. She was totally dependent on two staff members with bed mobility, transfers, walking, dressing and toileting. She utilized a wheelchair for mobility. She was documented as not having surgery 100 days prior to admission, being at risk for pressure sores, but not having any pressure sores or surgical wounds. The MDS also did not indicate she had received antibiotics within the first 7 days of her stay. Record review of Resident #1's care plan, with an admitted [DATE], indicated she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The skin conditions were marked as surgical incision, surgical wound and open [CONDITION(S)] other than stasis/venous areas. Interventions included treating per physician orders, monitor areas for increased breakdown or infection, monitor for and treat pain per physician orders, and assess skin weekly and record findings in the clinical record. Record review of Resident #1's order summary report, indicated active orders as of 11/07/22 included orders for three areas to her lumbar spine to be cleansed with normal saline, dried, treated with collagen and honey, and dressed once a day. Orders for the areas were entered on 10/27/22. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's order summary report, indicated discontinued orders as of 10/01/22 through 10/28/22 included the following orders: *[MEDICATION(S)] 100mg capsules twice a day and give long term, ordered on 9/27/22 and an end date of 10/03/22. *[MEDICATION(S)] [MEDICATION(S)] 100mg tablet twice a day was ordered on 10/21/22 and ended on 10/21/22. *[MEDICATION(S)] 100mg capsules twice a day was ordered on 10/21/22 with a start date of 10/26/22. *an x-ray to her lumbar spine for severe pain was ordered on 10/08/22 and ended on 10/11/22. Record review of Resident #1's September MAR, indicated she did not receive [MEDICATION(S)] through 09/01/22 to 09/30/22. Record review of Resident #1's October MAR, indicated she began receiving [MEDICATION(S)] 100mg capsules on 10/26/22 at 9 p.m. Record review on 11/03/22 at 3:00 p.m. of the facility drug destruction log revealed no record of Resident #1's [MEDICATION(S)] being destroyed within the past month. Record review of Resident #1's admission assessment, dated 09/27/22 and completed by LVN A, indicated she had a surgical incision to her upper-mid vertebrae, a pressure wound to the outer side of her left foot and the inner side of her left foot. The assessment did not indicate the size or condition of the wounds. Record review of Resident #1's weekly skin assessment, dated 09/27/22 and completed by LVN A, indicated she had a post-surgical site to her mid lumbar with 2 sutures noted, and a small area to the mid-site. The wound was covered with a dressing and tape. The two wounds to her left foot were covered with a foam dressing. The assessment did not indicate the size or condition of the wounds. Record review of Resident #1's electronic chart throughout the duration of the investigation between 11/01/22 to 11/9/22 revealed no other weekly skin assessments during her stay in the facility. Record review of a nurse's note, written by LVN A and dated 09/27/22 at 12:45 p.m. indicated Resident #1 was just admitted to the facility from the hospital. LVN A completed a head-to-toe assessment on the resident and wrote see assessments. The resident was described as alert and oriented, in no pain, and her medications were on order. The note did not indicate the resident having a surgical incision to her back or pressure wounds to her left foot. Record review of the 24-hour report dated 09/27/22 indicated Resident #1 admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The report did not indicate her surgical incision or the wounds to her feet. Record review of the 24-hour report dated 09/29/22 indicated Resident #1 yelled out all shift on the day shift. The night shift indicated she had [CONDITION(S)] of the vertebra. Record review of a nurse's note, written by LVN A and dated 09/30/22 at 3:27 p.m., indicated Resident #1 had nausea and vomiting caused by coughing. A COVID test was conducted, and she was found to be positive. Isolation and contact precautions were to be initiated. Record review of the 24-hour report dated 09/30/22 revealed no report found. Record review of the 24-hour report dated 10/01/22, during Resident #1's COVID isolation, indicated she changed rooms to 314. Record review of Resident #1's weekly skin assessment, dated 10/04/22 and completed by agency LVN B, indicated she had no surgical wounds, pressure wounds, or skin alterations. Record review of a nurse's note, written by agency LVN C and dated 10/08/22 at 1:10 p.m., indicated Resident #1 was yelling out, had increased agitation/anxiety, was throwing things, and reporting pain to her lower back. The physician gave an order to x-ray her lumbar spine related to severe pain. Record review of the 24-hour report dated 10/08/22, during Resident #1's COVID isolation, indicated she was to receive an x-ray to the lumbar spine on the day shift. She continued to yell out constantly on the night shift. Record review of the 24-hour report dated 10/09/22, during Resident #1's COVID isolation, indicated they were still awaiting the x-ray to her spine. Record review of the 24-hour report book on 11/03/22 at 4:00 p.m., revealed no other COVID wing 24-hour reports except for 10/01/22, 10/08/22 and 10/09/22. Record review of a nurse's note, written by agency LVN D and dated 10/10/22 at 3:26 a.m., indicated Resident #1 was continuing to yell out, banging on the walls, and yelling for staff to help her. LVN D indicated the resident was still awaiting the x-ray to her lumbar spine related to frequent pain. Record review of Resident #1's physician consult note, with an admitted [DATE], indicated she admitted for hospice and was to continue [MEDICATION(S)] [MEDICATION(S)] 100mg twice a day upon discharge and was to be on hospice services. The ID Physician who had previously treated Resident #1 indicated in her progress notes on 10/20/22, that the resident had discharged from the hospital on antibiotics with instructions to continue them indefinitely due to recurrent back infections. The physician also indicated the resident had gone off the antibiotics while residing in the facility. The paperwork did not indicate the condition of the resident's wounds, only wound care orders, and the resident's family wanted her to begin hospice care. Record review of a nurse's note, written by LVN A and dated 10/21/22 at 12:00 p.m., indicated Resident #1 was readmitted to the facility on hospice services. She was described as having discoloration to her heels, the dehisced wound over her lumbar vertebrae, and two open areas to her buttocks. Record review of Resident #1's readmission assessment, dated 10/21/22 and completed by LVN A, indicated she had a surgical incision to her upper-mid vertebrae, a pressure wound to her sacrum (the base of the spine, helping to form the pelvis), and vascular wounds to her left and right heels. The assessment did not indicate the size or condition of the wounds. Record review of Resident #1's discharge MDS, dated [DATE], indicated she had short-term memory problems, moderately impaired decision-making skills, and continued to exhibit behaviors not directed at others. She was totally dependent on staff for all ADLs, except for eating, which required only supervision. She was again documented as not having skin concerns or wounds, and as not receiving an antibiotic in the past 7 days. During an interview on 11/01/22 at 2:10 p.m. with RN F and LVN A, RN F said she had issues earlier in the day, on 11/01/22, while putting in orders for [MEDICATION(S)] [MEDICATION(S)] for a different resident. She said the pharmacy automatically kicked out the order and wanted to switch it to [MEDICATION(S)] instead. She said she had been looking for the order and realized it was no longer there, then she realized the pharmacy had sent the new order for her to confirm. She said because LVN A was an LVN, she could not confirm orders, only RNs could. She said LVN A would have put in the [MEDICATION(S)] order and then when an order change confirmation came in, the DON would have to approve it since she was an RN. LVN A said Resident #1 admitted and very quickly into her stay was sent to the COVID unit. She said she did not know if anything was done for the resident, such as skin assessments, wound care, and medication administration. The nurses said they did not have a wound care nurse and had do their own treatments on their halls. During an interview on 11/01/22 at 3:52 p.m. CNA E said she had worked with Resident #1 on the COVID hall. She denied observing any wounds on her back because on the COVID hall the resident would scream when touched and she would not turn all the way over. She said the night she found the wound on her back, 10/18/22, the resident had been complaining of pain from not having a bowel movement. The nurse gave the resident a [MEDICATION(S)] and later, the resident told the aide she had gone to the bathroom and needed to be changed. The aide went to change her, and saw the sheets were soiled and it was a very substantial amount. She said she believed the resident felt the wetness from her wound and thought it was a bowel movement. She said she initially thought it was a bowel movement as well, until she rolled the resident all the way over and saw the wound. The wound was purple and covered by the flaps of skin due to her obesity. She said when she pulled the resident's skin taught, she could physically see into the wound and large amounts of drainage came out with even minor touch. She said the drainage was chunky and gritty and was a yellowish-green tint, like a snot color, and it smelled. She said agency LVN B was unaware of the wound and looked in the chart to see if any wound care had been ordered for the wound but did not find any. She said LVN B sent the resident out because of the state of the wound. She said before the resident went to the hospital, she was cognitive and knew the aide's name and was with it, but after the hospital she did not know anyone and was no longer cognitively intact and would just holler out for help. During an interview on 11/01/22 at 4:18 p.m. CNA G said she did not remember Resident #1 having any wounds to her back or any wounds at all. She said she was never aware the resident had a surgical incision over her spine and had never been told of any wounds. She said she was not very familiar with the resident and only worked with her maybe 4 or 5 times during the resident's stay. During a phone interview on 11/01/22 a 4:30 p.m. agency LVN B said she had been going back and forth between days and nights. She said the 6a-2p was supposed to do most of the wound care. She said Resident #1 was obese and flabby and a skin fold on her back covered the wound. She said she had to pick up the fold and pull her skin taught, all while the resident was screaming and swinging at staff. She said the wound was pretty long because it was a surgical incision, but she did not know how long for sure. She said maybe a quarter of her spine. She said when she pulled the skin back, dark brown drainage poured out of it. She said she went back to look at the resident's chart and saw she had [CONDITION(S)] in her spine before she came to the facility. She said the drainage did not have an odor and the wound did not appear to be red or swollen. She said she did not remember the skin assessment she did for the resident on 10/04/22, but if she documented the resident had no wounds, she must have looked the resident over completely. She said she remembered the last time she took care of the resident, she recalled giving the resident brown and yellow pills, which would be [MEDICATION(S)]. She said that was right before the resident left with her family on 10/28/22. During a phone interview on 11/02/22 at 9:00 a.m. the Pharmacist said the medical director had signed for therapeutic interchanges to be made whenever an order was put in for a wrong medication. For example, if the doctor ordered [MEDICATION(S)] and staff entered [MEDICATION(S)] [MEDICATION(S)], the system would kick out the order for [MEDICATION(S)] and enter a new order for the [MEDICATION(S)], which an RN must approve. She said the corporate office was usually the one that requested the therapeutic interchanges and if one facility under the corporation did it then most likely all facilities under that corporation did. She said there were different reasons for the therapeutic interchanges, such as cost to the facility, or ensuring the correct order was followed. She said she saw in the system where the [MEDICATION(S)] was ordered on 09/27/22 and the system changed it to [MEDICATION(S)] capsules. She said they sent out 60 pills that day. The next order for them came in on 10/21/22, they did not send any out because the refill was too soon from the last fill date. During a phone interview on 11/02/22 at 10:36 a.m. the ID physician said she was told by the family and Resident #1, at the hospital, that she had not been receiving antibiotics at the facility. She said she had wanted the resident to follow up with her, but that never happened. She was unsure why a follow up never happened, whether it was due to hospital error, facility error, or even family error. She said she could not recall what the wound looked or smelled like at the hospital when she arrived for treatment. She said she did give an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/03/22 at 2:20 p.m. LVN A said she did part of Resident #1's admission assessment and paperwork. She said she was told in report from the discharging hospital that the resident had a surgical incision over her spine. When the resident arrived at the facility, she had a dressing over the incision. The nurse did not take off the bandage because she was told wound care had been done before the resident left the hospital. She did a thorough head to toe skin assessment and noted the resident had the wound to her spine and two wounds to her feet. She said the hospital did not say anything about what kind of wound care orders they had in place at the hospital or anything about the resident following up with a physician. She said when she saw the wounds to the resident's feet and back, she should have put the orders in for wound care, but she gave all the paperwork to the ADON. The ADON said she would put all the orders in, and the oncoming shift could take care of the rest. She said if she had given the initial dose of the resident's [MEDICATION(S)], she would have followed up on it for 72 hours, so if there were no notes following up on it, then she did not administer it. During an interview on 11/03/22 at 2:55 p.m. agency LVN D said she did not remember seeing any wound care orders for Resident #1 and did not remember seeing any wounds when she would do incontinent changes for her on the COVID wing. She said the resident was bad at turning and could not turn all the way over. She said she did not remember if the resident was on an antibiotic or not. During a phone interview on 11/03/22 at 4:00 p.m. agency LVN H said she did not remember Resident #1 having wounds while she worked the COVID wing. She said she did not remember the resident being on an antibiotic while she worked the COVID wing. During a phone interview on 11/03/22 at 4:05 p.m. agency LVN J said she did not ever remember doing wound care on Resident #1 while she worked the COVID wing. She did not remember if the resident was on an antibiotic or not. During a phone interview on 11/03/22 4:10 p.m. agency LVN K said she could not say for sure if Resident #1 had wounds while she worked the COVID wing. She said she did not remember if the resident took an antibiotic. She said she just remembered the resident yelling out and when they would go in her room, she would say she had not been yelling and did not need anyone to come in there. During an interview on 11/03/22 at 4:25 p.m. with the ADON and interim-DON, the ADON said she was not aware of Resident #1 having any wounds to her feet but did know she had a wound to her spine. She said she helped LVN A put the orders in and since she did not see any orders for wound care or for following up with a physician, she did not put any in. The ADON and the interim-DON said they were both unaware no one followed up on getting her wound care or to follow up with a physician. They also were unaware the pharmacy kept kicking out the [MEDICATION(S)] orders and the LVNs could not see the orders were being kicked out automatically and then resubmitted. They both denied knowing about the resident not receiving her antibiotics until 10/26/22. The interim-DON said she could not find the resident's x-ray of her back and it appeared the x-ray was never obtained. During a phone interview on 11/04/22 at 10:30 a.m. Resident #1's Physician said he was not aware of the resident not receiving wound care to her feet or her back. He was also not aware of her not receiving her [MEDICATION(S)]. He said he had not received the results of the x-ray to her back and had not been aware the x-ray was not obtained. He said had he known all this information, he would have made sure staff were giving her the ordered antibiotics, obtained the spinal x-ray, and gotten her into the ID for follow up. He said he believed she was seen by (ID physician's name) and was not aware the facility had never made a follow up appointment. During a phone interview on 11/05/22 at 10:19 a.m. agency LVN C said she did not remember if Resident #1 had wounds anywhere on her body. She said the resident would not let them turn her all the way over, so she did not know if the resident had any wounds to her back. She said the physician did order an x-ray for the resident's lumbar spine on 10/08/22 since she was complaining of pain to her there. She said the resident said she had pain to her back but then would not let them reposition her or turn her all the way over. She said she worked the 6a to 2p shift on 10/08/22 and then had to come back to work a 10p to 6 a shift. She said when she came back that night, she saw where the x-ray result was not received so she called the x-ray company to see where the results were. She said when she called the x-ray company , the on-call operator said the system had been out and he was not able to see anything on his end but would send a message to the x-ray technician. She said the technician never came on her shift and she notified the 6a to 2p nurse, the morning of 10/09/22 that the x-ray technician had not come and to call and follow up with the x-ray company about getting it done that day. During a phone interview on 11/08/22 at 3:28 p.m. LVN L denied ever being notified about an x-ray for Resident #1's back pain. She said the resident was always yelling out due to her psychological issues. She did not remember the resident having any wounds to her feet or her back. She denied anyone ever notifying her of the resident having a surgical wound to her back. Record review of the facility's Change in a Resident's Condition or Status policy indicated, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care .resident rights, etc.) . Policy Interpretation and Implementation 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): . .d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; . .g. need to transfer the resident to a hospital/treatment center; . Record review of the facility's General Guidelines for Medication Administration policy indicated, .6. If a dose of regularly scheduled medication is withheld, refused, or given at a time other than the scheduled time (e.g., the resident is not in the facility at a scheduled time or a started dose of an antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record. If 3 consecutive doses, or in accordance with facility policy, of a vital medication are withheld, refused, or not available, the physician is notified. Nursing documents the notification and physician response. An Immediate Jeopardy (IJ) was identified on 11/04/22 at 12:50 p.m., due to the above failures. The Administrator and DON were notified of the IJ and the IJ template was provided on 11/04/22 at 1:09 p.m. During an interview on 11/04/22 at 1:09 p.m. with the interim-DON, ADON and Administrator, the interim-DON and ADON both indicated they had not been aware of Resident #1's skin assessment on 10/04/22 not reflecting her wounds. The interim-DON said she documented the resident had no skin alterations because she did not know the resident had any skin issues. She said she could only go by what the LVN A had documented, and she didn't see any documentation about wounds. The interim-DON said she accepted the resident's change in [MEDICATION(S)] when she saw it was in the system awaiting approval. She did not realize the resident's [MEDICATION(S)] had been pending approval since 10/21/22 and was not approved by her until 10/26/22. She said she approved orders as they popped up in the system, but she did not realize they were popping up due to therapeutic interchanges. She said the reason it took her until 10/26/22 to approve the [MEDICATION(S)] was because she left the building on 10/21/22 and did not return until 10/26/22. The following Plan of Removal submitted by the facility was accepted on 11/06/22 at 8:52 a.m. and included the following: 11-4-22 Neglect Plan of Action Resident in question (Resident #1) that did not receive her antibiotics as ordered and is no longer in the building. A chart review of her pharmacy orders and therapeutic interchange was completed by the Director of Clinical Operations to review what transpired. At the time a new Director of Nurses in training was to review orders and failed to confirm new antibiotic orders. Audit of all medications compared to current orders for all residents in house was completed on 11/05/22 to ensure that no other residents have missed medications. Director of Clinical Operations, Assistant Director of Clinical Operations, Clinical Reimbursement Coordinator and Treatment Nurse reviewed clinical records for residents with wounds to ensure documented notification of family and physician. Director of Clinical Operations, Assistant Director of Clinical Operations, will review all x-rays ordered with over the last six months to ensure follow thru and notification of findings. The Director of Clinical Operations, Assistant Director of Clinical Operations, Treatment Nurse and All Licensed Nurses will be provided in-service education related to Notification of Change, including any signs and symptoms of worsening infections beginning on 11-4-22 by Director of Clinical Operations or designee which includes: 1. Physician must be notified of any new orders that were not written by the physician within 2 hours of admission or re-admission via phone. 2. Physician must be notified of any missed dosages of medication as prescribed no later than 3 missed doses as per policy. See attached. 3. Physician must be notified of any wounds present on admission or readmission and or wound orders within 2 hours of admission or re-admission via phone. 4. Physician to be notified of any change in medical conditions including worsening infections, falls, or medical changes withing 2 hours of assessment. See Monitoring form for changes in condition attached. The Director of Clinical Operations, Assistant Director of Clinical Operations, Treatment Nurse, and licensed nurses to be provided education on following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Nurses must complete orders as written. 2. If an order is not or cannot be complete physician must be notified via phone within 2 hours of receiving notification. 3. Each shift must follow up on x-ray orders until results are obtained. Newly hired nurses will receive in-services on proper physician notification processes. Validation/Monitoring Tools Director of Clinical Operations or designee will validate staff knowledge base through random questioning. Director of Clinical Operations or designee will review records for any newly admitted or readmitted resident daily in clinical meeting to ensure physician notification and appropriate follow up. Beginning 11-7-22. Director of Clinical Operations or designee will review all x-ray order daily in the clinical meeting to ensure x-rays are obtained and physician notification is completed. Admission check list form is to be completed by admitting nurse to ensure appropriate notification and completion of assessments to be initiated within 2 hours of admission. See form attached. Change in conditions check list to be utilized to ensure nurse competency with completion of assessments and physician notification. Beginning 11-7-22. On 11/06/22 from 11:40 a.m. to 2:50 p.m. the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During interviews with the RN weekend supervisor, the ADON, LVN L and LVN N between 11:45 a.m. and 2:15 p.m., staff indicated they had received adequate training regarding skin assessments, antibiotics, antibiotic orders and use of 24 hour reports. Record review of A Midnight Census Report dated 11/05/22 at 3:18 PM, by the interim-DON showed 37 Residents had been checked off as being reviewed by the DON for narcotics and all medications. Record review between 12:47 p.m. and 1:15 p.m. of staff who had received training, indicated 12 staff had been educated over the phone and stated their understanding of the education provided. During an interview on 11/02/22 at 12:47 p.m., the interim-DON said she conducted a full sweep of all 37 residents to ensure there were no new skin issues. She said she also reviewed all medications to ensure each resident had orders and medication available. The interim-DON said she also assessed each resident for pain. The interim-DON said all residents were to have a skin assessment on admission or re-admission within 2 hours. She said all nursing staff had been trained on skin assessments. She said nurses had also been trained on monitoring antibiotics for the duration of the schedule and 3 days after for any reactions. She said nurses were to notify the DON any time antibiotics are ordered. She said she is the Infection Control Preventionist for the facility at the time, until the new wound care nurse completes her training, then the new wound care nurse will take over that responsibility. Record review of PCP records between 12:47 p.m. and 1:15 p.m. showed orders were showing on the 24-hour report in the system. Paper 24-hour reports were also reviewed, and the nurses had documented new orders on the report. The Administrator and DON were informed the Immediate Jeopardy was removed on 11/06/22, at 2:50 p.m. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure treatment and care was provided based on the comprehensive assessment and in accordance with standards of practice for 1 of 6 residents reviewed for quality of care. (Resident #1) 1. The facility failed to ensure Resident #1's surgical incision to her lower back was monitored or received wound care. The surgical incision was found to be reopened, infected and draining on [DATE]. Two pressure wounds to her left foot, identified upon admission on [DATE], also never were monitored, or received treatment. 2. The resident was sent to the hospital on [DATE] when her surgical wound was found by staff and appeared to be infected. She returned to the facility on [DATE], under the care of hospice, with antibiotic orders which were not started until [DATE]. She left with her family AMA on [DATE] and expired at home on [DATE]. These failures could place residents at risk for not receiving necessary care and services to meet their needs, serious impairment, and death. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 12:50 p.m. While the IJ was removed on [DATE] at 2:50 p.m., the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure resulted in the resident not receiving urgent medical care and resulted in death. Findings included: Record review of Resident #1's face sheet, with a print date of [DATE], indicated she was [AGE] years old, admitted on [DATE], readmitted on [DATE] and discharged on [DATE]. She had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's hospital history and physical, with an admitted [DATE], indicated she had lumbar surgery in [DATE], but did not give the exact date. Her wound became infected, and she was readmitted to the hospital in [DATE] for removal of hardware in her spine. Blood cultures were positive for [CONDITION(S)] (a bacteria that is resistant to most antibiotics and causes hard to treat infections) and she was placed on antibiotics. After a few more re-hospitalization s, she was diagnosed with [CONDITION(S)] and underwent another surgery to stabilize her spine. An active drug list sent to the facility from the hospital on [DATE], indicated she was on [MEDICATION(S)] 100mg and was to receive it long term. The orders did not indicate she was to follow up with any physician and did not address wound care or monitoring of wounds. Record review of Resident #1's baseline care plan, completed on [DATE] by the interim-DON indicated she had no wounds or skin alterations. Record review of Resident #1's admission MDS, dated [DATE], indicated she had adequate hearing and vision, could understand and was understood by others, and had intact cognition. She exhibited behavioral symptoms not directed at others from 1 to 3 days of the look back period and she disrupted the living environment of others. She was totally dependent on two staff members with bed mobility, transfers, walking, dressing and toileting. She utilized a wheelchair for mobility. She was documented as not having surgery 100 days prior to admission, being at risk for pressure sores, but not having any pressure sores or surgical wounds. Record review of Resident #1's care plan, with an admitted [DATE], indicated she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The skin conditions were marked as surgical incision, surgical wound and open [CONDITION(S)] other than stasis/venous areas. Interventions included treating per physician orders, monitor areas for increased breakdown or infection, monitor for and treat pain per physician orders, and assess skin weekly and record findings in the clinical record. Record review of Resident #1's order summary report, indicated active orders as of [DATE] included orders for three areas to her lumbar spine to be cleansed with normal saline, dried, treated with collagen and honey, and dressed once a day. Orders for the areas were entered on [DATE] and no wound care orders were noted between her admission on [DATE] and her discharged on [DATE]. The resident was to receive a lumbar x-ray that was ordered on [DATE], with an end date of [DATE]. Record review of Resident #1's admission assessment, dated [DATE] and completed by LVN A, indicated she had a surgical incision to her upper-mid vertebrae, a pressure wound to the outer side of her left foot and the inner side of her left foot. The assessment did not indicate the size or condition of the wounds. Record review of Resident #1's weekly skin assessment, dated [DATE] and completed by LVN A, indicated she had a post-surgical site to her mid lumbar with 2 sutures noted, and a small area to the mid-site. The wound was covered with a dressing and tape. The two wounds to her left foot were covered with a foam dressing. The assessment did not indicate the size or condition of the wounds. Record review of Resident #1's electronic chart throughout the duration of the investigation between [DATE] to [DATE] revealed no other weekly skin assessments during her stay in the facility. Record review of a nurse's note, written by LVN A and dated [DATE] at 12:45 p.m. indicated Resident #1 was just admitted to the facility from the hospital. LVN A completed a head-to-toe assessment on the resident and wrote see assessments. The resident was described as alert and oriented, in no pain, and her medications were on order. The note did not indicate the resident having a surgical incision to her back or pressure wounds to her left foot. Record review of the 24-hour report dated [DATE] indicated Resident #1 admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The report did not indicate her surgical incision or the wounds to her feet. Record review of the 24-hour report dated [DATE] indicated Resident #1 yelled out all shift on the day shift. The night shift indicated she had [CONDITION(S)] of the vertebra. Record review of a nurse's note, written by LVN A and dated [DATE] at 3:27 p.m., indicated Resident #1 had nausea and vomiting caused by coughing. A COVID test was conducted, and she was found to be positive. Isolation and contact precautions were to be initiated. Record review of the 24-hour report dated [DATE] revealed no report found. Record review of the 24-hour report dated [DATE], during Resident #1's COVID isolation, indicated she changed rooms to 314. Record review of Resident #1's weekly skin assessment, dated [DATE] and completed by agency LVN B, indicated she had no surgical wounds, pressure wounds, or skin alterations. Record review of a nurse's note, written by agency LVN C and dated [DATE] at 1:10 p.m., indicated Resident #1 was yelling out, had increased agitation/anxiety, was throwing things, and reporting pain to her lower back. The physician gave an order to x-ray her lumbar spine related to severe pain. Record review of the 24-hour report dated [DATE], during Resident #1's COVID isolation, indicated she was to receive an x-ray to the lumbar spine on the day shift. She continued to yell out constantly on the night shift. The report did not contain any information regarding the resident's wounds to her feet or back. Record review of the 24-hour report dated [DATE], during Resident #1's COVID isolation, indicated they were still awaiting the x-ray to her spine. The report did not contain any information regarding the resident's wounds to her feet or back. Record review of the 24-hour report book on [DATE] at 4:00 p.m., revealed no other COVID wing 24-hour reports except for [DATE], [DATE] and [DATE]. Record review of a nurse's note, written by agency LVN D and dated [DATE] at 3:26 a.m., indicated Resident #1 was continuing to yell out, banging on the walls, and yelling for staff to help her. LVN D indicated the resident was still awaiting the x-ray to her lumbar spine related to frequent pain. Record review of Resident #1's physician consult note, with an admitted [DATE], indicated she admitted for hospice and was to continue [MEDICATION(S)] [MEDICATION(S)] 100mg twice a day upon discharge and was to be on hospice services. The ID Physician who had previously treated Resident #1 indicated in her progress notes on [DATE], that the resident had discharged from the hospital on antibiotics with instructions to continue them indefinitely due to recurrent back infections. The physician also indicated the resident had gone off the antibiotics while residing in the facility. The paperwork did not indicate the condition of the resident's wounds, only wound care orders, and the resident's family wanted her to begin hospice care. Record review of a nurse's note, written by LVN A and dated [DATE] at 12:00 p.m., indicated Resident #1 was readmitted to the facility on hospice services. She was described as having discoloration to her heels, the dehisced wound over her lumbar vertebrae, and two open areas to her buttocks. Record review of Resident #1's readmission assessment, dated [DATE] and completed by LVN A, indicated she had a surgical incision to her upper-mid vertebrae, a pressure wound to her sacrum (the base of the spine, helping to form the pelvis), and vascular wounds to her left and right heels. The assessment did not indicate the size or condition of the wounds. Record review of Resident #1's discharge MDS, dated [DATE], indicated she had short-term memory problems, moderately impaired decision-making skills, and continued to exhibit behaviors not directed at others. She was totally dependent on staff for all ADLs, except for eating, which required only supervision. Further review indicated the resident as not having skin concerns or wounds. During an interview on [DATE] at 2:10 p.m. LVN A said Resident #1 admitted and very quickly into her stay was sent to the COVID unit. She said she did not know if anything was done for the resident, such as skin assessments, wound care, and medication administration. The nurses said they did not have a wound care nurse and had do their own treatments on their halls. During a phone interview on [DATE] at 3:14 p.m. Resident #1's family member said she did not know if the resident was given antibiotics at the facility, but had assumed she was not given them, since her infection never got better. She said she took Resident #1 out of the facility and took her home on hospice care. She said Resident #1 died at home on [DATE]. During an interview on [DATE] at 3:52 p.m. CNA E said she had worked with Resident #1 on the COVID hall. She denied observing any wounds on her back because on the COVID hall the resident would scream when touched and she would not turn all the way over. She said the night she found the wound on her back, [DATE], the resident had been complaining of pain from not having a bowel movement. The nurse gave the resident a [MEDICATION(S)] and later, the resident told the aide she had gone to the bathroom and needed to be changed. The aide went to change her, and saw the sheets were soiled and it was a very substantial amount. She said she believed the resident felt the wetness from her wound and thought it was a bowel movement. She said she initially thought it was a bowel movement as well, until she rolled the resident all the way over and saw the wound. The wound was purple and covered by the flaps of skin due to her obesity. She said when she pulled the resident's skin taught, she could physically see into the wound and large amounts of drainage came out with even minor touch. She said the drainage was chunky and gritty and was a yellowish-green tint, like a snot color, and it smelled. She said agency LVN B was unaware of the wound and looked in the chart to see if any wound care had been ordered for the wound but did not find any. She said LVN B sent the resident out because of the state of the wound. She said before the resident went to the hospital, she was cognitive and knew the aide's name and was with it, but after the hospital she did not know anyone and was no longer cognitively intact and would just holler out for help. During an interview on [DATE] at 4:18 p.m. CNA G said she did not remember Resident #1 having any wounds to her back or any wounds at all. She said she was never aware the resident had a surgical incision over her spine and had never been told of any wounds. She said she was not very familiar with the resident and only worked with her maybe 4 or 5 times during the resident's stay. During a phone interview on [DATE] a 4:30 p.m. agency LVN B said she had been going back and forth between days and nights. She said the 6a-2p was supposed to do most of the wound care. She said Resident #1 was obese and flabby and a skin fold on her back covered the wound. She said she had to pick up the fold and pull her skin taught, all while the resident was screaming and swinging at staff. She said the wound was pretty long because it was a surgical incision, but she did not know how long for sure. She said maybe a quarter of her spine. She said when she pulled the skin back, dark brown drainage poured out of it. She said she went back to look at the resident's chart and saw she had [CONDITION(S)] in her spine before she came to the facility. She said the drainage did not have an odor and the wound did not appear to be red or swollen. She said she did not remember the skin assessment she did for the resident on [DATE], but if she documented the resident had no wounds, she must have looked the resident over completely. She said she remembered the last time she took care of the resident, she recalled giving the resident brown and yellow pills, which would be [MEDICATION(S)]. She said that was right before the resident left with her family on [DATE]. During a phone interview on [DATE] at 10:36 a.m. the ID physician said she had wanted the resident to follow up with her, but that never happened. She was unsure why a follow up never happened, whether it was due to hospital error, facility error, or even family error. She said she could not recall what the wound looked or smelled like at the hospital when she arrived for treatment. During an interview on [DATE] at 2:20 p.m. LVN A said she did part of Resident #1's admission assessment and paperwork. She said she was told in report from the discharging hospital that the resident had a surgical incision over her spine. When the resident arrived at the facility, she had a dressing over the incision. The nurse did not take off the bandage because she was told wound care had been done before the resident left the hospital. She did a thorough head to toe skin assessment and noted the resident had the wound to her spine and two wounds to her feet. She said the hospital did not say anything about what kind of wound care orders they had in place at the hospital or anything about the resident following up with a physician. She said when she saw the wounds to the resident's feet and back, she should have put the orders in for wound care, but she gave all the paperwork to the ADON. The ADON said she would put all the orders in, and the oncoming shift could take care of the rest. During an interview on [DATE] at 2:55 p.m. agency LVN D said she did not remember seeing any wound care orders for Resident #1 and did not remember seeing any wounds when she would do incontinent changes for her on the COVID wing. She said the resident was bad at turning and could not turn all the way over. During a phone interview on [DATE] at 4:00 p.m. agency LVN H said she did not remember Resident #1 having wounds while she worked the COVID wing. During a phone interview on [DATE] at 4:05 p.m. agency LVN J said she did not ever remember doing wound care on Resident #1 while she worked the COVID wing. During a phone interview on [DATE] 4:10 p.m. agency LVN K said she could not say for sure if Resident #1 had wounds while she worked the COVID wing. She said she just remembered the resident yelling out and when they would go in her room, she would say she had not been yelling and did not need anyone to come in there. During an interview on [DATE] at 4:25 p.m. with the ADON and interim-DON, the ADON said she was not aware of Resident #1 having any wounds to her feet but did know she had a wound to her spine. She said she helped LVN A put the orders in and since she did not see any orders for wound care or for following up with a physician, she did not put any in. The ADON and the interim-DON said they were both unaware no one followed up on getting her wound care or to follow up with a physician. The interim-DON said she could not find the resident's x-ray of her back and it appeared the x-ray was never obtained. During a phone interview on [DATE] at 10:30 a.m. Resident #1's Physician said he was not aware of the resident not receiving wound care to her feet or her back. He said he had not received the results of the x-ray to her back and had not been aware the x-ray was not obtained. He said had he known all this information, he would have made sure staff were giving her the ordered antibiotics, obtained the spinal x-ray, and gotten her into the ID for follow up. He said he believed she was seen by (ID physician's name) and was not aware the facility had never made a follow up appointment. During a phone interview on [DATE] at 10:19 a.m. agency LVN C said she did not remember if Resident #1 had wounds anywhere on her body. She said the resident would not let them turn her all the way over, so she did not know if the resident had any wounds to her back. She said the physician did order an x-ray for the resident's lumbar spine on [DATE] since she was complaining of pain to her there. She said the resident said she had pain to her back but then would not let them reposition her or turn her all the way over. She said she worked the 6a to 2p shift on [DATE] and then had to come back to work a 10p to 6 a shift. She said when she came back that night, she saw where the x-ray result was not received so she called the x-ray company to see where the results were. She said when she called the x-ray company , the on-call operator said the system had been out and he was not able to see anything on his end but would send a message to the x-ray technician. She said the technician never came on her shift and she notified the 6a to 2p nurse, the morning of [DATE] that the x-ray technician had not come and to call and follow up with the x-ray company about getting it done that day. During a phone interview on [DATE] at 3:28 p.m. LVN L denied ever being notified about an x-ray for Resident #1's back pain. She said the resident was always yelling out due to her psychological issues. She did not remember the resident having any wounds to her feet or her back. She denied anyone ever notifying her of the resident having a surgical wound to her back. Record review of the facility's Change in a Resident's Condition or Status policy indicated, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care .resident rights, etc.) . Policy Interpretation and Implementation 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): . .d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; . .g. need to transfer the resident to a hospital/treatment center; . An Immediate Jeopardy (IJ) was identified on [DATE] at 12:50 p.m., due to the above failures. The Administrator and DON were notified of the IJ and the IJ template was provided on [DATE] at 1:09 p.m. During an interview on [DATE] at 1:09 p.m. with the interim-DON, ADON and Administrator, the interim-DON and ADON both indicated they had not been aware of Resident #1's skin assessment on [DATE] not reflecting her wounds. The interim-DON said she documented the resident had no skin alterations because she did not know the resident had any skin issues. She said she could only go by what the LVN A had documented, and she didn't see any documentation about wounds. The interim-DON said she accepted the resident's change in [MEDICATION(S)] when she saw it was in the system awaiting approval. She did not realize the resident's [MEDICATION(S)] had been pending approval since [DATE] and was not approved by her until [DATE]. The following Plan of Removal submitted by the facility was accepted on [DATE] at 8:52 a.m. and included the following: [DATE] Neglect Plan of Action Resident in question (Resident #1) that did not receive her antibiotics as ordered and is no longer in the building. A chart review of her pharmacy orders and therapeutic interchange was completed by the Director of Clinical Operations to review what transpired. At the time a new Director of Nurses in training was to review orders and failed to confirm new antibiotic orders. Audit of all medications compared to current orders for all residents in house was completed on [DATE] to ensure that no other residents have missed medications. Director of Clinical Operations, Assistant Director of Clinical Operations, Clinical Reimbursement Coordinator and Treatment Nurse reviewed clinical records for residents with wounds to ensure documented notification of family and physician. Director of Clinical Operations, Assistant Director of Clinical Operations, will review all x-rays ordered with over the last six months to ensure follow thru and notification of findings. The Director of Clinical Operations, Assistant Director of Clinical Operations, Treatment Nurse and All Licensed Nurses will be provided in-service education related to Notification of Change, including any signs and symptoms of worsening infections beginning on [DATE] by Director of Clinical Operations or designee which includes: 1. Physician must be notified of any new orders that were not written by the physician within 2 hours of admission or re-admission via phone. 2. Physician must be notified of any missed dosages of medication as prescribed no later than 3 missed doses as per policy. See attached. 3. Physician must be notified of any wounds present on admission or readmission and or wound orders within 2 hours of admission or re-admission via phone. 4. Physician to be notified of any change in medical conditions including worsening infections, falls, or medical changes withing 2 hours of assessment. See Monitoring form for changes in condition attached. The Director of Clinical Operations, Assistant Director of Clinical Operations, Treatment Nurse, and licensed nurses to be provided education on following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Nurses must complete orders as written. 2. If an order is not or cannot be complete physician must be notified via phone within 2 hours of receiving notification. 3. Each shift must follow up on x-ray orders until results are obtained. Newly hired nurses will receive in-services on proper physician notification processes. Validation/Monitoring Tools Director of Clinical Operations or designee will validate staff knowledge base through random questioning. Director of Clinical Operations or designee will review records for any newly admitted or readmitted resident daily in clinical meeting to ensure physician notification and appropriate follow up. Beginning [DATE]. Director of Clinical Operations or designee will review all x-ray order daily in the clinical meeting to ensure x-rays are obtained and physician notification is completed. Admission check list form is to be completed by admitting nurse to ensure appropriate notification and completion of assessments to be initiated within 2 hours of admission. See form attached. Change in conditions check list to be utilized to ensure nurse competency with completion of assessments and physician notification. Beginning [DATE]. On [DATE] from 11:40 a.m. to 2:50 p.m. the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During interviews with the RN weekend supervisor, the ADON, LVN L and LVN N between 11:45 a.m. and 2:15 p.m., staff indicated they had received adequate training regarding skin assessments, antibiotics, antibiotic orders and use of 24 hour reports. Record review of A Midnight Census Report dated [DATE] at 3:18 PM, by the interim-DON showed 37 Residents had been checked off as being reviewed by the DON for narcotics and all medications. Record review between 12:47 p.m. and 1:15 p.m. of staff who had received training, indicated 12 staff had been educated over the phone and stated their understanding of the education provided. During an interview on [DATE] at 12:47 p.m., the interim-DON said she conducted a full sweep of all 37 residents to ensure there were no new skin issues. She said she also reviewed all medications to ensure each resident had orders and medication available. The interim-DON said she also assessed each resident for pain. The interim-DON said all residents were to have a skin assessment on admission or re-admission within 2 hours. She said all nursing staff had been trained on skin assessments. She said nurses had also been trained on monitoring antibiotics for the duration of the schedule and 3 days after for any reactions. She said nurses were to notify the DON any time antibiotics are ordered. She said she is the Infection Control Preventionist for the facility at the time, until the new wound care nurse completes her training, then the new wound care nurse will take over that responsibility. Record review of PCP records between 12:47 p.m. and 1:15 p.m. showed orders were showing on the 24-hour report in the system. Paper 24-hour reports were also reviewed, and the nurses had documented new orders on the report. The Administrator and DON were informed the Immediate Jeopardy was removed on [DATE], at 2:50 p.m. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assured accurate administering of all drugs to meet the needs of the residents, for 1 of 6 residents reviewed for medication regimen. (Resident #1) The facility failed to ensure Resident #1 was given her indefinitely prescribed [MEDICATION(S)] between 09/27/22 and 10/18/22 and again between 10/21/22 and 10/26/22. This failure placed residents at risk for medical complications, decreased quality of life, or even death. An Immediate Jeopardy (IJ) situation was identified on 11/04/22 at 12:50 p.m. While the IJ was removed on 11/06/22 at 2:50 p.m., the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. Findings included: Record review of Resident #1's face sheet, with a print date of 11/07/22, indicated she was [AGE] years old, admitted on [DATE], readmitted on [DATE] and discharged on [DATE]. She had diagnoses including [CONDITION(S)] of the lumbar (lower back) vertebra. Record review of Resident #1's hospital history and physical, with an admitted [DATE], indicated she had lumbar surgery in May 2022, but did not give the exact date. Her wound became infected, and she was readmitted to the hospital in July 2022 for removal of hardware in her spine. Blood cultures were positive for [CONDITION(S)] (a bacteria that is resistant to most antibiotics and causes hard to treat infections) and she was placed on antibiotics. After a few more re-hospitalization s, she was diagnosed with [CONDITION(S)] and underwent another surgery to stabilize her spine. An active drug list sent to the facility from the hospital on 09/23/22, indicated she was on [MEDICATION(S)] [MEDICATION(S)] 100mg and was to receive it long term. The orders did not indicate she was to follow up with any physician and did not address wound care or monitoring of wounds. Record review of Resident #1's admission MDS, dated [DATE], indicated she had adequate hearing and vision, could understand and was understood by others, and had intact cognition. She exhibited behavioral symptoms not directed at others from 1 to 3 days of the look back period and she disrupted the living environment of others. She was totally dependent on two staff members with bed mobility, transfers, walking, dressing and toileting. She utilized a wheelchair for mobility. She was documented as not having surgery 100 days prior to admission, being at risk for pressure sores, but not having any pressure sores or surgical wounds. The MDS also did not indicate she had received antibiotics within the first 7 days of her stay. Record review of Resident #1's care plan, with an admitted [DATE], indicated she had a history of falls due to her cognition, had impaired cognitive function, and had current skin conditions. The skin conditions were marked as surgical incision, surgical wound and open [CONDITION(S)] other than stasis/venous areas. Interventions included treating per physician orders, monitor areas for increased breakdown or infection, monitor for and treat pain per physician orders, and assess skin weekly and record findings in the clinical record. Record review of Resident #1's order for [MEDICATION(S)] 100mg capsule by mouth twice a day (an antibiotic) was entered on 10/21/22 and had a start date of 10/26/22. Record review of Resident #1's order summary report, indicated discontinued orders as of 10/01/22 through 10/28/22 included the following orders: *[MEDICATION(S)] [MEDICATION(S)] 100mg capsules twice a day and give long term, ordered on 9/27/22 and an end date of 10/03/22. *[MEDICATION(S)] [MEDICATION(S)] 100mg tablet twice a day was ordered on 10/21/22 and ended on 10/21/22. *[MEDICATION(S)] [MEDICATION(S)] 100mg capsules twice a day was ordered on 10/21/22 with a start date of 10/26/22. *an x-ray to her lumbar spine for severe pain was ordered on 10/08/22 and ended on 10/11/22. Record review of Resident #1's September MAR, indicated she did not receive [MEDICATION(S)] [MEDICATION(S)] through 09/01/22 to 09/30/22. Record review of Resident #1's October MAR, indicated she began receiving [MEDICATION(S)] [MEDICATION(S)] 100mg capsules on 10/26/22 at 9 p.m. Record review on 11/03/22 at 3:00 p.m. of the facility drug destruction log revealed no record of Resident #1's [MEDICATION(S)] being destroyed within the past month. Record review of the 24-hour report dated 09/27/22 indicated Resident #1 admitted to the facility with a diagnosis of [CONDITION(S)], diabetes, high blood pressure, low [CONDITION(S)], a foley catheter, and weakness. The report did not indicate her surgical incision or the wounds to her feet. Record review of the 24-hour report dated 09/29/22 indicated Resident #1 yelled out all shift on the day shift. The night shift indicated she had [CONDITION(S)] of the vertebra. Record review of the 24-hour report dated 09/30/22 revealed no report found. Record review of a nurse's note, written by agency LVN C and dated 10/08/22 at 1:10 p.m., indicated Resident #1 was yelling out, had increased agitation/anxiety, was throwing things, and reporting pain to her lower back. The physician gave an order to x-ray her lumbar spine related to severe pain. Record review of Resident #1's physician consult note, with an admitted [DATE], indicated she admitted for hospice and was to continue [MEDICATION(S)] [MEDICATION(S)] 100mg twice a day upon discharge and was to be on hospice services. The ID Physician who had previously treated Resident #1 indicated in her progress notes on 10/20/22, that the resident had discharged from the hospital on antibiotics with instructions to continue them indefinitely due to recurrent back infections. The physician also indicated the resident had gone off the antibiotics while residing in the facility. The paperwork did not indicate the condition of the resident's wounds, only wound care orders, and the resident's family wanted her to begin hospice care. Record review of Resident #1's discharge MDS, dated [DATE], indicated she had short-term memory problems, moderately impaired decision-making skills, and continued to exhibit behaviors not directed at others. She was totally dependent on staff for all ADLs, except for eating, which required only supervision. She was again documented as not having skin concerns or wounds, and as not receiving an antibiotic in the past 7 days. During an interview on 11/01/22 at 2:10 p.m. with RN F and LVN A, RN F said she had issues earlier in the day, on 11/01/22, while putting in orders for [MEDICATION(S)] [MEDICATION(S)] for a different resident. She said the pharmacy automatically kicked out the order and wanted to switch it to [MEDICATION(S)] [MEDICATION(S)] instead. She said she had been looking for the order and realized it was no longer there, then she realized the pharmacy had sent the new order for her to confirm. She said because LVN A was an LVN, she could not confirm orders, only RNs could. She said LVN A would have put in the [MEDICATION(S)] order and then when an order change confirmation came in, the DON would have to approve it since she was an RN. LVN A said Resident #1 admitted and very quickly into her stay was sent to the COVID unit. She said she did not know if anything was done for the resident, such as skin assessments, wound care, and medication administration. The nurses said they did not have a wound care nurse and had do their own treatments on their halls. During an interview on 11/01/22 at 3:52 p.m. CNA E said she had worked with Resident #1 on the COVID hall. She said the night she found the wound on her back, 10/18/22, the resident had been complaining of pain from not having a bowel movement. The aide went to change her, and saw the sheets were soiled and it was a very substantial amount. She said she believed the resident felt the wetness from her wound and thought it was a bowel movement. She said she initially thought it was a bowel movement as well, until she rolled the resident all the way over and saw the wound. The wound was purple and covered by the flaps of skin due to her obesity. She said when she pulled the resident's skin taught, she could physically see into the wound and large amounts of drainage came out with even minor touch. She said the drainage was chunky and gritty and was a yellowish-green tint, like a snot color, and it smelled. She said agency LVN B was unaware of the wound and looked in the chart to see if any wound care had been ordered for the wound but did not find any. During a phone interview on 11/01/22 a 4:30 p.m. agency LVN B said when she pulled Resident #1's skin back, dark brown drainage poured out of the wound over her spine. She said she went back to look at the resident's chart and saw she had [CONDITION(S)] in her spine before she came to the facility. She said the drainage did not have an odor and the wound did not appear to be red or swollen. She said she remembered the last time she took care of the resident, she recalled giving the resident brown and yellow pills, which would be [MEDICATION(S)]. She said that was right before the resident left with her family on 10/28/22. During a phone interview on 11/02/22 at 9:00 a.m. the Pharmacist said the medical director had signed for therapeutic interchanges to be made whenever an order was put in for a wrong medication. For example, if the doctor ordered [MEDICATION(S)] [MEDICATION(S)] and staff entered [MEDICATION(S)] [MEDICATION(S)], the system would kick out the order for [MEDICATION(S)] and enter a new order for the [MEDICATION(S)], which an RN must approve. She said the corporate office was usually the one that requested the therapeutic interchanges and if one facility under the corporation did it then most likely all facilities under that corporation did. She said there were different reasons for the therapeutic interchanges, such as cost to the facility, or ensuring the correct order was followed. She said she saw in the system where the [MEDICATION(S)] was ordered on 09/27/22 and the system changed it to [MEDICATION(S)] [MEDICATION(S)] capsules. She said they sent out 60 pills that day. The next order for them came in on 10/21/22, they did not send any out because the refill was too soon from the last fill date. During a phone interview on 11/02/22 at 10:36 a.m. the ID physician said she was told by the family and Resident #1, at the hospital, that she had not been receiving antibiotics at the facility. She said she did give an order for the resident to have indefinite [MEDICATION(S)] at the facility, but since she did not go to the facility, or write orders there, she was not sure if the resident received the antibiotics or not. During an interview on 11/03/22 at 2:20 p.m. LVN A said she did part of Resident #1's admission assessment and paperwork. She said if she had given the initial dose of the resident's [MEDICATION(S)], she would have followed up on it for 72 hours, so if there were no notes following up on it, then she did not administer it. During a phone interview on 11/03/22 at 4:00 p.m. agency LVN H said she did not remember the resident being on an antibiotic while she worked the COVID wing. During a phone interview on 11/03/22 at 4:05 p.m. agency LVN J said she did not remember if the resident was on an antibiotic or not. During a phone interview on 11/03/22 4:10 p.m. agency LVN K said she did not remember if the resident took an antibiotic. She said she just remembered the resident yelling out and when they would go in her room, she would say she had not been yelling and did not need anyone to come in there. During an interview on 11/03/22 at 4:25 p.m. with the ADON and interim-DON, the ADON said she was not aware of Resident #1 having any wounds to her feet but did know she had a wound to her spine. She said she helped LVN A put the orders in and since she did not see any orders for wound care or for following up with a physician, she did not put any in. The ADON and the interim-DON said they were unaware the pharmacy kept kicking out the [MEDICATION(S)] orders and the LVNs could not see the orders were being kicked out automatically and then resubmitted. They both denied knowing about the resident not receiving her antibiotics until 10/26/22. The interim-DON said she could not find the resident's x-ray of her back and it appeared the x-ray was never obtained. During a phone interview on 11/04/22 at 10:30 a.m. Resident #1's Physician said he was not aware of her not receiving her [MEDICATION(S)]. He said had he known this information, he would have made sure staff were giving her the ordered antibiotics. During a phone interview on 11/08/22 at 3:28 p.m. LVN L denied ever being notified about an x-ray for Resident #1's back pain. She said the resident was always yelling out due to her psychological issues. She did not remember the resident having any wounds to her feet or her back. She denied anyone ever notifying her of the resident having a surgical wound to her back. Record review of the facility's General Guidelines for Medication Administration policy indicated, .6. If a dose of regularly scheduled medication is withheld, refused, or given at a time other than the scheduled time (e.g., the resident is not in the facility at a scheduled time or a started dose of an antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record. If 3 consecutive doses, or in accordance with facility policy, of a vital medication are withheld, refused, or not available, the physician is notified. Nursing documents the notification and physician response. An Immediate Jeopardy (IJ) was identified on 11/04/22 at 12:50 p.m., due to the above failures. The Administrator and DON were notified of the IJ and the IJ template was provided on 11/04/22 at 1:09 p.m. During an interview on 11/04/22 at 1:09 p.m. with the interim-DON, ADON and Administrator, the interim-DON said she accepted the resident's change in [MEDICATION(S)] when she saw it was in the system awaiting approval. She did not realize the resident's [MEDICATION(S)] had been pending approval since 10/21/22 and was not approved by her until 10/26/22. She said she approved orders as they popped up in the system, but she did not realize they were popping up due to therapeutic interchanges. She said the reason it took her until 10/26/22 to approve the [MEDICATION(S)] was because she left the building on 10/21/22 and did not return until 10/26/22. The following Plan of Removal submitted by the facility was accepted on 11/06/22 at 8:52 a.m. and included the following: 11-4-22 Neglect Plan of Action Resident in question (Resident #1) that did not receive her antibiotics as ordered and is no longer in the building. A chart review of her pharmacy orders and therapeutic interchange was completed by the Director of Clinical Operations to review what transpired. At the time a new Director of Nurses in training was to review orders and failed to confirm new antibiotic orders. Audit of all medications compared to current orders for all residents in house was completed on 11/05/22 to ensure that no other residents have missed medications. Director of Clinical Operations, Assistant Director of Clinical Operations, Clinical Reimbursement Coordinator and Treatment Nurse reviewed clinical records for residents with wounds to ensure documented notification of family and physician. Director of Clinical Operations, Assistant Director of Clinical Operations, will review all x-rays ordered with over the last six months to ensure follow thru and notification of findings. The Director of Clinical Operations, Assistant Director of Clinical Operations, Treatment Nurse and All Licensed Nurses will be provided in-service education related to Notification of Change, including any signs and symptoms of worsening infections beginning on 11-4-22 by Director of Clinical Operations or designee which includes: 1. Physician must be notified of any new orders that were not written by the physician within 2 hours of admission or re-admission via phone. 2. Physician must be notified of any missed dosages of medication as prescribed no later than 3 missed doses as per policy. See attached. 3. Physician must be notified of any wounds present on admission or readmission and or wound orders within 2 hours of admission or re-admission via phone. 4. Physician to be notified of any change in medical conditions including worsening infections, falls, or medical changes withing 2 hours of assessment. See Monitoring form for changes in condition attached. The Director of Clinical Operations, Assistant Director of Clinical Operations, Treatment Nurse, and licensed nurses to be provided education on following physician's orders as it pertains to x-ray services on 11-4-22 by Director of Clinical Operations or designee which includes: 1. Nurses must complete orders as written. 2. If an order is not or cannot be complete physician must be notified via phone within 2 hours of receiving notification. 3. Each shift must follow up on x-ray orders until results are obtained. Newly hired nurses will receive in-services on proper physician notification processes. Validation/Monitoring Tools Director of Clinical Operations or designee will validate staff knowledge base through random questioning. Director of Clinical Operations or designee will review records for any newly admitted or readmitted resident daily in clinical meeting to ensure physician notification and appropriate follow up. Beginning 11-7-22. Director of Clinical Operations or designee will review all x-ray order daily in the clinical meeting to ensure x-rays are obtained and physician notification is completed. Admission check list form is to be completed by admitting nurse to ensure appropriate notification and completion of assessments to be initiated within 2 hours of admission. See form attached. Change in conditions check list to be utilized to ensure nurse competency with completion of assessments and physician notification. Beginning 11-7-22. On 11/06/22 from 11:40 a.m. to 2:50 p.m. the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During interviews with the RN weekend supervisor, the ADON, LVN L and LVN N between 11:45 a.m. and 2:15 p.m., staff indicated they had received adequate training regarding skin assessments, antibiotics, antibiotic orders and use of 24 hour reports. Record review of A Midnight Census Report dated 11/05/22 at 3:18 PM, by the interim-DON showed 37 Residents had been checked off as being reviewed by the DON for narcotics and all medications. Record review between 12:47 p.m. and 1:15 p.m. of staff who had received training, indicated 12 staff had been educated over the phone and stated their understanding of the education provided. During an interview on 11/02/22 at 12:47 p.m., the interim-DON said she conducted a full sweep of all 37 residents to ensure there were no new skin issues. She said she also reviewed all medications to ensure each resident had orders and medication available. The interim-DON said she also assessed each resident for pain. The interim-DON said all residents were to have a skin assessment on admission or re-admission within 2 hours. She said all nursing staff had been trained on skin assessments. She said nurses had also been trained on monitoring antibiotics for the duration of the schedule and 3 days after for any reactions. She said nurses were to notify the DON any time antibiotics are ordered. She said she is the Infection Control Preventionist for the facility at the time, until the new wound care nurse completes her training, then the new wound care nurse will take over that responsibility. Record review of PCP records between 12:47 p.m. and 1:15 p.m. showed orders were showing on the 24-hour report in the system. Paper 24-hour reports were also reviewed, and the nurses had documented new orders on the report. The Administrator and DON were informed the Immediate Jeopardy was removed on 11/06/22, at 2:50 p.m. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observations, interviews and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 15 residents (Resident #11) reviewed for accidents The facility failed to ensure Resident #11 was properly secured in his wheelchair during transport resulting in the Resident #11 coming out of his wheelchair and having bilateral femur fractures and a clavicle fracture. This was determined to be past a non-compliance Immediate Jeopardy (IJ) with actual harm due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. The Administrator was notified of the past non-compliance Immediate Jeopardy (IJ) on 9/13/22 at 4:22 p.m. This failure could place residents at risk for injury/death from a vehicle accident and decreased quality of life. Findings Include: 1. Record review of the face sheet dated 9/15/22 indicated Resident #11 was a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses including fracture of the left femur, [CONDITION(S)] (a group of disorders that affect a person's ability to move and maintain balance and posture), fracture of the left clavicle, fracture of the right femur, [CONDITION(S)] (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), [CONDITION(S)] (paralysis of the legs and lower body, typically caused by spinal injury or disease), and muscle weakness. Record review of the comprehensive MDS dated [DATE] indicated Resident #11 was usually understood by others and usually understood others. The MDS indicated Resident #11 had a BIMS assessment had not been completed. The MDS indicated Resident #11 required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS indicated Resident #11 required limited assistance with eating. Record review of the care plan last revised on 5/31/22 indicated Resident #11 was at risk for falls related to diagnoses of [CONDITION(S)], [CONDITION(S)] disease, [CONDITION(S)], and unspecified convulsions. The care plan indicated Resident #11 had limited physical mobility related to [CONDITION(S)], [CONDITION(S)] disease, and [CONDITION(S)] with interventions including resident had a manual wheelchair and a motorized wheelchair special made for his body/contractures. The care plan indicated Resident #11 had alteration in mobility related to sustained multiple fractures (bilateral femurs (upper leg bone) and left clavicle (collar bone)). Record review of the provider investigation report dated 5/31/22 indicated Resident #11 and Resident #15 were being transported by the facility van and accompanied by facility staff when Resident #11 fell out of his wheelchair when the vehicle stopped. The provider investigation report indicted Resident #11 was transferred from the scene of the incident to the emergency department by ambulance for assessment. The provider investigation report indicated the facility was notified by the hospital on 5/31/22 Resident #11 had a fracture to both lower extremities that would require surgery and may have had additional injuries as some results were still pending. The provider investigation report indicated CNA R and the former SW were found negligent in their actions when failing to properly secure Resident #11 and his wheelchair after performing a demonstration of how the Resident #11 and his wheelchair were secured prior to the accident. The provider investigation report indicated CNA R and the former SW were both terminated following the investigation by the facility. Record review of an in-service dated 5/31/22 indicated staff had been in-serviced on driver and vehicle safety, driver and vehicle safety policy, and hands on demonstration. Record review of Resident #15's witness statement dated 6/01/22 indicated Resident #15 said she and Resident #11 were not buckled in securely during the transport on 5/31/22. Resident #15 said in her witness statement the driver was reckless and hit the brakes hard. Resident #15 said in her witness statement she had to brace herself when the van came to a stop and Resident #11 came out of his wheelchair. Resident #15 said on the trip from the facility to her appointment her wheelchair had not been strapped down and that only the wheelchair break had been applied. Record review of an action plan agenda dated 6/1/22 indicated the facility recognized an issue/concern of securing and transporting residents. The action plan agenda had a measurable goal of no resident would be injured during transport related to loading or securing mechanisms. The action plan agenda included the following interventions: All staff that would be allowed to operate the facility van had performed a return demonstration on loading residents who use wheelchairs and securing residents in wheelchairs. All new employees who would operate the facility van, on the skill check off, including loading riders who use wheelchairs, power chairs vs wheelchair, and procedures for securing wheelchairs. Director of Maintenance and/or any trained administrative designee will in-service and train all staff that would provide transportation. Record review of CNA R employee file indicated she was terminated from the facility on 6/8/22. Record review of the former SW's employee file indicated she was terminated from the facility on 6/8/22. Record review of CNA C's employee file it indicated had a New Driver Form including DL number signed by the administrator on 8/04/22, had signed acknowledgement and consent agreement company or rental vehicle policy on 8/04/22, had Vehicle Safety Acknowledgement signed 8/04/22, and a Securing Resident in Van Competency signed by the Administrator. Record review of the Maintenance Supervisor's employee file indicated New Driver Form including DL number signed by the administrator on 8/04/22, had signed acknowledgement and consent agreement company or rental vehicle policy on 8/04/22, had Vehicle Safety Acknowledgement signed 8/04/22, and a Securing Resident in Van Competency signed by the Administrator. During an interview on 9/12/22 at 10:49 a.m. Resident #11 said on 5/31/22 he had gone to the surgical center and was transported by the facility van. Resident #11 said he went to the surgical center for pain management. Resident #11 said he was picked up by the facility van. Resident #11 said the driver of the facility van was a transportation aide in training. Resident #11 said there was stuff on the floor of facility van. Resident #11 said the transportation aides had to move things around to put him on the facility van. Resident #11 said the transportation aides only secured his wheelchair with two straps on the left-hand side. Resident #11 said he did not have a strap across his body (shoulder harness or lap belt). Resident #11 said the transportation aide came to abrupt stop and resident flipped out of his WC. Resident #11 said he was lying in the floor of the bus. Resident #11 said he insisted the facility staff call the for transport to the emergency department. Resident #11 said he was transferred to the emergency department and test results revealed he had bilateral femur fractures and a clavicle fracture. During an interview on 9/12/22 at 12:19 pm the BOM said the former SW had transported residents in the facility van prior to the accident involving Resident #11. She said the former SW was training new transportation drivers at the time of the accident involving Resident #11. During an interview on 9/12/22 at 3:08 p.m. Resident #15 said she remembered the incident on 5/31/22 involving Resident #11 getting injured on the facility van. Resident #15 said they were being transported in the facility van and the transportation aide stopped too fast. Resident #15 said Resident #11's wheelchair was not locked down properly and he came out of the wheelchair. Resident #15 said she was pulled forward by the sudden stop, but her wheelchair did not move and she did not come out of her wheelchair. During an interview and observation on 9/13/22 at 9:00 a.m. CNA, C demonstrated securing a wheelchair in the facility van. CNA C secured the wheelchair with 5 straps attached to the floor and a shoulder strap and lap belt over where the resident would be sitting in the wheelchair. CNA C said she had been working at the facility for about 1 month. CNA C said she was trained on facility transport by the Maintenance Supervisor. The van was observed to have accommodations for one wheelchair to be secured in the facility van. CNA C said she had been trained to only transport one resident in a wheelchair at a time. During an interview on 9/13/22 at 9:46 am the Administrator said she expected only one resident in a wheelchair to be transported at a time. The Administrator said only one resident in a wheelchair should be transported due to the van only being equipped to safely secure one wheelchair. During an interview on 9/13/22 at 9:49 a.m. the former SW said she was not training the transport person. The former SW said she was in the van with the transport person when she picked up the Resident #11. The former SW said she had assisted in transporting residents. The former SW said she had not been trained on transporting residents. The former SW said she had transported residents on her own and with CNA's. The former SW said there were 2 residents in the van both were in wheelchairs at the time of the accident. The former SW said she did not know how many wheelchairs the van could safely secure. The former SW said that was the first time 2 residents in wheelchairs had been transported at the same time. During an interview on 9/13/22 at 10:50 a.m. the Maintenance Supervisor said he trained the new certified transportation aide. The Maintenance Supervisor said he was trained by the Administrator. The Maintenance Supervisor said he watched videos and performed demonstrations to become trained. The Maintenance Supervisor said when he trains a new transportation aide they watched the required videos and then performed safety demonstrations on securing residents who were in wheelchairs and who ambulate, using the lift, securing loose items, and driving the facility van. During an interview on 9/13/22 at 10:52 a.m. the former DON said it was her first week working in the facility when the accident occurred on 5/31/22. The former DON said she was notified of the accident by the former Administrator. The former DON said Resident #11 was sent to the ER after the accident. The former DON said Resident #11 suffered a clavicle fracture and bilateral femur fractures. The former DON said there had been 2 residents on the van in wheelchairs when the accident occurred. The former DON said she thought the van was equipped to transport 2 residents in a wheelchair at the same time. The former DON said the former SW and CNA R were not trained on transporting residents. The former DON said after the incident the former Administrator, the former SW, CNA R, and she were trained regarding transporting residents by the corporate nurses. During an interview on 9/13/22 at 11:30 a.m. the former Administrator said the former SW was training CNA R on transporting. The former Administrator said he had been led to believe the former SW had been trained on transports. The former Administrator said on 5/30/22 CNA R shadowed the former SW during resident transports. The former Administrator said on 5/31/22 CNA R return demonstrated back to the former SW the proper way to transport residents. The former Administrator said 2 residents in wheelchairs had been transported together at the time of the accident. The former Administrator said the van was equipped to secure 2 residents in wheelchairs at the same time. The former Administrator said there was adequate equipment to secure both residents when the accident occurred. The former Administrator said Resident #11 sustained injuries including 2 broken femurs and a broken clavicle. The former Administrator said the Maintenance Supervisor was trained along with other staff members a day or two after the incident. The former Administrator said the training was performed by corporate nurses. During an observation on 9/13/22 at 3:15 p.m. the surveyor watched the following training videos provided by the facility: SURE-LOK Wheelchair Restraints by NW Bus Sales Commercial Wheelchair Operators Video Wheelchair Lift Overview Video All videos observed by the survey gave instruction for properly loading and unloading residents via the lift on the facility van and properly securing a resident in a wheelchair for transport. Record review of the facility's undated Driver and Vehicle Safety Manual indicated, .The objective of this policy is to implement safe driving policies and practices so that the following goals are met .No employee or resident injuries in or around a vehicle .Residents are properly secured at all times .Employees droving the company vehicle shall also: Know how to safely load and unload residents/passengers and properly secure wheelchairs and other equipment if responsible for transporting residents .Team members who drive the company vehicle for residents must watch the following videos: SURE-LOK Wheelchair Restraints by NW Bus Sales, Commercial Wheelchair Operators Video, and Wheelchair Lift Overview Video .

Based on observation, interview, and record review the facility failed to ensure necessary treatment and services consistent with professional standards of practice to promote healing of a pressure injury was provided based on the comprehensive assessment for 1 of 4 residents reviewed for pressure injury. (Resident #11) The facility did not implement interventions to prevent the worsening of a pressure injury for Resident #11. The resident's Stage 3 pressure injury re-opened and worsened to a Stage 4. The facility did not turn and reposition the resident daily and set the resident's mattress to the appropriate setting. This failure could place residents at risk for developing pressure injuries and worsening pressure injuries. Findings included: Record review of Resident #11's face sheet indicated Resident #11 was admitted to the facility on [DATE], was [AGE] years old, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #11's quarterly MDS dated [DATE] indicated Resident #11 usually understood, usually understood others, was cognitively intact, and did not exhibit any behaviors or rejection of care. She required extensive assistance of two staff for bed mobility and toileting, and total dependence of two staff for transfers. She was always incontinent of bowel. Resident #11 was noted to be at risk of developing pressure ulcers/injuries but was not noted to have any unhealed pressure ulcers/injuries on this assessment. The MDS indicated the resident had a pressure reducing device. The MDS indicated the resident had a weight of 259. Record Review of an undated care plan indicated Resident #11 consistently refused medical treatment. Interventions were allow the resident to make decisions about treatment regime . provide consistency in care to promote comfort with ADLs . provide resident with opportunities for choice during care provision. Record review of the clinical record for May, June, and July 2021 did not contain documentation of Resident #11 refusing care. Record review of Resident #11's undated care plan regarding ADL care indicated Resident #11 required total assistance of two staff for transfers via a mechanical lift and extensive physical assistance of two staff for bed mobility. Record review of Resident #11's undated care plan regarding Resident #11's stage 3 pressure injury indicated the pressure injury was to the right trochanter (outside point of right hip) area and it reopened due to immobility. The care plan indicated staff were to avoid positioning the resident on her right side. This care plan did not address the frequency the resident was supposed to be repositioned. Record review of Resident #11's undated care plan regarding skin breakdown indicated Resident #11 was to have a low air-loss mattress with settings: alternate 2-3. The care plan indicated Resident #11 needed to be turned/repositioned at least every 2 hours. Record review of progress notes indicated the following: *7/9/21 11:58 - stage 3 pressure area to right flank was noted to be re-opened. *7/11/21 13:50 - two superficial areas on residents right upper hip have reopened. *7/11/21 14:48 - physician notified of area to right hip, new orders received *7/12/21 10:46 a.m. - New orders included clean open areas to right upper hip with normal saline, pat dry. Apply moisture barrier cream peri-wound then place Xeroform Petroleum dressing. Cover with large silicone dressing. Change every other day until healed. A wound care note dated 6/1/21 indicated Resident #11's wound healing is delayed due to the following factor(s): Impaired Mobility and Decrease Functional Ability, Co-Morbid Conditions, Incontinence, Dementia/Impaired Cognition, Inevitable effect of aging, Diabetic complicating factors, Resident refusal of care and treatment (non-compliance). A weekly wound assessment dated [DATE] completed by Nurse E indicated Resident #11's stage 3 pressure injury to the right flank was resolved. Interventions included low air loss mattress, pillows for positioning and off-loading, and resident was dependent on staff for turning and repositioning. A weekly wound assessment dated [DATE] completed by Nurse E indicated Resident #11's stage 3 pressure injury to the right flank was reopened and measured 3cmx1.5cmx0.1cm. The wound was noted to have granulation tissue, but no slough. Interventions included low air loss mattress, pillows for positioning and off-loading, and resident was dependent on staff for turning and repositioning. A weekly wound assessment dated [DATE] completed by Nurse E indicated Resident #11's stage 3 pressure injury to the right flank measured 3cmx1cmx.3cm. The wound bed now contained slough. Interventions included low air loss mattress, pillows for positioning and off-loading, and resident was dependent on staff for turning and repositioning. A weekly wound assessment dated [DATE] completed by Nurse E indicated Resident #11's stage 3 pressure injury to the right flank went from a stage 3 to a stage 4, and the measurements increased to 6cmx1cmx0.3cm. Interventions included low air loss mattress, pillows for positioning and off-loading, and resident was dependent on staff for turning and repositioning. A dietary note dated 7/21/21 indicated Resident #11 had significant weight loss during July 2021. The note indicated the resident had a monthly weight of 239.2 pounds. The note indicated she had a stage 3 pressure injury to right flank per 7/20/21 wound report. The note indicated the resident refused care regularly per nursing. The note indicated the resident required an increase in nutritional needs due to increased demands for wound healing related to the stage 3 pressure injury to right flank. During an interview and observation on 7/19/21 at 11:41 a.m. Resident #11 said she currently had a pressure injury to the right hip. She said the pressure injury had been there off and on since 2020. The resident had a low air loss mattress set to 100 pounds and not 200 to 250. Low air loss settings for this mattress are based on resident weight. She was noted to have an amputation to right leg. During an observation and interview on 07/19/21 at 3:01 p.m. Resident #11 was lying on her back on her butt. She said she cannot reposition herself and most staff do not reposition her every 2 hours like they were supposed to daily. She said in the mornings when one person worked, she was good about making sure she was off her hip. She said the low air loss mattress did not circulate like it was supposed to. The low air loss mattress was set at 100 pounds. During an observation on 7/20/21 at 8:37 a.m. Resident #11 was lying on her back on her butt. The bed was set at 100 pounds. During an observation on 7/20/21 at 10:30 a.m. Resident #11 was lying on her back on her butt. The bed was set at 100 pounds. During an observation and interview on 7/20/21 at 11:13 a.m. Resident #11 was lying on her back on her butt. The bed was set at 100 pounds. The resident said she had not been repositioned. During an observation on 7/20/21 at 3:55 p.m. Resident #11 was lying on her back on her butt. The bed was set at 100 pounds. During an observation on 7/21/21 at 8:20 a.m. Resident #11 was lying on her back on her butt. The bed was set at 100 pounds. During an observation on 7/21/21 at 11:05 a.m. Resident #11 was lying on her back on her butt. The bed was set at 100 pounds. During an observation on 7/21/21 at 1:00 p.m. Resident #11 was lying on her back on her butt. The bed was set at 100 pounds. During an observation on 7/21/21 at 2:44 p.m.- Resident #11 was lying on her back on her butt. During an observation and interview on 7/22/21 at 10:45 a.m. Resident #11 received care from CNA D. The CNA placed a pillow behind the resident's right side and elevated her leg with a pillow. The resident did not refuse care. CNA D said the resident did not complain about care or refuse care. The bed was set at 100 pounds. The Website https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf accessed on 8/4/21 indicated: .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 . Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. The website https://npiap.com/general/custom.asp?page=PreventionPoints accessed 8/4/21 indicated .Repositioning and Mobilization 1. Turn and reposition all individuals at risk for pressure injury, unless contraindicated due to medical condition or medical treatments. 2. Choose a frequency for turning based on the support surface in use, the tolerance of skin for pressure and the individual's preferences 7. Consider the level of immobility, exposure to shear, skin moisture, perfusion, body size and weight of the individual when choosing a support surface. 8. Continue to reposition an individual when placed on any support surface.

Based on interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 2 residents reviewed for supervision. (Resident #1) The facility failed to provide Resident #1 with adequate supervision to prevent elopement after he displayed exit seeking behavior and elopement attempts. Resident #1 eloped on 5/10/21 and was found approximately 17 miles from the facility. This failure could place residents at risk of elopement, resulting in physical harm, injury, or death. An Immediate Jeopardy (IJ) situation was identified on 6/18/21. While the IJ was removed on 6/21/21, the facility remained out of compliance at a level of no actual harm, with a potential for more than minimal harm, at a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. Findings included: 1. A face sheet dated 5/10/21, indicated Resident #1 admitted on [DATE] and discharged on [DATE]. The resident was [AGE] years old and had diagnoses including: chronic obstructive pulmonary disorder, [CONDITION(S)] of the liver (disease of the liver, leading to scarring and liver failure), paralysis of right side, diabetes, abnormal gait and mobility, [CONDITION(S)], hypertension, falls and weakness. The undated care plan indicated Resident #1 had a history of falls, an unsteady gait and generalized weakness. He had impaired cognitive function with cognitive loss related to a previous stroke. He had a communication problem in which he usually understood others but had difficulty making his needs known. The care plan did not address any wandering, exit seeking or elopement attempts. The MDS dated [DATE] indicated Resident #1 had minimal difficulty hearing, usually understood others, was usually understood and had moderately impaired cognition. He required the limited assistance of two staff for bed mobility and the limited assistance of one staff member for transfers, walking, dressing and toileting. He used a walker and wheelchair for mobility. The MDS did not indicate the resident had exit seeking or wandering behaviors. The order summary report with a print dated of 6/18/21 did not address any type of monitoring for elopement or a WanderGuard (an electronic bracelet that sets off an alarm if the wearer gets too close to a sensor placed on an entry/exit door) for Resident #1. An elopement assessment dated [DATE] indicated Resident #1 was a low elopement risk. A progress note, by LVN A, dated 5/10/21 at 11:50 a.m. indicated Resident #1 was very agitated, anxious, confused and was exit seeking. The physician was notified and a new order for [MEDICATION(S)] 0.5 mg three times a day for anxiety and agitation was received. LVN A called the pharmacy and [MEDICATION(S)] 0.5 mg was given to the resident at noon, from the emergency medication kit. During a phone interview on 6/18/21 at 2:24 p.m. LVN A said she did not remember Resident #1 very well, but she did not recall him threatening to, or attempting to, leave the facility. She said in the event a resident attempted to elope from the facility, the staff should monitor the resident on a 1:1 ratio, notify the physician and DON, and place a WanderGuard on the resident. A progress note, by the DON, dated 5/10/21 at 12:55 p.m. indicated the DON placed 2 calls to Resident #1's family members at his request. The resident appeared anxious, was pacing and actively exit seeking. The resident's family member visited the facility and agreed with transferring the resident to a facility with a secured unit. A progress note, by the DON, dated 5/10/21 at 1:21 p.m. indicated Resident #1 continued pacing and verbalizing he wanted to leave the facility. The resident was mobile with his wheelchair but could ambulate short distances with poor balance. A progress note, by the DON, dated 5/10/21 at 3:37 p.m. indicated the DON again called Resident #1's family members. She notified the family member of the resident's acceptance to a secured unit. A progress note, by the DON, dated 5/10/21 at 3:55 p.m. indicated the DON was alerted that the resident had exited the front door of the facility, had crossed the highway and was walking down the side of the highway. While the nurse was running down the side of the highway looking for the resident, an electric company driver pulled over and stated that a man in a commercial service truck had picked up the resident and notified her of the direction they were heading in. The DON left in her personal car to try and locate the commercial truck driver. She called 911 at 4:04 p.m. The resident's name, physical description and a description of the vehicle was provided to police. The local police and county sheriff's department responded to the 911 call. Officers were dispatched to the town the resident was taken to and they located the commercial truck driver. He said he left the resident in the vicinity of the road the resident asked to be taken to. The DON alerted the resident's family members where he was stated he may have gone to another family member's home who lived one block behind the resident's prior address. A progress note, by the DON, dated 5/10/21 at 4:00 p.m. indicated all areas of the facility, including resident rooms, bathrooms, employee offices, outside storage and common areas were searched. The HR (human resources) Director saw Resident #1 walking across the highway from the facility. An in-service dated 5/10/21, held after the resident eloped, was held with facility staff to discuss an elopement and drill process. During an interview on 6/18/21 at 2:00 p.m. the HR director said Resident #1 left his wheelchair by the front door when he left the facility. She said no one was assigned to monitor him that day. She said the resident told the DON he wanted a different kind of pain medication and if he got it, he would quit trying to leave. She said she took him back to his room from the front door several times that day before his elopement. A progress note, by the DON, dated 5/10/21 at 4:45 p.m. indicated Resident #1's family members were notified of the resident's elopement at 4:30 p.m. The resident was located at another family member's house at 4:45 p.m. The resident's family members said they would pick him up and return him to the facility. A progress note, by the DON, dated 5/10/21 at 5:37 p.m. indicated Resident #1's family member called the facility and said the resident would not return to the facility with them. The resident agreed to allow the chief of police to bring him back to the facility, and he would then be sent to the secured unit he had been accepted to. A progress note, by the DON, dated 5/10/21 at 6:02 p.m. indicated Resident #1 was returned to the facility. The resident was assessed by nursing staff and was found to have no injuries and full range of motion of all extremities. The resident was assisted to the facility transport van and was transferred to the secured unit he was admitted to. An in-service dated 5/10/21, held after Resident #1 eloped, was held with facility staff to discuss an elopement and drill process. During an interview on 6/18/21 at 9:50 a.m. the DON said Resident #1 was never an exit seeker. She said on the day the resident eloped, the staff offered to put a WanderGuard on the resident, but the family declined and said he would remove it. She said staff were monitoring him throughout the day and taking him out to smoke breaks. She said the staff called the resident's family to come and visit him. She said the electric company employee told her he saw the commercial truck driver pick the resident up. She said she drove about 10 to 15 miles towards the direction the resident was seen going. She said she called 911 and described the resident so they could begin looking for him. The resident was found at his family member's house and would not allow his family to return him to the facility. She said his family could not get him to agree to being returned to the facility or admitted to the secured unit he had been accepted to. She said he finally agreed to allow the chief of police from the town he was visiting to take him back to the facility. She said when the resident returned to the facility, he was assessed from head to toe and then transported to the secured unit. The DON said the facility did not have a policy regarding steps to take once a resident has exhibited exit seeking behaviors or suggested monitoring for such residents. During an interview on 6/18/21 at 2:00 p.m. the door screener said she had a difficult day with Resident #1 the day of his elopement. She said she asked the DON to place a WanderGuard on him twice that day. She said she thought the DON had put one on him before he eloped. She said the resident left his wheelchair at the front door when he eloped from the facility. She said she took the resident back to his room from the front door several times that day and at one point was able to redirect him into the dining room for a short time. She said she did not recall the resident ever having a 1:1 monitor with him that day. She said she notified the DON there would be a short lapse in time between her and the oncoming door screener. She said the resident eloped from the facility during this time lapse, right after she left the facility and before the oncoming door screener came on duty. She said the facility called her and asked her to return to the facility within minutes of her leaving and told her the resident had eloped. During an interview on 6/18/21 at 2:55 p.m. the ADON said she was working as a floor nurse on the day Resident #1 eloped, but she was not his nurse. She said she did not recall being notified the resident was exit seeking that day, so she did not know to assist with monitoring him. During an interview on 6/18/21 at 3:00 p.m. Resident #1's family member said the facility notified him of the resident eloping. He said he was told the resident crossed the highway, caught a ride in a truck and then walked from where he was dropped off at. He said the resident was moved from the facility and to a secured unit. He said he was told by facility staff the resident was given an ankle monitor and removed it and that was how he was able to leave the facility without anyone knowing. The family member said he never told the DON not to put a WanderGuard on the resident. He said the DON told him she put a WanderGuard on the resident. He said he did not come to the facility the day the resident eloped and only talked to the facility staff over the phone. During an interview on 6/18/21 at 3:10 p.m. the HR director said she did not go outside to get Resident #1 when she saw him walking. She said she notified the DON and from there the DON and the resident's nurse left the facility to get him, but by then the resident was already gone. During an interview on 6/18/21 at 3:14 p.m. LVN B said she believed she was told at shift change, Resident #1 had been exit seeking. She said she and the aides were trying to monitor and redirect him. She said they did not have anyone assigned 1:1 for the resident but they tried their best to monitor him. She said staff were going to put him in a WanderGuard but she was told by his family member he did not want one placed on the resident and that he would take it off. She said the resident also told staff not to put one on him. She said she could not remember the exact time she saw the resident last before he eloped, but she knew it was after 2 p.m. when shift change took place. During an interview on 6/18/21 at 3:48 p.m. the DON said Resident #1 would stay with one staff member and then another staff member throughout the day he eloped. She said the resident would go visit one staff member and then leave to visit another staff member and so on. She said the resident visited with his family that day. She said the facility was trying to transfer him out to the secured unit he had been accepted to. She said the resident's family member told her not to try to place a WanderGuard on the resident because he would try and take it off. She said the staff rotated him around that day and got an order for [MEDICATION(S)]. She said she considered putting a WanderGuard on the resident at one point during the day. She denied any staff members asking her to put a WanderGuard on the resident and denied any point in time where there was not a door screener present. She said the door screeners have other duties than screening staff and visitors and the screener may have been in the bathroom, on the phone, or away from the desk when the resident eloped. She said she felt the facility did everything they could to keep the resident from eloping, including diversion, contacting family and medication. She said she could not recall the exact time she last saw the resident before he eloped. During an interview on 6/18/21 at 5:15 p.m. the administrator said the facility discussed Resident #1's elopement in QAPI but she did not remember the date the meeting was held and did not have documentation of the meeting. She said the resident was supposed to be leaving the facility for transfer to the secured unit at around 5:30 p.m. the day he eloped. She said she was told the resident was upset because he wanted pain medication the physician would not prescribe him. She said when the resident eloped the staff called the resident's family members and physician. She said all staff members were watching the resident that day and he went to smoke several times. She said she could see the front of the building from her office window, but she did not see him leave that day. She said the resident was not given a WanderGuard before he eloped because the family told staff he would pull it off. She said she did not know if they should have put a WanderGuard on him since he was leaving to the secured unit later that day. She said she did not feel the resident needed 1:1 because she felt like he just needed to adjust to the facility. She said the door screener was not always present in the front lobby and may have been busy when he eloped. During an interview on 6/18/21 at 5:40 p.m. the DON said she was not aware of the time lapse between door screeners being present at the door and she did not realize this was when the resident eloped. 2. A face sheet with a print date of 6/21/21 indicated Resident #3 admitted on [DATE], was [AGE] years old and had diagnoses including: [CONDITION(S)], dementia, abnormal gait, depression, anxiety, high blood pressure, kidney failure. The undated care plan indicated Resident #3 was an elopment risk/wanderer and was at risk for possible injury related to impaired safety awareness and diagnosis of dementia. Interventions included distracting the resident, providing structured activities, and placing a wanderguard. The MDS dated [DATE] indicated Resident #3 had moderately impaired cognition. She required the limited assistance of 1 staff member with bed mobility, toilet use and personal hygiene. She required the supervision of 1 staff member for transfers, walking, dressing and eating. The MDS did not indicate the resident wandered. An elopement assessment dated [DATE] indicated Resident #3 was a high elopement risk. A nurse's note dated 6/18/21 at 6:27 p.m. indciated Resident #3 stated to therapy staff that she would need to leave the faciity if she found out her husband was really dead. An elopement assessment was completed and a wander guard was placed on the resident. A nurse's note dated 6/19/21 at 4:18 a.m. indicated Resident #3 had opened the door at end of the 100 hall. Her last known location approximately 30 minutes before this was resting in her bed closed with her eyes closed. The resident said she heard her husband outside and had to get to him. The resident was redirected/reoriented/calmed and taken to the nurse's station. The resident requested to sit in a chair by the television to rest. Other staff members were available and aware of possible the resident's possible elopement risk. An RN was walking the outside perimeter of the facility to check the windows on the 100 hall. The WanderGuard alarm sounded at the front door and the resident was seen running out of the front door and down the facility driveway. The RN intercepted the resident approximately half way across parking lot. The resident was again redirected/reorientated/calmed and returned to building. An assessment was completed and no injuries were found. The resident was placed on 1:1 monitoring with the RN for remainder of the shift. The administrator and the DON were notified on 6/18/21 at 5:40 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The IJ template was provided to the administrator by email on 6/18/21. The facility's Plan of Removal was accepted on 6/21/21 at 10:07 a.m. and included: Plan of Action All residents will have a new Elopement assessment completed by DCO/ADCO/charge nurse to be completed by 6/18/21 Residents will have updated Kardex for those identified at high risk for elopement based on updated elopement assessments, by the DCO or regional DCO by 6/18/211 In-service initiated 6/18/21 for elopement policy and procedure by DCO/[NAME] and staff will be in-serviced prior to next scheduled shift 1:1 in-service with DCO by RDCO regarding elopement policy and interventions to reduce risk of elopement with residents who are at risk or exit seeking RCPs will be educated on identification of elopement risk on Kardex and location of elopement binder Staff will be re-educated on recognizing changes in condition of residents, notification of physician (after completion of change of condition) and RP, and the completion of the e-INTERACT change in condition form. Physician will be notified, and intervention implemented immediately if a resident exhibits new signs of elopement. No direct staff to work before they have been in-serviced on identified areas. DON/ADON will be providing in-services for elopement policy and procedure, intervention utilization for exit seeking residents, Kardex identification of high-risk residents, and elopement binder location/usage, and changes in condition RCPs will be re-educated by DCO/ADCO on documenting resident behaviors in POC and completing Stop and Watch forms when residents have a change in condition. Ongoing Monitoring DCO/[NAME] will review behavior documentation in PCC to identify newly identified or changes in behaviors to ensure resident's plan of care was reviewed and updated. DCO will include resident at risk for elopement in SOC meetings. Validation/Monitoring tool Stop and Watch Standard of care QAPI process Kardex Behavior report [NAME]-Executive Director of Operations (Administrator) DCO-Director of Clinical Operations (DON/Director of Nursing) ADCO-Assistant Director of Clinical Operations (ADON/Assistant Director of Nursing) RCP-Resident Care Provider (CNA/Certified Nurse's Aide) SOC-Standard of Care (Weekly Meeting to review changes in care or needs) On 6/21/21 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During an interview on 6/21/21 at 12:39 p.m. the administrator and the DON said they had assessed all 44 residents in the facility for being at risk of elopement. The DON said that on Saturday 6/19/21, Resident #3 had been identified as an elopement risk and was placed on 1:1 monitoring. While on 1:1 monitoring, she went out of the front door. Staff immediately identified her elopement and redirected her back into the facility. The DON said staff had reached out to their sister facility and the resident was transferred there on 6/19/2021 to the secured unit. The DON said based on elopement assessments they performed some residents were identified as being at risk for elopement based on their comments of wanting to leave the facility. The DON said all of the staff in the facility, except for 2 staff members, had been in-serviced on the facility's elopement policy, how to identify a change in condition, physician and responsible party notification and how to document on residents that were at risk of elopement. The DON said dietary aide C was out due to personal reasons but was going to be coming to the facility later in the day for in-servicing. The DON said one other staff member was on vacation and would be in-serviced when she returned to work. During an interview on 6/21/21 at 1:23 p.m. Resident #4 said she was admitted to the facility on [DATE] for rehab services. She said she was not an elopement risk. She said she had not and would not try to leave the facility without approval. She said once her rehab was completed, she would be discharged back home. She said she had no complaints other than she could not go outside unassisted, and staff had to be with her and other residents when they went outside. During an interview on 6/21/21 at 1:30 p.m. Resident #5 was noted sitting in hallway on Hall 200. He said that he was admitted into the facility about 6 weeks ago because his family could no longer take care of him at home. He was alert and oriented and he denied having thoughts of eloping or leaving the facility without permission. During an interview on 6/21/21 at 1:28 p.m. CNA D said she was in-serviced 1 or 2 days ago regarding facility policy and procedures on elopement and the steps to take if she identified or became aware of a resident that was an elopement risk. She said she would immediately redirect the resident and notify the charge nurse, ADON or DON. She said that she would also ask the nurse or ADON or DON about placing a WanderGuard on resident. During an interview on 6/21/21 at 2:26 p.m. the DON said residents who scored as at risk for elopement, and had the ability to physically leave the facility, had an order obtained for a WanderGuard and one was placed on those residents. She said she thought there were 6 residents in the facility that were wearing WanderGuards. She said the WanderGuards in the facility had to be activated by using an activation/deactivation box and once it was activated it was placed on the residents. She said once the device was applied it could not be removed unless it was deactivated by the deactivation box. She said in order to ensure the WanderGuard was working, staff looked at the LED light on the WanderGuard and if the LED light was on, the WanderGuard was functioning properly and was active. She said an electronic system monitored the functioning of the WanderGuards in real time. During an interview on 6/21/21 at 3:50 p.m., the DON said Resident #2 was not identified as an elopement risk until 6/18/2021. Upon assessment, she was considered a moderate elopement risk and this past weekend was when she started talking about eloping and it was care planned at that time. Review of the Elopement Assessments indicated that all were completed on 6/18/2021. 20 residents were found to be at medium risk of elopement and 5 residents were found to be at high risk of elopement. An in-service was completed with staff on 6/18/2021 for competency check offs regarding elopement. 20 staff members were listed as passing the competency test. In-services on Elopement Policy (22 staff attended), Elopement Finder, Risk Kardex Stop and watch, and Change of Condition (21 Staff attended), Strategies for Prevention (19 Staff attended), and Wandering and Unsafe Residents (19 staff attended) were conducted on 6/18/21. On 6/18/2021 the regional nurse in-serviced the DON on Elopement Policy and appropriate response to residents exhibiting exit seeking behavior. On 6/21/21 at 4:47 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a level of of no actual harm, with a potential for more than minimal harm, at a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 of 3 residents reviewed for accidents and supervision. (Resident # 1) The facility did not provide adequate supervision when CNA A left Resident #1 unattended on an elevated bed. The resident rolled off the bed and suffered a broken femur (large bone in the top of the leg). This failure could place residents at risk of injury, pain and decreased quality of life. Findings included: An admission record dated 3/9/21 indicated Resident #1 was admitted to the facility 1/2/2016, was [AGE] years old with diagnoses including: cognitive communication deficit, pain in left hip, lack of coordination and muscle weakness. The MDS dated [DATE] indicated Resident #1 was unable to complete the Brief Interview for Mental Status (BIMS - an assessment used to determine cognitive functioning). The assessment indicated the resident had a short-term and long-term memory problem, was not normally able to recall the current season, location of own room, staff names and faces, or that she was in a nursing home. The assessment indicated the resident had severely impaired decision making skills. The assessment indicated resident was totally dependent upon staff with 2+ plus persons physical assist with bed mobility and transfers. The care plan updated 1/15/21 for Resident #1 indicated she was at risk for increased falls and fractures. The care plan indicated a Morse Fall Scale (instrument used to assess likelihood of resident falling) placed the resident at high risk for falling with the following interventions:' .Resident to be on her right side while in bed to assist in prevention of falls . A facility in-service training report for the nursing department with a topic of positioning dated 2/9/21 indicated: .Bed to be in low position . A Morse Fall Scale dated 3/4/21 indicated Resident #1 was a high risk for falls. The resident scored a 55 on the scale. A score of 45 and higher indicates a high fall risk. An incident report dated 3/5/21 at 4:45 p.m., completed by LVN C indicated LVN D found resident (Resident #1) lying on the floor beside the bed. The report indicated the resident's bed was elevated and the lift pad was on the bed. The report indicated the nurse educated 2 RCPs on not leaving the bed high when staff were not in the room. The report indicated the resident was complaining of left hip pain and was transported via EMS to the local emergency room . A nursing note dated 3/5/21 at 4:45 p.m., completed by LVN C indicated LVN D walked by Resident #1's room and found the resident on the floor. The note indicated LVN C went to the residents room and observed Resident #1 lying on the floor on her right side. The note indicated the lift pad was on the bed and the bed was elevated. The noted indicated Resident #1 was guarding her left hip, screaming and breathing fast. The resident responded, my hip and pointed to her left hip when asked where she was hurting. The note indicated the resident was sent to a local ER for evaluation. During an interview on 4/22/21 at 7:16 p.m., LVN C said she was the nurse providing care for Resident #1 on 3/5/21. She said she entered the room and saw Resident #1 lying on the floor. She said the bed was elevated to about waist high, she said it was an appropriate level to elevate the bed if you were going to use the lift to transfer. She said 1 of the CNAs raised the bed to transfer the resident and left the resident alone in the room with the bed elevated to go get the Hoyer lift. She said it was never appropriate to leave the room with the resident in any position other than the lowest. A nursing note dated 3/6/21 at 12:15 a.m., indicated Resident #1 returned to the facility from the ER via EMS and there were no new orders. A nursing note dated 3/8/21 at 5:45 p.m., indicated Resident #1 had swelling noted to the entire knee with bruising on the back of the knee (side not specified). The note indicated the nurse received a new order for an x-ray of the left knee. A facility radiology result report of the left knee dated 3/8/21 for Resident #1 indicated an acute fracture of the distal left femoral diametaphysis (long bone in the leg near the knee). A nursing note dated 3/9/21 at 5:31 a.m. indicated Resident #1 had an acute fracture (no location specified). A nursing noted dated 3/9/21 at 6:10 a.m. indicated Resident #1 was transported to a local ER via EMS for an acute fracture of the left knee. A 1:1 facility in-service training report with no topic or department, dated 3-9-21 for CNA A indicated the following: All residents beds are to be in the lowest position at all times before leaving resident room. A hospital x-ray report dated 3/9/21 indicated Resident #1 had a mildly displaced fracture of the distal formal metaphysis (long bone in the upper leg, close to the knee). A hospital history and physical dated 3/9/21 indicated Resident #1 was admitted to the hospital with a diagnosis of a mildly displaced fracture of the distal femoral metaphysis with soft tissue swelling present. A hospital orthopedic surgery consult note completed by the orthopedic physician dated 3/11/21 indicated Resident #1 would be treated with non-surgical interventions including a pillow between her legs and an ace wrap. The note indicated a surgery may be required in the future. The note indicated the resident was in a moderate amount of pain. A hospital orthopedic progress note completed by an orthopedic physician dated 3/11/21 indicated Resident #1 was to place her knee in an immobilizer for comfort and stabilization, plan to see in the clinic 1 week after discharge. A nursing note dated 3/13/21 indicated Resident #1 returned to the facility from the hospital via EMS. During an observation on 4/26/21 at 1:30 p.m., Resident #1 was lying in her bed. The resident was yelling out and a caregiver entered to provide care. The bed was noted to be in the lowest position and a fall mat was in place. Resident #1 was not able to be interviewed due to her cognitive status. During an interview on 4/22/21 at 1:42 p.m., Resident #1's family member said Resident #1 was left lying on the bed on 3/5/21, rolled off the bed and broke her leg. She said a CNA (name unknown) told her Resident #1's bed was up high because they were getting ready to transfer her. She said the CNA told her CNA A left the resident alone with the bed in the high position while she went to get the lift (Hoyer lift). The family member said Resident #1 did not have the mentality to know not to roll off the bed. She said the residents left hip was bone on bone and very painful. She said staff were to keep her positioned on her right side because of the pain in her left hip. She said if the resident was left lying on her back, she would do anything (including rolling) to try to stop the pain to her left hip. The family member said she asked for the incident report, but had not received it. She said the resident was transported to the hospital on 3/5/21 for an x-ray of her left hip. She said the hospital reported there was no fracture of the resident's left hip and sent the resident back to the nursing facility at approximately 1:00 a.m. on the morning of 3/6/21. The family member said on 3/8/21 on the 2-10 shift, she noticed Resident #1's left leg was swollen and reported it to the charge nurse. She said an x-ray of the resident's left knee was ordered. She said the facility called her the next morning and indicated Resident #1 had a fracture of her left femur right above the knee and the resident was transferred to the hospital on the morning of 3/9/21. The family member said the resident did not have surgical intervention. She said she spoke with the orthopedic physician and he discussed the pros and cons of having surgery. She said she choose to not have the resident undergo surgery. During a telephone interview on 4/22/21 at 6:31 p.m., CNA A said on the evening of 3/5/21 she got Resident #1 ready for a transfer from her bed to chair and left the room to get another CNA to assist her with the transfer. She said she needed assistance because it required 2 staff to transfer with the Hoyer lift. She said she answered 2 more call lights while she was waiting for someone to help her. She said she guessed Resident #1 rolled over on the bed remote, which elevated the bed, and rolled off the bed. She said the bed was jacked up pretty high when they went back into the room. She said the resident was on the floor and EMS was called to transport the resident to the hospital. During an interview on 4/22/21 at 5:25 p.m., the ADON said she was not in the facility on 3/5/21 when Resident #1 fell from the bed. She said CNA A raised the bed and put the lift pad under the resident, then left the room to go get the Hoyer lift. She said Resident #1 rolled out of the bed while CNA A was out of the room. The ADON said she did a 1:1 counseling with CNA A related to not leaving a residents room without making sure the bed is in the lowest position. During an interview on 4/22/21 at 6:11 p.m., the DON said she was not present when Resident #1 fell off the bed on 3/5/21. She said on 3/5/21, CNA A was preparing to transfer Resident #1 from her bed to the chair using the Hoyer lift. She said CNA A placed the mat under the resident and raised the bed to a higher position. She said CNA A stepped out of the room to get the Hoyer lift and the resident changed position and rolled off the bed. The DON said CNA A should have put the bed back down before leaving the resident's room. She said CNA A did not think through what she needed to do and how she needed to do it. She said the resident was sent to the ER for evaluation on 3/5/21. During an interview on 4/23/21 at 11:15 a.m., the primary care physician for Resident #1 said he was notified on 3/5/21 she had a fall from the bed. He said staff should not have left her unattended on an elevated bed. He said the resident was initially sent to the hospital and a fracture was not identified. The physician said Resident #1 likely fractured her leg when she hit the floor from her fall from the bed on 3/5/21. He said a fracture was easily missed when a resident could not identify the pain. He said sometimes knee pain would refer to the hip. He said the fracture was not identified until 3/9/21 when a second x-ray revealed a fracture on her left femur right above the knee. A facility policy entitled Falls and Fall Risk, Managing, revised March 2018 indicated the following: .The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls .

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care based on their comprehensive assessment and in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 residents reviewed for pain management. (Resident #12) The facility did not accurately assess, manage, or treat Resident #12's pain during turning and incontinent care and did not administer pain medication to prevent/alleviate the resident's pain resulting in the resident crying in pain during care. Resident #12 experienced pain in her right knee pain during care. She could not be touched or moved without experiencing excruciating pain. This failure could place residents who received as needed pain medication for pain management at risk for not having their pain addressed. Findings included: A face sheet dated 12/02/2016 indicated Resident #12 admitted [DATE] and was [AGE] years old. Physician orders [REDACTED].#12 had [DIAGNOSES REDACTED]. The orders indicated Resident #12 received Tylenol #4 300-60 mg one (1) tablet by mouth every 6 hours as needed for pain and [MEDICATION NAME] 750 mg one (1) tablet by mouth every 6 hours as needed for muscle spasms. (prescribed 11/29/17) The care plan with initiated date of 1/26/18 and target date of 1/28/19 indicated Resident #12 complained of increased pain and discomfort and at risk for injury from decreased in activities of daily living. The care plan indicated pain had made it hard for the resident to sleep at night, pain over the past 5 days had limited her day-to-day activities, and pain was indicated as severe by resident. The Interventions for her pain were to assess the characteristics of pain such as location, severity on a scale of 1-10, the type and frequency of pain. Discuss with the resident the factors that precipitate pain and what may reduce it. Discuss with the physician that for maximum pain relief pain medication were best given around the clock, with as needed pain medication for breakthrough pain. The MDS dated [DATE] indicated Resident #12 was cognitively intact. She required extensive assistance with bed mobility and total dependence with the assistance of two-person physical assist with transfers and toilet use. A pain interview assessment dated [DATE] for Resident #12 indicated she had occasional pain that did not affect her ability to sleep, her pain was moderate. An x-ray report dated 1/6/19 at 8:28 PM indicated Resident #12 had an old fixated healing right femur fracture, an old fixated distal femur right knee fracture, and an old healed right lower leg fracture. A nursing note for Resident #12 dated 1/07/19 at 2:42 PM indicated the resident was sent to the hospital during the morning for confirmation of mobile x-rays as they were unclear. Resident #12 returned to the facility from the hospital with no new orders. During an interview on 1/16/19 at 11:45 AM, with LVN D she indicated Resident #12 was sent to the hospital for x-rays because the Mobilex x-ray results were unclear. A hospital emergency department physician documentation sheet dated 1/07/19 indicated Resident #12 weight was 399 pounds. The hospital imaging report for Resident #12's right femur dated 1/07/19 indicated an old distal right femur fracture status [REDACTED]. There was a questionable healing [MEDICAL CONDITION] tibial plateau (knee) with a periosteal reaction along the region which was not present in (MONTH) (YEAR). The conclusion of the study indicated a probable healing medial tibial plateau fracture which was new since (MONTH) (YEAR). A recommendation for a dedicated knee series was requested. During an interview on 1/17/19 at 10:22 AM, with the DON said she was not aware of any follow-up test scheduled for Resident #12 right leg. A nursing note for Resident #12 dated 1/11/19 at 10:05 PM by LVN C indicated the resident stated she needed stronger pain medication because right leg was fractured and she had increased pain. The request was faxed to the physician. A pain interview assessment dated [DATE] for Resident #12 indicated she had severe pain frequently that affected her ability to sleep at night and limited her day to day activities. No other pain interviews assessments were completed within the past 12 months. During an interview on 1/16/19 at 2:23 PM, LVN C indicated on 1/11/19 Resident #12 complained of increased pain in her right leg. She said she faxed the request for additional pain medication to the physician at the end her shift. She said she did not call to ensure he received the faxed because the faxed sheet indicated it was confirmed and went through. She could not recall if she passed the information on to the next nurse. The MAR indicated [REDACTED]. A controlled drug record for Resident #12 indicated on 1/11/19 she received an as needed dose of Tylenol #4 1 tablet at 8:00 AM, 3:20 PM and at 9:00 PM, all administered by LVN C. During an interview on 1/16/19 at 2:23 PM, LVN D indicated she saw a physician communication form today (1/16/19). LVN D said Resident #12's orders were changed today (1/16/19). From Tylenol #4 1 tablet every 6 hour to Tylenol #4 1 tablet every 4 hours. (5 days later/after surveyor's intervention). During an interview on 01/15/19 at 11:16 AM, Resident #12 said she was in pain and did not want to get up out of bed anymore. She said she used to get up and sit for about 4 hours. Resident #12 said about a week ago when staff transferred her with the Hoyer lift they moved her leg and it popped 3 times and she had been in pain since that day. She said she went to the hospital but was told her leg was not broke. Resident #12 said her leg had been broken in the past and had a rod. She said all she wanted to do was lay still so she does not move her leg because it hurts so bad. Resident #12 said she took Tylenol #4 but it did not help. She said the physician would not order her anything else. A nursing note dated 1/06/19 at 10:27 PM indicated the nurse and two CNAs were in the room while a second nurse stood Resident #12's door. Resident #12 felt a pop in her right leg and responded with ouch. The LVN and both CNAs all heard the pop. Later the CNA went to the resident's room to place a pillow under her leg and she complained of pain. 911 was called and the resident refused to go the hospital. Mobile x-rays were ordered. During an interview on 1/16/19 at 12:35 PM, with CNA J indicated about two weeks ago she and another CNA and a nurse transferred Resident #12 from her bed to her wheelchair with a Hoyer lift. She said the RN week-end supervisor was present and stood at the door during the transfer. CNA J indicated they all heard Resident #12's right leg make a popping sound. She said when Resident #12 was lowered into the chair she started to yell out in pain. CNA J said Resident #12 complained of pain behind her right knee. She said approximately thirty minutes later Resident #12 called her to put a pillow on the floor underneath her right foot. CNA J said when she lifted her right leg to place the pillow under her foot Resident #12 cried out in pain. She said when emergency medical services (EMS) arrived Resident #12 did not want to go to the hospital and told EMS she was not hurting. CNA J said since that day Resident #12 had refused care. She said Resident #12 did not want them the turn her or clean her because she was in pain. She said Resident #12 always complained of pain in her right leg when they turned her CNA J said prior to the incident Resident #12 allowed staff to turn her and would laugh and talk with them while they provided her care During an interview on 1/16/19 at 1:09 PM, CNA I indicated Resident #12 started to refuse care about two weeks ago. She said when she and other CNAs turned Resident #12 she always complained of pain in her right leg and refused peri-care because of the pain. CNA I said she reported Resident #12's pain to LVN D and notified her Resident #12 constantly refused to be cleaned because of her pain. She said before two weeks ago Resident #12 would allow peri-care with no complaints. During an observation on 1/16/19 at 11:58 AM, CNAs G and H attempted to provide incontinent care for Resident #12. Resident #12 said God-Damn! It hurt so bad, bad, bad! She said she did not want to move her right leg. CNAs G and H told Resident #12 they needed to change her and the resident asked if they could do it without moving her leg. Resident #12 asked the CNAs if they had to change her because State was there and they nodded yes. This surveyor intervened and asked the CNAs to notify Resident #12's nurse. During an observation on 1/16/19 at 12:08 PM, LVN D asked Resident #12 where she hurt. Resident #12 complained of pain in her right leg, LVN asked how bad and Resident #12 responded a 17 and a half. LVN D asked her what her pain was on a scale of 1-10, Resident #12 said a 10. LVN D Informed Resident #12 she had notified the physician today and he changed her one Tylenol #4 tablet from every 6 hour to every 4 hours. LVN D gave her 1 Tylenol #4 tablet at 12:11 PM. Resident #12 asked if she could have her [MEDICATION NAME] also, LVN D informed her she could not have it until 2 PM. The MAR for Resident #12 dated 1/01/19 through 1/31/19 indicated LVN D documented the resident had no pain on 1/16/19 during the evening shift. A controlled drug record for Resident #12 indicated on 1/16/19 she received an as needed dose of Tylenol #4 1 tablet at 2:15 AM, 8:00 AM and at 12:00 PM all administered by LVN D. During an observation and interview on 1/16/19 at 3:13 PM, CNAs E and F provided incontinent care for Resident #12. CNA E moved Resident #12's shoulder to position her in the center of the bed and Resident #12 clinched her fists and closed her eyes, she said it hurt to move. CNAs E and F turned Resident #12 to her left side and the resident cried out in pain. The two briefs, the blanket, fitted sheet, draw sheet and mattress were saturated with urine. The urine stains on the briefs, and linen were brown. CNA E indicated each time they provided incontinent care for Resident #12 she cried out in pain like she did during this observation. She said she has reported it to LVN C more than once. She said she told the nurse something was wrong with Resident #12's leg because she was in so much pain and her leg in more pink than usual. She said prior to the resident's incident two weeks ago she would help turn herself in bed and hold herself over on her side. She said Resident #12 would laugh and talk with her while she was turned and cleaned. Resident #12 would get up to her chair and had started to sit up for 3-4 hours. But since the incident she did not want to be turned, moved or get up in her chair anymore and she cry out when she is turned because of the pain. CNA E said that was why they started to use the torpedo (rolled-up brief placed between her legs). Resident #12 said the torpedo was so they did not have to turn her every 30 minutes. She said she did not sit up in the chair anymore and did not want to be moved because it hurt her so bad to be moved. Resident #12 said she just try to lay as still as she can all the time because it hurt bad each time she moved. During an interview on 1/16/19 at 4:20 PM, Resident #12's physician indicated he was not aware Resident #12 was in pain causing her to refuse incontinent care and cried when turned or changed. He said if he had known he would have probably given her additional pain medication until the pain was controlled or sent her to a pain management physician. Resident #12's physician said he was not notified on 1/11/19 of the resident's increased pain and request for additional pain medication. He said he was looking through his faxes during this interview and he did not receive the fax. He also said he expected the nurses to call him rather than fax. Resident #12's physician said he had an answering service for his calls after hours. During an interview on 1/16/19 at 4:45 PM, the DON indicated she expected nurses to follow-up with the resident's physician until a response was received. She indicated a fax was not notification. The undated Pain management policy indicated the following: .Residents are routinely evaluated for level of pain (0-10) each shift and is designated by initials on the MAR. If the resident is expressing pain, the pain is to be addressed. A Pain Evaluation will be completed upon admission, re-admission, and any new episode of pain or exacerbation of pain. The PRN (as needed) Pain Management Flowsheet will be completed for the administration of as needed pain medication. If the resident is assessed for unrelieved pain. The nurse will notify the attending physician to obtain an order for [REDACTED]. During an interview on 1/18/19 at 11:40 AM, LVN D indicated she was not aware of any further follow-up test Resident #12 had on her knee. She said Resident #12 was sent to the hospital today (1/18/19) because her leg was tender, pink, warm to the touch.

Based on observation, interview, and record review, the facility failed to ensure the physician was consulted and family was notified regarding pain for 1 of 6 residents reviewed for physician notification. (Resident #12) The facility did not consult with Resident #12's physician and notify family regarding pain during turning and incontinent care. Resident #12 experienced pain in her right knee and was crying during care. She could not be touched or moved without experiencing excruciating pain. This failure could place residents at risk for a delay in treatment. Findings included: A face sheet dated 12/02/2016 indicated Resident #12 admitted [DATE] and was [AGE] years old. Physician orders [REDACTED].#12 had [DIAGNOSES REDACTED]. The orders indicated Resident #12 received Tylenol #4 300-60 mg one (1) tablet by mouth every 6 hours as needed for pain and [MEDICATION NAME] 750 mg one (1) tablet by mouth every 6 hours as needed for muscle spasms. (prescribed 11/29/17) The care plan with initiated date of 1/26/18 and target date of 1/28/19 indicated Resident #12 complained of increased pain and discomfort and at risk for injury from decreased in activities of daily living. The care plan indicated pain had made it hard for the resident to sleep at night, pain over the past 5 days had limited her day-to-day activities, and pain was indicated as severe by resident. The Interventions for her pain were to assess the characteristics of pain such as location, severity on a scale of 1-10, the type and frequency of pain. Discuss with the resident the factors that precipitate pain and what may reduce it. Discuss with the physician that for maximum pain relief pain medication were best given around the clock, with as needed pain medication for breakthrough pain. The MDS dated [DATE] indicated Resident #12 was cognitively intact. She required extensive assistance with bed mobility and total dependence with the assistance of two-person physical assist with transfers and toilet use. A pain interview assessment dated [DATE] for Resident #12 indicated she had occasional pain that did not affect her ability to sleep, her pain was moderate. An x-ray report dated 1/6/19 at 8:28 PM indicated Resident #12 had an old fixated healing right femur fracture, an old fixated distal femur right knee fracture, and an old healed right lower leg fracture. A nursing note for Resident #12 dated 1/07/19 at 2:42 PM, indicated the resident was sent to the hospital during the morning for confirmation of mobile x-rays as they were unclear. Resident #12 returned to the facility from the hospital with no new orders. During an interview on 1/16/19 at 11:45 AM, LVN D indicated Resident #12 was sent to the hospital for x-rays because the results were unclear. The hospital imaging report for Resident #12's right femur dated 1/07/19 indicated an old distal right femur fracture status [REDACTED]. There was a questionable healing [MEDICAL CONDITION] tibial plateau (knee) with a periosteal reaction along the region which was not present in (MONTH) (YEAR). The conclusion of the study indicated a probable healing medial tibial plateau fracture which was new since (MONTH) (YEAR). A recommendation for a dedicated knee series was requested. During an interview on 1/17/19 at 10:22 AM, the DON said she was not aware of any follow-up test scheduled for Resident #12 right leg. A nursing note for Resident #12 dated 1/11/19 at 10:05 PM by LVN C indicated the resident stated she needed stronger pain medication because right leg was fractured and she had increased pain. The request was faxed to the physician. A pain interview assessment dated [DATE] for Resident #12 indicated she had severe pain frequently that affected her ability to sleep at night and limited her day to day activities. No other pain interviews assessments were completed within the past 12 months. During an interview on 1/16/19 at 2:23 PM, LVN C indicated on 1/11/19 Resident #12 complained of increased pain in her right leg. She said she faxed the request for additional pain medication to the doctor at the end her shift. She said she did not call to ensure he received the faxed because the faxed sheet indicated it was confirmed and went through. She could not recall if she passed the information on to the next nurse. The MAR indicated [REDACTED]. A controlled drug record for Resident #12 indicated on 1/11/19 she received an as needed dose of Tylenol #4 1 tablet at 8:00 AM, 3:20 PM and at 9:00 PM, all administered by LVN C. During an interview on 1/16/19 at 2:23 PM, LVN D indicated she saw a physician communication form today (1/16/19). LVN D said Resident #12's orders were changed today (1/16/19). From Tylenol #4 1 tablet every 6 hour to Tylenol #4 1 tablet every 4 hours. (5 days later/after surveyor's intervention) During an interview on 01/15/19 at 11:16 AM, Resident #12 said she was in pain and did not want to get up out of bed anymore. She said she used to get up and sit for about 4 hours. Resident #12 said about a week ago when staff transferred her with the Hoyer lift they moved her leg and it popped 3 times and she had been in pain since that day. She said she went to the hospital but was told her leg was not broke. Resident #12 said her leg had been broken in the past and had a rod. She said all she wanted to do was lay still so she does not move her leg because it hurts so bad. Resident #12 said she took Tylenol #4 but it did not help. She said the doctor would not order her anything else. A nursing note dated 1/06/19 at 10:27 PM indicated the nurse and two CNAs were in the room while a second nurse stood Resident #12's door. Resident #12 felt a pop in her right leg and responded with ouch. The LVN and both CNAs all heard the pop. Later the CNA went to the resident's room to place a pillow under her leg and she complained of pain. 911 was called and the resident refused to go the hospital. Mobile x-rays were ordered. During an interview on 1/16/19 at 12:35 PM, with CNA J indicated about two weeks ago she and another CNA and a nurse transferred Resident #12 from her bed to her wheelchair with a Hoyer lift. She said the RN week-end supervisor was present and stood at the door during the transfer. CNA J indicated they all heard Resident #12's right leg make a popping sound. She said when Resident #12 was lowered into the chair she started to yell out in pain. CNA J said Resident #12 complained of pain behind her right knee. She said approximately thirty minutes later Resident #12 called her to put a pillow on the floor underneath her right foot. CNA J said when she lifted her right leg to place the pillow under her foot Resident #12 cried out in pain. She said when emergency medical services (EMS) arrived Resident #12 did not want to go to the hospital and told EMS she was not hurting. CNA J said since that day Resident #12 had refused care. She said Resident #12 did not want them the turn her or clean her because she was in pain. She said Resident #12 always complained of pain in her right leg when they turned her. CNA J said prior to the incident Resident #12 allowed staff to turn her and would laugh and talk with them while they provided her care. During an interview on 1/16/19 at 1:09 PM, CNA I indicated Resident #12 started to refuse care about two weeks ago. She said when she and other CNAs turned Resident #12 she always complained of pain in her right leg and refused peri-care because of the pain. CNA I said she reported Resident #12's pain to LVN D and notified her Resident #12 constantly refused to be cleaned because of her pain. She said before two weeks ago Resident #12 would allow peri-care with no complaints. During an observation on 1/16/19 at 11:58 AM, CNAs G and H attempted to provide incontinent care for Resident #12. Resident #12 said God-Damn! It hurt so bad, bad, bad! She said she did not want to move her right leg. CNAs G and H told Resident #12 they needed to change her and the resident asked if they could do it without moving her leg. Resident #12 asked the CNAs if they had to change her because State was there and they nodded yes. This surveyor intervened and asked the CNAs to notify Resident #12's nurse. During an observation on 1/16/19 at 12:08 PM, LVN D asked Resident #12 where she hurt. Resident #12 complained of pain in her right leg, LVN asked how bad and Resident #12 responded a 17 and a half. LVN D asked her what her pain was on a scale of 1-10, Resident #12 said a 10. LVN D Informed Resident #12 she had notified the physician today and he changed her one Tylenol #4 tablet from every 6 hour to every 4 hours. LVN D gave her 1 Tylenol #4 tablet at 12:11 PM. Resident #12 asked if she could have her [MEDICATION NAME] also, LVN D informed her she could not have it until 2 PM. The MAR for Resident #12 dated 1/01/19 through 1/31/19 indicated LVN D documented the resident she had no pain on 1/16/19 during the evening shift. A controlled drug record for Resident #12 indicated on 1/16/19 she received an as needed dose of Tylenol #4 1 tablet at 2:15 AM, 8:00 AM and at 12:00 PM all administered by LVN D. During an observation on 1/16/19 at 3:13 PM, CNAs E and F provided incontinent care for Resident #12. CNA E moved Resident #12's shoulder to position her in the center of the bed and Resident #12 clinched her fists and closed her eyes, she said it hurt to move. During an interview on 1/16/19 at 3:40 PM, CNA E indicated each time they provided incontinent care for Resident #12 she cried out in pain. like she did during this observation. She said she has reported it to LVN C more than once. She said she told the nurse something was wrong with Resident #12's leg because she was in so much pain and her leg in more pink than usual. She said prior to the resident's incident two weeks ago she would help turn herself in bed and hold herself over on her side. She said Resident #12 would laugh and talk with her while she was turned and cleaned. Resident #12 would get up to her chair and had started to sit up for 3-4 hours. But since the incident she did not want to be turned, moved or get up in her chair anymore and she cry out when she is turned because of the pain. CNA E said that was why they started to use the torpedo. Resident #12 said the torpedo was so they did not have to turn her every 30 minutes. She said she did not sit up in the chair anymore and did not want to be moved because it hurt her so bad to be moved. Resident #12 said she just try to lay as still as she can all the time because it hurt bad each time she moved. During an interview on 1/16/19 at 4:20 PM, Resident #12's physician indicated he was not aware Resident #12 was in pain causing her to refuse incontinent care and cried when turned or changed. He said if he had known he would have probably given her additional pain medication until the pain was controlled or sent her to a pain management doctor. Resident #12's physician said he was not notified on 1/11/19 of the resident's increased pain and request for additional pain medication. He said he was looking through his faxes during this interview and he did not receive the fax. He also said he expected the nurses to call him rather than fax. Resident #12's physician said he had an answering service for his calls after hours. During an interview on 1/16/19 at 4:44 PM, Resident #12's son indicated the facility staff had not notified him his mother was in pain which caused her to refuse incontinent care and cry when she was turned or changed. He said his mother told him she was in severe pain. He indicated the last call he received from facility staff was when she returned from the hospital on [DATE]. During an interview on 1/16/19 at 4:45 PM, the DON indicated she expected nurses to follow-up with the resident's physician until a response was received. She indicated a fax was not notification. An undated change in condition policy indicated .it will be the policy that once the nurse has notified the physician for a change in condition the resident will be monitored every one hour until the physician has responded. The monitoring will include vital signs, pulse ox, and finger stick blood sugar if a diabetic (one time only). A physical assessment should be completed relative to the symptoms present and a pain assessment. If you are unable to reach the physician within 2 hours, repeat call. If you are still unable to reach the physician, you may call the Medical Director .

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person- centered care plan that included measurable objectives and timeframes to meet a resident's needs for 8 of 22 residents reviewed for care plans. (Resident #s 3, 4, 39, 53, 55, and 410) The facility did not have care plans to address the following: Resident #3's correct consistency for her liquids and indicated the resident was receiving Promod as a supplement when she was not; Resident #4's bruise to her face or her wander guard; Resident #39's [MEDICAL CONDITION]; Resident #53's correct catheter size; Resident #55's wounds to his right foot; and Resident #410's indwelling urinary catheter. This failure could place residents at risk for not receiving the care and services required to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings included: 1. Physician order [REDACTED].#3, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. There was no order for ProMod supplement. The care plan dated 12/18/18 indicated Resident #3 had nutritional impairment was to receive regular consistency liquids and ProMod. The care plan indicated an intervention to provide and serve diet as ordered. The most recent MDS dated [DATE] indicated Resident #3 had clear speech, was usually understood, and could sometimes understand. Her cognition was severely impaired with short and long term memory problems. The MDS indicated Resident #3 received a mechanically altered diet, required a change in texture of food or liquids. The (MONTH) 2019 physician order [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. During an interview on 01/18/19 at 11:21 a.m., the MDS nurse said Resident #3's care plan should not indicate the resident received ProMod. The MDS nurse said there was no order for ProMod for Resident #3. She said Resident #3's orders noted the resident was on nectar thick liquids and the care plan should match the physician orders [REDACTED].#3 was to receive nectar thick liquids and not regular consistency liquids. She said the information from the care plan was shared on the CNAs kiosk providing them with information to take care of the residents, so the care plans needed to be accurate. 2. Physician order [REDACTED].#53, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The indwelling urinary catheter was noted 20FR 10 cubic centimeter (cc) bulb to continuous drainage. The most recent MDS dated [DATE] indicated Resident #53 had clear speech, was understood, and could usually understand. Her cognition was moderately impaired. Resident #53 required extensive 2- person assistance with toileting, had an indwelling urinary catheter and was frequently incontinent of bowel. The care plan dated 12/26/18 indicated Resident #53's catheter size was 18FR 10cc bulb to continuous drainage. During an interview on 01/18/19 at 11:21 a.m., the MDS nurse said Resident #53's catheter tubing size was not care planned per the physician's orders [REDACTED]. 3. Physician order [REDACTED].#410, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. There was no order for Resident #410's indwelling urinary catheter. A discharge continuity of care dated 11/23/18 indicated Resident #410 was readmitted to the facility from the hospital with an indwelling urinary catheter. The most recent MDS dated [DATE] indicated Resident #410 had no speech, was rarely/never understood, and could rarely/never understand. Her cognition was severely impaired. The MDS indicated Resident #410 did not have an indwelling urinary catheter and was always incontinent of bowel and bladder. The skilled charting form dated 12/01/18 noted Resident #410 had an indwelling urinary catheter and received care. The care plan dated 12/26/18 did not include Resident #410's indwelling urinary catheter. During an observation on 01/14/19 at 9:36 a.m., Resident #410 was lying in bed with an indwelling urinary catheter. During an observation on 01/15/19 at 9:30 a.m., 9:40 a.m., and 9:56 a.m., Resident #410 was lying in bed with an indwelling urinary catheter. During an observation on 01/17/19 at 12:28 p.m , Resident #410 was lying in bed with an indwelling urinary catheter. During an interview on 01/18/19 at 2:20 p.m., the administrator said Resident #410 should has had her catheter for quite some time and there should be a care plan for it. 4. A face sheet dated 01/17/19 indicated Resident #55, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #55 was cognitively impaired and required on staff extensive assistance from two staff for ADLs. Resident #55 had one stage 3 pressure injury, and had no venous or arterial ulcers. The physician orders [REDACTED].#55 included apply sureprep (skin prep) to right great toe arterial wound every day. A care plan with initiated dated of 7/30/18 and target date of 3/29/19 indicated Resident #55 had an unstageable pressure injury to his right great toe related to new shoes. Interventions included weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Report improvements and decline to the physician. There were no care plans for wounds on Resident #55's right lateral foot, right medial foot (bunion area), second toe on right foot or third toe on left foot. The nursing wound assessments for Resident #55's right great toe indicated the following: 0/15/19- Nursing wound assessment indicated an arterial wound to his/her right great toe with a scabbed (scab - a dry, rough protective crust that forms over a cut or wound during healing. A raised area without depth.) wound bed. The wound measured 0.3 cm x 0.4 cm x 0.1 cm. The wound doctor's assessments for Resident #55's right great toe indicated the following: 01/08/19- Wound doctor's evaluation indicated an arterial wound to his right lateral foot with dried [MEDICATION NAME] exudate. scab The wound measured 0.3 cm x 0.4 cm x 0.1 cm. Continue to apply skin prep daily. During an observation and interview on 1/17/19 at 3:44 PM, treatment nurse RN L said the area on Resident # 55's right medial (inner) foot (hallux/bunion area) was the only wound the wound care doctor was following. She said a second area on Resident #55's right great toe, near the nail bed used to be a blood blister, but now it was just hard. Treatment nurse, RN L said the only wound for Resident #55 being treated was his/her right medial foot. (bunion area) She said all the other wounds on Resident #55's right foot had been there for at least a month but were scabbed. Treatment nurse, RN L provided wound care for Resident #55, and following wounds were measured and noted for Resident #55: Right medial (inner) foot (bunion area)- 0.3 cm x 0.3 cm x <0.2 cm. Skin prep was applied to the wound. Right great toe, near nail bed - 0.6 cm x 0.4 cm x <0.2 cm, scabbed. No treatment was provided. Right second toe- 0.3 cm x 0.3 cm x <0.2 cm, scabbed. No treatment was provided. Right lateral foot -0.6 cm x 0.6 cm x <0.2 cm, scabbed. No treatment was provided. Left third toe - 0.5 cm x0.4 cm x <0.2 cm, scabbed. No treatment was provided. During an interview on 1/17/19 at 4:15 PM, treatment nurse RN L indicated there was no assessment, tracking or documentation for the wounds on Resident #55's right great toe near the nail bed, right second toe, right lateral foot or his left third toe. During an observation of Resident #55's wounds on 1/17/19 at 4:20 PM, the DON and treatment nurse RN L, the DON asked RN Treatment Nurse L if the wound care physician was treating Resident #55's right lateral foot wound. Treatment nurse RN L said, no he was only treating the right bunion area. 5. A face sheet dated 1/04/18 indicated Resident #39, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. A care plan dated 11/08/18 indicated Resident #39 was at risk for falls and was not steady without staff assistance with transfers. The MDS dated [DATE] indicated Resident #39 had moderate cognitive impairment and required total assistance of 2 staff with transfers, extensive assistance of 2 staff with bed mobility and toileting. A Medical Imaging Report dated 12/27/18 indicated a MRI with and without contrast was done. The report indicated Resident #39 had a left femoral neck fracture from recent fall. A physician order [REDACTED].#39 was to have an orthopedic referral for MRI (magnetic resonance imaging) results of left femoral neck (left hip) fracture. The care plans dated 2/18/18 through 1/16/19 indicated no care plan for Resident #39's left [MEDICAL CONDITION]. During an interview on 01/14/19 09:22 AM, Resident #39 indicated she slid out of bed about a month ago. She was told she had a cracked bone in one of her legs. Resident #39 said she did not have any feeling below her waist and had not felt any pain in her legs. Resident #39 said she was not sure if the fracture happened when she fell or not. During an interview on 1/18/19 at 2:40 PM, CNA J indicated back in approximately (MONTH) or (MONTH) (YEAR) she was coming down the hall when she got to work (not sure of time) and saw people in Resident #39's room and went in to help. She said Resident #39 was on the floor and she assisted staff in putting the resident back in the bed with a draw sheet. She said she could not remember who helped her put her back to bed. CNA J said Resident #39 seemed to be ok. She did not notify the nurse, to her recollection the nurse was in the room and helped put her back in bed. During an interview on 1/17/19 at 10:22 AM, the DON indicated she did not recall at this-time if she was aware of Resident #9's left [MEDICAL CONDITION]. During an interview on 1/17/19 at 10:26 AM, the administrator indicated he was not aware of Resident #9's left [MEDICAL CONDITION]. His expectations were to be notified of all fractures. During an interview on 1/17/19 at 10:30 AM, the DON indicated she was not aware of Resident 39's fracture and her expectation was to be notified by the nurse who entered the physician's orders [REDACTED]. During an interview on 1/17/19 at 10:32 AM, the ADON indicated she received the results from the physician on 1/07/19 and entered the order for the orthopedic referral in the computer. She said she notified the administrator and DON during the morning meeting. She said no care plan was done for the fracture. 6. A face sheet dated 1/04/18 indicated Resident #4, admitted [DATE] was [AGE] years old with [DIAGNOSES REDACTED]. Physician orders [REDACTED].#4 had an order for [REDACTED]. The MDS dated [DATE] indicated Resident #4 had severe cognitive impairment and required supervision with ambulation and transfers by one staff. The care plans for Resident #4 dated 10/07/17 through 1/17/19 indicated no care plan for the wander-guard or the bruising to right side of Resident #4's face. A nursing note for Resident #4 dated 12/15/18 by RN Treatment Nurse L indicated wander-guard was to be checked every shift to ensure it was on the resident. A nursing note for Resident #4 dated 1/12/19 by LVN C indicated purple bruising on the right side of her forehead. During an observation on 01/14/19 at 10:25 AM, Resident #4 had a wander-guard on her right ankle. There was a bruise on the right side of her face and eye, black, purple and green in color. During an interview on 01/15/19 at 09:26 AM, LVN D indicated the bruise on the right side of Resident #4's face was from a fall. During an observation on 01/15/19 at 02:28 PM, Resident #4 had a wander guard on her right ankle. There was bruising to the right side of her face. During an interview on 1/18/19 at 11:00 AM, the MDS nurse indicated the wander-guard was addressed on Resident #4's care plan but would only print with the word safety however, on her computer it showed the entire plan of care. During an observation with the MDS nurse on 1/18/19 at 11:10 AM of Resident #4's care plan on the MDS computer indicated the word Safety and the care plan for the wander-guard was added 1/18/19, after surveyor intervention. The safety care plan was not on the original care plans, and there was no care plan for the bruising. The care plan policy and procedure revised (MONTH) 2010 indicated: .An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy Interpretation and Implementation: 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS .

Based on observation, interview, and record review, the facility failed to provide care, consistent with professional standards of practice and based on a comprehensive assessment, to promote healing, prevent infection and prevent the development of new pressure injuries for 1 of 7 residents reviewed for pressure injuries. (Resident #3) The facility did not implement pressure redistribution and dietary interventions to prevent Resident #3 from developing a facility acquired coccyx wound that worsened to a stage 3 pressure injury and 2 facility acquired pressure injuries on her buttocks. Resident #3 did not receive wound care as ordered. This failure could place residents with pressure injuries at risk for development of new pressure injuries and the decline in existing pressure injuries. Findings included: Physician orders dated (MONTH) 2019 indicated Resident #3, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The order indicated Resident #3 should be receiving house supplement 2.0 two times a day, have a low air loss mattress, and staff were to apply Medseptic (barrier cream) to her peri-area and buttocks after each incontinent episode and as needed. The resident was receiving hospice services starting 09/13/18. The care plan dated 12/18/18 indicated Resident #3 had a history of [REDACTED]. Interventions related to the history of pressure injuries included follow facility policies/protocols for the prevention/treatment of [REDACTED].#3's Braden Scale for pressure sores indicated she was at moderate risk for wounds. The intervention addressed .shearing to bilateral buttocks: cleanse with wound cleanser, pat dry, apply collagen, cover with [MEDICATION NAME]. (MONTH) change as needed for soilage/dislodgement. Discontinue when healed . Resident #3 required assistance with ADLs, bed mobility, transfers and toileting. The care plan noted the resident required total dependence with 2-person physical assist with toileting, and extensive 2-person assistance with transfers and bed mobility. The most recent MDS dated [DATE] indicated Resident #3 had clear speech, was usually understood, and could sometimes understand. Her cognition was severely impaired with short- and long-term memory problems. The assessment indicated the resident had two stage 2 pressure injuries and no other skin issues. Resident #3 required extensive 2 person assist with bed mobility, transfers, and dressing. She was incontinent of bowel and bladder. The most recent dietary note dated 11/01/18 did not address if Resident #3 had any wounds. It indicated she was currently receiving a house supplement and no new recommendations were noted. A Weekly Skin assessment dated [DATE] noted Resident #3 did not have any kind of skin issue. A Weekly Wound assessment dated [DATE] completed by treatment nurse RN Q indicated Resident #3 had a pressure ulcer on her coccyx measuring 2.2 centimeters, (cm) x 2.0 cm x 0.3 cm. It was noted the wound bed margins were rolled under, the wound bed was pink, and the skin around the wound had moisture associated skin damage (MASD). The assessment indicated the current wound treatment, received from the physician (no dates provided) was to cleanse daily with wound cleanser, pat dry, and apply collagen and dry bordered dressing daily. The assessment indicated pressure reducing devices in place included utilizing a low air loss mattress, pillows for positioning/off-loading, and a heel suspension boot. Nutritional interventions noted was vitamin therapy. The telephone/verbal Physician order record dated 01/06/19 indicated to clean Resident #3's coccyx injury daily with wound cleanser, pat dry, and apply collagen a dry boarder dressing. (MONTH) change as needed for soilage/dislodgement. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The treatment nurse RN L documented completing 1 treatment (on 01/07/19) as ordered for the stage 2 pressure injury. The new order was discontinued on the same day, 01/07/19, by treatment nurse RN L. Another treatment for [REDACTED]. It indicated to change the dressing only as needed for soilage/dislodgement. The MAR indicated [REDACTED]. A physician order indicated an order start date of 01/07/19 for Resident #3 noted shearing to her coccyx: cleanse with wound cleanser, pat dry, apply collagen, and cover with [MEDICATION NAME] dressing on the day shift every 3 day(s) for wound healing related to muscle wasting and atrophy. It indicated to change the dressing as needed for soilage/dislodgement. The MAR indicated [REDACTED]. The resident received the treatment including collagen and covering with a [MEDICATION NAME] dressing on 01/12/19. A Weekly Skin assessment dated [DATE], completed by treatment nurse RN L noted Resident #3 had MASD (location not identified) and had no pressure injuries. The assessment indicated the resident had shearing on her coccyx. There were no measurements provided. The MAR indicated [REDACTED]. The order indicated to cleanse the shear with wound cleanser, pat dry, apply collagen, and cover with [MEDICATION NAME] dressing every 3 days. (MONTH) change as needed for soilage/dislodgement for wound healing. There was no indication a treatment was provided on 01/10/19 when the order was received. A Weekly Wound assessment dated [DATE], completed by treatment nurse RN Q, noted Resident #3 had a pressure injury on her coccyx. The assessment did not indicate the stage of the wound. The assessment indicated the wound bed was pink with rolled under wound bed margins, no drainage, and no odor. The skin surrounding the wound had MASD. The measurement noted the coccyx pressure injury identified on 01/06/19, measured 2.0 cm x 1.8 cm x 0.3 cm. The Weekly Wound Assessment noted the treatment as the current wound treatment, received from the physician, to cleanse daily with wound cleanser, pat dry, apply collagen, and cover with a dry bordered dressing daily. Pressure reducing devices in place included utilizing a low air loss mattress, pillows for positioning/off-loading, and a heel suspension boot. Nutritional interventions noted was vitamin therapy. During an observation and interview with LVN R on 01/17/19 at 9:27 a.m., Resident #3 was in bed lying on her back asleep on a low air loss mattress. LVN R lifted the resident's covers and there were no pillows or other devices present to off-load the resident's heels or her coccyx area. LVN R said Resident #3 should have pillows to offload pressure from her coccyx area and feet for offloading pressure. During an interview on 01/17/19 at 2:51 p.m., treatment nurse RN L said Resident #3 was not being seen by the wound physician because the wound to the resident's coccyx was being called a shear. She said on 01/03/19 Resident #3's wound was closed and resolved but the area opened back up on 01/06/19. The treatment nurse RN L said treatment nurse RN Q indicated on 01/06/19 Resident #3 had a stage 2 pressure injury on her coccyx. The treatment nurse RN L said she changed the wound from a stage 2 pressure injury to a shear because it looked like the area that healed previously on 01/03/19. The treatment nurse RN L said open wounds with depth and over a pressure point/boney prominent area were pressure injuries. She said since Resident #3's wound was located over a boney prominent area and had depth, it would be a pressure ulcer. During an interview on 01/17/19 at 5:30 p.m., LVN S said Resident #3 usually had pillows for off-loading her feet and for positioning. She said while the resident was eating her meal at this time, the pillows were not being used. LVN S said Resident #3 had never had heel suspension boots. She said staff should be turning Resident #3 every 2 hours. During an observation on 01/17/19 at 5:32 p.m., Resident #3 was sitting up in bed and was being assisted with her meal by her spouse. The resident did not have pillows or other devices present for off-loading her heels and positioning off of her coccyx. During an interview on 01/17/19 at 5:34 p.m., CNA E said Resident #3 has never had heel suspension boots. She said she has worked at the facliity for [AGE] years. During an observation on 01/18/19 at 8:45 a.m., Resident #3 was lying in bed on her back with no pillow or device present to off-load her heels and coccyx area. There was 1 pillow on the chair next to the bed. During an observation and interview with the treatment nurse RN L on 01/18/19 at 10:02 a.m., Resident #3 was lying in bed with a pillow behind her back; however, the resident's coccyx was not off loaded. The treatment nurse RN L said there was no physician's order for Resident #3 to have heel suspension boots, so the pillow was being used to off-load Resident #3's heels. The treatment nurse RN L said there should have been 2 pillows in Resident #3's bed, 1 to off-load her heels and 1 to off-load her coccyx. During an observation and interview on 01/18/19 at 10:25 a.m., treatment nurse RN L provided wound care for Resident #3. Upon removing the [MEDICATION NAME] dressing from Resident #3's coccyx treatment nurse RN L identified had developed the following pressure injuries: * Coccyx area - The wound was measured to be 2.5 cm x 3.2 cm x 0.2 cm with irregular edges, slough covering approximately 40% of the wound bed, with no drainage, and the wound had MASD surrounding it. Treatment nurse RN L said the wound was now a stage 3, had increased in size, and worsened. * Left medial buttock - The wound was measured to be 1.5 cm x 3.8 cm. It was an open pressure injury with a pink wound bed and MASD surrounding the wound. The treatment nurse said it was a new stage 2 pressure injury. * Right medial buttock - The wound measured to be 5.0 cm x 3.2 cm. It was an open pressure injury with a pink wound bed and MASD surrounding the wound. The treatment nurse said it was a new stage 2 pressure injury. During an interview on 01/18/19 at 11:33 a.m., the treatment nurse RN L said prior to the treatment today, Resident #3 only had 1 shear on her coccyx but now she had 3 pressure injuries. She said she last saw the resident's shear on 01/16/19 while providing a treatment. She said Resident #3 should be repositioned every 2 hours with a pillow used to off-load her heels and a pillow to be used to assist in positioning the resident off her coccyx area. The treatment nurse RN L said Resident #3 was not receiving nutritional interventions, vitamin therapy, and did not have any heel suspension boots as indicated on the Weekly Wound Assessments. During an interview on 01/17/19 at 3:31 p.m., the DON said if there was an open area with depth over a boney area it was a pressure injury. She said when she was made aware of a resident having a wound she looked at the area for herself and determine if the wound was a pressure injury. The DON said upon identifying a wound she would expect the physician to be notified and an order for [REDACTED]. During an interview on 01/18/19 at 11:08 a.m., the DON said she expected the physician, DON, family and the administrator to be notified of skin issues. She said an order should be obtained, initiated, and a referral should be made to the wound care physician as soon as possible. The DON said the dietician should be notified as well even if the resident received hospice services. According to the National Pressure Ulcer Advisory Panel (NPUAP) website, http://www.npuap.org/resources/educational-and-clinical-resources, accessed 1/18/19, the following was indicated: .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. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury .

Based on interview and record review, the facility failed to ensure necessary treatment and services consistent with professional standards of practice to promote healing of a pressure injury was provided for 1 of 3 residents reviewed for pressure injury. (Resident #2) The facility did not identify the wound on the MDS (comprehensive) assessment, develop a care plan, identify signs and symptoms of infection, and notify the physician the injury worsened. Resident #2 was admitted with moisture associated skin damage on her sacral area and developed a stage 2 pressure injury after admission. The pressure injury progressed to an unstageable pressure injury 3 weeks after admission. This failure contributed to Resident #2's unstageable pressure injury to her sacrum necessitating excision (cut out) completely down to the bone. This failure could place 53 residents receiving preventive skin care at risk for developing pressure injuries and 2 residents with pressure injuries at risk for decline in existing pressure injuries. Findings included: A communication form and progress note dated 6/7/18 indicated Resident #2 was transferred to an acute care facility for evaluation and treatment. Resident #2 did not return to the facility. An admission record dated 7/11/18 indicated Resident # 2 admitted [DATE], was [AGE] years old and had [DIAGNOSES REDACTED]. A skin observation tool dated 5/12/18 indicated Resident #2 had a right hip surgical incision and moisture associated skin damage (MASD) on her sacrum. A baseline care plan dated 5/12/18 indicated Resident #2 had a goal of preventing pressure ulcers with interventions including provide pressure device, turn and reposition, inspect skin according to facility protocol and incontinent care. The baseline care plan included a goal to reduce size and facilitate healing of pressure sores with interventions including treat according to physician orders [REDACTED]. A wound-weekly skin observation dated 5/16/18 indicated Resident #2 had a stage 2 pressure injury on her sacrum measuring 1.5 centimeters (cm) x 3 cm x 0.1 cm. The wound had a scant amount of serous drainage and the skin tissue around the wound had MASD and was red and blanchable. The documentation indicated the physician was notified and ordered a treatment to apply barrier cream as needed, clean with wound cleaner, pat dry, apply collagen and cover with [MEDICATION NAME] every three days. The observation note did not indicate Resident #2 was on a turning and repositioning routine. The MDS dated [DATE] indicated Resident #2 had moderate cognitive impairment. Resident #2 was described as always incontinent of bladder and bowel and required extensive assistance with bed mobility, dressing, personal hygiene and locomotion on and off the unit. The MDS indicated Resident #2 was not at risk for developing pressure ulcers and did not have a pressure ulcer. A wound-weekly skin observation dated 5/23/18 indicated the pressure injury on Resident #2's sacrum was a stage 2, was unchanged and measured 1.5 cm x 3 cm x 0.1 cm. The observation indicated the area around the wound had MASD and was red and blanchable. The observation indicated Resident #2 was educated on the need to stay off loaded and stay turned and Resident #2 indicated it hurt her leg if she was on her side. The observation did not indicate Resident #2 was on a turning and repositioning schedule. A care plan dated 5/24/18 indicated Resident # 2 had an ADL self-care deficit and required assistance by staff with turning and repositioning in bed, was incontinent and required monitoring for incontinence every 2 hours and as needed and was at risk for skin breakdown. The care plan did not address Resident #2's stage II pressure injury. The care plan did not include interventions to prevent the wound from worsening and did not include an intervention of turning and repositioning Resident #2 every 2 hours. A wound-weekly skin observation dated 5/29/18 indicated Resident # 2's pressure injury was a stage 2 and was worsening with measurements of 1.5 cm x 3.5 cm x 0.1 cm. The observation indicated the treatment nurse had notified a family member of the wound having a slight increase in size and resident not wanting to stay off loaded and wanting to stay flat on her back. The observation indicated the area around the wound was red and blanchable. The observation indicated Resident #2 was on a turning and repositioning routine with no frequency indicated and had positioning pillows. The physician was not notified and there was no change in treatment or treatment frequency. A wound-weekly skin observation dated 6/4/18 indicated Resident #2's pressure injury was worsening and unstageable due to the wound bed being 100% covered by slough. The wound measurement had increased to 5.5 cm x 3.5 cm x 0.5 cm with the surrounding tissue being red and blanchable. The observation indicated the physician was updated and the treatment was changed to Santyl with a dry dressing to be changed every day and a low air loss mattress was ordered for Resident #2. A physician fax communication form dated 6/4/18 indicated the physician was notified the wound was unstageable due to yellow slough. The form indicated the treatment was changed to Santyl with a dry dressing every day and a low air loss mattress was ordered for Resident #2. The faxed communication did not include the measurements of the wound. A wound-weekly skin observation dated 6/7/18 indicated Resident #2's pressure injury was worsening, unstageable and the wound bed was covered by 100% slough. Wound measurements were 5.5 cm x 3.5 cm x 0.5 cm with surrounding tissue being red and blanchable. The observation did not indicate the wound had any necrotic tissue or any signs and symptoms of infection. A history and physical dated 6/7/18 completed by a physician at an acute care hospital indicated Resident #2 had a 7 cm diameter sacral decubitus with [MEDICATION NAME] exudate in the central aspect and somewhat necrotic-appearing dark black tissue on the periphery. A clinical documentation report dated 6/8/18 at 8:00 am indicated Resident #2 had a pressure wound measuring 7 cm x 5 cm x 1 cm with yellow slough. The report indicated the wound had a scant amount of odorous drainage and had signs of infection including [MEDICAL CONDITION], redness and warmth at site. An operative report dated 6/10/18 indicated Resident #2 had an excisional debridement of wound for infection. The report indicated the decubitus ulcer on the sacrum was excised completely down to the bone with a final area of 10 cm x 10 cm. During an interview on 7/11/18 at 12:00 p.m., CNA A indicated every resident had a CNA care plan that indicated the care each resident needed. She indicated the care plan was in a closet on one of the hallways. CNA A said the care plan would indicate if a resident needed to be repositioned and how often. CNA A said residents that could not move themselves in the bed needed to be turned by the CNAs. CNA A said she did not remember Resident #2. CNA A said she would report any changes in a resident's skin to the charge nurse immediately. During an interview on 7/10/18 at 2:22 p.m. ,the DON said the facility had a treatment nurse who worked Monday through Friday and a weekend RN that completed wound care on the weekends. The DON said as far as she knew Resident #2 had an open area upon admission, but it was not stageable due to it being excoriated or having moisture associated [MEDICAL CONDITION]. The DON said a stage 2 pressure injury was identified on the coccyx of Resident #2 a few a days after admission. The DON said wounds were measured weekly by the treatment nurse. The DON said she expected the physician to be notified any time there was a new wound and when there was a change in a wound. She said the physician should be notified if a wound worsened. The DON said if the wound had no positive progress the treatment was usually changed after two weeks. The DON said every patient that was incontinent was on every 2-hour turning and repositioning routine. She said the facility did not keep a documentation sheet or a record of when Resident # 2 was turned and repositioned. The DON said the facility did not keep a copy of the CNA care plan once a resident was discharged from the facility. The DON said the treatment nurse may have not notified the physician of the 0.5 increase in the size of the pressure injury for Resident #2 on 5/29/18 because the resident's clinical conditions may have been contributing to the wound not improving. The DON said the treatment nurse did educate the family and Resident #2 about offloading and she considered that an intervention. The DON said the facility skin care policy was that residents with stage 3 and 4 pressure injuries would be placed on a specialty mattress. During an interview on 7/12/19 at 1:39 p.m., the MDS coordinator indicated when a resident had a pressure injury it should be addressed on their care plan and MDS. She indicated she added pressure injuries and other skin issues on the MDS and care plan as soon as she was notified a resident developed an issue. She said she could not remember specifics about Resident #2's MDS and care plan. She said if Resident #2 had a pressure injury or any skin issue it should have been noted on the MDS and it should have been care planned. An undated pressure injury staging, and recommended products algorithm utilized by the facility indicated .clinical signs of infected wounds included the following: [DIAGNOSES REDACTED] outside of proportion to wound size; induration; marked foul odor; elevated temperature; increased WBC count' increasing wound size; increasing drainage; increasing odor; new onset pain; failure to progress as anticipated . A revised facility policy dated 4/17 entitled Skin Management System indicated the following: .keep open lines of communication with physicians, families, and residents regarding status of wounds. A facility document revised 10-15 entitled Routine Skin Care indicated the following: .2. Turn and position at least every two hours in bed and relieve position when in chair .6. All stage III & IV pressure ulcers will be placed on a specialty mattress . The website http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ accessed 7/16/18 indicated: .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 . Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions) . Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. 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 [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed . The CMS 672 dated 7/3/18 indicated 53 residents received preventive skin care and 2 residents had pressure injuries.

Based on observation, interview, and record review, the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new pressure injuries from developing for 5 of 8 residents reviewed for pressure injuries. (Resident #s 1, 2, 3, 5, and 6) Resident #5 admitted to the facility without pressure ulcers and developed a Stage 3 pressure ulcer to his left elbow, a deep tissue injury to his left elbow, 2 Stage 3 pressure ulcers to his right elbow and a worsening deep tissue injury to his left heel. The facility failed to notify the physician of change in condition, did not obtain nutritional interventions to promote wound healing and did not provide pressure relief or offloading to pressure ulcers to prevent deterioration or the development of new pressure ulcers. Resident #6 admitted to the facility with deep tissue injury. The facility did not accurately assess deep tissue injury on admission; did not provide timely incontinent care; did not notify physician of new stage 2 pressure ulcer of the right buttock; did not provide repositioning or pressure relief in accordance with the comprehensive assessment and plan of care. Resident #1 had a Stage 2and 3 pressure ulcer to the left heel and a Stage 4 to the right heel. The resident's heels were not offloaded to prevent worsening of the pressure ulcers and the treatment nurse did not provide appropriate treatment as ordered for the resident's right ischium and gluteal fold pressure ulcers. Resident #2 developed a Stage IV pressure ulcer to the sacrum in the facility. The resident's air mattress was not set at the low air loss mattress setting to promote wound healing and relieve pressure. Resident #3 had orders for an alternating pressure mattress. The mattress was not set on alternating as ordered by the physician. This failure placed 48 residents who received preventive skin care at risk for the development of new or worsening pressure injuries. Findings included: 1. Physician orders [REDACTED].#6, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The orders indicated the resident may have a pressure redistribution mattress with a start date of 1/10/17. The orders indicated (start date of 3/14/17) to clean a sacral pressure injury with normal saline, apply zinc paste to the peri-wound skin, apply collagen to the wound bed, cover with foam dressing, and change every day and as needed. A hospital assessment report dated 1/4/17 indicated Resident #6 had a deep tissue injury (DTI) of both buttocks, the coccyx, and sacrum with dark black discoloration, more on the right than left buttock. The assessment indicated Resident #6 was placed on a low air loss mattress and a low air flow positioning pad with turning and positioning every 2 hours and as needed. It indicated not to drag the resident while repositioning, to offload the resident's heels, and an emphasis for no diapers. The Nursing Home Admission physician orders [REDACTED].#6 was admitted from the hospital with orders for a low air loss mattress and air flow pads for repositioning and to turn/reposition every 2 hours. An undated physician's telephone order completed by LVN S indicated Resident #6 was admitted to the facility and to discontinue the low air loss mattress in place of a pressure redistribution mattress. An Admission Nursing Review dated 1/6/17 at 7:46 p.m. completed by LVN S indicated Resident #6 was always incontinent, and was totally dependent on 2 staff for ADLs and bed mobility. Resident #6 had range of motion impairment of the right upper extremity and both hips and knees with severe impairment of upper and lower body strength. A care plan with a problem onset date of 1/6/17 indicated Resident #6 had an unstageable pressure injury on her sacrum. Approaches included: to monitor daily and apply zinc based skin protectant to red areas daily and as needed, two people to assist with turning every 2 hours to avoid friction and sheer, employ a pressure reducing mattress, monitor for changes that may indicate worsening of my pressure injury, and notify the physician. The Wound assessment report, completed by LVN S, indicated Resident #6 had the following skin issues: *1/6/17 (admission) strikethrough Resident #6 was identified with irritation/excoriation of the sacrum, described as red or darker pink in color with moderate irritation on admission, measuring 4.0 cm x 3.5 cm. The assessment indicated the attending physician was notified. The Wound Assessment Reports for Resident #6 completed by the treatment nurse indicated the following: *1/6/17 (completed on 1/9/17) -unstageable pressure injury on her sacrum due to suspected DTI measuring 5.0 cm x 6.0 cm x 0.0 cm. The assessment indicated a large area of redness was on her sacral area with suspected DTI to the left side of her sacrum. Red area measures 11 cm x 14 cm and DTI measures 5cm x 6cm. No open areas noted at this time. During an interview on 3/28/17 at 8:42 a.m., treatment nurse said she did not perform the initial assessment of Resident #6's pressure injury on the day of admission (1/6/17). The treatment nurse indicated the resident was admitted on a Friday afternoon. She said she first assessed the pressure injury on 1/9/17 since that was her first day back. She said the computer signature indicated a date of 1/6/17, but that was not correct. A physician telephone order dated 1/9/17 written by the treatment nurse indicated to monitor Resident #6's sacral DTI every day and apply zinc based skin protectant as needed for redness. The resident was to be kept off of her back and turned from side to side. An MDS dated [DATE] indicated Resident #6 had clear speech, was understood, had clear comprehension, and was moderate cognitively impaired. She required extensive assistance of 2 staff for bed mobility, transfers, and hygiene, and was incontinent of bowel and bladder. The assessment indicated the resident had a DTI upon admission. An MDS dated [DATE] indicated Resident #6 had clear speech, was understood, had clear comprehension, and was moderate cognitively impaired. She required extensive assistance of 2 staff for bed mobility, transfers, and hygiene, and was incontinent of bowel and bladder. The assessment indicated the resident had one unstageable pressure injury with slough/eschar. The pressure injury was 5 cm x 4 cm x 0.1 cm. The Wound Assessment Reports for Resident #6 completed by the treatment nurse indicated the following: *1/18/17 - Sacral area pressure injury - the wound status was deteriorated; unstageable due to slough/eschar measuring 10 cm x 14 cm x .10 cm, the wound bed had 25 percent slough, the wound edges were macerated and the surrounding skin was pink and slightly swollen. * 3/14/17-Sacral area pressure injury - stage 3 measuring 4.10 cm x 2.60 cm x 0.10 cm with a small amount of serosanguineous (thin and watery, pink in color; it can also be a darker red) drainage. The surrounding skin was pink with swelling and maceration (occurs when moisture is in contact with skin for extended periods of time). Notes indicated all sloughy tissue noted to be gone from sacral wound. * 3/21/17-Sacral area pressure injury (most recent)- stage 3 measuring 4.0 cm x 2.60 cm x 0.10 cm with a small amount of serous drainage. The surrounding skin was pink with swelling and maceration. During observations on 3/27/17, Resident #6 was in bed on her back on a pressure reduction mattress. She was not provided pressure relief by offloading her sacrum and heels at the following times: 1:07 p.m., 2:00 p.m., 2:45 p.m., 3:20 p.m., 4:05 p.m., 4:25 p.m., and 4:50 p.m. During an observation and interview on 3/28/17 at 8:30 a.m., Resident #6 was on her back in the bed on a pressure reduction mattress; the resident's sacrum and heels were not offloaded. Resident #6's room had a strong urine odor. CNA M said she was the CNA for Resident #6 today. She said the resident did not have an open area or a wound dressing on her buttocks. She said the resident required one person assistance with her ADLs. CNA M provided incontinent care after surveyor intervention. Resident #6 was wearing a brief soaked through with urine and the incontinent pad, the draw sheet, and the bottom sheet were soaked through with urine and a brown ring was noted on the sheet. The CNA pushed Resident #6 over to her right side and pulled on the draw sheet causing friction between the resident and the mattress. Resident #6 was unable to assist in repositioning. A wound dressing was hanging by one corner over the resident's sacral area dated 3/26/17. There were two open pressure injuries noted, one just right of midline over the sacrum and the other on the right buttock just adjacent to the first wound. During an interview on 3/28/17 at 9:30 a.m., RN K said on 3/27/17 she was the charge nurse for Resident #6. She said she did not change the resident's sacral pressure injury dressing on 3/27/17. RN K said she did not know she was supposed to change the dressing. RN K indicated she had never assessed Resident #6's skin. During an interview on 3/28/17 at 2:00 p.m., the DON said the charge nurse should have changed Resident #6's dressing on the 3/27/17. She said Resident #6 should have pressure areas off loaded. During an observation and interview on 3/28/17 at 8:42 a.m., the treatment nurse said Resident #6 should not have a brief on while in bed. She verified the resident's brief was totally saturated with urine and the sheets were soaked through, which she said was unacceptable. The treatment nurse said Resident #6 had orders for daily dressing changes and she should have her heels and sacrum off loaded while in bed. The treatment nurse said Resident #6's wound treatment was not completed on 3/27/17 because she was working the floor and the charge nurse who worked was responsible for changing the dressing. During an observation on 3/28/17 at 8:59 a.m., the treatment nurse provided Resident #6 with wound care. The resident had the following skin issues: *Pressure Injury #1 -Sacrum (admitted with) -Measuring 4.0 cm x 2.0 cm x 0.2 cm - with a wound bed consisting of subcutaneous tissue (fat), wound edges were rolled on the left medial wound from 6 o'clock to 12 o'clock. The surrounding skin was purple and measured 8.0 cm x 8.0 cm nodular in appearance did not rebound to touch on the midline of the right buttock and extended to the left buttock. *Pressure Injury #2 - Right buttock (to the right of the sacral wound) (new) -Measuring 2.5 cm x 1.0 cm x 0.1cm - with beefy red wound bed center The Wound Assessment Reports for Resident #6 completed by the treatment nurse indicated the following: Pressure Injury #1 * 3/28/17- Sacral area pressure injury - stage 3 (measurements same as above) with a wound bed with 75% granulation and 25% slough. The surrounding skin was pink, slight swelling, and wound edges well defined and rolled. Notes indicated the sacral wound was slowly improving, purple discoloration measuring 8.0 cm x 8.0 cm around the wound. New area of concern noted to right of current wound. The notes indicated to provide the same treatment every day and monitor and the physician was aware of the current skin issues. * 3/28/17- Right buttock pressure injury - stage 2 (measurements same as above) with a scant amount of serosanguineous drainage. The wound bed contained 75% granulation tissue and slough 25%. The assessment indicated the physician was notified. During an interview on 3/28/17 at 8:59 a.m., the treatment nurse said Resident #6's pressure injury on her right buttock was a new stage 2 pressure injury and she would apply the same treatment as ordered for the stage 3 on her sacrum. The treatment nurse said the new right buttock stage 2 ulcer was not open when she assessed the wound on 3/26/17. During an interview on 3/28/17 at 12:00 p.m., the treatment nurse said Resident #6 did not have the dark purple discoloration on her right buttock and left buttock last week. She said according to the protocol a low air loss mattress would be indicated if multiple stage 2 pressure injuries were present or a stage 3 or greater. The treatment nurse indicated the resident did not have a low air loss mattress ordered. During an interview on 3/28/17 at 12:01 p.m., the ADON said a low air loss mattress was indicated for a stage 3 or higher or multiple stage 2s. The ADON said they treated a suspected DTI as if it was a stage 4 or as unstageable. The ADON indicated Resident #6 should have a low air loss mattress. The ADON said she expected staff to turn and reposition residents every 2 hours and provide incontinent care every 2 hours. She said Resident #6's heels and pressure injuries should be off loaded. During an interview on 3/29/17 at 8:12 a.m., Resident #6's physician said he believed an RN provided the initial assessment of Resident #6's skin. He said a low air loss mattress would be beneficial for a DTI of the sacrum and if the wound deteriorated. He said he was not notified of the new stage 2 pressure injury identified on 3/28/17. During an interview on 3/29/17 at 10:30 a.m., Resident #6's physician said he had not provided the facility with wound care protocols or standing orders. He said he expected the nurses to notify him of new or worsening pressure ulcers. He said the nurse could make a treatment suggestion and he would accept or provide an alternative treatment plan. 2. A face sheet dated 3/28/17 indicated Resident #5 was admitted [DATE] and readmitted [DATE]. Physician orders [REDACTED].#5 was [AGE] years old and had [DIAGNOSES REDACTED]. The orders indicated to cleanse a stage 3 pressure injury on his left elbow with wound cleaner, pat dry, apply skin prep to the peri-wound, cover with foam dressing and change every 7 days and as needed with an initial start date of 3/20/17. The orders indicated to cleanse a stage 3 pressure injury on his right elbow with wound cleaner, pat dry, apply skin prep to the peri-wound, cover with foam dressing and change every 7 days and as needed with an initial start date of 3/27/17. The orders indicated the resident was to have a pressure redistribution mattress with an initial start date of 3/19/17. A Braden scale assessment dated [DATE] indicated Resident #5 was at a mild risk for skin breakdown. The most recent MDS dated [DATE] indicated Resident #5 was moderately cognitively impaired, had clear speech, was understood by others, and usually understood others. The resident required extensive assistance of two or more with bed mobility, transfers, and dressing and he was occasionally incontinent of bowel and bladder. The resident was at risk for developing pressure injuries and did not have a pressure injury at the time of this assessment. The most recent care plan dated 2/16/17 indicated Resident #5 had a skin tear/laceration on his left arm. Approaches included: observing the area daily for signs of infection and monitor for changes in the skin status that may indicated worsening of skin tear and notify the physician. The plan indicated the resident was at risk for pressure injuries due to functional abilities. Approaches included placing a pressure reducing device/product mattress on bed/chair. The plan indicated the resident required assistance with ADLs. An approach was the resident was to wear a sling on his left arm at all times and the nurse was to check placement every shift. The care plan did not indicate Resident #5 had any pressure injuries. The nursing notes dated 3/19/17 indicated Resident #5 returned to the facility the hospital with a stage 3 pressure injury on his right elbow (1.2 x 1.3 cm), and a skin tear to his right elbow (1 x 1.5 cm). The notes indicated his feet were boggy in the heels. The notes indicated Resident #5's skin tear on his right elbow was cleansed with wound cleanser, patted dry, and a dressing applied every 3 days and as needed. It indicated to cleanse Resident #5's stage 3 on his right elbow with wound cleanser and apply a foam dressing every 7 days and as needed. The nursing notes did not indicate the resident had a pressure injury on his left elbow. A Wound Assessment Report dated 3/19/17 indicated Resident #5 had the following pressure injuries: Left heel -(identified 3/19/17) - Unstageable measuring 1.5 cm x 3 cm with no drainage noted. Left elbow: -(identified 3/19/17) - stage 3 measuring 2.2 cm x 2.5 cm x 0.1 cm. with scant serous drainage. The wound bed had 25% [MEDICATION NAME] tissue and 75% granulation tissue. Right elbow: -(identified 3/19/17) stage 3 pressure ulcer measuring 1.2 cm x 1.30 no drainage noted. During an interview on 3/29/17 at 10:52 a.m., LVN R said she readmitted Resident #5 on 3/19/17. She said the resident admitted with new pressure ulcers. She said she did not call the physician to notify of the new pressure ulcers; she faxed the physician's office. The clinical record for Resident #5 did not contain a fax to the physician regarding the new pressure ulcers identified on 3/19/17. A Wound Assessment Report dated 3/27/17 indicated Resident #5 had the following pressure injuries: Left heel *(identified 3/19/17) Unstageable - measuring 2.1 cm x 4 cm with no drainage. Left elbow *(identified 3/19/17) Stage 3 measuring 2 cm [MEDICAL CONDITION] cm [MEDICAL CONDITION] cm with scant serous drainage. The wound had 80 percent slough Right elbow: *(identified 3/19/17) - stage 3 pressure ulcer, measuring 2.2 cm x 0.6 cm x 0.1 cm. with scant serous drainage. The wound bed had 20% granulation tissue and 80% slough *(identified 3/27/17) - stage 3 that evolved from skin tear measuring 1cm x 1.5 cm x 0.1 cm. with serous scant drainage. The wound bed had 25% granulation tissue and 75% slough. During an observation on 3/27/17 at 11:06 a.m., Resident #5 was lying in bed on a pressure redistribution mattress. His elbows were on the mattress; not offloaded. The resident's heels were not offloaded. During an observation and interview on 3/27/17 at 3:28 p.m., Resident #5 was on a pressure redistribution mattress and his left arm was in a sling. The resident's heels and elbows were not offloaded. Resident #5 had a stage 3 pressure injury on his left elbow measuring 2.2 cm x 2.5 cm x 0.1 cm with a pink wound bed. He had [MEDICAL CONDITION] in his left arm. Resident #5 had a new DTI to his left elbow measuring 2.1 x 4 cm. It was dark purple in color and was closed. He had a new stage 3 pressure ulcer to his right elbow measuring 1.2 x 1.3 x 0.1cm. The treatment nurse indicated the new pressure ulcer evolved from a skin tear. The wound bed was pink with approximately 20% slough. Resident #5 had a stage 3 pressure on his right elbow, identified today, measuring 1 x 1.5 x 0.1 cm. The treatment nurse said the new stage 3 was from a skin tear that was identified on 3/20/17 and now worsened to a stage 3 pressure injury. The wound bed was covered with 80% slough. He had a DTI on his left heel that measured 2.1 cm x 4 cm. The treatment nurse said the DTI on Resident #5's left heel had worsened in size. During an observation and interview on 3/27/17 at 3:49 a.m., Resident #5 was in bed on a pressure redistribution mattress. He rubbed his elbows against the mattress and his heels were not offloaded. He said he was not sure how he got the pressure injuries on his elbows and heel. During an interview on 3/28/17 at 9:28 a.m., the treatment nurse said Resident #5 did not have elbow protectors on his arms because he moved his arms too much. During an interview on 3/28/17 at 12:57 p.m. the treatment nurse said she faxed the physician notification of wound status for Resident #5. She said she did not call the physician to discuss wound status on 3/19/17 or 3/27/17. A fax communication dated 3/28/17 indicated Resident #5 had an increase in size of the left heel suspected deep tissue injury. The communication did not have a physician response. During an interview on 3/28/17 at 9:30 a.m., the DON said she was aware of Resident #5's DTI on his left heel and the pressure injuries on both of his elbows. She indicated the resident's elbows and heels should be offloaded. She said she did not know why the resident did not have elbow and heel protectors. She said I guess those need to be ordered. She said elbow and heel protectors should have already been ordered for Resident #5. During an interview on 3/28/17 at 9:59 a.m., the ADON said they got an alternating air mattress for Resident #5 yesterday. She said the resident should have heel and elbow protectors. During an interview on 3/28/17 at 11:47 a.m., the DON said the dietician came to the facility on ce a month. She indicated Resident #5 should be seen by the dietician due to the pressure injuries. She said she did not know if the dietician was updated as to the pressure injuries on Resident #5. During an interview on 3/28/17 at 11:59 a.m., the ADON said she did not know if the facility had updated the dietician regarding Resident #5's pressure ulcers. A departmental note dated 3/2/17 indicated Resident #5 was seen by the dietician. The note did not indicate the dietician was notified of the resident's pressure ulcer. The note was the only dietician note in the clinical record. During an interview on 3/28/17 at 12:25 p.m., the treatment nurse said Resident #5 should have had elbow protectors ordered when the stage 3 pressure injuries were identified on 3/19/17. She said the DTI on Resident #5's heel declined over the weekend. She said she did not order heel protectors for Resident #5, but she should have. She said Resident #5 should have had heel protectors ordered when the DTI was identified on his left heel on 3/19/17. She said she did not notify the dietician, but she was going to. During an interview 3/28/17 at 1:57 p.m. the DON said if a resident had a change of condition the physician was notified by fax or phone. The DON said if the physician responds he will document his response on the communication form. During an interview on 3/29/17 at 8:05 a.m., the physician for Resident #5 said he should be notified within 24 hours of any resident change of condition. During an interview on 3/29/17 at 10:04 a.m. the treatment nurse said she always notified the physician of wound updates by via fax. She said she usually put treatments in place without a physician's orders [REDACTED]. During an interview on 3/29/17 at 10:28 a.m., Resident #5's physician said the treatment nurse usually faxed wound care suggestions to him. He said when he received a fax he would sign the fax if he agreed with the treatment or if he did not agree with the treatment he would write no. He said he had not approved any wound protocols for the facility. During an interview on 3/29/17 at 12:30 p.m., Resident #5's physician said he was not notified on 3/27/17 of the deterioration to the resident's left heel. During an interview 3/29/17 at 12:30 p.m., Resident #5's physician said he signed a (wound care) protocol at the facility today. He said he had not signed a protocol before today. He said he did not know the facility had a protocol until today. He said he did not have standing orders for wounds and expected the treatment nurse to notify him. 4. Physician orders [REDACTED].#2 admitted [DATE] was an [AGE] year old with [DIAGNOSES REDACTED]. The orders indicated the resident may have an alternating air pressure mattress with a start date of 1/9/17. A care plan updated 1/5/17 indicated Resident #2 had a stage 4 pressure injury on her sacrum and an approach was to have a pressure reducing mattress. The most recent MDS dated [DATE] indicated Resident #2 required extensive one person for physical assistance with toileting and transfers and was always incontinent. The assessment indicated resident had a pressure injury. A care plan updated 1/26/17 indicated Resident #2 was at risk for pressure injuries due to immobility, end stage disease, and poor nutrition. The plan listed an approach of may have low air loss mattress. The mattress was to be checked every shift to prevent bottoming out and the filter was to be cleaned every month and as needed. During an observation and interview on 3/28/17 at 11:58 a.m., Resident # 2's alternating pressure mattress was set to static and firm. LVN A said she thought the mattress should be set to the middle instead of firm. During an interview on 3/28/17 at 12:03 p.m., the treatment nurse indicated the hospice agency was responsible for setting the air mattress. The treatment nurse said if the mattress was set on firm, it defeated the purpose of wound healing. A Wound Assessment Report dated 3/23/17 documented Resident #2 had a Stage IV pressure ulcer with measurements of 0.8 cm x 1 cm x 0.3 cm. The wound had a small amount of blood tinged drainage and no slough. The wound was first identified on 8/26/16. During an observation on 3/27/17 at 3:00 p.m., Resident #2 received wound care for her stage 4 on her sacrum. The air mattress was set to firm and static. The wound was 0.8 cm x 1 cm x 0.4 cm. The wound bed had a small amount of slough (dead tissue). The undated operator's manual for the alternating pressure mattress replacement system with low air loss indicated the pump was preset in the alternating mode. The manual indicated the normal pressure indicator and the low pressure indictor would turn on when the mattress was set at these setting. The manual indicated the static mode provided a firm surface to make resident transfer and repositioning easier. The mode prevented the resident from bottoming out while in a sitting position. 5. Physician orders [REDACTED].#3 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The orders indicated the resident was to have an alternating air pressure mattress. The most recent MDS assessment dated [DATE] indicated Resident #3 was cognitively intact, required extensive assistance for ADLs, transfers, and bed mobility. The assessment documented the resident had a stage 3 or 4 pressure injury with measurement of 3.0 cm x 3.4 cm x 1.9 cm. The wound was described as having slough or being mucinous. A Wound Assessment Report dated 3/29/17 indicated Resident #3 had a stage 4 pressure injury on her sacrum. The wound was 3.4 cm x 3.9 cm x 2 cm. The wound had 30% slough and a moderate amount of blood tinged drainage. The wound status was deteriorated. The wound was identified on 9/16/16. A care plan updated 03/22/17 indicated Resident #3 was at risk for pressure injuries and the resident had a stage 4 pressure injury on her the sacrum. An approach was to have an alternating air mattress. During an interview on 03/28/17 at 12:03 p.m., the treatment nurse said if Resident #3's orders said have an alternating mattress the resident should have an alternating mattress. The treatment nurse said if the mattress was set on firm it defeated the purpose of wound healing. During an interview and observation on 03/28/17 at 12:32 p.m., Resident #3 was in bed and her mattress was set at level firm static mode. Resident #3 said she was given the mattress to promote wound healing. She said she was told that the mattress was supposed to alternate, but it never alternated. During an observation on 03/29/17 at 9:55 a.m., Resident #3 was in bed and her mattress was set at level firm static mode. During an interview on 03/28/17 at 12:40 p.m., LVN C indicated she did not operate the air mattress. She said it was the treatment nurse's job to set the mattress to the correct setting because the mattress was supposed to promote wound healing. During an interview and observation on 03/29/17 at 3:10 p.m., Resident #3 had a stage 4 pressure ulcer to the sacrum. The wound was 3.4 cm by 3.9 cm by 2 cm. The wound had 30% slough and a moderate amount of blood tinged drainage. The resident's bed was not set on the alternating mode; it was set at the firm static mode. The treatment nurse indicated the alternate setting meant the air mattress would move independently and the static setting meant the mattress would firm up. The treatment nurse said the mattress being firm defeated the purpose of needing the mattress. She said one reason the mattress settings may be wrong was because during incontinent care the CNAs do not like the bed to move. A Wound Assessment Report dated 3/29/17 indicated Resident #3 had a stage 4 pressure ulcer to the sacrum. The wound was 3.4 cm by 3.9 cm by 2 cm. The wound had 30% slough and a moderate amount of blood tinged drainage. 6. Physician orders [REDACTED].#1 was [AGE] years old, admitted on [DATE], with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #1's cognition was moderately impaired, she required extensive assistance for ADLs, transfers, and bed mobility The MDS indicated Resident #1 had 2 stage 2, 1 stage 3, 1 stage 4, and 2 unstageage pressure ulcers. A care plan updated 3/13/17 indicated Resident #1 had venous statis ulcer to the left top of foot, and right ankle. An approach was to use pillows or other supportive/protective devices to assist with positioning. The plan indicated the resident had a Stage 2 pressure ulcer to the left lateral malleolus. An approach was to float the heels on a pillow. Wound Assessment Report dated 3/22/17 indicated Resident #1 had the following pressure ulcers: *Stage 2 to the left lateral malleolus, measured 0.5cm x 0.4cm x 0.2cm, small amount of serous drainage, *Stage 3 to left heel, measured 0.5 cm x 0.7cm x 0.3cm, small amount of serous drainage, treatment cleanse with wound cleanser, pat dry *Stage 4 to right heel, measured 3.0 cm x 2.1 cm x 0.2 cm, moderate amount of serous drainage, and 25% slough, *Stage 4 right posterior calf, measured 3.5 cm x 2.7 x1.0 cm, moderate amount of serous-sanguinous drainage, 25% slough, *Stage 4 to left buttock, measured 3cmX3cmX3cm, moderate amount of serous-sanguinous drainage, 50% slough and 50% granulation tissue, *Stage 4 right ischium, measured 4.5cmX4.5cmX6.1cm, moderate amount of serous-sanguinous drainage, 50% slough *Stage 4 sacrum, measured 6cmX8cmX2.9cm, moderate amount of serous-sanguinous drainage, 25% slough. During an observation of wound care and interview on 3/28/17 at 3:10 p.m., Resident #1 was in bed and was not wearing heel protectors, her heels were not offloaded. The treatment nurse said Resident #1 refused to wear her heel protectors. During an interview on 3/29/17 at 9:45 a.m., Resident #1 said she did not refuse to wear her heel protectors, she said she had heel protectors prior to going to the hospital, she said they were not sent back with her and the facility had not gotten her anymore. Resident #1 said she would wear them if they put them on her. During an interview on 3/30/17 at 5:00 p.m., the ADON said she expected staff to follow physician orders, she said Resident #1 should have her heel protectors on as ordered. During an observation of wound care on 3/29/17 at 10:36 a.m., the treatment nurse provided wound care for Resident #1's right ischium and sacrum. The treatment nurse packed the right ischium and sacr

Based on observation, interview, and record review, the facility failed to ensure interventions based on a comprehensive assessment to prevent development and worsening of pressure ulcers were provided for 2 of 9 residents reviewed for pressure ulcers. (Resident #s 4, and 6) Resident #4 was admitted without pressure ulcers. The resident was found with multiple facility-acquired pressure ulcers on 2/8/16; however, the facility did not complete an accurate skin assessment, notify the physician , or obtain treatment for [REDACTED]. Resident #6 was admitted without pressure ulcers. The resident was identified as having three Stage II pressure ulcers on her left buttock and one Stage I pressure ulcer on her right buttock. The facility did not complete an accurate skin assessment, notify the physician immediately, and provide appropriate treatment for [REDACTED]. This failure contributed to the development of new pressure ulcers and the worsening of existing pressure ulcers for Resident #s 4 and 6. This failure could place 8 residents who had pressure ulcers at risk for developing new pressure ulcers and decline in existing pressure ulcers. Findings included: 1. Physician orders [REDACTED].#4, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The orders indicated the resident was admitted to hospice on 11/11/15. The resident had an order initiated 1/14/16 to apply Z-Guard (skin protectant-treat and prevent diaper rash caused from wetness, urine, and/or stool) to both buttocks two times a day and as needed. The most recent MDS assessment dated [DATE] indicated Resident #4 required extensive assistance with bed mobility and toilet use, had a catheter and was incontinent of bowel. The resident had minimal problems in the area of mental status and no behavior problems. Resident #4 had no pressure ulcers at the time of the assessment. A care plan with a problem onset date of 11/9/15 indicated Resident #4 was at high risk for pressure ulcers and required daily observation of the skin with routine skin care. The care plan indicated the resident was frequently incontinent of bowel and required observation of skin daily for irritation and redness. The plan indicated Z-guard was to be applied to both buttocks two times a day and as needed. A Braden scale assessment dated [DATE] indicated Resident #4 was high risk for skin breakdown. The LVN treatment sheet for February 2016 indicate Resident # 4 received Z-guard to both buttocks two times a day on February 1st, 2nd, 3rd, 4th, 5th, 7th, and 8th. The sheet indicated Resident #4 did not receive Z-guard on February 6th. The sheet indicated the resident ' s last weekly head to toe skin check was completed 2/2/15 and the assessment was abnormal. A Wound Assessment Report dated 2/2/16 indicated Resident #4 had irritation/excoriation to the right buttock that measured 1.10 cm by .60 cm with a depth of .10 cm. The area was red or dark pink and had no drainage. The report indicated the area was identified on 1/14/16 and the wound status was unchanged and was resolved 2/9/16. A skin assessment sheet dated 2/2/16 indicated Resident #4 had multiple scratches on both arms. The assessment did not document the resident had skin concerns or pressure ulcers to his buttocks. A hospice Visit Note Report dated 2/4/16 indicated Resident #4 had wounds to both arms that were scabbed over. The report did not indicate the resident had skin concerns or pressure ulcers to the buttocks. The report indicated interventions provided were assessment of wounds. During an observation on 02/08/16 at 9:00 a.m., Resident #4 was lying in bed on a low air loss pressure relieving mattress. During an interview on 2/8/16 at 9:15 a.m. LVN A said Resident #4 had skin concerns with his legs and arms. She did not indicate the resident had pressure ulcers. During an observation and interview on 02/09/16 at 9:50 a.m., hospice CNAs L and M provided ADL care for Resident #4. The resident had multiple reddened open areas on both buttocks. The areas had a reddish drainage that was noted on the pads underneath the resident. The hospice CNAs said they observed the areas on 02/08/16 and reported the areas to their hospice case manager and LVN A on 2/8/16. During an interview on 02/09/16 at 10:00 a.m., LVN A said she was unaware of Resident #4 having open areas on his buttocks. She said they did not perform daily skin assessments but expected the CNAs to report any changes in the resident ' s skin to the charge nurse. During an interview on 02/09/16 at 10:50 a.m., hospice CNAs L and M said Resident #4 did not have multiple areas on his buttocks on Friday (2/5/16). The CNAs indicated they provided the resident with a bed bath Monday through Friday. During a telephone interview on 02/09/16 at 11:00, the hospice case manager said she was informed Resident #4 had skin concerns to his buttocks on 2/8/16. She said she did not notify the physician and she did not observe the areas. During an observation with the treatment nurse on 02/09/16 at 02:00 p.m., Resident #4 had the following pressure ulcers: Left buttock *10 cm x 0.8 cm open Stage II pressure ulcer with a red wound bed. *1.0 cm x 0.8 cm - open Stage II pressure ulcer with a red wound bed. *1.0 cm x 0.5 cm - Stage II pressure ulcer with a red wound bed. *2.0 cm x 0.5 cm - Stage II pressure ulcer with a red wound bed. *11.0 cm X 0.5 cm - closed dark red unblanchable. *9.0 cm X 0.8 cm - closed dark red unblanchable. Right buttock *1.5 cm X 2.0 cm-Stage II pressure ulcer with a red wound bed, *3.5 cm X 3.2 cm -Stage II pressure ulcer with a red wound bed. *1 cm X 1.5 cm - Stage II pressure ulcer with a red wound bed. *1.0 cm X 2.0 cm - Stage II pressure ulcer with a red wound bed. *3.0 cm X 1.5 cm - Stage II pressure ulcer with a red wound bed. *1.7 cm X 4.0 cm - Stage II pressure ulcer with a red wound bed. *3.0 X 0.2 cm - closed dark red unblanchable. Gluteal crease *2.5 cm X 0.5 cm - Stage II pressure ulcer with a red wound bed. *9.0 X 0.4 cm - Stage II pressure ulcer with a red wound bed. *1.5 cm X 0.3 cm - Stage II pressure ulcer with a red wound bed. The surrounding tissue was red, firm and measured 21 cm X 24 cm around the entire buttocks/gluteal crease. During an interview on 02/09/16 at 10:40 a.m., the treatment nurse said she was unaware Resident #4 had open areas on his buttocks. She said they did not perform daily skin assessments but expected the CNAs to report any changes to the residents' skin to the charge nurse. During an interview on 02/10/16 at 2:45 p.m., the hospice case manager said she did assess Resident #4's buttocks on 2/8/16 after the hospice CNAs reported new areas to the buttocks. She said she reported it to LVN A. She said it had been two weeks since she examined the resident's buttocks and at that time he did not have any pressure ulcers. A hospice Visit Note Report dated 2/8/16 indicated Resident #4 had wounds to both arms that were bleeding. The report did not indicate the resident pressure ulcers to the buttocks. The report indicated interventions provided were assessment of wounds. The report included a late entry that was completed on 2/10/16 at 5:43 p.m. (after surveyor intervention). The entry indicated the hospice CNAs reported red area to the right outer thigh and the area was reported to LVN A. The entry indicated the plan was to assess the resident ' s back side on the next hospice nurse visit. During an interview on 02/10/16 at 4:00 p.m., Resident #4's physician said he examined the resident's buttocks area on the morning of 2/10/16. He said the areas to the resident ' s buttocks were a result of shearing pressure. He said the areas were chronic. He said today was the first time he examined the resident's buttocks. He said he expected the staff to call him if there was a change in the resident's skin and that no staff had contacted him with the changes on Monday (2/8/16). During an interview on 02/11/16 at 4:40 p.m., the DON said she expected the staff to communicate with hospice staff. She said she expected the hospice nurse and aides to inform the staff of any changes they found and submit their documentation in a timely manner. 2.Physician orders [REDACTED].#6 admitted [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. A Braden Assessment Report dated 02/03/16 indicated Resident #6 was at mild risk for pressure ulcer development. The Wound Assessment Reports and Visual Body Map dated 02/03/16 indicated Resident #6 had 3 surgical wounds to the right shoulder, right hip, and right thigh area and a bruise to the back of the right forearm. There was no indication the resident had peri-rashes or pressure ulcers. A Skin Risk Analysis and Interventions form dated 02/04/16 indicated Resident #6 was to be kept clean and dry and staff were to report any skin issues noted during care. The clinical record from 2/3/16 to 2/8/16 indicated Resident #6 did not have an admission care plan. The Admission Care Plan dated 02/09/16 indicated a goal for Resident #6 was to prevent/heal pressure ulcers and skin breakdown. Interventions included report any redness or skin breakdown immediately, required 1 person assistance with bathing and apply Z-guard (skin protectant). During an interview on 02/09/16 at 11:06 a.m., the treatment nurse said Resident #6's record indicated a full body skin assessment was completed on 02/03/16. She indicated the assessment documented the resident had 3 surgical wounds and a bruise. She said skin assessments were conducted weekly and Resident #6 was not due for her next weekly skin assessment until 02/10/16. The treatment nurse said she completed a skin assessment on 02/04/16; however she did not document the assessment. The treatment nurse said the resident did not have pressure ulcer or skin concerns to her buttocks. The February 2016 TAR indicated Resident #6 was to have Zguard applied to her buttocks twice a day and as needed. The record indicated the cream was applied on the 6-2 and 2-10 shift on 02/04/16, 02/05/16, 02/07/16, and 02/08/16. The record indicated the Z-guard was not applied on 2/6/16. During an interview on 02/09/16 at 8:20 a.m., Resident #6 said she wanted a bed bath. She indicated she had not received a bed bath or shower since admission (02/03/16). The resident said she was told her bath schedule was Monday, Wednesday, and Fridays. The resident indicated staff assisted her with using a bed pan. The Daily Completed Care Tasks report printed on 02/09/16 indicated from 02/04/16 through 02/09/16 Resident #6 received one bath on 02/08/16 by CNA K. During an interview on 02/09/16 at 3:49 p.m., CNA K said she did not give Resident #6 a bed bath or shower on 02/08/16. CNA K said, the other day while assisting Resident #6 onto the bed pan, Resident #6 complained her butt was a little sore and the nurse was supposed to get her some cream. CNA K said when she looked at the resident's buttocks it was a little red. CNA K said Resident #6 indicated she told a nurse, so she (the CNA) did not report the redness or of the resident complaining of soreness to her buttocks. During an observation on 02/09/16 at 10:20 a.m., Resident #6's outer labial area was reddish/pink. Resident #6 had 3 Stage II pressure ulcers on her left buttock. She had a Stage I pressure ulcer on her right buttock. Resident #6 had a red rash on both buttocks. During an interview on 02/09/16 at 11:10 a.m., Resident #6 said, her bottom started hurting and burning about 2 days after admission to the facility (2/5/16) especially when she urinated. The resident said she felt it was like a diaper rash most likely because she had a day or two of diarhea. During an observation and interview on 02/09/16 at 12:21 p.m., the treatment nurse said the wounds on Resident #6's buttocks were excoriation from the bed pan. The treatment nurse documented the following skin issues: *upper medial left buttock 1.8 cm x 1 cm; *outer left buttock 1.1cm x 0.4 cm; *outer lower left buttock 0.4cm x 0.4 cm; *right buttock 1.5cm x 0.5 cm; and *red rash on right and left buttocks 18 cm x 5.5 cm. During an interview on 02/09/16 at 12:04 p.m., the treatment nurse said, she was not aware of any skin issues until today (2/9/16). She said on 02/04/16 Resident #6 said she felt the bedpan was sticking to her bottom so she ordered the resident some Zguard cream to be applied to buttocks two times daily and as needed. During an interview on 02/09/16 at 11:18 a.m., the DON said if any skin issues or change of conditions are noticed during care she expected staff to report the changes immediately to the charge nurse and treatment nurse so the issue can be addressed. The DON indicated she was not aware Resident #6 had shearing and a yeast infection to her buttocks prior to surveyor intervention. During an interview on 02/09/16 at 12:35 p.m., the regional consultant nurse said Resident #6 appeared to have a yeast infection. The regional consultant nurse said Resident #6's open areas were excoriation. A physician progress notes [REDACTED].#6's buttocks. The note indicated the resident had shearing and a yeast infection. During an interview on 02/11/16 at 8:53 a.m., the medical director said he was first notified of skin issues with Resident #6 on 02/09/16. The medical director said Resident #6 had a yeast infection to her peri-area and buttocks and skin shearing to her buttocks. He said the yeast infection could have been prevented if the resident was cleaned properly and kept dry. A Pressure ulcer prevention program document dated October 2010 indicated the following: . If a pressure ulcer/skin breakdown is identified, the following will be done- The licensed nurse will complete a thorough assessment of the affected area . The licensed nurse will notify the physician and family. Treatment will be initiated per physician's order [REDACTED]. The website, http://www.npuap.org/wp-content/uploads/2012/03/Final_Quick_Treatment_for_web_2010.pdf, accessed 02/12/16, indicated a pressure ulcer was localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. Regarding healing the website indicated individuals should be reassessed if the ulcer did not show signs of healing as expected despite adequate local wound care, pressure redistribution, and nutrition. The website http://www.epuap.org/guidelines/Final_Quick_Treatment.pdf accessed 2/12/16 indicated Pressure Ulcer Treatment Quick Reference Guide indicated .Common Definition of Pressure Ulcers A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. International NPUAP- EPUAP Pressure Ulcer Classification System Category/Stage I: Non-blanchable redness of intact skin Intact skin with non-blanchable [DIAGNOSES REDACTED] of a localized area usually over a bony prominence. Discoloration of the skin, warmth, [MEDICAL CONDITION], hardness or pain may also be present. Darkly pigmented skin may not have visible blanching. Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage I may be difficult to detect in individuals with dark skin tones. May indicate at risk persons. Category/Stage II: Partial thickness skin loss or blister Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising. This category/stage should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation Suspected Deep Tissue Injury-depth unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Further description: The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with treatment Pressure Ulcer Assessment . 3. Assess and accurately document physical characteristics such as location, Category/Stage, size, tissue type(s), wound bed and periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate, necrotic tissue, odor, presence/absence of granulation tissue, and [MEDICATION NAME]. The CMS Form 672 dated 02/08/16 indicated 8 residents had pressure ulcers.

Based on interview and record review the facility failed to provide supervision to prevent accidents for 1 of 4 residents reviewed for accidents. (Resident #1) Resident # 1 ' s care plan indicated he was a two-person transfer. CNAs D and E did not supervise Resident #1 to prevent him from falling during a Hoyer lift transfer. This failure contributed to Resident #1 falling out of the Hoyer lift and suffering fractured ribs, hip, foot, and a closed head injury. This failure could place 11 residents who required the use of a Hoyer lift for transfers at risk for injury. Findings included: The face sheet dated [DATE] indicated Resident #1 was an [AGE] year old male admitted on [DATE]. A physician progress notes [REDACTED].#1 had [DIAGNOSES REDACTED]neuropathy (nerve damage), congestive heart failure, history of pulmonary embolism and recurrent bouts of bronchitis. An MDS dated [DATE] indicated Resident #1 had severe cognitive impairment. He was totally dependent on two people for bed mobility, transfer, and dressing. He was able to stabilize himself with staff assistance from surface-to-surface, such as transfer between bed and chair. A fall risk assessment last updated [DATE] indicated Resident # 1 was a high risk for falls. A [DIAGNOSES REDACTED].# 1 had [DIAGNOSES REDACTED]. An undated care plan indicated Resident #1 had a problem of falls due to generalized weakness, decreased mobility, dizziness and psychotropic medication use. Resident #1 required extensive assistance of 2 staff persons with all ADLs except eating and locomotion. There was no care plan for abnormal posture, leaning or use of Hoyer lift for transfers. A Report of Resident Fall dated [DATE] at 7:30 p.m., indicated Resident #1 fell out of the Hoyer lift during a transfer from the bed to the chair. The report indicated two CNAs witnessed the fall. The resident sat up and his upper body toppled out of the lift sling. He was found on the floor with a contusion to the right forehead and a skin tear to the right inside foot. The resident complained of pain. The resident ' s right leg and hip was swollen. A nursing note dated [DATE] at 11:30 p.m., indicated the nurse at the hospital said Resident #1 was admitted with a broken femur, a couple of broken ribs, a fractured foot and a closed head injury. An undated physician discharge summary indicated Resident #1 was, "discharged to the hosp. [DATE] after fall in Nursing home. Expired in hospital.". During a telephone interview on [DATE] at 5:08 p.m., CNA D said on [DATE] he and CNA E who was in training transferred Resident #1 from the bed to the chair with the Hoyer lift. He said he put all four loops on the last ring. He said he did this because if one loop broke there were three more to hold the resident. CNA D said he operated the Hoyer lift, CNA E positioned the wheelchair, but no one held Resident #1 while he was being moved with the lift. He said Resident #1's hands were holding the lift straps. He said during Hoyer lift transfers residents normally had their hands in their lap, but he had not instructed Resident #1 to put his hands down. CNA D said he did not know if Resident #1 leaned up or not, but his body shifted suddenly. He said the Hoyer lift did not shift, but the sling did and Resident # 1 fell to the floor. CNA D said he was not aware Resident #1 had a problem of leaning. He said he was told after the fall. During a telephone interview on [DATE] at 6:08 p.m., CNA E said on [DATE] she was in orientation with CNA D. She said she assisted CNA D with transferring Resident #1 with the Hoyer lift. CNA E said she had not been trained on how to use the lift. She said she did not assist with the placement of the pad or the loops of the pad to the lift. CNA E said CNA D operated the lift and she watched. She said Resident #1 shifted in the lift and fell to the floor. During a telephone interview on [DATE] at 5:43 p.m., the DON said she was called to Resident #1 ' s room on [DATE] and he was lying on the floor with his right leg underneath him. She said there were two CNAs in the room. The DON said the lift pad was still attached to the lift and the resident was facing the bed. During an interview on [DATE] at 2:59 p.m., CNA A said Resident #1 would always lean one way or the other. She said she was familiar with the resident and when she transferred Resident #1 she put his hands on the inside of the Hoyer lift and made sure he did not lean forward. During an interview on [DATE] at 4:04 p.m., CNA B said Resident #1 leaned to the front or the side all the time. She said during the Hoyer lift transfers they made sure he did not lean. During an interview on [DATE] at 6:40 p.m., the ADON said Resident #1's posture made it obvious he was a leaner and no one should have to be told that he was. The ADON said normally the second person in the room was to help guide the resident, and support them by holding on to the lift swing and making sure their hands were inside the lift. They did not have a specific policy for step by step. The policy that they had was when they had manual lifts that required pumping. The current lifts were electric. An incidents and Accidents Preventions System for the Mechanical Lift procedure last revised ,[DATE] indicated: " ...At no time will a staff member attempt to use a mechanical lift without being in-serviced on the equipment specific procedures. A Mechanical lift transfer must always be done with 2 staff members present. Adhere to any equipment specific operational instructions. Elevate the head of the bed; fold the resident's arms across the chest. Position the resident over the surface and guide them into proper position while lowering the lift ... " The facility instruction booklet for the use of the electric Hoyer lift dated 2014 indicated " ...read separate sling user guide for information on selecting and attaching and using lift with slings...To lift in a reclined position use a longer set of loops at the shoulders and a shorter set of loops at the legs. This allows the resident head to be level with their legs. Note lift the resident ,[DATE] inches over bed or chair, stop and then check all straps are secure, the sling is holding resident before further lifting. The wrong sling size can allow the resident to fall out ... " A daily census dated [DATE] indicated 11 residents were transferred by Hoyer lift.