Every finding on record at Gracy Woods Nursing Center

Based on observation, interview, and record review, the facility failed to ensure the resident's right to be treated with respect and dignity, including the right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents for 3 of 12 residents (Residents #8, 19 and 25) reviewed for dignity and use of personal possessions.The facility failed to ensure NA K treated Resident #19 and Resident #8 with dignity when he tried to provide Resident #19 redirection and walked into Resident #8's room while speaking into a Bluetooth earpiece.The facility failed not to clutter Reisdent#25's space in her room with facility owned oxygen concentrator, oxygen cylinder and laundry basket of her roommate.These failures placed residents at risk of an escalation of behaviors in dementia and discomfort, accidents and a diminished quality of life. Findings included:1. Review of the undated face sheet for Resident #19 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease and mood disorder due to known physiological condition. Review of the quarterly MDS for Resident #19 dated 02/26/2026 reflected a BIMS score of 11, indicating a moderate cognitive impairment. Review of the care plan for Resident #19 dated 05/25/2026 reflected the following: PROBLEMImpaired social interaction related to cognitive impairment, anxiety, or unmet needs as evidenced by intrusive behaviors such as entering others' rooms, pushing residents in their wheelchair, or invading personal space.GOALResident will maintain appropriate boundaries with minimal staff cueing thru the next 90 days.APPROACHRedirect resident calmly when approaching others' rooms or personal space. Offer meaningful activities. Provide structured routines. Use consistent boundary-setting phrases ('This is [another resident's] room; let's go this wayinstead.')Use simple, clear instructions and calm tone. Provide reassurance if resident appears anxious or fearful. Review of the undated face sheet for Resident #8 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hemiplegia and hemiparesis (paralysis on one side of the body), cognitive communication deficit (problems communicating due to cognitive impairment), mood disorder, anxiety disorder, and need for assistance with personal care. Review of the quarterly MDS for Resident #8 dated 02/26/2026 reflected a BIMS score of 12, indicating a moderate cognitive impairment. Review of the care plan for Resident #8 dated 03/03/2026 reflected the following: PROBLEMResident has impaired cognitive functioning S/P CVA (after a stroke) with residual Cognitive Communication deficit. She is forgetful, is impulsive and has impaired problem solving, safety awareness, memory.GOALResident will be assisted with memory, decision making/ safety, orientation with dignity X 90 days.APPROACH-Check on resident at routine intervals to assess needs and monitor safety issues. Provide needed care PRN.-Explain each activity/care procedure prior to beginning.-Orient to surroundings, staff, environment, ADL needs and activities. Observation on 06/03/2026 at 2:12 PM revealed NA K was standing on the hall where Resident #19 and Resident #8 lived. He had a Bluetooth earpiece in his left ear and was talking very quietly and very quickly. Resident #19 came out of her room with a handful of paper towels. As she approached NA K with the paper towels, he was talking almost constantly, apparently into his Bluetooth earpiece. He took the paper towels from her and disposed of them. He then said to her Come on (Resident #19) let's go to your room and was still speaking into the earpiece before and after speaking to her. She pursed her brow and looked at him with an angry expression. He shrugged and walked the other direction, still speaking intermittently into his earpiece. Another staff person came up to Resident #19 and directed her to an activity. NA K then walked down the hall and into Resident #8's room, where he stood just inside the doorway talking quietly for 30 seconds. Resident #8 did not respond to his presence in her room. During 06/04/2026 at 1:28 PM, LVN C stated she had worked with NA K a little bit but not very much. She stated she taught the student nurse aides and educated the CNAs when there was some change they needed to know about on the hall. She stated she has tried to explain to the staff who did not speak English that they should not just nod their heads and agree but to make sure they understand what is being communicated. She stated educating the staff on things might have required more than one time of explaining to him. She stated she was not sure if NA K knew the best way to redirect Resident #19. She stated he should have known staff were not allowed to be on their phones or Bluetooth. She stated the student nurse aides should have been shadowing CNAs and learning the job, not just standing around on the phone. She stated the potential negative impact on residents of staff trying to provide care while on the phone was the staff would not be able to pay attention to what the resident needed. During an interview using a telephone interpreter on 06/04/2026 at 2:47 PM, NA K stated he had worked at the facility for one month. He stated he had training on redirecting residents with dementia. He stated he was still in training. He stated if a resident was angry or upset he had to report to the nurse or authority. He stated it was not acceptable to use the phone while working. He stated he only used his phone while in the breakroom. He stated the Bluetooth earpiece he had on the day before was for English lessons he was listening to. He stated when he was talking, he was practicing English. He stated he did not walk into Resident #8's room to engage her, but he was just checking on her. He stated he did not mean to have his earpiece on while he was redirecting Resident #19 or going into Resident #8's room. He stated he wanted to apologize, as he did not mean to be disrespectful to the residents, but he was still learning. During an interview on 06/04/2026 at 3:31 PM, the DON stated she was responsible for training staff to be respectful to residents and treat them with dignity. She stated she ensured staff were trained in a language they understood by checking for understanding and providing online translation for more complicated instruction. She stated she in-serviced about cell phone use and did not allow it on the hall at all. She stated the no cell phones policy applied to Bluetooth earpieces or headphones, as well. She stated they should not have been worn or listened to by any staff on the hall. She stated a potential negative impact on residents was they would feel like they were not listened to. During an interview on 06/04/2026 at 4:00 PM, the ADM stated she had in-serviced the staff several times about cell phones, earpieces, and headphones being prohibited while on duty. She stated that use of cell phones, earpieces, or headphones was not allowed anywhere except the employee break room. She stated she expected staff would not be on their phones while working. She stated the rule was in the employee handbook. She stated she ensured staff who did not speak English learned the material by making the teaching tool they used for abuse/neglect/exploitation training available in nine languages. She stated all their in-services were presented in English, Spanish, and French. She stated the potential negative impact of the staff being on cell phones while caring for residents was a lack of attention and not being heard. 2. Review of Resident #25's face sheet dated 06/02/26 reflected Resident #25 was initially admitted to the facility on [DATE] and readmitted on [DATE]. She was a [AGE] year-old female diagnosed with seizures, cerebral palsy, legal blindness, need for assistance with personal care, muscle weakness , lack of coordination, drug induced secondary parkinsonism(shaking) and muscle spasm (muscle cramp). Review of Resident #25's initial MDS dated [DATE] reflected a BIMS score of 12 indicating her cognition was moderately impaired. Review of Resident #25's care plan dated 04/02/26 reflected that :Resident #25 preferred her bed to be placed against the wall, and the relevant intervention was ensuring adequate access to call bell, light, and personal items on the open side.Resident #25 had severely impaired vision and was legally blind. The relevant intervention was not to rearrange furnishings to enable the resident to recognize objects/own environment.Resident #25 was potential for falls due to history of falling. The relevant intervention was to keep the floor clean and dry and clutter free environment.During an observation and interview with the FM of Resident #25 on 06/02/26 at 11:20 a.m., it was revealed that Resident #25 was sharing the room with another resident who was in hospice care. There was an oxygen cylinder, an oxygen concentrator, and a laundry basket stored in the area designated for Resident #25. The FM stated that these items belonged to Resident #25's roommate. She said that the staff had stored these items in Resident #25's space, likely for convenience. She said ,although she was okay with the arrangement since the roommate was in hospice care, she expressed dissatisfaction because this setup restricted the room space allocated for Resident #25. During an interview on 06/04/26 at 12:35 p.m., LVN B, the nurse in charge of Hall 500 where Resident #25 resides, stated that the oxygen cylinder, concentrator, and laundry basket in Resident #25's room were for Reisdent#25's roommate for using in emergency situations. LVN B explained that organizing these items within the room was necessary to ensure they were readily available, given that Resident #25's roommate was in hospice care. She said that the equipment was the property of the facility and should have been placed in the designated area for Resident #25's roommate. LVN B stated that the setup in Resident #25's area was done solely by the facility staff and that there was no pressure from Resident #25's roommate or her family for storing them in Resident #25's space. She stated that this situation was a violation of Resident #25's right to have her permitted space, as the items belonging to her roommate cluttered the area. LVN B stated that the staff had not taken steps to remove the items because neither Resident #25 nor her family had made any complaints or observed of having any inconvenience due to them. During an interview on 06/04/26 at 4:10 p.m., the DON stated that it was the right of each residents to have their allotted space in their room available for their personal needs. She said that storing items that did not belong to Resident #25 diminished the usable space designated for her. The DON said that she was not aware of this situation, as neither Resident #25 nor staff had brought it to her attention. She stated she would make alternative arrangements to store her roommate's equipment elsewhere safely to ensure Resident #25 can fully utilize her space. Review of the facility policy Resident Rights revised in December 2016 reflected: Employees shall treat all residents with kindness, respect and dignity.Federal and state laws guarantee certain basic rights to all residents of this facility . These rights include the residents' right to:a dignified existence;be treated with respect, kindness, and dignity;Exercise his or her rights without interference, coercion, discrimination or reprisal from the facility;ae. Retain and use personal possessions to the maximum extent that space and safety permits.

Based on observations, interviews, and record review the facility failed to ensure that a resident who is unable to carry out activities of daily living, receives the necessary services to maintain grooming and personal care for 3 of 8 residents (Resident #45 and Resident #88 and Resident #67) reviewed for ADL care. The facility failed to provide nail care to Resident #45 and Resident #88 and Resident #67, leaving the nails on the fingers and toes , long, and discolored. This failure could place residents at risk of social embarrassment, isolation, infection, injury, pain, deterioration of health and a diminished quality of life. Findings included:Resident #88Record review of Resident #88's face sheet dated 06/02/26 reflected Resident #88 was admitted to the facility on [DATE]. He was a [AGE] year-old male diagnosed with cerebral infarction (stroke), lack of coordination, muscle weakness, muscle spasm, anemia and contracture of the hand (tightening of the hand muscles).Record review of Resident #88's quarterly MDS dated [DATE] reflected that an assessment for BIMS could not be completed as the resident was rarely/never understood. Further review revealed that for self-care he was fully dependent.Record review of Resident #88's care plan dated 04/22/26 reflected that he required assistance for performing ADLs and mobility tasks due to the history of CVA(stroke). He had reduced ROM to bilateral elbows, wrists, hands and left lower extremity weakness. The relevant intervention was to provide moderate assistance for personal hygiene tasks.An observation on 06/02/26 at 09:47am, revealed Resident #88 was in bed . He had contracted hands, with nails about 1/2 inch long on both the hands. The nails were thick and yellow. Resident #88 nodded yes when asked if he wanted his nails to be trimmed.Resident #45Record review of Resident #45's face sheet dated 06/02/26 reflected Resident #45 was admitted to the facility on [DATE]. He was a [AGE] year-old male diagnosed with Parkinsonism(a group of neurological disorders that cause movement problems, such as tremors, slow movement, stiffness, and balance issues), Other lack of coordination, Weakness, Localized edema, chronic pain, Wrist drop and left wrist and Muscle weakness.Record review of Resident #45's initial MDS dated [DATE] reflected a BIMS score of 07 indicating his cognition was severely impaired. Further review revealed he was fully dependent for self-care.Record review of Resident #45's care plan dated 05/14/26 reflected that he had a significant decline in functional independence for ADL and mobility tasks due to generalized weakness, poor endurance / activity tolerance, impaired balance and Parkinson's Disease with Tremor. The relevant intervention was providing Resident #45 moderate assistance for personal hygiene tasks.An observation on 06/02/26 at 10:30am revealed Resident #45 was in bed . Both of his hands had tremors. All the nails on both the hands were about 1/2 inch long and were thick and yellow. Resident #45 stated he wanted his nails to be trimmed and said he did not remember whether he was offered nail trimming or when they were trimmed lately.Resident #67Record review of Resident #67's face sheet dated 06/03/26 reflected Resident #67 was initially admitted on [DATE] and readmitted on [DATE]. He was a [AGE] year-old male diagnosed with acute respiratory failure with hypoxia (low oxygen), congestive heart failure, Type 2 diabetes mellitus, muscle weakness, muscle wasting, and lack of coordination.Record review of Resident #67's initial MDS dated [DATE] reflected a BIMS of 14 indicating his cognition was intact. Further review indicated that he was independent with personal hygiene. Record review of Resident #67's care plan dated 03/09/26 reflected resident was primarily independent for ADL and mobility tasks however had potential for decline in functional independence due to Spinal Stenosis (narrowing of the spaces within your spine), Neuropathy (nerve damage) and history of pain. Relevant intervention was encouraging /reminding resident to use bell to call for assistance and checking on resident at routine intervals to assess needs, monitoring safety issues and offering assistance as needed.During an observation and interview on 06/03/26 at 2:30pm , Resident #67 stated he was able to trim his fingernails independently however was unable to bend down and trim his toenails. Observation of his feet revealed that the toenails were about 1/2 inch long on both the feet. He stated that he neither requested nor had any staff offered trimming toenails. Resident #67 stated staff did a skin assessment recently and might have noticed the overgrown toe nails. During an interview conducted on 06/04/26 at 2:35 PM, CNA H stated that she began working at the facility about a month ago and had worked in all halls, including Hall 500. She said that she did not notice any residents with overgrown nails in Hall 500. CNA H stated that if she were to find any residents with overgrown nails, she would report it to the nurse in charge rather than trimming them herself, as in some disease conditions might not be safe to handle without clinical expertise. She added however, that she would clean the nails if they were dirty and then report the issue to the nurse.During an interview conducted on 06/04/26 at 2:50 pm, CNA G stated that he had been working at the facility for three months and had noticed overgrown nails on Residents #45 and #88 about a week ago. He stated that he was unaware of the toenails of Resident #67 . CNA G said that he informed the charge nurse at that time about the overgrown nails; the charge nurse was a different individual than LVN B. He stated he would trim the nails if the nurse assessed the resident and determined it was safe to do so. CNA G said it was not safe to trim complex nail growth or nails of residents with conditions such as diabetes unless performed by someone properly trained. CNA G also stated that trimming nails in a timely manner was important to prevent the spread of infectious diseases transmitted through debris accumulated in the nail beds.During an interview on 06/04/26 at 12:35 PM, LVN B stated that she was the nurse in charge of Hall 500, where Resident #45, Resident #88, and Resident #67 reside. LVN B said she had offered to clip Resident #45's nails approximately one week ago; however, he declined the offer. She said that she would encourage him again to have his nails trimmed. LVN B stated she did not know why the nails of Resident #88 had not been trimmed. She also said, Resident #67 was capable of trimming his own nails and was unaware of the long toenails of Resident #67. LVN B stated she preferred a podiatrist to perform this task, considering that Resident #67 was diabetic and required the expertise of a podiatrist. She stated that regular nail trimming was important for the residents to prevent injuries and infections.During an interview on 06/04/26 at 4:10 PM, the DON stated that there was no reason for Resident #45, Resident #88, and Resident #67's nails not to have been cut. She explained that at the facility, nurses were responsible for nail trimming, and CNAs were tasked with informing the nurse in charge of any residents with overgrown fingernails. She further stated that if a resident declines the service, the nurse should approach the resident two more times. If the resident still refuses, the nurse must report this to the DON, and the IDT would intervene. The DON stated that the facility maintains a file for documenting nail trimmings, and the ADON routinely audits this file. The DON said she would be investigating why the nails of Residents #45, #88, and #67 were not trimmed in a timely manner. She said that overgrown nails were an infection control concern, as the nail bed can harbor germs that cause infectious diseases. Additionally, she noted that long nails can cause scratches and injuries, which could have more serious consequences for residents with diabetes, peripheral vascular disease, or those taking blood thinners.Record review of the facility policy Fingernails/Toenails, care of revised in February 2018 reflected : Purpose: The purposes of this procedure are to clean the nailbed, to keep nails trimmed and to prevent infections.General Guidelines:Nail care included daily cleaning and regular trimming.Proper nail care can aid in the prevention of skin problems around nail bed.Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments.Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.Reporting:1.Notify the supervisor if the resident refuses the care.2. Report on other information in accordance with the facility policy and professional standard of practice.

Based on observation, interview and record review, the facility failed to ensure the residents' right to privacy during personal care for 1 of 1 resident (Resident #38) reviewed for privacy. The facility failed to ensure CNA D and CNA E provided privacy by drawing the privacy curtain during incontinent care for Resident #38. This failure could place residents at risk of feeling embarrassed, diminishing the residents' quality of life and not having residents' rights acknowledged.Findings Included: Record review of Resident #38's undated face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: Heart failure, unspecified (heart cannot pump enough blood to meet the body's needs, but the exact type such as systolic or diastolic is not yet determined), obstructive and reflux uropathy, unspecified (urinary tract blockage or urine flowing backward into the kidneys. The root cause is not currently specified), Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (dementia symptoms such as memory loss and cognitive decline but a doctor cannot definitively determine the exact underlying cause without exhibiting behavioral, psychotic, mood, or anxiety disturbances), age-related physical debility (geriatric syndrome characterized by a loss of muscle mass, decreased physiological reserve, and increased vulnerability to stressors). Record review of Resident #38's Comprehensive MDS Assessment, dated 03/05/2026, reflected Resident #38 had a BIMS score of 07 indicating severe cognitive impairment. Resident #38 had indwelling catheter, including suprapubic catheter and nephrostomy tube (nephrostomy and suprapubic catheters are external urinary drainage systems. The primary difference is their anatomical location: a nephrostomy tube drains urine directly from the kidney through lower back, while a suprapubic catheter is inserted directly into the bladder through a small incision in the lower abdomen). Resident #38 needed partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with the following ADLs: toileting hygiene, showering/bathing, personal hygiene, lower and upper body dressing. Record review of Resident #38's Care Plan, revised on 03/03/2026, reflected [Resident #38] required indwelling Foley Catheter due to obstructive Uropathy 2nd to penile (obstructive uropathy or urethral stricture, where a physical blockage in the penis or urethra restricts urine flow) and scrotal swelling and he occasionally incontinent of bowel. Potential for UTI. Potential for constipation. Approach: Provide incontinent care promptly when found wet/soiled and make sure clothes/linens are clean, dry, wrinkle free: change PRN. The care plan also revealed [Resident #38] had impaired cognitive functioning BIMS score 10 with deficits in orientation and recall. Approach: Observe for and report changes in cognitive status. Orient to surroundings, staff, environment, ADL needs and activities. During an observation of perineal care with indwelling catheter on 06/03/2026 at 8:14 a.m., CNA D and CNA E were providing incontinent care to Resident #38. CNA D and CNA E did not pull the privacy curtain therefore exposing Resident #38 who was nude from the waist down. Resident #38's roommate Resident #99 was in his bed, and he was looking at his cell phone during the incontinent care. During an interview on 06/03/2026 at 8:55 a.m. with Resident # 38 he stated that he did not feel ok when the privacy curtain was not closed while staff were cleaning his private parts because someone could enter the room. He stated that his roommate also could see him being exposed. Resident # 38 stated that staff rarely pulled the privacy curtain when they were changing him or his roommate. He stated he wanted staff to pull the curtain every time he was provided with incontinent care. He said it upset him when staff changed him and did not pull the curtain closed. During an interview on 06/04/2026 at 8:32 a.m., with DON she stated that she had been working in the facility for 2.5 years. She stated she had been trained in resident rights. DON stated the policy was that staff were to have the curtain pulled to provide privacy when providing incontinent care. She stated that most of the privacy curtains in the residents' rooms are not working, that is why the staff did not provide privacy while providing incontinent care for Resident #38. She stated that whoever provided care to the residents was responsible for providing privacy. She stated if staff did not provide privacy during incontinent care the residents may feel embarrassed, and it is dignity issue. She stated that the facility did order new curtains and privacy curtains accessories and all non-working curtains will be fixed. During an interview on 06/04/2026 at 8:54 a.m. with CNA E she stated she had been trained in providing incontinent care and resident rights. She stated that she had an incontinent care in service last week. She could not recall when she had the resident right training last time. She stated that pulling curtains and providing privacy during incontinent care was resident's rights and it was important to respect resident's dignity; resident did not want to be exposed to his roommate or to someone who comes into his room during incontinent care. She stated if staff did not provide privacy to the residents, the residents may feel exposed or unsafe. She stated she was assisting CNA D during incontinent care, and she thought that the curtains did not move because the moving parts were broken. She stated that she did not know why CNA D did not attempt to pull the privacy curtain. During an interview on 06/04/2026 at 9:04 a.m. with CNA D he stated he had been trained in resident rights. He said he did not remember what was covered in the training. He stated he had been trained on incontinent care. He stated his last incontinent care in service training was within two weeks. He stated the policy for providing privacy when providing incontinent care was that staff were to pull the privacy curtain before starting providing incontinent care. He stated that providing privacy during incontinent care was very important because someone who entered the room could see residents' private parts. It could make them feel bad. He stated all staff were responsible for providing the residents with privacy. He stated that he did not pull the privacy curtain because he thought it was not working but the privacy curtain worked when he checked it out later. During an interview on 06/04/2026 at 1:32 p.m. with ADON she stated that it was her second year working in the facility. She stated that the facility provided an incontinent care in service last week. ADON could not recall when she had resident rights training last time. She stated that providing privacy during incontinent care was important to maintain residents' dignity. ADON stated that staff were expected to provide privacy during incontinent care. She stated she did not know why CNA D did not provide privacy for the resident at the time of care. She stated that resident could feel embarrassed because his roommate or someone who entered his room during care could see his private parts. She stated that all staff were responsible for maintaining residents' dignity. During an interview on 06/04/2026 at 3:17 p.m. with the RNC she stated that she had been trained in resident rights. She stated the policy was that all staff were to provide privacy to the residents when giving care. She said the DON, ADON and administration team monitored to ensure staff was providing privacy when doing incontinent care. She stated that if residents were cognitive, it would affect residents negatively, and the residents would feel embarrassed if staff did not provide privacy during incontinent care. During an interview on 06/04/2026 at 4:25 p.m. with ADM she stated she had been working in the facility for 2 years. She stated that she used to be a CNA and she was familiar with providing incontinent care to residents. She stated her expectation was that staff provide the residents with privacy while providing incontinent care. She stated that residents may feel embarrassed or even depressed if privacy was not provided during incontinent care. ADM stated that it was nurses', DON's, and ADON's responsibility to ensure staff was providing privacy during incontinent care. She stated that the facility ordered new curtains to replace the current curtains in the residents' rooms. Record review of the facility's document titled, Catheter Care, Urinary policy dated 2001 and revised on 09/2014 revealed: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Steps in the Procedure: 1. Place the clean equipment on the bedside stand or overbed table. Arrange the supplies so they can be easily reached. Wash and dry your hands thoroughly. Fill the wash basin one-half (1/2) full of warm water. Place the wash basin on the bedside stand within easy reach. If the resident's physical or medical condition permits, assist the female resident on her back with knees bent and feet flat or the male resident on his back position. Refer to the resident's plan of care and/or request information from the Nurse Supervisor regarding safe positioning for the resident. Put on gloves. Place bed protector under resident. Wash the resident's genitalia and perineum thoroughly with soap and water. Rinse the area well and towel dry. Pour water down the commode. Flush the commode. Place soiled linen into designated container. Put on clean gloves. Remove gloves and discard into the designated container. Wash and dry your hands thoroughly. Provide privacy. Cover the resident with a sheet, exposing only the perineal area. Record review of the facility's document titled, Resident Rights policy dated 2001 and revised on 12/2016 revealed: Policy Statement: Employees shall treat all residents with kindness, respect, and dignity.1. 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 adequately equip to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area from each resident's bedside for 2 of 32 residents (Residents #53 and 84) reviewed for call system. The facility failed to ensure Residents #53 and 84 had functioning nurse call buttons on 06/02/2026, 06/03/2026, and 06/04/2026. This failure placed residents at risk of not having their needs met.Findings included: Review of the undated face sheet for Resident #53 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included cerebral infarction (a medical condition that occurs when the blood flow to the brain is disrupted due to issues with the arteries that supply it), hemiplegia and hemiparesis (paralysis on one side of the body), history of falling, lack of coordination, muscle weakness, abnormalities of gait and mobility, and need for assistance with personal care. Review of the quarterly MDS for Resident #84 dated 04/16/2026 reflected a BIMS score of 14, indicating intact cognition. Review of the care plan for Resident #53 dated 04/21/2026 reflected the following: PROBLEMResident requires assistance for ADL and mobility tasks due to CVA with residual Right Dominant Hemiplegia, generalized weakness, impaired balance.GOALResident will be clean / well-groomed / appropriately dressed, will have mobility needs met and will maintain highest practical level of functional ability X 90.APPROACHKeep call light within reach. Encourage/remind resident to use bell to call for assistance. Check on resident at routine intervals to assess needs, monitor safety issues and offer/provide assistance as needed. Review of the undated face sheet for Resident #84 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included type II diabetes mellitus (disease caused by the body's inability to properly use sugar), congestive heart failure (chronic condition in which the heart muscle is unable to pump enough blood to supply the entire body), history of falling, hemiplegia and hemiparesis (paralysis on one side of the body), and repeated falls. Review of the quarterly MDS for Resident #84 dated 04/16/2026 reflected a BIMS score of 10, indicating moderate cognitive impairment. It reflected he was independent with all transfers and ambulation. Review of the care plan for Resident #84 dated 04/21/2026 reflected the following: PROBLEMResident is independent for ADL and mobility tasks. Potential for unavoidable decline due to generalized weakness and chronic low back pain.GOALResident will be clean / well-groomed / appropriately dressed, will have mobility needs met and will maintain highest practical level of functional independence X 90 days.APPROACHEncourage/remind resident to use bell to call for assistance. Check on resident at routine intervals to assess needs, monitor safety issues and offer/provide assistance as needed. Observation and interview on 06/02/2026 at 1:14 PM revealed Resident #84 stated his call button was not working. He pulled it out, pressed the button, and the light did not come on outside the door or an alarm at the nurse's station. Resident #84 stated he had reported it was out to someone, but he did not remember who. He stated the button had just been out that morning. He stated there had not been any unmet needs as a result of the button not working, but he did occasionally need it. Resident #53 entered the room during the observation and stated his call button also did not work. A test of Resident #53's call button revealed the light did not come on outside the room and an alarm did not sound at the nurse's station. Observation and interview on 06/03/2026 at 10:31 AM revealed Resident #84's call button was still not working. He stated it had not worked since the day prior, but he had not needed it. Resident #53's call button was also not working. He stated he had been checked on and had not tried to use the call button since the day prior. LVN C entered the room and checked the call buttons, noticing they did not work. She left the room and returned five minutes later with two handbells. She gave a hand bell to Resident #53 and one to Resident #84. Observation and interview on 06/04/2026 at 9:27 AM revealed Resident #53 tested his call button, which did not activate the light outside his room. He stated he had tried to ring his bell overnight and no one had responded, and his bed was soaked in urine when he woke up. He rang his hand bell, and NA I, who was standing in the hall, did not respond. NA I stated she had not heard the handbell when it rang. During an interview on 06/04/2026 at 1:10 PM, NA J stated she had helped Resident #53 wake up that morning, and his brief was very saturated, but she had spoken to the aide who worked overnight who stated she had tried to check and help change Resident #53 several times, but he would not wake up. She stated she did know the handbells were in use as call bells for Resident #53 and 84, but she did not know if she could have heard them, because she did not think they had used the bells while she was working. During an interview on 6/4/26 at 1:19 PM using a telephone interpreter, NA I stated she had worked at the facility for three months and was in a nurse aide training class to obtain her certification. She stated she was aware of the broken call buttons in Resident #53 and 84's room. She stated nobody had a conversation with her letting her know that the call system had been temporarily replaced by handbells. During an interview on 06/04/2026 at 1:28 PM, LVN C stated she told the aides on the hall the day prior (06/03/2026) that Resident #53 and 84's call buttons had been temporarily replaced by handbells. She stated she specifically told NA I. When asked how she ensured NA I understood the instructions since she did not speak very much English, LVN C stated she thought the call button was working again, because midday she went in and pushed it, and it had worked. She stated she reported the broken call buttons to the MAINTD on 06/03/2026, and he had already known about them. During an interview on 06/04/2026 at 3:13 PM the MAINTD stated he did not know if staff had been in-serviced on the use of handbells for Resident #53 and 84. He stated he had not heard from the nursing staff that the call buttons were out but was told about it by Resident #53 on the morning of 06/02/2026. He stated he had gone into the room and tried to replace the call buttons with ones that did work, but that method was not successful. He stated he had figured out the problem was that staff were wrapping the cords around bed frames to make them accessible, but this was causing a short at the panel where they connected with the wall. He stated after he started fixing the call buttons and he did not speak with the nurse, but she came to him the following day and asked if Residents #53 and 84 had handbells. He stated it was his responsibility to ensure the call system was functional for all residents' rooms. He stated he would have to come up with a system for monitoring for compliance. He stated the potential negative impact of the call system not functioning in a resident room was that the resident might not get the help they needed. During an interview on 06/04/2026 at 3:31 PM, the DON stated the person responsible for ensuring the resident call system was the MAINTD, but the floor staff was responsible for identifying it. She stated the residents should each have had functioning methods of calling the nursing staff to their bedsides, and they had bells as a back up plan. She stated she had not done any training for staff on how to listen for handbells when the call buttons did not work. She stated a potential negative impact of the call bells or call buttons not working was residents would not be able to alert staff to get the help they needed. During an interview on 06/04/2026 at 4:00 PM, the ADM stated the responsibility for the call system was ultimately hers, but it was also overall the responsibility of anyone who discovered it was not working to enter it into the maintenance log. She stated the nursing and maintenance staff knew to place a bell at the resident's bedside if the call button was not working. The ADM stated she monitored for compliance with the process by in-servicing regularly. She stated the potential negative impact of not having a way to call for staff could be vast such as fall injuries or delay of care.Review of facility policy dated October 2010 and titled Answering the Call Light reflected the following: PurposeThe purpose of this procedure is to respond to the resident's requests and needs.General GuidelinesExplain the call light to the new resident.Demonstrate the use of the call light.Ask the resident to return the demonstration so that you will be sure that the resident can operate the system. (Note: Explain to the resident that a call system is also located in his/her bathroom. Demonstrate how it works.)Be sure that the call light is plugged in at all times.When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.Some residents may not be able to use their call light. Be sure you check these residents frequently.Report all defective call lights to the nurse supervisor promptly.Answer the resident's call as soon as possible.Be courteous in answering the resident's call.

Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #38) of 1 resident reviewed for incontinent care with foley catheter. The facility failed to ensure Resident #38's catheters' drainage bag was positioned lower than Resident's urinary bladder to prevent urine from flowing back to urinary bladder. This failure could place residents at risk of UTI and other serious infections. Findings included:Record review of Resident #38's undated face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: Heart failure, unspecified (heart cannot pump enough blood to meet the body's needs, but the exact type such as systolic or diastolic is not yet determined), obstructive and reflux uropathy, unspecified (urinary tract blockage or urine flowing backward into the kidneys. The root cause is not currently specified), Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (dementia symptoms such as memory loss and cognitive decline but a doctor cannot definitively determine the exact underlying cause without exhibiting behavioral, psychotic, mood, or anxiety disturbances), age-related physical debility (geriatric syndrome characterized by a loss of muscle mass, decreased physiological reserve, and increased vulnerability to stressors). Record review of Resident #38's Comprehensive MDS Assessment, dated 03/05/2026, reflected Resident #38 had a BIMS score of 07 indicating severe cognitive impairment. Resident #38 had indwelling catheter, including suprapubic catheter and nephrostomy tube (suprapubic and nephrostomy tube catheters are external urinary drainage systems. The nephrostomy tube drains urine directly from the kidney through lower back, while a suprapubic catheter is inserted directly into the bladder through a small incision in the lower abdomen). Resident #38 needed partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with the following ADLs: toileting hygiene, showering/bathing, personal hygiene, lower and upper body dressing. Record review of Resident #38's Care Plan, revised on 03/03/2026, reflected [Resident #38] required indwelling Foley Catheter due to obstructive Uropathy 2nd to penile and scrotal swelling and he occasionally incontinent of bowel. Potential for UTI. Potential for constipation. Approach: Provide incontinent care promptly when found wet/soiled and make sure clothes/linens are clean, dry, wrinkle free: change PRN. Urine collection bag to be kept below level of bladder. Privacy bag in place on wheelchair and/or bed at all times. Foley collection bag to be kept off of the floor at all times. Monitor for signs and symptom of UTI. The care plan also revealed [Resident #38] had impaired cognitive functioning BIMS score 07 with deficits in orientation and recall. Approach: Observe for and report changes in cognitive status. Orient to surroundings, staff, environment, ADL needs and activities. During an observation of perineal care with indwelling catheter on 06/03/2026 at 8:14 a.m. Resident #38 had a urine collection bag that was hanging on the left side of the resident's bed frame and was below the resident's bladder. CNA D stated that he just emptied Resident 38's urine collection bag. He removed the urine collection bag from the resident's bed frame, placed it inside of a clear plastic bag and put it on the resident's bed, next to his left leg. The Foley bag was on the level of the resident's bladder. Further observation revealed Resident #38's Foley catheter had a yellow-colored urine inside, and the urine was moving from the middle of the catheter to the insertion site at the resident's penis during repositioning of the resident from his back to his right side. The Foley bag remained on the bed until the incontinent care was completed During an interview on 06/03/2026 at 8:55 a.m. with Resident # 38 he stated he was not aware that the Foley bag must be kept below his bladder. He stated that he did not want to get any infections. Resident # 38 stated that his indwelling foley catheter will be removed soon because he had a care plan meeting a few days ago and this was discussed during the meeting. During an interview on 06/04/2026 at 8:32 a.m., with DON she stated that she had been working in the facility for 2.5 years. DON stated that resident's Foley bag was to be placed inside of the protective plastic bag and to be placed on the residents' bed during incontinent care. She stated that placing Foley bag on resident's bed was to prevent the indwelling catheter from yanking it out of the resident's body. She stated that she told CNA D to empty Resident #38's Foley bag, protect it by covering with a plastic bag and place it on his bed. She stated that in this case the indwelling catheter was not compromised during repositioning the resident. She stated that she did not feel that resident could potentially get an infection because the urinary bag was empty and it was below his bladder. During an interview on 06/04/2026 at 8:54 a.m. with CNA E she stated she had been trained in providing incontinent care for the residents with foley bags. She stated that her last incontinent care in service was last week. She stated that residents' foley bag must be placed below the residents' kidneys and bladder because residents were at risk of getting UTIs. She stated that she was assisting CNA D during incontinent care provided for Resident #38. She stated that the resident's Foley bag was emptied prior to providing incontinent care for the resident and she did not notice the urine inside of the indwelling catheter. During an interview on 06/04/2026 at 9:04 a.m. with CNA D he stated he had been trained in providing incontinent care with indwelling catheter. He stated his last incontinent care in service training was within two weeks. CNA D stated that the foley bag should be placed below the resident's bladder to prevent backflow of the urine to the resident's body and potentially getting a UTI. CNA D stated that it was his mistake that Resident #38's Foley bag was placed on the resident's bed. During an interview on 06/04/2026 at 1:32 p.m. with ADON she stated that it was her second year working in the facility. She stated that the facility provided an incontinent care in service last week. ADON stated that Foley bag was supposed to be kept below the resident's bladder because the urine in Foley bag and catheter could back flow into resident's bladder and resident could get a UTI. ADON stated she was not aware that CNA D kept Resident #38's Foley bag on his bed during incontinent care and she did not know the reason for keeping it on the bed. During an interview on 06/04/2026 at 3:17 p.m. with the RNC she stated that staff was expected to keep the Foley bag below resident's bladders at all the time because the urine inside of the Foley bag could go back to the resident's bladder and put resident at risk for infection. During an interview on 06/04/2026 at 4:25 p.m. with ADM she stated she had been working in the facility for 2 years. She stated that she used to be a CNA and she was familiar with providing incontinent care to residents. She stated her expectation was that staff kept residents' Foley bags below residents' bladders to prevent back flow of urine and potentially causing residents to get infections, UTIs and being hospitalized . Record review of the facility's document titled, Catheter Care, Urinary policy dated 2001 and revised on 09/2014 revealed: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Maintaining Unobstructed Urine Flow: 1. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. 2. Unless specifically ordered, do not apply a clamp to the catheter. 3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Findings included: Record review of Resident #38's undated face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: Heart failure, unspecified (heart cannot pump enough blood to meet the body's needs, but the exact type such as systolic or diastolic is not yet determined), obstructive and reflux uropathy, unspecified (urinary tract blockage or urine flowing backward into the kidneys. The root cause is not currently specified), Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (dementia symptoms such as memory loss and cognitive decline but a doctor cannot definitively determine the exact underlying cause without exhibiting behavioral, psychotic, mood, or anxiety disturbances), age-related physical debility (geriatric syndrome characterized by a loss of muscle mass, decreased physiological reserve, and increased vulnerability to stressors). Record review of Resident #38's Comprehensive MDS Assessment, dated 03/05/2026, reflected Resident #38 had a BIMS score of 07 indicating severe cognitive impairment. Resident #38 had indwelling catheter, including suprapubic catheter and nephrostomy tube (suprapubic and nephrostomy tube catheters are external urinary drainage systems. The nephrostomy tube drains urine directly from the kidney through lower back, while a suprapubic catheter is inserted directly into the bladder through a small incision in the lower abdomen). Resident #38 needed partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with the following ADLs: toileting hygiene, showering/bathing, personal hygiene, lower and upper body dressing. Record review of Resident #38's Care Plan, revised on 03/03/2026, reflected [Resident #38] required indwelling Foley Catheter due to obstructive Uropathy 2nd to penile and scrotal swelling and he occasionally incontinent of bowel. Potential for UTI. Potential for constipation. Approach: Provide incontinent care promptly when found wet/soiled and make sure clothes/linens are clean, dry, wrinkle free: change PRN. Urine collection bag to be kept below level of bladder. Privacy bag in place on wheelchair and/or bed at all times. Foley collection bag to be kept off of the floor at all times. Monitor for signs and symptom of UTI. The care plan also revealed [Resident #38] had impaired cognitive functioning BIMS score 07 with deficits in orientation and recall. Approach: Observe for and report changes in cognitive status. Orient to surroundings, staff, environment, ADL needs and activities. During an observation of perineal care with indwelling catheter on 06/03/2026 at 8:14 a.m. Resident #38 had a urine collection bag that was hanging on the left side of the resident's bed frame and was below the resident's bladder. CNA D stated that he just emptied Resident 38's urine collection bag. He removed the urine collection bag from the resident's bed frame, placed it inside of a clear plastic bag and put it on the resident's bed, next to his left leg. The Foley bag was on the level of the resident's bladder. Further observation revealed Resident #38's Foley catheter had a yellow-colored urine inside, and the urine was moving from the middle of the catheter to the insertion site at the resident's penis during repositioning of the resident from his back to his right side. The Foley bag remained on the bed until the incontinent care was completed During an interview on 06/03/2026 at 8:55 a.m. with Resident # 38 he stated he was not aware that the Foley bag must be kept below his bladder. He stated that he did not want to get any infections. Resident # 38 stated that his indwelling foley catheter will be removed soon because he had a care plan meeting a few days ago and this was discussed during the meeting. During an interview on 06/04/2026 at 8:32 a.m., with DON she stated that she had been working in the facility for 2.5 years. DON stated that resident's Foley bag was to be placed inside of the protective plastic bag and to be placed on the residents' bed during incontinent care. She stated that placing Foley bag on resident's bed was to prevent the indwelling catheter from yanking it out of the resident's body. She stated that she told CNA D to empty Resident #38's Foley bag, protect it by covering with a plastic bag and place it on his bed. She stated that in this case the indwelling catheter was not compromised during repositioning the resident. She stated that she did not feel that resident could potentially get an infection because the urinary bag was empty and it was below his bladder. During an interview on 06/04/2026 at 8:54 a.m. with CNA E she stated she had been trained in providing incontinent care for the residents with foley bags. She stated that her last incontinent care in service was last week. She stated that residents' foley bag must be placed below the residents' kidneys and bladder because residents were at risk of getting UTIs. She stated that she was assisting CNA D during incontinent care provided for Resident #38. She stated that the resident's Foley bag was emptied prior to providing incontinent care for the resident and she did not notice the urine inside of the indwelling catheter. During an interview on 06/04/2026 at 9:04 a.m. with CNA D he stated he had been trained in providing incontinent care with indwelling catheter. He stated his last incontinent care in service training was within two weeks. CNA D stated that the foley bag should be placed below the resident's bladder to prevent backflow of the urine to the resident's body and potentially getting a UTI. CNA D stated that it was his mistake that Resident #38's Foley bag was placed on the resident's bed. During an interview on 06/04/2026 at 1:32 p.m. with ADON she stated that it was her second year working in the facility. She stated that the facility provided an incontinent care in service last week. ADON stated that Foley bag was supposed to be kept below the resident's bladder because the urine in Foley bag and catheter could back flow into resident's bladder and resident could get a UTI. ADON stated she was not aware that CNA D kept Resident #38's Foley bag on his bed during incontinent care and she did not know the reason for keeping it on the bed. During an interview on 06/04/2026 at 3:17 p.m. with the RNC she stated that staff was expected to keep the Foley bag below resident's bladders at all the time because the urine inside of the Foley bag could go back to the resident's bladder and put resident at risk for infection. During an interview on 06/04/2026 at 4:25 p.m. with ADM she stated she had been working in the facility for 2 years. She stated that she used to be a CNA and she was familiar with providing incontinent care to residents. She stated her expectation was that staff kept residents' Foley bags below residents' bladders to prevent back flow of urine and potentially causing residents to get infections, UTIs and being hospitalized . Record review of the facility's document titled, Catheter Care, Urinary policy dated 2001 and revised on 09/2014 revealed: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Maintaining Unobstructed Urine Flow: 1. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. 2. Unless specifically ordered, do not apply a clamp to the catheter. 3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

Based on observation, interview, and record review, the facility failed to post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility for 1 of 4 required postings (survey results) reviewed. The facility failed to ensure the results of the recertification survey dated 12/31/2026 were present in the survey inspection results binder on 06/02/2026 and 06/03/2026. This facility placed residents and their responsible parties at risk of not being able to inspect survey results. Findings included: Review of the survey event database utilized by HHSC to track surveys reflected the facility was a special focus facility, indicating there would be two full recertification surveys every calendar year. It also reflected the most recent full recertification survey was 12/31/2025. Observation on 06/02/2026 at 10:45 AM revealed a white binder on the shelf behind the reception desk, in a placement reachable to passersby, including those in wheelchairs, with the title Survey Inspection Results on the jacket. Within the book were surveys dating back to 2022, and the most recent was dated 07/31/2025. Observation on 06/03/2026 at 1:13 PM revealed the survey results binder was still lacking the survey results from 12/31/2025. During a confidential group interview, five anonymous residents stated they did not know how to view the results of previous surveys. Three of them stated they would like to view the results of the most recent survey. During an interview on 06/04/2026 at 4:00 PM, the ADM stated she had worked through a survey readiness checklist on 05/11/2026 and the results were not there on that day, so she printed them and put them in the book. She stated she could not say what happened, but someone must have removed the results from 12/31/2025. She stated she was responsible for ensuring the most recent survey results were posted for the public, and her habit was to place the results right after survey.She stated a potential negative impact of the most recent results not being available was if a resident wanted to see outcomes or previous history, they would not be able to access it. She stated she knew some residents were able to look up results online. Review of facility policy dated 12/2016 and titled Resident Rights reflected the following: Policy StatementEmployees shall treat all residents with kindness, respect, and dignity.Policy Interpretation and Implementation1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to: w. examine survey results.

Based on observation, interview and record review the facility failed to ensure the resident had a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 3 of 4 shower rooms (halls 200, 300, and 500) and 1 of 1 medication room reviewed for environment. The facility failed to ensure the shower rooms for halls 200, 300, and 500 were clean, functional, and in good repair on 05/13/2026 and 05/14/2026. These failures could place residents at risk of infection, injury, and diminished quality of life. Record review of work orders dated 04/13/2026 to 05/13/2026 reflected no work order related to the shower rooms or the medication room sink and cabinet. All work orders on the list were completed. Observation and interview on 05/13/2026 at 9:29 AM revealed the hall 300 shower room had no paper towels or hand soap near the handwashing sink. The toilet had a large translucent plastic bag wrapped around the bowl with the lid closed on top of it, and when the lid was lifted, the plastic bag was filled with yellow and brown liquid and toilet paper. CNA B entered the hall 300 shower room and saw the yellow liquid in the toilet. She stated it was likely urine and should not have been there, because the toilet was broken. She stated she did not know who was responsible for leaving the waste in the toilet, but the CNAs were all supposed to clean the bathroom between every resident shower, and she did. She stated she used sanitizing spray to clean the whole shower room, but if the resident did not use the toilet, she did not think to check the toilet and clean it. She stated she was not sure who was supposed to restock hand soap and paper towels, but they used the gallon jugs of body soap to wash their hands. She stated paper towels were preferable for drying hands to letting her hands air dry. She stated she thought it was someone in housekeeping who was supposed to replace paper towels and soap. Observation on 05/13/2026 at 9:50 AM revealed the hall 200 shower room toilet was out of order. The toilet had a translucent plastic bag around the bowl. There was no waste within the plastic bag but the water underneath the plastic bag was yellow and smelled foul. There were no paper towels in the dispenser or anywhere in the shower room. Observation on 05/13/2026 at 9:56 AM revealed the hall 500 shower room had a small waste basket that was broken around the top and had a large, thick smear of a brown substance that smelled like feces. The mirror affixed to the wall over the sink was broken in several areas (though no loose glass was observed). There were no paper towels in the dispenser or anywhere in the shower room. Observation on 05/14/2026 at 12:41 PM revealed the hall 200 and hall 500 bathrooms were in the same condition as they had been observed on 05/13/2026. Observation on 05/14/2026 at 1:02 PM revealed paper towels and plastic bags were in abundant supply in several supply closets throughout the facility. During an interview on 05/14/2026 at 1:15 PM, HK C stated she worked cleaning halls 400 and 300. She stated she cleaned resident rooms and the shower rooms once daily. She stated there were not enough wastebasket bags to hand out to staff, so she always put wastebasket bags in the wastebaskets herself. She stated she only replaced paper towels every so often, as the CNAs did that. She stated the maintenance director had to replace soap because she could not open the soap dispensers. She stated she reported maintenance concerns to her supervisor, the HKS, but he was out on leave right now. She stated she did not know who else to talk to about maintenance issues. During an interview on 05/14/2026 at 1:23 PM, HK D stated she worked in the facility on hall 300 for one year. She stated she cleaned the shower rooms with bleach every day. She stated she reported maintenance problems to the HKS, who was her manager. She stated when she reported maintenance concerns to her manager or to any other staff person, she always was told the building was old. She stated all problems were blamed on the building being old. She stated she did not know who to report maintenance concerns to if her manager was unavailable or necessary repairs were not being addressed. She stated she did not replace paper towels in the shower rooms, and she did not know who was responsible for that. During an interview on 05/14/2026 at 1:32 PM, HK E stated she cleaned the shower every day. She stated she did not know who was responsible for stocking paper towels and soap in the shower rooms. She stated she saw the toilet was broken on hall 200, but she thought it had already been addressed. She stated she told her manager, the HKS, if there was a maintenance concern. She stated she did not know who to tell if the HKS was not available. During an interview on 05/14/2026 at 1:57 PM, CNA F stated he worked at the facility for 10 years, and usually worked on hall 500. He stated he sprayed the shower room between every resident shower, but he did not have access to wastebasket bags or paper towels and thought the housekeepers stocked those items. He stated he noticed the items were not always stocked. He stated he did not think the housekeepers cleaned the shower rooms every day. He stated he asked for a wastebasket bag sometimes and was always told by housekeeping they did not have access to bags. When asked how he washed and dried his hands in the shower rooms, he said, Exactly. He stated he reported maintenance concerns to the charge nurse. He stated he could also report to the MAINTD, but he had only ever reported to the charge nurse. During an interview on 05/14/2026 at 2:07 PM, CNA G stated she worked hall 300 for 20 years. She stated the shower rooms should be cleaned and disinfected. She stated the wastebaskets often did not have bags in them, and she told her DON about it. She stated she told her charge nurse and her DON when something was broken or needed attention. She stated she did not notice the toilet in the hall 300 shower room was broken or had waste in it, because she had not helped any resident use the toilet in the shower room. During an interview on 05/14/2026 at 2:55 PM, the MAINTD stated it was the whole facility's responsibility to ensure maintenance requests were submitted, and his job to ensure they were completed. He stated he had no incomplete work orders in his system. He stated the staff had a program with kiosks into which they could input work requests. He stated the CNAs did not have the program available on their documentation system, yet, but the facility had ordered that service. He stated the kiosk was available to the nurses, and that was how he found out about many of the maintenance needs. He stated he had been at the facility for a year, and there were still many things to be repaired. He stated he did not have prior work orders for the shower rooms. He stated he was not aware the toilet was clogged in both bathrooms, but only the toilet in hall 200. He stated the importance of compliance in the areas of housekeeping and maintenance was the residents needed environmental conditions to be safe and sanitary. During an interview on 05/14/2026 at 3:17 PM, the DON stated she could not honestly say she had done a paper in-service with staff about the conditions in the shower rooms or about what was required by policy and procedure in the shower rooms, but she stated she had spoken to staff verbally about it. She stated it was the dual responsibility of housekeeping and the CNAs to ensure the shower rooms were cleaned and everything in good repair. She stated the housekeeping department held the wastebasket bags, and there were some conflict over the distribution of wastebasket bags. She would not elaborate on the conflict but said she thought it had been resolved. She would not say how she thought it was resolved or who had played a role in resolving it. During an interview on 05/14/2026 at 3:36 PM, the ADM stated she had not been aware of any of the environmental issues identified during the investigation. She stated the nurse managers were responsible for ensuring medication carts and rooms were cleaned and in good repair. She stated, ultimately, it was on the DON to ensure compliance. The ADM stated she ensured compliance by making rounds every day. She stated the person responsible for ensuring the shower rooms were clean was HKS, but he was out on leave. She stated the CNAs were also supposed to clean the shower rooms between showers and report any concerns to housekeeping. She stated there were some issues with the housekeeping department not wanting to give wastebasket bags to nursing staff, but she thought the issue was over. She stated ultimately she (the ADM) was responsible for everything in the building. She stated they had a Guardian Angel program in which a member of management was assigned several resident rooms and had to visit each day to ensure everything for that resident was acceptable, but the shower rooms had not been added to the angel rounds. She stated she also made rounds twice a day nearly every day and tried to visit each shower room every other day. She stated the potential negative impact on residents of the shower room being unsanitary or having broken equipment was infection. Record review of the facility policy, dated May 2017, and titled Quality of Life - Homelike Environment reflected the following: Policy StatementResidents are provided with a safe, clean, comfortable, and homelike environment, and encouraged to use their personal belongings to the extent possible.Policy Interpretation and Implementation1. Staff shall provide person centered care that emphasizes the residents' comfort, independence, and personal needs and preferences.2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment.

Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 2 medication carts (Cart A) reviewed for pharmacy services. 1. The facility failed to ensure medications in the hall 400 medication cart (Cart A) were stored in a clean environment. 2. The facility failed to follow its pharmacy services policy when it allowed storage of a dose of Resident #1's Tramadol taped into a compartment with a broken seal. These failures could place resident's medications at risk of prompt identification of loss, and potential diversion of controlled medications. Findings Included:Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included schizoaffective disorder- bipolar type (a chronic mental illness that combines features of schizophrenia-such as hallucinations and delusions-with mood disorder symptoms, which can include episodes of mania or depression), asthma (a condition causing airways to swell, narrow and fill with mucus making it hard to breathe or causing other symptoms, like chest tightness, cough and wheezing), hypertension (high blood pressure), and pain. Record review of Resident #1's quarterly MDS assessment, dated 05/06/2026, reflected a BIMS score of 14, which indicated little or no cognitive impairment. It reflected he did not receive PRN pain medication and was not offered and declined pain medication. Record review of Resident #1's care plan, dated 05/07/2026, reflected the following:ProblemFalls- Potential for falls due to history of falling, Right Femur Fracture (April 2024), generalized weakness, impaired balance, impaired safety awareness, right hip pain and cardiovascular, pain and psychotropic medication administration.ApproachMonitor medication effectiveness and for S/S of adverse reaction/side effects. Record review of Resident #1's physician orders reflected the following order with a start date of 05/16/2024:Tramadol- Schedule IV tablet; 50 mg; amt: 1; oral Every 6 hours- PRN Record review of the MAR for Resident #1 from 03/24/2026 to 05/13/2026 reflected he was not administered Tramadol PRN during this time. Record review of Resident #1's most recent Consultant Pharmacist Summary Report, dated 03/31/2026, reflected the facility was compliant in every area of medication storage. Observation and interview on 05/13/2026 at 10:43 AM during an audit of the 400-hall medication cart with LVN A revealed a brown substance dripped and dried onto two of the medication blister packages and the lids of several of the medication bottles. It also revealed a blister package of Tramadol 50 mg labeled as ordered to Resident #1 was in the hall 400 medication cart's locked container for controlled substances. The blister package had 30 pills still within it, but the backing on one of the pill compartments (#11 on the blister package) was punctured and re-covered with adhesive tape. The pill in that compartment looked the same as the other pills. LVN A stated she was responsible for keeping the medication cart clean. She stated she did not know what the brown substance was on the medication packaging, but she should have reported it to her DON and did not know why she had not but that some effort should be made to ensure the cleanliness of the cart. She stated something spilled on the medication packaging could contaminate medications. Observation on 05/13/2026 at 10:51 AM in the medication room revealed the bottom fascia (front) board was falling off the cabinet. The cabinet covering the right side of the under-sink area was half sized, vertically, so the cabinet was open to the room. The floor of the cabinet, made of particle board, was crumbling and had evidence of dead mold and insects in the right, rear corner. Observation and interview on 05/13/2026 at 11:30 AM with the DON revealed she opened the hall 400 medication cart and stated she could see the substance on the blister packs and medicine bottles. She said she did not know what it might be, but it could be cough syrup. She said she did not see how the substance could affect residents, because their medications were in sealed packages. She stated the substance spilled on the medication packing could not contaminate medications. During an interview on 05/13/2026 at 12:28 PM, the pharmacist (PH) stated she had been to the facility the day before and conducted cart audits as part of her monthly review, but she did not see a cart with a brown substance spilled on medication packages. She stated she would have directed the staff to clean the cart if she had seen that. She stated she also had not noticed the odor in the medication room hot water tap. She stated she did notice the broken cabinet, but she assumed that was being fixed. She stated if a blister pack compartment was punctured, the drug should have been wasted. Observation on 05/14/2026 at 12:40 PM revealed Resident #1 lying in his bed in his room demonstrating no sweating, grimacing, or other signs of pain. He refused an interview. Observation on 05/14/2026 at 1:02 PM revealed paper towels were in abundant supply in several supply closets throughout the facility. Observation and interview on 05/14/2026 at 2:53 PM revealed the MAINTD entered the medication room to observe the under-sink cabinet. He stated he had never seen the state of the cabinet under the sink, and it had not been reported to him. He turned on the hot water, and stated there was a strong foul odor emanating from it. He stated he was not aware of the state of the hot water in the medication room prior to the state surveyor intervention. He stated both issues should have been reported to him and were not suitable conditions for the medication room. He stated the nurses had an electronic system where they could enter work orders. During an interview on 05/14/2026 at 2:55 PM, the MAINTD stated he knew their medical records had a restroom that smelled like that, but he did not know the medication room had that problem. He stated it was the whole facility's responsibility to ensure maintenance requests were submitted, and his job to ensure they were completed. He stated he had no incomplete work orders in his system. He stated the staff had a program with kiosks into which they could input work requests. He stated the CNAs did not have the program available on their documentation system, but the facility had ordered that service, and the nurses could enter work orders. He stated that was how he found out about many of the maintenance needs. He stated he had been at the facility for a year, and there were still many things to be repaired. He stated he thought perhaps the nursing staff did not tell him about the medication room, because he did not have a key to it and they thought he could not get in. He stated the hot water smell in the medication room would need a professional plumber to address. He stated he did not know the cause of the smell. He stated the importance of compliance in the areas of housekeeping and maintenance was the residents needed environmental conditions to be safe and sanitary. He stated the foul odor in the medication room hot water was especially unsafe as it was connected to an eyewash station. During an interview on 05/14/2026 at 3:17 PM, the DON stated she knew about the sink and cabinet in the medication room before the state surveyor arrived. She stated the MAINT knew about the issue but did not say whether she had reported it to the MAINTD or not. She stated she was not aware of a specific plan to fix it, because that was the MAINTD's responsibility. She stated the medications were all covered, so the state of the sink and cabinet could not affect residents. She stated they used the cold-water side of the sink, which did not have a bad odor. She stated they usually washed their hands before and after handling medication in the medication room. She then said they always washed their hands. She stated she was responsible for ensuring the medication room and medication carts were safe and sanitary, and she ensured compliance by doing rounds. During an interview on 05/14/2026 at 3:36 PM, the ADM stated the nurse managers were responsible for ensuring medication carts and rooms were cleaned and in good repair. She stated, ultimately, it was on the DON to ensure compliance. The ADM stated she ensured compliance by making rounds every day. She stated she checked for cart cleanliness on her rounds and reported problems to the nursing staff. She stated the potential negative impact of medication storage areas not being clean and in good repair was cross contamination. Record review of the facility's policy, dated and titled, Storage of Medications reflected the following: Policy StatementThe facility stores all drugs and biological in a safe, secure, and orderly manner.Policy Interpretation and Implementation1. Drugs and biological used in the facility are stored and locked compartments under proper temperature, light and humidity controls.2. Drugs and biological are stored in the packaging, container, containers, or other dispensing systems in which they are received. Only the issuing pharmacies are authorized to transfer medications between container containers.3. The nursing staff is responsible for maintaining medication storage and preparation error areas in a clean, safe, and sanitary manner.

Based on observation, interview and record review the facility failed to ensure the resident had a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 1 of 1 medication room reviewed for environment. The facility failed to ensure the medication storage room sink and the under-sink cabinet was in good repair on 05/13/2026 and 05/14/2026. These failures could place residents at risk of not receiving the full benefit of their pharmaceutical regimen and infection. Record review of work orders dated 04/13/2026 to 05/13/2026 reflected no work order related to the shower rooms or the medication room sink and cabinet. All work orders on the list were completed. Observation on 05/13/2026 at 10:51 AM in the medication room revealed the bottom fascia (front) board was broken and falling off the cabinet. The cabinet covering the right side of the under-sink area was half sized, vertically, so the inner cabinet was opened to the room. The floor of the cabinet, made of particle board, was crumbling on the entire right side and had evidence of dead mildew/water damage and insects in the right, rear corner. Observation and interview on 05/14/2026 at 2:53 PM revealed the MAINTD entered the medication room to observe the under-sink cabinet. He stated he had never seen the state of the cabinet under the sink, and it had not been reported to him. He turned on the hot water, and stated there was a strong foul odor emanating from it. He stated he was not aware of the state of the hot water in the medication room prior to state surveyor intervention. He stated both issues should have been reported to him and were not suitable conditions for the medication room. He stated the nurses had an electronic system where they could enter work orders for him. During an interview on 05/14/2026 at 2:55 PM, the MAINTD stated it was the whole facility's responsibility to ensure maintenance requests were submitted, and his job to ensure they were completed. He stated he had no incomplete work orders in his system. He stated the staff had a program with kiosks into which they could input work requests. He stated the CNAs did not have the program available on their documentation system, yet, but the facility had ordered that service. He stated the kiosk was available to the nurses, and that was how he found out about many of the maintenance needs. He stated he had been at the facility for a year, and there were still many things to be repaired. He stated he thought perhaps the nursing staff did not tell him about the medication room, because he did not have a key to it and they thought he could not get in. He stated the hot water smell in the medication room would need a professional plumber to address. He stated the importance of compliance in the areas of housekeeping and maintenance was the residents needed environmental conditions to be safe and sanitary. He stated the foul odor in the medication room hot water was especially unsafe as it was connected to an eyewash station. He stated he did not know what was causing the foul odor. During an interview on 05/14/2026 at 3:17 PM, the DON stated she knew about the sink and cabinet in the medication room before the survey began. She stated the MAINTD knew about the issue but did not say whether she had reported it to the MAINTD or not. She did not say how she knew the MAINTD was aware of it. She stated there was no reason to lie about the medication room, because they were going to fix it. She stated she was not aware of a specific plan to fix it, because that was the MAINTD's responsibility. She stated the medications were all covered, so the state of the sink and cabinet could not affect residents. She stated they used the cold water side of the sink, which did not have a bad odor. The DON stated the lack of paper towels was an inconvenience and then answered yes when asked if paper towels played a role in infection control. She stated the toilet in the hall 300 shower room had been out of order for a long time, but she did not have an exact duration or date it stopped functioning. She stated she did not know why it had not been repaired. During an interview on 05/14/2026 at 3:36 PM, the ADM stated she had not been aware of any of the environmental issues identified during the investigation. She stated the nurse managers were responsible for ensuring medication carts and rooms were cleaned and in good repair. She stated, ultimately, it was on the DON to ensure compliance. The ADM stated she ensured compliance by making rounds every day. She stated she checked for cart cleanliness on her rounds and reported problems to the nursing staff. She stated the potential negative impact of medication storage areas not being clean and in good repair was cross contamination. She stated ultimately, she (the ADM) was responsible for everything in the building. She stated she made rounds twice a day nearly every day and tried to visit each shower room every other day. She stated the potential negative impact on residents of the shower room being unsanitary or having broken equipment was infection. Record review of the facility policy, dated May 2017, and titled Quality of Life - Homelike Environment reflected the following: Policy StatementResidents are provided with a safe, clean, comfortable, and homelike environment, and encouraged to use their personal belongings to the extent possible.Policy Interpretation and Implementation1. Staff shall provide person centered care that emphasizes the residents' comfort, independence, and personal needs and preferences.2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment.Record review of the facility's policy, dated and titled, Storage of Medications reflected the following: Policy StatementThe facility stores all drugs and biological in a safe, secure, and orderly manner.Policy Interpretation and Implementation1. Drugs and biological used in the facility are stored and locked compartments under proper temperature, light and humidity controls.2. Drugs and biological are stored in the packaging, container, containers, or other dispensing systems in which they are received. Only the issuing pharmacies are authorized to transfer medications between container containers.3. The nursing staff is responsible for maintaining medication storage and preparation error areas in a clean, safe, and sanitary manner.

Based on interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections for 1 of 5 residents (Resident #1) reviewed for infection control/sanitary environment. The facility failed to ensure staff performed hand hygiene for Resident #1 and fecal matter was removed from his hands prior to being fed in the dining room. This failure could place residents at risk for developing communicable diseases and infections.Findings included:Record review of Resident #1's face sheet dated 03/03/26 reflected a [AGE] year-old male admitted [DATE]. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 11 indicating moderate cognitive impairment. Active diagnosis reflected progressive neurological conditions, hypertension (high blood pressure), viral hepatitis (inflammation of the liver), diabetes mellitus (condition when the body cannot properly use blood sugar or glucose), and non-Alzheimer's dementia (loss of memory and other intellectual functions severe enough to cause problems with ones abilities to perform usual personal, social, and occupational activities). Section GG for functional abilities reflected Resident #1 required substantial/ maximal assistance with both eating and personal hygiene. Record review of Resident #1's care plan last revised 02/11/26 reflected a focus potential for weight loss due to impaired cognitive functioning with dementia, difficulty with self-feeding 2nd to blindness/ visual loss, therapeutic diet that may not always be appealing to him interventions included ensure resident is clean, dry, and comfortable before meal time and provide assistance as needed for meal completion; resident requires substantial assistance for meal intake. An additional focus included resident requires assistance for ADL and mobility tasks due to impaired cognitive functioning with dementia, visual deficit with left eye blindness, generalized weakness, poor endurance/ activity tolerance, impaired balance, reduced ROM to bilateral shoulders with interventions that included resident requires maximum assistance for personal hygiene tasks. Record review of a facility grievance report dated 02/27/26 reflected FM expressed concern r/t hand hygiene during meals.on follow up the documentation revealed residents hands cleaned immediately social worker present to resolve concern. Record review of Resident #1's progress dated 02/28/26 written by the ADM reflected this writer was notified of the grievances related to this resident from family on Friday 02/27/2026. Family expressed concerns related to meal service. The social worker of the facility was present during the grievance resolution process at dinner on 02/27/2026 and ensured that the grievances by this resident's [family member] was addressed promptly. During an interview on 03/03/26 at 11:56 AM, Resident #1's FM (family member) stated he arrived at the facility on Friday 02/27/26 in the evening during mealtime and went to the dining room to find Resident #1 being assisted with his meal. FM stated that as he approached Resident #1's table he smelled a foul odor that smelled like BM. When he arrived at the table, he could see Resident #1's hands which were at chest level and could see BM on both of his hands. FM stated he became extremely upset by this and demanded that Resident #1 be cleaned up. FM stated the SW was still at the facility and he went to the dining room and also witnessed Resident #1 in the condition he was in. FM stated he was upset that Resident #1 was being fed with obvious fecal matter on his hands without staff cleaning him first. During an interview on 03/03/26 at 12:40 PM with Resident #1, he stated he could not recall the event in the dining room that occurred 02/27/26. During an interview on 03/03/26 at 03:12 PM with the SW, he stated he was at the facility the evening of Friday 02/27/26. He stated he was alerted of the complaint made by FM and went to the dining room and observed fecal matter on both of Resident #1's hands. SW stated he was shocked and alarmed when he saw it and it was upsetting to see that in the cafeteria. He stated Resident #1 had known behaviors of scratching himself and putting his hands in his pants but stated he was surprised that Resident #1 was able to make it to the dining room without being cleaned. SW stated he observed upon entry was that Resident #1 was being fed by CNA A. The SW stated upon getting to the table he questioned CNA A about seeing the fecal matter on Resident #1's hands and if he was aware of it, CNA A denied being aware of it. The SW stated he then notified the ADM about it right away after ensuring Resident #1 was cleaned. The SW stated that he could not understand how he [CNA A] could not see that. The residents hands were at chest level where he usually maintained them. The SW denied being able to smell the fecal matter but stated it was probably due to allergies and had he not had allergies he believed he would be able to smell it. The SW stated the amount of fecal matter on Resident #1's hands was enough to be noticed. During an interview on 03/03/26 at 03:34 PM with CNA A, he stated he was at the facility on 02/27/26 when the incident occurred and was the CNA assisting Resident #1 with his meal. CNA A stated he was already feeding Resident #1 and had been for approximately 10 minutes before Resident #1's FM had arrived at the table and alerted him to the BM on the residents hands. CNA A stated he had not noticed the BM on Resident #1's hands as the resident doesn't use his hands. CNA A denied there being a smell to the BM on Resident #1's hands and stated it appeared it had already dried up. He stated it was the expectation that residents were groomed and cleaned prior to going to the dining room. He stated a negative outcome to residents having BM on their hands while being fed was infection control. During an interview on 03/03/26 at 04:07 PM with LVN B stated he worked in the dining room on Friday 02/27/26 and was in the dining room assisting with dinner services as the nurse checking meal trays. LVN B stated he was alerted to the incident when he heard Resident #1's FM bring attention to it and saw CNA A feeding Resident #1 and Resident #1 having BM on his hands. LVN B stated he instructed CNA A to clean Resident #1's hands and sanitizer wipes were used to clean the resident's hands. LVN B stated a negative outcome to BM on residents hands during mealtime is infection control, he also stated everyone wants to be clean, it can affect him psychosocially. During an interview on 03/03/26 at 04:19 PM with the DON she stated she was not in the facility when the incident occurred on Friday 02/27/26 but she was alerted to it the same day. She stated Resident #1 has known behaviors of putting his hands in his pants and getting fecal matter on his hands. The DON stated it was the expectation that residents should be clean when they are being fed and stated this was an unfortunate situation. She stated a negative outcome was infection control and dignity issues. The DON stated they initiated training on expectations including hand hygiene and infection control, but that training was still ongoing and there were still staff that had not completed training. During an interview on 03/03/26 at 04:55 PM with the ADM, she stated she became aware of the incident on the evening of 02/27/26 when it occurred via a phone call from the SW and advised that Resident #1 be cleaned immediately. She stated that it was known of residents behavior related to putting his hands in his briefs and was care planned. The ADM stated the DON was working on re-educating staff in the facility and that it was still ongoing as not everyone had received the training yet. She stated she was not aware of any negative outcome that occurred. She stated there was a potential for breach of infection control if he touched surfaces or food.Review of the facility Infection Prevention and Control policy effective 11/28/17 reflected: Objective: To effectively investigate, control, and/or prevent infections. Responsible departments: All staff the facility shall investigate, control and/or prevent infections through implementation of an Infection Prevention & Control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Based on interviews, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and failed to protect and promote the rights of the residents for 1 of 5 (Resident #1) residents observed for dignity. 1. The facility failed to ensure Resident #1 was clean while in the dining room being assisted with feeding. Resident #1 was in the dining room being fed with fecal matter on both of his hands. This failure could place residents at risk of experiencing humiliation, degradation, and a decreased quality of life.The findings included: Record review of Resident #1's face sheet dated 03/03/26, reflected a [AGE] year-old male admitted to the facility on [DATE]. The face sheet did not indicate active diagnoses. Record review of Resident #1's quarterly MDS assessment dated [DATE], reflected a BIMS score of 11 indicating moderate cognitive impairment. Active diagnosis reflected progressive neurological conditions, hypertension (high blood pressure), viral hepatitis (inflammation of the liver), diabetes mellitus (condition when the body cannot properly use blood sugar or glucose), and non-Alzheimer's dementia (loss of memory and other intellectual functions severe enough to cause problems with ones abilities to perform usual personal, social, and occupational activities). Section GG for functional abilities reflected Resident #1 required substantial/ maximal assistance with both eating and personal hygiene. Record review of Resident #1's care plan last revised 02/11/26 reflected a focus potential for weight loss due to impaired cognitive functioning with dementia, difficulty with self-feeding 2nd to blindness/ visual loss, therapeutic diet that may not always be appealing to him interventions included ensure resident is clean, dry, and comfortable before meal time and provide assistance as needed for meal completion; resident requires substantial assistance for meal intake. An additional focus included resident requires assistance for ADL and mobility tasks due to impaired cognitive functioning with dementia, visual deficit with left eye blindness, generalized weakness, poor endurance/ activity tolerance, impaired balance, reduced ROM to bilateral shoulders with interventions that included resident requires maximum assistance for personal hygiene tasks. Record review of facility grievance report dated 02/27/26 reflected FM expressed concern r/t hand hygiene during meals. follow up documentation revealed residents hands cleaned immediately social worker present to resolve concern. Record review of Resident #1's progress notes dated 02/28/26 written by the ADM reflected, this writer was notified of the grievances related to this resident from family on Friday 02/27/2026. Family expressed concerns related to meal service. The social worker of the facility was present during the grievance resolution process at dinner on 02/27/2026 and ensured that the grievances by this residents [family member] was addressed promptly. During an interview on 03/03/26 at 11:56 AM, Resident #1's FM (family member) stated he arrived at the facility on Friday 02/27/26 in the evening during mealtime and went to the dining room to find Resident #1 being assisted with his meal. FM stated as he approached Resident #1's table, he smelled a foul odor that smelled like BM. He said when he arrived at the table, he could see Resident #1's hands which were at chest level and saw BM on both of his hands. FM stated he became extremely upset by this and demanded that Resident #1 be cleaned up. FM stated the SW was still at the facility and the SW came to the dining room and witnessed Resident #1 in the condition he was in. The FM stated he was upset that Resident #1 was being fed with obvious fecal matter on his hands without staff cleaning him first. During an interview on 03/03/26 at 12:40 PM with Resident #1, he stated he could not recall the event in the dining room that occurred 02/27/26. During an interview on 03/03/26 at 03:12 PM, the SW stated he was at the facility the evening of Friday 02/27/26. He stated he was alerted of the complaint made by Resident #1's FM he went to the dining room and observed fecal matter on both of Resident #1's hands. The SW stated he was shocked and alarmed when he saw it, and it was upsetting to see that in the cafeteria. He stated Resident #1 had known behaviors of scratching himself and putting his hands in his pants. The SW stated he was surprised that Resident #1 was able to make it to the dining room without being cleaned. The SW stated he observed upon entry was that Resident #1 was being fed by CNA A. The SW stated he questioned CNA A about the fecal matter on Resident #1's hands and if he was aware of it, CNA A denied being aware of it. The SW stated he notified the ADM about the situation after ensuring Resident #1 was cleaned. The SW stated he could not understand how he [CNA A] could not see that. The residents hands were at chest level where he usually maintained them. The SW stated he did not smell the fecal matter but stated it was probably due to allergies and had he not had allergies he believed he would be able to smell it. The SW stated the amount of fecal matter on Resident #1's hands was enough to be noticed. The SW stated that Resident #1 was calm and did not recognize he had fecal matter, he was not crying, not upset, and only responded to the family member being upset asking why are you upset. The SW stated he was startled by the event and processing the event and reaction by the family member that he was not thinking about psychosocial effects and did not complete a psychosocial evaluation for Resident #1. He stated I dropped the ball, that evening or the next day I should've asked those questions. He stated he should've completed the psychosocial evaluation within 72 hours. He stated he saw Resident #1 that Saturday and he did not appear to have any adverse psychosocial effects. During an interview on 03/03/26 at 03:34 PM CNA A stated he was at the facility on 02/27/26 when the incident occurred and was the CNA assisting Resident #1 with his meal. He stated he did not assist the resident to the dining room and was not sure who did, but after he completed passing out meal trays he was to sit and assist those who needed meal assistance so he had sat down that day to assist Resident #1. CNA A stated he had been feeding Resident #1 for approximately 10 minutes before Resident #1's FM arrived at the table and alerted him to the BM on the residents hands. CNA A stated he had not noticed the BM on Resident #1's hands as the resident doesn't use his hands. CNA A stated he did not smell the BM on Resident #1's hands and stated it appeared it had already dried up so he believed that is why he did not smell it or take notice. He stated the expectation was that residents were groomed and cleaned prior to going to the dining room. He stated a negative outcome to residents having BM on their hands while being fed was infection control. CNA A stated when FM brought attention to the matter in the dining room Resident #1 was saying shut up to the FM and he believed it was due to Resident #1 being embarrassed by the situation. CNA A stated LVN B was in the dining room at the time and saw the situation and instructed for staff to clean the resident. During an interview on 03/03/26 at 04:07 PM, LVN B stated he worked the dining room on Friday 02/27/26. He said he assisted with dinner services as the nurse checking meal trays. LVN B stated he was alerted to the incident when he heard Resident #1's FM bring attention to it and saw CNA A feeding Resident #1 and Resident #1 having BM on his hands. LVN B stated he had instructed CNA A to clean Resident #1 and they used sanitizer wipes to clean his hands. LVN B stated a negative outcome to BM on residents hands during mealtime is infection control, he stated everyone wants to be clean, it can affect him psychosocially. LVN B stated that based on the residents behavior at the time he did not appear upset or negatively impacted. During an interview on 03/03/26 at 04:19 PM, the DON stated she was not in the facility when the incident occurred on Friday 02/27/26 but she was alerted to it the same day. She stated Resident #1 had known behaviors of putting his hands in his pants and getting fecal matter on his hands. The DON stated it was her expectation that residents were clean when they are were fed and stated this was an unfortunate situation. She stated a negative outcome was infection control and dignity issues. The DON stated there was no reported psychosocial effects at the time of the event. The DON stated they initiated training on expectations including hand hygiene and infection control but that training was still ongoing and there were still staff that had not completed training. During an interview on 03/03/26 at 04:55 PM, the ADM stated she became aware of the incident on the evening of 02/27/26, when it occurred via a phone call from the SW and advised that Resident #1 be cleaned immediately. She stated it was known of residents behavior related to putting his hands in his briefs and was care planned. The ADM stated the DON was working on re-educating staff in the facility and it was still ongoing because all staff had not received the training yet. She stated she was not aware of any negative outcome that occurred. She stated there was a potential for breach of infection control if he touched surfaces or food. Review of the facility Resident Rights policy revised December 2016 reflected: Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a dignified existence;be treated with respect, kindness, and dignity

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen. The facility failed to date food and beverages found within the facility's freezer and refrigerator on 12/29/2025The facility failed to date and properly seal food products in facility freezer and refrigerator on 12/29/2025. These failures could place the residents who ate food from the kitchen at risk of cross contamination, loss of nutritional value, weight loss, and foodborne illness. Findings included:In an observation on 12/29/2025 at 9:15 AM, the facility's one door freezer was found to contain an open undated box of breakfast sausage patties with a partially opened bag of breakfast sausage patties that were exposed to air. The freezer contained a large clear plastic bag with green peas covered with ice. There was no date or label on the bag. The freezer contained 5 individual servings of vanilla ice cream that had leaked into inside of the box and the lids on two of the containers had slid to the side exposing the ice cream to the air. In an observation on 12/29/2025 at 9:22 AM, the facility's single door refrigerator was found to contain a plastic container labeled Golden Italian Dressing. There was no open date or expiration date on the container. In an interview on 12/30/2025 at 10:30 AM, the DM stated that the box containing the individual ice cream should have been thrown out. The DM said the salad dressing container II showed him in the refrigerator should have been dated and labeled. The DM stated that failure to properly seal bags containing food in the freezers could lead to freezer burn. He stated this could cause the residents to get stomachaches or make them sick. In an interview on 12/30/2025 at 2:55PM the Consultant Dietician stated she understood the importance of labeling and dating food when it comes in and when it was opened. She stated residents could become ill if items are not properly dated and labeled. She told me she had in serviced the dietary staff on labeling and dating food that morning. Review of Chapter 3 Food Production and Food Safety Policy and Procedure Manual dated 2023, Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Procedure: 7. All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods. B. Food should be dated as it is placed on the shelves if required by state regulation. C. Date markings should be visible on all high-risk food to indicate the date by which a ready to eat food should be consumed, sold or discarded.12. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. 13. Refrigerated food storage: f. All foods should be covered, labeled and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their use by dates, or frozen (where applicable) or discarded. 14. Frozen Foods. C. All foods should be covered, labeled and dated. All foods will be checked to ensure that foods will be consumed by their use by dates or discarded.

Based on interviews, and record reviews, the facility failed to develop and implement an accurate comprehensive person-centered care plan that met the residents' medical needs and treatment plan for 1(Resident # 38) of 6 residents reviewed for comprehensive care plans. The facility failed to provide interventions / approaches consistent with facility policy of being a non-smoking facility for Resident # 38 vape use listed as a problem on her care plan. This failure could affect residents by placing them at risk of not receiving appropriate interventions and care to meet their current needs.Findings included: Record review of Resident # 38 face sheet dated 12/31/2025 reflected a [AGE] year-old female admitted on [DATE].Record review of Resident # 38 continuity of care document dated 12/31/2025 reflected a diagnosis of unspecified visual loss, cough, pain, age related cataract bilateral (a clouding of the eye's natural lens causing blurry or hazy or dim vision on both eyes), depression, muscle weakness, lack of coordination, unspecified asthma, chronic obstructive pulmonary disease (a progressive group of lung disease that block airflow and make breathing difficult), hear failure, cardiomyopathy (a group of diseases affecting the heart muscle making it difficult for the heart to pump blood effectively to the body), hyperlipidemia (fat particles in the blood), hypertensive heart disease with heart failure (heart problems caused by long term high blood pressure where the heart muscle thickens and has to work harder to pump blood), and tremors.Record review of Resident # 38's quarterly MDS dated [DATE] reflected a BIMS score of 15 indicating intact cognition. Further review reflected under section GG functional abilities resident required set up or clean up assist for eating, toileting, dressing, and personal hygiene. Resident # 38 required supervision or touching assist for shower/bath and shower/bathing transfer. Resident # 38 was independent for transfers.Record review of Resident # 38's comprehensive care plan dated 12/17/2025 reflected a problem of resident uses vape dated 5/19/2025 with intervention and approaches of explain/show where designated smoking areas are repeat PRN. Post smoking schedule for resident to refer to facility smoking times. Staff to supervise during use of vape as needed.In an interview on 12/31/2025 at 3:50 pm with MDS Nurse D revealed MDS Nurse D stated she was unaware that Resident # 38's care plan had approaches concerning her vape use that were inconsistent with facility policy. MDS Nurse D stated she and her fellow MDS Nurse E were responsible for completing the care plans. MDS Nurse D stated that she did not believe it could negatively impact the residents care if her care plan was not correct concerning the resident vaping since the resident was alert and oriented x4 and goes outside to vape after signing herself out since the facility is non-smoking.In an interview on 12/31/2025 at 4:20 pm with DON revealed DON stated it depends on the specific information being documented in the care plan as to whether it could negatively affect the resident. DON stated MDS is responsible for updating care plans. DON stated she has received ANE and Resident Rights training and has worked at the facility for 2 years. DON stated it was her expectation that each care plan would be tailored for the individual resident and that there is consistency with facility policies and procedures.In an interview on 12/31/2025 at 4:41 pm with ADM revealed ADM stated the MDS nurse complete the comprehensive part of the care plan and the charge nurse completes the acute care part of the care plan. ADM stated it was her expectation that care plan approaches coincide with facility policy and procedure. ADM stated that depending on what the information in question is could potentially negatively impact a resident but thankfully in this instance it did not. It had the potential to affect them emotionally and possibly cause frustration. ADM stated the MDS Nurse E who had completed the care plan for Resident # 38 had previously worked at a smoking facility and she felt that is where she drew her knowledge base from. ADM stated she would be educating the MDS Nurse E and explaining this facility policy and procedures. Record review of facility Care plans, Comprehensive person-centered policy dated 12/2026 reflected under policy statement:A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.Under policy interpretation and implementation:8. The comprehensive person-centered care plan will:g. incorporate identified problem areash. incorporate risk factors associated with identified problemsk. reflect treatment goals, timetables and objectives in measurable outcomesl. identify the professional services that are responsible for each element of care10. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident are the endpoint of an interdisciplinary process.11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.Record review of facility Smoking policy undated reflected the facility was a smoke-free and tobacco-free facility. Smoking is strictly prohibited on campus for all residents. Residents who wish to smoke may do so only after signing out and leaving the facility grounds. Lighters and smoking paraphernalia are not permitted within the facility. Residents may request that a nurse secure such items until they are ready to leave the premises. Any smoking related items found on-site will be confiscated and securely stored by nursing staff until the resident signs out. This facility does not oversee or manage resident smoking.

Based on record reviews and interviews, the facility failed to ensure evidence reflects the facility did not complete a discharge summary to include a recapitulation of the resident's stay and a final summary of the resident's status at the time of discharge as resident was discharged to the hospital for a change in condition and the family chose to not readmit to the facility for 1 (Resident #94) of 4 residents reviewed for safe transfer or discharge. The facility failed to record the reasons for the transfer/discharge in Resident # 94's medical record when discharged on 11/30/2025. This failure could place residents at risk of being discharged without alternative placement, discharge options, their rights to appeal and access to advocacy services. Findings included:Record review of Resident # 94's face sheet dated 12/31/2025 reflected a [AGE] year-old female admitted on [DATE] and discharged on 11/30/2025.Record review of Resident # 94's continuity of care document dated 12/31/2025 reflected diagnosis of infection following a procedure, other surgical site, elevated white blood cell count, muscle weakness, abnormalities of gait and mobility, lack of coordination, type 2 diabetes (a chronic condition where the body either doesn't produce enough insulin or can't use the insulin properly, leading to high blood sugar levels because sugar can't get into cells for energy), GERD (a chronic digestive disorder where stomach acid frequently flows back into the esophagus), hyperlipidemia (fat particles in the blood), history of malignant neoplasm of breast ( breast cancer), acute postprocedural pain, lymphedema (swelling caused by buildup of protein-rich lymph fluid in soft tissues because the lymphatic system is damaged or blocked preventing proper fluid drainage), and encounter for surgical aftercare following surgery on the skin and subcutaneous tissue (the deepest layer of the skin).Record review of Resident # 94's baseline care plan reflected a completion date of 11/202/2025 with needs of assist by 1 for bed mobility, bathing, and grooming/hygiene. Assist by 2 for locomotion and transfers. Total dependence on walking and toileting. Set up assist for eating. Further review reflected Resident # 94 had a wound vac required a specialty mattress and required turning and repositioning.Record review of Resident # 94's comprehensive MDS dated [DATE] reflected a BIMS score of 14 indicating intact cognition. Further review of section GG functional abilities reflected substantial/maximal assistance required for toileting hygiene, shower/bathing, upper body dressing, and putting on footwear. Resident # 94 was dependent on staff for lower body dressing. Resident # 94 required partial/moderate assistance for transfers and personal hygiene.In an interview on 12/31/2025 at 12:30 pm with RNC revealed RNC stated for resident discharges there should be a progress notification regarding discharge or hospitalization to the RP, ADM, and MD. RNC stated after the resident went out to the hospital and did not return the SW should have put in a progress note about the resident discharge. RNC stated she had called the LVN that completed the hospital discharge and the LVN told her that the family was present when the JP drain was dislodged and was made aware that the resident would have to go to the hospital to have the JP drain reinserted. RNC stated it was her expectation that a progress note be documented in the resident chart to show that the RP was notified of the resident transfer. RNC also stated it was her expectation that when a resident is discharged that a progress note be put in the EHR for the resident regarding the resident discharge and the notifications made. RNC stated it could negatively impact resident care if documentation is not completed.Attempted telephone interview with LVN A on 12/31/2025 at 3:33 pm no answer voicemail left awaiting return call.In an interview on 12/31/2025 at 4:03 pm with LVN B revealed LVN B has worked at the facility for 26 years. LVN B stated she has received many ANE and Resident Rights trainings. LVN B stated for the discharge or hospitalization process that there are many steps. LVN B stated the first step for a COC is the required parties are notified including the DON, NP, RP, and ADM then the COC order is written. LVN B stated a progress note is documented in the resident EHR and it is also documented in the COC binder and the 24-hour report. LVN B stated all COC, and discharges are also discussed when the verbal shift change report is conducted. LVN B stated she was unsure if it could negatively affect a resident if the party notification is not documented but she knew it would disrupt the communication chain for the staff and could potentially cause issues if staff were unaware of resident status or where a resident was.In an interview on 12/31/2025 at 4:20 pm with DON revealed DON stated it is was her expectation that for COC's and discharge that the required parties are notified and that the notification is documented in the EHR. The nurse that sends the resident out or whoever assisted in the process is responsible for documenting for the resident. DON stated she did not feel it could negatively affect the resident or staff by not documenting the required notifications because all the information had been communicated verbally there was just not a progress note charted. In an interview on 12/31/2025 at 4:41 pm with the ADM revealed ADM stated it was her expectation that a progress note would have been put in the EHR stating that the family was present and notified upon the resident's discharge for her COC. ADM stated the charge nurse is was responsible for completing the documentation relating to the discharge of the resident. ADM stated she did not feel it could negatively affect the residents' care for not putting a progress note in concerning her discharge since she was in the hospital.Record review of nursing progress note by LVN A dated 11/30/25 1:45 pm reflected Jackson Pratt tube pulled out reported by wound nurse. EMS called and will be here anytime to pick Resident # 94 up to transport to hospital for reinstalment. Record review of nursing progress note by LVN C dated 11/30/2025 6:57 pm reflected Resident # 94 remains at hospital.Record review of nursing progress note ADM dated 12/1/2025 recorded as a late entry created on 12/31/2025 reflected ADM and Admissions Director went to visit Resident 94 at the hospital. The resident was unavailable after 2 attempts to visit due to receiving wound care. Admissions Director to follow up with family.Record review of nursing progress note by ADM dated 12/15/2025 recorded as late entry created on 12/31/2025 reflected ADM notified the Regional Business Development and the BOM that the family was choosing to have their loved one go to an alternative facility. ADM stated the family had concerns related to wanting their loved one to be in a higher level of care.Record review of facility Change in a Resident's Condition or Status policy dated 05/2017 reflected under policy statement:Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status.Under policy interpretation and implementation: 8. The nurse will record information on the resident's medical record information relative to changes in the resident's medical/mental conditions or status.

Based on interview and record review the facility failed to ensure professional staff were licensed certified or registered in accordance with applicable state laws for 13 Nurse Aides of 13 nurse aides reviewed for assessments. The facility failed to ensure NAs A, B, C, D, E, F, G, H, I, J, K ,L ,M, Nurse Aide Curriculum skill performance checklists were checked off. This failure could place residents at risk of not being provided care by qualified staff, which could cause inadequate care and injury resulting in decreased health and psycho-social well-being.Findings include:Record review of NA A's employee record revealed they were hired 10/09/25 as a Nurse Aide trainee. The Nurse Aide Program training was completed on 10/03/25. There was no proof of a Nurse Aide Curriculum skill performance checklist. Record review of NA B's employee record revealed they were hired 09/02/25 as a Nurse Aide trainee. The Nurse Aide Program training was completed on 09/02/25. There was no proof of a Nurse Aide Curriculum skill performance checklist. Record review of NA C's employee record revealed they were hired 09/02/25 as a Nurse Aide trainee. The Nurse Aide Program training was completed on 09/02/25. There was no proof of a Nurse Aide Curriculum skill performance checklist. Record review of NA D's employee record revealed they were hired 09/09/25 as a Nurse Aide trainee. The Nurse Aide Program training was completed on 08/22/25. There was no proof of a Nurse Aide Curriculum skill performance checklist. Record review of NA E's employee record revealed they were hired 09/12/25 as a Nurse Aide trainee. The Nurse Aide Program training was completed on 09/12/25. There was no proof of a Nurse Aide Curriculum skill performance checklist. Record review of NA F's employee record revealed they were hired 08/04/25 as a Nurse Aide trainee. The Nurse Aide Program training was completed on 08/04/25. There was no proof of a Nurse Aide Curriculum skill performance checklist. Record review of NA G's employee record revealed they were hired 09/09/25 as a Nurse Aide trainee. The Nurse Aide Program training was completed on 09/02/25. There was no proof of a Nurse Aide Curriculum skill performance checklist. Record review of NA H's employee record revealed hired 10/09/25 as a Nurse Aide trainee. The Nurse Aide Program training was completed on 09/02/25. There was no proof of Nurse Aide Curriculum skill performance checklist. Record review of NA I's employee record revealed they were hired 10/09/25 as a Nurse Aide trainee. The Nurse Aide Program training was completed on 09/02/25. There was no proof of a Nurse Aide Curriculum skill performance checklist. Record review of NA J's employee record revealed they were hired 09/02/25 as a Nurse Aide trainee. The Nurse Aide Program training was completed on 09/02/25. There was no proof of a Nurse Aide Curriculum skill performance checklist. Record review of NA K's employee record revealed they were hired 10/09/25 as a Nurse Aide trainee. The Nurse Aide Program training was completed on 09/02/25. There was no proof of a Nurse Aide Curriculum skill performance checklist. Record review of NA L's employee record revealed they were hired 09/09/25 as a Nurse Aide trainee. The Nurse Aide Program training was completed on 09/02/25. There was no proof of a Nurse Aide Curriculum skill performance checklist. Record review of NA M's employee record revealed they were hired 08/13/25 as a Nurse Aide trainee. The Nurse Aide Program training was completed on 08/08/25. There was no proof of a Nurse Aide Curriculum skill performance checklist. Interview on 11/24/25 at 3:48 PM, the DON stated the Staffing Coordinator was responsible for checking the student NAs off once they completed a skills task. The DON stated that each NA student's skills had been checked off but was unable to locate the binder. The DON stated the entire facility was checked and they were unsuccessful in locating. The DON stated all 13 NA students would be re-checked and the binder would be kept in her office. The DON stated it was expected for the binder with the NAs training to be presented for review. The DON stated that without providing the training binder it would look like the training check offs would not have been completed. The DON stated it was expected for the NAs training check off to be completed and validated.Interview on 11/24/25 at 3:56 PM, the ADM stated it was expected for the NAs skill check off binder to be kept up to date and available when asked for. The ADM stated the Staffing Coordinator was responsible for checking off the NAs' skills completed. The ADM stated the binder that kept that skill performances check offs was not able to be located in the facility. The ADM stated the Staffing Coordinator was responsible for checking off the student NAs. The ADM stated if the binder with the check was not able to be presented it would look like they were not done. It was expected for the checkoffs to be presented to ensure the student NAs were able to care for the residents.Interview on 11/24/25 at 4:52 PM, the Staffing Coordinator stated she was responsible for making sure student NAs were checked off once they completed the skills. The Staffing Coordinator stated the binder with the checkoffs was not able to be located. The Staffing Coordinator stated the skills performance checklist on the NAs was completed and it was expected for the binder to be presented when asked to validate that the skills had been checked off on. The Staffing Coordinator stated the skills performance for the NAs was not accounted for and without able to present would indicate that the skill checks were not done. 1. Record review of the facility's Nurse Aide Qualification and training requirements dated 2001 revised 2019, revealed Nurse Aide must undergo a state approved training program. 2. Applicants who meet the qualifications for a nurse aide and are in training will have a minimum of 16 hours of training in the following areas prior to direct contact with the residents:a. Communication and interpersonal skills.b. Infection control.c. Safety/emergency procedures.d. Promoting residents' independence.e. Respecting residents' rights.f. Basic nursing skills (including):(1) Taking and recording vital signs.(2) Measuring and recording height and weight.(3) Caring for the residents' environment.(4) Recognizing abnormal changes in body functioning and the importance of reporting such changes to a supervisor; and(5) Caring for residents when death is imminent.g. Personal care skills (including):(1) Bathing;(2) Grooming, including mouth care;(3) Dressing;(4) Toileting;(5) Assisting with eating and hydration;(6) Proper feeding techniques;(7) Skin care; and(8) Transfers, positioning, and turning.h. Mental health and social service needs (including):(1) Modifying aide's behavior in response to residents' behavior;(2) Awareness of developmental tasks associated with the aging process;(3) How to respond to resident behavior;(4) Allowing the resident to make personal choices, providing and reinforcing other behavior consistent with the resident's dignity; and(5) Using the resident's family as a source of emotional support.I Care of cognitively impaired residents (including):(1) Techniques for addressing the unique needs and behaviors of individuals with dementia (Alzheimer's and others);(2) Communicating with cognitively impaired residents;(3) Understanding the behavior of cognitively impaired residents;(4) Appropriate responses to the behavior of cognitively impaired residents; and(5) Methods of reducing the effects of cognitive impairments.J. Basic restorative services (including):(1) Training the resident in self care according to the resident's abilities;(2) Use of assistive devices in transferring, ambulation, eating, and dressing;(3) Maintenance of range of motion;(4) Proper turning and positioning in bed and chair;(5) Bowel and bladder training; and(6) Care and use of prosthetic and orthotic devices. k. Resident rights (including):(1) Providing privacy and maintenance of confidentiality;(2) Promoting the residents' rights to make personal choices to accommodate their needs;(3) Giving assistance in resolving grievances and disputes;(4) Providing needed assistance in getting to and participating in resident and family groups and other activities;(5) Maintaining care and security of residents' personal possessions;(6) Promoting the resident's right to be free from abuse, mistreatment, and neglect and the need to report any instances of such treatment to appropriate facility staff; and(7) Avoiding the need for restraints in accordance with current professional standards.

Based on interviews and records review the facility failed to develop and implement a person-centered comprehensive care plan to meet the preferences and goals of each resident and address the resident's medical, physical, mental and psychosocial needs for one (Resident #1) of three residents reviewed for care plan. The facility failed to update Resident #1's care plan after an X-ray (a form of electromagnetic radiation used in medicine to create images of the inside of the body for diagnostic purposes) result dated 10/17/2025 reflected a nondisplaced fracture of the medial epicondyle (a bony prominence on the inner side of the elbow where muscles and the ulnar collateral ligament (is a circular ligament on the inner side of the elbow that connects the upper arm to the forearm bone) attach ) of the distal end of the right humerus (the long bone in the upper arm, connecting the shoulder blade to the forearm bones.) This deficient practice placed Residents at risk for not getting right interventions, risk for harm and hospitalization Findings included: Review of Resident #1's face sheet printed 11/07/2025 reflected a [AGE] year-old female who was admitted on [DATE] with the following dx: Unspecified Dementia, mild with agitation (Dementia is a general term for a group of conditions that cause a decline in cognitive functions, such as memory, thinking, reasoning, and problem-solving, severe enough to interfere with daily life.), Anxiety disorder, (a normal reaction to stress that can become an overwhelming and persistent disorder, characterized by excessive worry, fear, or dread). Review of Resident #1's incident report dated 10/16/2025 at 6:00 pm reflected:Resident #1 was found on the floor on the mat near her bed with a skin tear to her elbow. Review of Resident #1's progress notes dated 10/17/2025 at 3:23 pm written by LVN A reflected: Hospice nurse orders x-ray. Nurse reports ETA 5:30pm, X-ray, rt arm due to pain.Nursing will continue to monitor the residents. Review of Resident #1's X-ray completed on 10/17/2025 reflected: HISTORY / PRELIM DIAGNOSIS: RT HUMERUS; PAIN POST FALLRight humerus 2 views: A nondisplaced fracture of the medial epicondyle of the distal end of the right humerus is present.no angulation is seen. There is no dislocation or focal bone lesion ( a specific, abnormal area within the bone, often identified on imaging scans.) no angulation (the act of forming angle or an angular position, shape or form) is seen. There is no dislocation or focal bone lesion.Impression:Nondisplaced fracture of the medial epicondyle of the distal end of the right humerus. Review of Resident 1's care plan revised 10/16/2025 reflected Resident #1 was at risk for falls due to weakness, impaired mobility, incontinence of bowel and bladder. It also reflected that Resident #1 required staff assistance with ADLs and Resident #1 had disturbed thought process related to neurological changes, evidenced by memory loss, confusion, and impaired judgement. Resident #1's care plan did not address Resident #1 had a fracture to her right humerus, no interventions and goals. Review of Resident #1's Progress notes dated 10/18/2025 at 12:47 pm written by LVN B reflected: New order received for APAP (is a non-opioid analgesic and antipyretic agent utilized for treating pain and fever) with Codeine 1-tab TID routine and may continue prn dose but not to exceed 3gm of Acetaminophen in 24 hours. RP in facility at this time. Notified this writer that resident does have a fracture to the Rt Humerus from the unwitnessed fall that occurred on 10/16/25. Hospice telephoned for clarification of results of XRAY performed on 10/17/25. Hospice nurse stated resident does have a fracture and will send results via email to Administrator of facility. RP declined ER visit due to resident's decline in health and wishes for facility/hospice to keep resident comfortable at this time. Prn Morphine given at approx. 11:40 am. Review of Resident#1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 09, indicating moderate cognitive impairment. During an interview on 11/07/2025 at the DON stated the facility was aware of Resident #1's right humerus fracture due to a fall on 10/16/2025. The DON stated the X-ray was completed on 10/17/2025 on Resident #1's right arm and was positive for a fracture. The DON stated Resident #1 was on hospice services and Resident #1's RP had declined aggressive treatment to the right humerus fracture. The DON stated Resident #1's right fracture should have been care planned to enable staff to know what interventions to provide for Resident #1. The DON stated the MDS nurse was responsible to update Resident #1's care plan to reflect right humerus fracture with interventions. During an interview on 11/07/2025 at 12:40 pm the MDS Nurse stated she was responsible for completing and updating comprehensive care plan and MDS assessment. The MDS Nurse stated the floor nurses were responsible for doing the acute care plan and they should have done an acute care plan for Resident #'s fracture. The MDS Nurse stated an acute care plan was for something that happened to the resident right away, and examples like falls, fractures and infections, interventions were listed right away. The MDS Nurse stated comprehensive care plans were done whenever there was a resident's assessment, generally quarterly and annually. The MDS nurse stated the Administrator had just asked her to update Resident #1's comprehensive care plan to include risk for fall and fracture. The MDS Nurse later stated care plans were updated for significant changes and fracture was considered a significant change. The MDS Nurse stated, I agree with you. {Resident #1's] comprehensive care plan should have been updated to reflect fracture of her right humerus, but we have 14 days to update the comprehensive care plan for significant change. On 11/07/2025 at about 2:12 pm a request for acute care plans from the DON was made and there was no acute care plan for Resident #1 regarding the fracture of the right humerus. Review of the facility's policy revised December 2016 titled Care Plans, Comprehensive Person-Center reflected: Policy Statement: A comprehensive, person-center care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representatives, develops and implements comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Assessment of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.The Interdisciplinary Team must review and update the care plan:--when there has been a significant change in the residents' condition.--when the desire outcome is not met.--when the resident has been readmitted to the facility from a hospital stay; and --at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on interview, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (Resident #1) reviewed for accidents, hazards, and supervision. The facility failed to put effective measures in place to prevent Resident #1 from eloping. Resident #1 was found 26 hours after he eloped. The facility did not have a plan in place for monitoring the windows to ensure resident supervision/monitoring was in place to prevent Resident #1's elopement. On 09/12/2025 at 5:05 p.m., an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/13/2025 at 3:00 p.m., the facility remained out of compliance at a severity level of not actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of experiencing accidents, injuries, and/or death. The findings included:Record review of Resident #1's face sheet dated 09/12/2025 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnosis included cerebral infraction (long term effects of a stroke), left middle cerebral artery mixed receptive-expressive language disorder (a language disorder in which both the receptive and expressive areas of communication may be affected in any degree from mild to severe), heart failure, cardiomyopathies (progressive heart disease), aphasia following cerebral infraction (unable to comprehend after a stroke), cannabis intoxication with delirium (a disturbance in attention and awareness along with other cognitive impairments), and methamphetamine abuse (a synthetic stimulant to increase alertness and energy). Record review of Resident #1's entry MDS dated [DATE] revealed Resident #1's BIMS was not completed. During interviews with staff on 09/12/2025 from 11:00a.m. to 3:00p.m., (LVN A, LVN B, CNA C and RN D) and record review of progress notes revealed Resident #1 was cognitively impaired. Resident #1's care plan dated 09/10/2025 revealed, Resident #1 was confused. The baseline care plan also stated that the resident had behavior concerns- confusion. The care plan revealed Resident #1 was ambulatory. Record review of Resident #1's elopement assessment revealed the resident was not marked as having cognitive impairment. The elopement risk also did not indicate Resident #1 was an elopement risk. During an interview with Resident #1's FM #1 on 09/12/2025 at 9:34a.m., revealed the resident was admitted to the facility on [DATE] at around 6pm. She said the facility called her on 09/11/2025 at around 8:30am and said he had left the facility. She said that Resident #1 did not even know who his FM was when asked. She said the facility was trying to get the family to sign a document that stated they were not liable, but she said she would not sign the documents. She said Resident #1 had never been in a facility before. She said the facility would give her different stories as to what happened. During an interview with Resident #1's FM #2 on 09/12/2025 at 9:59a.m., revealed the facility called and told her that Resident #1 was gone. She said the facility said they checked on Resident #1 at 6:30am and when they checked again at 8:30am he was not there. She said he had been homeless. She said when they went to see Resident #1 right before he was discharged from the hospital, he did not know who they were. She said that the police had not come to talk to the FM. She said the facility had called the police when Resident #1 eloped from the facility. During an interview with LVN A on 09/12/2025 at 11:15a.m., revealed she had gone to do her rounds around 6:00am and Resident #1 was in the bed. She said she went back to see if Resident #1 got his breakfast around 8:00am and he was not in the room. She said she checked to see if Resident #1 was in the bathroom, and he was not. She said she then called the ADM. She said she did a head count and staff searched for Resident #1. She said that when she was searching for Resident #1, she noticed the window up and the screen was off. She said with Resident #1 being confused he was considered an elopement risk. She said she did not know why the other nurse did not mark Resident #1 on the elopement assessment as cognitively impaired. She also said she was trained on completing the elopement assessment in the computer in July of 2025. During an interview with LVN B on 09/12/2025 at 11:26a.m., revealed she admitted Resident #1. She said when he came in, he was friendly. She said as soon as EMS dropped him off, he was walking around the facility. She also said that he was not trying to exit the building and did not say he wanted to leave. She said he looked normal but when you had a conversation with him, he could not remember stuff. She said he was confused. She said he could not tell her what day it was, who the president was, and what month it was. She said he did not appear anxious when he was walking around the facility. She said she did not consider him an elopement risk. She also said he did not appear to be one that would elope. She said with Resident #1 on the elopement assessment she would have checked the box that he was cognitively impaired, but he was not going around to the doors or showing he wanted to leave. She said that she had been trained on completing the elopement assessment in the computer in October 2024. During an interview with CNA C on 09/12/2025 at 11:38a.m., revealed that she worked with Resident #1. She said he was admitted to the facility on [DATE]. She said at 6:15a.m., she went into Resident #1's room and introduced herself and he introduced himself. She said he had the cover over his head when she first went into the room and Resident #1 seemed anxious and really confused. She said she showed him how to use the call light and asked Resident #1 if he needed anything before, she left the room. She said he wanted her to close the door when she left. She said that she did consider Resident #1 an elopement risk with how confused he was. During an interview with the RN C on 09/12/2025 at 12:05p.m., revealed staff had been trained on completing the elopement assessments in the new computer system. She said that the facility rolled out the new system mid-July of 2025. She said she did not have any interaction with Resident #1 but saw in his medical records that he was confused. She said she did not know Resident #1 was walking up and down the hall when he got to the facility. She said she did not consider Resident #1 an elopement risk because he did not say he wanted to leave. She said he was aimlessly wandering. She said the box on the elopement assessment for cognitively impaired should have been checked. She said just because he was confused did not make him an elopement risk. She said he would have to have behaviors showing he was an elopement risk. She said he was not going towards the doors or saying he wanted to leave. During an interview with RN D on 09/12/2025 at 3:00p.m., revealed that she had done Resident #1's admission and assessment. She said that Resident #1 got to the facility around 6:00pm and she signed papers for EMS and then introduced herself to Resident #1. She said she did her assessment and asked Resident #1 who the president was, what was the date, and other questions. She said he appeared to know what was going on but when she started talking to him, he did not know what was going on. She said the only question he could answer was his name. She said he did not appear to be anxious or wandering the halls. She said she did the elopement risk and Resident #1 did not appear to be an elopement risk at that time . She said when she finished with him it was 7:00p.m., she said he did not show her that he was somebody who would be exit seeking. She said he stayed in his room the whole night. She said when she finished with Resident #1, she got him some food for the kitchen. She said on the assessment she should have marked cognitively impaired. She said she overlooked the question. She said the hospital did not give her enough information, and the hospital did not call her and give her a report. During an interview with the MD on 09/12/2025 at 4:04p.m., revealed that she would not expect the staff to increase supervision on the resident due to his medical history of homelessness and drug abuse. She said she would not consider him an elopement risk. She said there were a lot of residents who had strokes and different neurologic disorders, which do not try to elope. She also said it was hard to distinguish who had the capacity of knowing where the risk come from. She also said staff could not predict the resident's behavior or if he was going to elope. She said they encourage residents to walk, and they are safe to move around the facility. She said she would not have staff increase supervision for a new admission for 72 hours. She said staff already round frequently and do regular vitals and medications and then the aids give out medication She said there were a lot of people who their baseline was neurologic conditions and then become confused after they come to the facility. She said they could have been more vigilant in figuring out what happened. During an interview with FM #2 on 09/12/2025 at 12:32pm revealed that Resident #1 had just showed up to FM #1's house. She said Resident #1 was acting aggressive and FM #1 feared him. Record review of Investigation Report for intake dated 9/11/2025 revealed that the facility had a QAPI meeting regarding the incident, CNA C wrote a statement, and the ADM and DON were re-educated by the CN. There was no training done for staff related to elopement. There was no retraining on the elopement assessments. Record review of progress notes dated 09/12/2025 at 1:05pm revealed that the ADM phoned FM #1 of Resident #1 who verified Resident #1 was at her house. FM #1 told the ADM that Resident #1 was agitated and appeared to be under the influence. FM #1 told the ADM that police were at her house and Resident #1 was refusing to go to the hospital. The ADM documented that the police escorted Resident #1 away from FM #1's house a block away the FM's house. Record review of Wandering and Elopements Policy revised March 2019 revealed, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. If a resident is missing, initiate the elopement/missing resident emergency procedure: Determine if the resident is out on an authorized leave or pass; If the resident was not authorized to leave, initiate a search of the building(s) and premises; and if the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative, the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.). This was determined to be an Immediate Jeopardy (IJ) on 09/12/2025 at 5:05p.m. The ADM was notified. The ADM was provided with the IJ template on 09/12/2025 at 5:05p.m. The following Plan of Removal submitted by the facility and was accepted on 09/13/2025 at 12:15 PM. PLAN OF REMOVALF689On 09/12/2025 an abbreviated survey was initiated at facility. On 09/12/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate jeopardy states as follows: The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the alleged issue of elopement risk: Regional [NAME] President of Operations and Regional Nurse Consultant educated the facility administrator and DON on recognizing and intervening on potential for elopement on all resident population as well as immediate notification of Administrator, DON, RP, and MD. Initiated: 09/12/2025 Completion: 09/12/2025. The Administrator/Director of Nursing/Designee educated all facility staff on recognizing and intervening on potential for elopement on all resident population as well as immediate notification of Administrator, DON, RP, and MD. Initiated: 09/12/2025 Completion: 09/12/2025. DON/Designee completed an elopement drill for all facility staff. Initiated:9/12/2025. Completion: Ongoing Administrator/Designee secured all resident windows to a maximum opening of 6 inches. Initiated: 09/11/2025 Completion: 09/11/2025 Administrator/Designee assessed all wander guard door alarms, and no issues were identified. Initiated: 09/11/2025 Completion: 09/11/2025 DON was educated by Regional [NAME] President of Operations and Regional Nurse Consultant on accurate completion of elopement evaluation. DON/Designee to re-educate all licensed nurse on accurate completion of the elopement evaluation. Signatures obtained to demonstrate understanding. Initiated: 09/12/2025 Completion: 09/12/2025 DON/Designee completed elopement risk assessments on all residents in facility with no further residents deemed at immediate risk of wandering/elopement risk. Resident in question was found at his sister's house on 09/12/2025. Initiated 9/11/25. Completed 09/11/2025. Staff that are on leave from the facility will be re-educated by Administrator/DON/Designee on elopement risks prior to next shift. This facility does not employ the use of agency personnel. Initiated: 09/12/2025 Completion: Ongoing The policy and procedure already in place for elopement and reporting was reviewed by Regional [NAME] President of Operations and Regional Nurse Consultant with no revisions required. Initiated: 9/12/2025 Completed: 9/12/2025 To prevent future occurrences, Resident #1 was located and decided to discharge from the facility AMA. APS report filed 9/12/25. All residents residing in facility were screened for elopement risk. No additional residents identified. Initiated 9/11/25. Completed 09/11/2025. Facility Administrator discussed findings from survey allegations with medical director to ensure continuation and participation of all practitioners with resident elopement risks. Initiated: 9/12/2025 Completed: 9/12/2025 The Medical Director was notified of Immediate Jeopardy. Initiated: 9/12/2025 Completed: 9/12/2025 Monitoring included: Observations on window in room [ROOM NUMBER] on 09/13/2025 at 11:59am revealed that the window stopped at 6 in. Observations on window in room [ROOM NUMBER] on 09/13/2025 at 12:01pm revealed that the window stopped at 6 in. Observations on window in room [ROOM NUMBER] on 09/13/2025 at 12:04pm revealed that the window stopped at 6 in. Observations on window in room [ROOM NUMBER] on 09/13/2025 at 12:05pm revealed that the window stopped at 6 in. Observations on window in room [ROOM NUMBER] on 09/13/2025 at 12:07pm revealed that the window stopped at 6 in. During an interview with LVN E on 09/13/2025 at 12:38p.m., revealed she had been trained on elopement and completing the elopement assessments. She said the training covered what to do if there was an elopement, what to do to assess the resident and how to answer the questions. She also said she would ask about behaviors. She said elopement was when a resident left the facility without staff and did not sign out. She said signs of an elopement were wandering around the facility pushing on doors and looking for a way out. She said for a new resident staff would look at the resident's chart and elopement assessment to see if the resident was an elopement risk. She said if a resident eloped staff were to call a code yellow, look for the resident in the room, bathroom, closet, under the bed, as well as do a head count and put a trash can in the doorway of a room after it had been searched. She also said staff would look outside the facility around the building, drive around the neighborhoods looking for the resident. She also said staff would call the DON, ADM, MD, and RP. She said if a resident was an elopement risk staff were to call the DON and the MD to get orders for a wander guard. She said she did do the elopement drill and staff were searching and called a code yellow. During an interview with CNA F on 09/13/2025 at 1:14p.m., revealed that he had been trained on elopement. He said the training covered what to do if someone was missing. He said staff were to call a code yellow, do a head count of all residents, check rooms, closets and outside and make sure everything was clear. He said elopement was when resident left the facility and did not sign out and staff could not find the Resident. He said staff were to also call the nurse and the ADM and inform them of the missing resident. He said that signs of an elopement risk were pushing doors and asking how to get out. He said if he had a new resident and did not know if the resident were an elopement risk he would look at the resident's chart and ask the nurse about the resident. He said that he did participate in the elopement drill and staff searched for a missing resident and put the trash can in the door once done searching the room.During an interview with CNA G on 09/13/2025 at 1:38p.m., revealed she had been trained on elopement. she said the training covered what to do if someone was missing. She said staff were to search for the resident that was missing. She also said that staff were to call a code yellow and notify the charge nurse. She said signs of elopement were the resident wanting to leave. She said she was in the elopement drill and the ADM had staff searching like a resident was missing. During an interview with LVN H on 09/13/2025 at 1:53p.m., revealed that he had been trained on elopement and completing the elopement assessments. He said that the training covered how to report a resident who is confused and watch new residents what to do and who to notify. He said elopement was when a resident left the facility without notifying staff. He said signs of elopement were when a resident wanders from door to door, confused and going into other residents' rooms. He said to find out if a new resident were an elopement risk he would look at the report from the previous nurse, go check on the resident and observe the resident. He said if a new resident were an elopement risk he would let the DON know and call the doctor to get orders for a wander guard. He said that signs of elopement were a resident and pushing the doors and wanting to leave. He said he did attend the elopement drill and staff looked for residents, did a head count of residents, and called a code yellow. During an interview with LVN I on 09/13/2025 at 2:01p.m., revealed that she was trained on elopement and completing the elopement assessments. She said the training covered what to do when a resident was missing. She also said the training covered when doing the assessment staff were to ask the resident questions and get to know the resident's history. She said that elopement was when a resident left the facility without staff knowledge. She said signs of elopement risk were wandering to the doors, asking to leave, and cognitive impairment. She said if a resident was missing staff were to check the last place the resident was, check the whole facility, rooms, shared areas, bathrooms and outside. She said staff were to notify the DON, ADM, RP, and MD. She said depending on what is found out about the resident would depend on if the staff were to call the doctor and get an order for wander guard. During an interview with CNA J on 09/13/2025 at 2:23p.m., revealed she had been trained on elopement. she said the training covered what to do if a resident was missing. She said that elopement was when the resident left the facility without notice and did not sign out. She said a sign of elopement risk was when a resident would wander to the doors and push on them to get out. She said to find out if a new resident were an elopement risk she would ask the charge nurse about the resident. She said when a resident was missing staff were to call a code yellow, search all halls, all rooms, everywhere. She said staff were to report to the nurse, DON, and ADM if a resident was missing. She said she did participate in the evacuation drill. She said the staff went to all the halls, checked the rooms, the bathrooms, under the beds. She said when staff came out of a room after searching staff would put a trash can in the doorway to show the room had already been searched. During an Interview with the RDO on 09/13/2025 at 2:12pm revealed that he did review the policy and did not make any revisions to the policy.During an interview with the MD on 09/13/2025 at 2:19pm revealed that the administrator did discuss the finding and ensured continuation and participation of all practitioners with resident elopement risk. Record Review revealed that the RDO re-educated the ADM with CN present on 09/12/2025. The CN educated the DON on 09/12/2025. Record review of Wandering and Elopements, policy Interpretation and Implementation In-service and Elopement Drill revealed that the DON educated staff and conducted an elopement drill with 39 of 90 staff. Record review revealed that wander guard monitoring checklist has been completed for all shifts starting Sept. 1, 2025. Record review of Elopement Evaluation Observation In-service Training dated 09/12/2025 revealed 16 of 34 Licensed Nurses were in-serviced on completing the elopement assessments. Record review of elopement risk assessments revealed 93 0f 93 residents had elopement risks assessments completed. Six residents identified as elopement risk. 6 of 6 residents' elopement risk assessment, care plan and MDS match. Record review revealed some PRN staff have been educated. Record review of AMA dated 09/12/2025 revealed the resident refused to sign.Record review revealed that the medical director was called by the ADM on 09/12/2025 at 1:14pmRecord review revealed that a QAPI meeting was held on 9/11/2025. On 09/12/2025 at 5:05 p.m., an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/13/2025 at 3:00 p.m., the facility remained out of compliance at a severity level of not actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on observation, interviews, and record reviews; the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to dispose of open stored perishable food products. 2. The facility failed to properly label and date food products in the walk-in refrigerator and walk in freezer. 3. The facility failed to ensure Dietary Manager wore a facial hair restraint while performing duties throughout the kitchen. These failures could place residents who were served from the kitchen at risk for consuming contaminated food and developing foodborne illnesses.Findings included: Observation on 07/29/2025 at 8:15 AM revealed the Dietary Manager had a mustache in which was not covered with a facial hair restraint while he was performing duties in the kitchen area. Observation revealed Dietary Manager was not wearing a facial hair restraint while walking throughout the main kitchen area, food preparation area, and the walk-in refrigerator. Observation revealed the Dietary Manager did not put on a facial hair restraint during the entire time visiting in the kitchen conducting a walk-through. Observation on 07/29/2025 at 8:20 AM during a walk-through of the facility kitchen revealed the following:walk-in refrigerator*Open undated garlic,*Open undated white cheddar cheese,*Undated yellow cheddar cheese,*Open undated parmesan cheese,*Open undated cranberry juice,*Open undated deli ham,*Open undated sliced carrots, and*Open undated tortillas. walk-in freezer*Open undated frozen hamburger patties,*Open undated frozen broccoli,*Open undated frozen cheese pizzas,*Open undated frozen okra,*Open undated frozen mixed vegetables, and*Open undated frozen biscuit dough. Observation on 07/29/2025 at 12:00 PM revealed the Dietary Manager did not have his mustache covered while performing duties in the kitchen area. Observation revealed Dietary Manager was not wearing a facial hair restraint while walking throughout the main kitchen area, and food preparation area. Observation revealed Dietary Manager presented extra facial hair restraints to confirm there were facial hair restraints in supply and Dietary Manager did not put a facial hair restraint to cover his mustache once having facial hair restraints in his hands. Observation revealed Dietary Manager continued to perform duties in the kitchen area without utilizing a facial hair restraint. Observation revealed the Dietary Manager never put on a facial hair restraint, Observation on 07/30/2025 at 11:34 AM revealed the Dietary Manager scooped gravy into a cup assisting kitchen [NAME] in which Dietary Manager was not wearing a facial hair restraint to cover his mustache. Observation revealed Dietary Manager flipped chicken fried steak in a deep fryer while not wearing a facial hair restraint. Observation revealed Dietary Manager was checking food in the hot table station while not wearing a facial hair restraint. Observation revealed Dietary Manager walking through out the kitchen area performing duties without having a facial hair restraint on. Observation revealed Dietary Manager was checking food temperature without wearing facial hair restraint. Observation revealed the Dietary Manager never put on a facial hair restraint; Observation revealed Dietary Manager was checking food temperature without wearing facial hair restraint. Observation revealed Dietary Manager never put on and wore a facial hair restraint while conducting duties in the kitchen and working around food. During an interview on 07/30/2025 at 11:58 AM with [NAME] A, she stated she has been working at the facility for 3 years. [NAME] A stated she has been trained in wearing facial and hair restraints. [NAME] A stated it is important to wear facial and hair restraints to prevent hair going in the food and contaminating it. [NAME] A stated it is important because if there was hair in the food, a resident can feel upset from it and think the facility staff do not care about their well-being. [NAME] A stated all staff in the facility when entering the kitchen area have been trained to wear facial and hair restraints. [NAME] A stated the expectation was for all staff to wear facial and hair restraints no matter who the staff member was, if a staff member was seen without facial and hair restraints, the facility staff tell the individual to put on facial and hair restraints when working in the kitchen. [NAME] A did not provide a comment as to why the Dietary Manager was not utilizing a facial hair restraint for his mustache when he was in the kitchen area working but stated was the responsibility of all staff to always wear facial and hair restraints every day. [NAME] A stated has been trained in labeling and dating food products. [NAME] A stated the training went over labeling and dating food products or anything that has been opened needs to be labeled and dated, if it is open that day then staff are to label and date it. [NAME] A stated all food products need to be shut and secured properly. [NAME] A stated if there is any food not labeled or dated in the dry food storage, walk in refrigerator, and walk in freezer, it can get bacteria and get residents sick if consumed. [NAME] A stated all food not labeled and dated needs to be thrown away since staff will not know how long it has been stored. [NAME] A stated its import to label and date food products to make sure it is safe to consume for the residents. [NAME] A stated food exposed and not secured properly is a health contamination issue and cause foodborne illnesses. [NAME] A stated it will be an issue giving residents exposed open food or undated and unlabeled food, as it can make a resident ill or hospitalize the resident, and or potentially leading to a resident dying if they have a specific health issue. [NAME] A stated facility staff in the kitchen not labeling and dating food products poses a concern on the resident's quality of life. During an interview on 07/30/2025 at 12:12 PM with [NAME] B, he has been working at the facility for a little over a year. [NAME] B stated he has been trained in utilizing facial and hair restraints. [NAME] B stated the facility staff must wear facial and hair restraints to prevent food getting contaminated by any hair falling in during the preparation process. [NAME] B stated it was important to wear facial and hair restraints to prevent a resident having hair in the food and a resident can choke on the hair or get sick. [NAME] B stated some negative affects if facility staff are not wearing proper facial and hair restraints is a resident can get a foodborne illness. [NAME] B stated all staff in the facility have been trained to wear facial and hair restraints if they have facial hair or hair in general. [NAME] B stated the expectation is for all staff to wear facial and hair restraints while following the rules the facility has put in policy. [NAME] B stated it was the responsibility of the staff member and the Dietary Manager to make sure all staff are wearing facial and hair restraints as well as make sure there is always appropriate supplies. [NAME] B stated if he must wear facial hair restraint to cover his facial hair then anyone that comes into the kitchen must wear one. [NAME] B stated all staff in the kitchen are to wear facial and hair restraints at all times [NAME] B stated staff not wearing hair or facial hair restraints can cause a quality-of-life issue with residents because they would not want to eat food with hair in it and make residents think staff do not know what they are doing in the kitchen. [NAME] B stated he has been trained in labeling and dating food products. [NAME] B stated the training went over labeling and dating food products or anything that has been opened needs to be labeled and dated, to make sure the product is labeled the correct food item. [NAME] B stated all food products need to be shut and secured properly by the facility staff due to bacteria can grow and food can get spoiled or rotten effecting the other foods surrounding it. [NAME] B stated if there is any food not labeled or dated in the dry food storage, walk in refrigerator, and walk in freezer, it needs to be thrown away if they aren't able to get an exact date and timeframe it was opened to determine if the food product is still good to be given to residents. [NAME] B stated its import to label and date food products to make sure it is safe to consume for the residents and not run into the issue of not knowing when the food is potentially expiring. [NAME] B stated food exposed and not secured properly is a health contamination and consumption issue, overall, it is a health hazard since facility staff will not know if the food has been affected by bacteria and potential foodborne pathogens. [NAME] B stated facility staff cannot be too cautious when dealing with elderly populations and individuals who may be vulnerable that the facility is serving. [NAME] B stated it will be an issue giving residents exposed open food or undated and unlabeled food, as it can get a resident ill or hospitalize the resident depending on the contaminated food product and the resident's health. [NAME] B stated not labeling and dating food products poses a concern on the resident's quality of life if they eat food that may potentially get them sick. During an interview on 07/30/2025 at 12:35 PM with Dietary Manager, he stated he has been working here for 3 years and has 45 years of experience working with residents in the nursing home population. Dietary Manager stated he has been trained in facial and hair restraints. Dietary Manager stated it is important to wear facial and hair restraints to prevent hair falling into food when prepping, cooking, and while in the kitchen performing duties. Dietary Manager stated he is not sure if the facility has a facial and hair restraint policy that stated any form of statement that facility staff need to wear facial hair restraints, he stated that he pleads the fifth (Pleading the fifth refers to invoking the Fifth Amendment right against self-incrimination in the United States) about not answering if he wears a facial hair restraint or not. Dietary Manager stated some negative affects if facility staff are not wearing proper facial and hair restraints is that a resident can potentially get sick if hair is in the food. Dietary Manager stated facial and hair restraints is to prevent food contamination and all staff are to wear them while in the kitchen. Dietary Manager stated he has beard guards, and it is appropriate for staff to wear a ball cap if there is a hair restraint along with it. Dietary Manager stated all staff in the facility are to wear facial and hair restraint and follow the rules of what the facility has trained staff. Dietary Manager stated all staff have been trained to wear facial and hair restraints and to follow it. Dietary Manager stated the expectation is for all staff to wear facial and hair restraints, all staff need to wear them when working with the population the facility serves. Dietary Manager stated it was the facility and responsibility of all staff that enter the kitchen to wear facial and hair restraints, staff make sure that is followed. Dietary Manager admitted he was not wearing a facial restraint to cover his mustache; he did not provide a statement as to why he was not wearing a facial hair restraint when asked about it. Dietary Manager stated he will be utilizing posted signs moving forward about facility staff wearing proper facial and hair restraints. Dietary Manager stated staff not wearing hair or facial hair restraints can cause a quality-of-life issue with residents if they find hair in their food. Dietary Manager stated he has been trained in labeling and dating food products. Dietary Manager stated he has a working kitchen and serving a purpose. Dietary Manager stated the training went over labeling and dating food products or anything that has been opened needs to be labeled and always dated. Dietary Manager stated all food products need to be shut and secured properly despite any food product it is, it should be tight and secured. Dietary Manager stated if there is any food not labeled or dated in the dry food storage, walk in refrigerator, and walk in freezer, it needs to be thrown away since staff will not know how long it has been stored. Dietary Manager stated any food not labeled or dated is not given to residents due to it being a hazard as well as lead to residents getting sick. Dietary Manager stated its import to label and date food products to make sure it is safe to consume for the residents. Dietary Manager stated food exposed and not secured properly is a health contamination issue and needs to be tossed out. Dietary Manager stated it will be an issue giving residents exposed open food or undated and unlabeled food, as it can get a resident ill or hospitalize the resident, and or potentially leading to death if it affects the resident. Dietary Manager stated not labeling and dating food products poses a concern on the resident's quality of life and they are here to take care of the residents, not put them in danger. During an interview on 07/30/2025 at 1:05 PM with Dietitian, she stated she has been working at this facility for 9 years. Dietitian stated she has been trained in wearing facial and hair restraints. Dietitian stated it is important to wear facial and hair restraints as it is helping with food sanitation. Dietitian stated some negative affects if facility staff are not wearing proper facial and hair restraints is that staff's hair can fall into the resident's food and cause contamination. Dietitian stated the facial and hair restraints is used as a precaution barrier. Dietitian stated all staff in the facility have been trained to always wear facial and hair restraints when inside the kitchen area. Dietitian stated the expectation is for all staff to always wear facial and hair restraints with no exceptions. Dietitian stated if there is anyone not wearing facial and hair restraints in the facility kitchen, it is the facility staff responsibility to advise the individual in the kitchen who are not wearing restraints to do so. Dietitian stated she does not remember the last in-service that was conducted for facial and hair restraints. Dietitian stated it is the responsibility of all staff to wear facial and hair restraints. Dietitian stated wearing facial and hair restraints and following the policy is the kitchens precaution measures. Dietitian stated staff not wearing hair or facial hair restraints can cause a quality-of-life issue with residents such as if there is hair in the resident's food and the resident being upset by it. Dietitian stated she has been trained in labeling and dating food products in which there has been in-service for labeling and dating in the last few months. Dietitian stated the labeling and dating food products training went over anything that has been opened needs to be labeled and dated as well as any food products that come into the facility kitchen should always be labeled and dated. Dietitian stated all food products need to be shut and secured properly as well as covered as it is a food safety issue that can lead to food contamination. Dietitian stated it is her professional opinion if there is any food not labeled or undated in the dry food storage, refrigerator, and freezer, it needs to be thrown away and not given to residents to eat. Dietitian stated its import to label and date food products to make sure it is safe to consume for the residents. Dietitian stated any food exposed and not secured properly is a health contamination issue and should not be consumed as it would be questionable. Dietitian stated it will be an issue giving residents any exposed open food or undated and unlabeled food, as it can get a resident ill or potentially hospitalize the resident in some cases based on their vulnerability level. Dietitian stated not properly labeling and dating food products or providing unknown expired food poses a safety concern on the resident's quality of life. During an interview on 07/30/2025 at 2:42 PM with Director of Nursing, she stated she has been working at the facility for approximately 2 years. Director of Nursing stated she has been trained in facial and hair restraints in the kitchen area. Director of Nursing stated it is important to wear facial and hair restraints to prevent hair getting into food or utensils. Director of Nursing stated some negative affects if facility staff are not wearing proper facial and hair restraints is a resident can find hair in the food and mess with the resident psychologically. Director of Nursing stated all staff in the facility have been trained to wear facial and hair restraints while being in the kitchen. Director of Nursing stated the expectation is for all staff to wear facial and hair restraints when cooking and preparing food since it is a regulation that must be always abided by. Director of Nursing stated it is the responsibility of the Dietary Manager and all staff to wear facial and hair restraints in the kitchen, it is her expectation for the Dietary Manager to monitor it. Director of Nursing stated it is her expectation for all staff to undergo in-services for wearing facial and hair restraints, in which she does not recall the last in-service. Director of Nursing stated staff not wearing hair or facial hair restraints can cause a quality-of-life issue with residents if they find hair in the food and may pose a hazardous issue for residents that have swallowing issue, and it will not be pleasant for the resident. Director of Nursing stated she has been trained in labeling and dating food products, but that is the kitchen staff and Dietary Managers responsibility. Director of Nursing stated the training went over dating food products for the resident and to not keep it for an extended period or expiring. Director of Nursing stated any food that has been opened is not labeled and dated; it needs to be thrown away. Director of Nursing stated all food needs to be shut and secured properly. Director of Nursing stated its import to label and date food products to make sure it is safe to consume for the residents and food does not last for an extended period in which it can pose a health concern if residents eat expired food that is not properly labeled and dated. Director of Nursing stated it will be an issue giving residents exposed open food or undated and unlabeled food, as it is a health concern. Director of Nursing stated not labeling and dating food can affect the resident's quality of life if they are eating food that has been potentially sitting for an extended period. During an interview on 07/30/2025 at 3:07 PM with Administrator, she stated she has been working at the facility for approximately over a year. Administrator stated she has been trained in facial and hair restraints. Administrator stated it is important to wear facial and hair restraints to prevent hair falling into the food and cause cross contamination. Administrator stated some negative affects if facility staff are not wearing proper facial and hair restraints is that a resident can find the food off putting when finding hair in the food. Administrator stated all staff in the facility have been trained to wear facial and hair restraints. Administrator stated she is unaware of any facial and hair restraints signs posted on the entrance or exit of the kitchen. Administrator stated the expectation is for all staff to wear facial and hair restraints if there is facial hair or hair on the individual. Administrator stated it is the responsibility of the Dietary Manager to make sure all staff are to wear facial and hair restraints. Administrator stated she does not recall the last facial and hair restraint in-service training. Administrator stated staff not wearing hair or facial hair restraints can cause a quality-of-life issue with residents as it is off putting in which the resident will not want to eat the food they are provided, and they would need to provide another food tray for the resident to eat. Administrator stated if the Dietary Manager were not wearing a facial hair restraint and she saw it, she would in-service him. Administrator stated when she has entered the kitchen, she has not seen a staff member not wearing a facial or hair restraint and if there were every any incidents, she would remind the staff. Administrator stated she has been trained in labeling and dating food products. Administrator stated the training went over labeling and dating food products or anything that has been opened needs to be labeled and dated as well as the facility staff will monitor for expiration dates. Administrator stated all food products need to be shut and secured properly. Administrator stated the Dietary Manager monitors to make sure all food is labeled and dated as well as to make sure all food products are secured properly. Administrator stated the Dietary Manager in-services the facility kitchen staff. Administrator stated if there is any food not labeled or dated in the dry food storage, walk in refrigerator, and walk in freezer, it needs to be thrown away since staff will not know the correct date and staff can't know for sure if the food is expired or not. Administrator stated its import to label and date food products to make sure it is safe to consume for the residents, so residents are served food that are not expired. Administrator stated she cannot comment on residents being served expired food being a health issues in terms of what can happen to them since she is not a nurse. Administrator stated food exposed and not secured properly is a health contamination issue as the food can become stale or lead to potential foodborne pathogens. Administrator stated it will be an issue giving residents exposed open food or undated and unlabeled food and paused stating that's a good question; and continued to state it can cause gastrointestinal distress issues for residents, it can get a resident ill, and or hospitalize residents who are more vulnerable than others. Administrator stated in terms of facility staff not labeling and dating food products posing a concern on the resident's quality of life, she states at this time it has not and she has not been reported that. Observation on 07/31/2025 at 11:09 AM during a walkthrough of the facility kitchen revealed the following:walk-in refrigerator* Open undated white cheddar cheese,*Open undated deli ham, and*Open undated tortillas. walk-in freezer*Open undated frozen mixed vegetables, and *Open undated frozen biscuit dough. Observation on 07/31/2025 at 11:13 AM revealed Dietary Manager did not have on a facial hair restraint to cover his mustache while being in the kitchen area. During an interview on 07/31/2025 at 11:20 AM with Dietary Manager, he did not state as to why he was not wearing a facial hair restraint to cover his mustache while being in the facility kitchen. Observation on 07/31/2025 at 1:28 PM revealed Dietary Manager did not have on a facial hair restraint to cover his mustache while being in the kitchen area. Observation revealed there were no posted signs stating that facility staff are required to wear facial hair and hair restraints before entering the kitchen. Observation revealed the Dietary Manager never put on a facial hair restraint during the entire 3-day survey when conducting at random observations. Record review of facility policy Food Safety and Sanitation dated 2021 reflected the following: All local, state, and federal standards and regulations will be followed to assure a safe and sanitary food and nutrition services department.1. Food and Nutrition Services Departmenta. The department will be routinely inspected by the environmental health services of the local public health department, following their accepted standards and regulations. The director of food and nutrition services will have a copy of the applicable regulations on file and should be familiar enough with this information to implement policies and procedures to meet the regulations. Note: Not all states require local health department inspections.b. The state and/or federal survey team as part of the annual survey process will inspect the department.2. Employeesa. All staff will be in good health, will have clean personal habits, and will use safe food handling practices.b. Hair restraints are required and should cover all hair on the head. c. [NAME] nets are required when facial hair is visible.3. Leftover Foodsa. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days or discarded as per the 2017 Federal Food Code. Check state regulations as some states may allow shorter time frames for use of leftovers.4. Refrigerated food storage.a. All refrigerator units should be kept clean and in good working condition at all times.b. All foods should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded.5. Frozen Foodsa. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. Record review of facility policy Preventing Foodborne Illness - Employee Hygiene and Sanitary dated 2017 reflected: Food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. 1. All employees who handle, prepare, or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents.Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens.

Based on interview and record review, the facility failed to establish and maintain a homelike environment for 2 or 3 residents (Resident #87 and Resident #14) observed for environmental conditions. The facility failed to ensure Resident #87's and Resident #14's bedroom walls were upkept and homelike. This failure could cause residents psychological distress or feel uncomfortable. Based on interview and record review, the facility failed to establish and maintain a homelike environment for 2 or 3 residents (Resident #87 and Resident #14) observed for environmental conditions. The facility failed to ensure Resident #87's and Resident #14's bedroom walls were upkept and homelike.This failure could cause residents psychological distress or feel uncomfortable.Findings Included:Resident #87Record Review of Resident #87's face sheet revealed was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #87 had a diagnosis of schizoaffective disorder (mental health condition that is marked by symptoms such as depression and mania), Muscle Weakness, Hyperlipidemia (abnormally elevated levels of fat in the blood) and Hypothyroidism (condition where the thyroid gland does not produce enough thyroid hormone). Record Review of Resident #14's MDS record indicated Resident #87 had a BIMS of 14 which implied the resident was cognitively intact. An observation on 07/29/2025 at 11:45AM in Resident #87's bedroom revealed the resident's wall was scratched and torn next to his head. An interview on 07/29/2025 at 11:45AM. Resident #87 stated the wall next to his head has been ripped and scratched up since he has arrived at the facility. He stated he did not do damage the wall. Resident #87 stated it bothered him that the wall was like that. He denied telling the facility about this problem.Resident #14Record Review of Resident #14's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #14 had a diagnosis of Paranoid Schizophrenia, Unspecified Convulsions (involuntary muscle contraction sand spasms) and Benign Prostatic Hyperplasia Without Lower Urinary Tract (non-cancerous enlargement of the prostate gland).Record Review of Resident #14's MDS record indicated Resident #14 had a BIMS of 8 which implied the resident had moderate impairment with his cognition. An observation on 07/29/2025 at 12:00PM in Resident #14's bedroom revealed the resident's wall was scratched and torn up next to his head. An interview on 07/31/2025 at 2:41PM Resident #14 stated the wall next to his head has been damaged since before he arrived at the facility. He stated his bedroom, or home would not look like this if he were at home. An interview was conducted on 07/31/2025 at 3:00PM with the Maintenance Manager (MM). The MM reported he had been employed at the facility for 6 months. MM stated the policy for ensuring a homelike environment was for staff to notify him of environmental concerns. The MM stated he was not aware of any bedroom issues on the 400 halls. The MM stated the expectation when the rooms conditions are not good was to fix it. The MM stated the condition of the walls could negatively impact a resident by the resident potentially not wanting to be in the room. The MM stated the process for completing conditions inside the facility was for him to check the maintenance log, and he would go down the line to fix them. If there is something tremendously horrible then he will have someone come in to help him.An interview was conducted on 07/31/2025 at 4:30PM the DON reported they have been employed at the facility since January 2024. The DON reported receiving trainings on resident rights. The DON stated the policy for homelike environment was that the facility should provide an environment life that was conducive, good looking and better than one can live and be comfortable in. The DON stated she was aware of complaints for had been complaints about the condition of the resident's rooms on 400 halls. The DON stated the expectation when room conditions are not good would to be work on it right away. The DON stated depending on what it the environmental issue was, it could psychologically bother the residents and wish there were paint on the wall. An interview on 07/31/2025 at 5:15PM the ADM reported they have been employed at the facility since May 2024. The expectation for homelike environment was to try to meet the standard of a homelike environment. The ADM stated the residents are hard on the building and the facility try their best to keep up with it. The ADM stated multiple staff members in and out which could lead to scratches on the wall and try to keep up with those things as quickly and timely as they can. The ADM stated she was unaware of any complaints of issues on the 400 hall. The ADM stated the expectation when room conditions are not good are to have maintenance go and assess the room, depending on what it was they would rectify the situation, or they would meet back with her. The ADM stated a negative impact this could have on a resident could be that the resident could not be happy with their room. Record review of facility provided document labeled Quality of Life: Homelike Environment and dated May 2017 reflected the following:1. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include:a. Clean, sanitary, and orderly environmentb. Comfortable yet adequate lightingc. Inviting colors and decord. Personalized furniture and room arrangementse. Clean bed and bath linens that are in good condition.f. Pleasant neutral scents

Based on observation, interview and record review, the facility failed to provide reasonable accommodations for 2of 6 residents (Resident # 73 and Resident #47) reviewed for resident rights. The facility failed to ensure:*Resident #73 could communicate his needs and preferences. *Resident #47 had access to call light button. These failures could place residents at risk of isolation, not receiving needed care or nursing interventions to meet the resident's needs. Finding included: Record review of Resident #73's Face Sheet dated 06/17/2025, revealed Resident #73 was admitted to the facility on [DATE] and was an [AGE] year-old male with diagnoses of: Insomnia (sleep disorder characterized by difficulty falling asleep), Dysphagia (difficulty in swallowing), Hypertensive Heart disease with heart failure (a condition where high blood pressure (hypertension) over time damages the heart, leading to heart failure), and Paroxysmal atrial fibrillation (irregular heart rhythm). Review of Resident #73's Quarterly MDS, dated [DATE] reflected the following: Section GG Functional Abilities, the resident was “Independent” for ADLs meaning, Resident completes the activity by themself with no assistance from a helper. Section C, (BIMS) Brief Interview for Mental Status is scored of 14 (indicates high cognitive functioning). Review of Resident #73's Comprehensive Care Plan dated 06/19/2025 reflected Resident # 73 problem of impaired verbal communication related to language differences and difficulty understanding or expressing needs in English. The identified goal for this resident is ability to express the basic needs effectively through the next 90 days. The approach specified for all staff to involve resident in care planning using his preferred language (Russian) using communication board and visual aids, gestures, or translation apps when appropriate. An attempted interview with Resident #73 on 07/30/2025 at 8:20 a.m., was unsuccessful due Resident #73 only speaks Russian. Resident #73 made eye contact with Surveyor and used hand gestures to attempt to communicate. Surveyor brought Russian speaking Team Member to interview Resident. Observation of Resident #73 and interview on 07/30/2025 at 8:20 a.m., Resident #73 appeared well-groomed and ambulating in his room independently. He was very emotional stating he was so glad finally being able to speak to somebody who can understand him. Resident # 73 stated this was his first time at a medical facility when no e-translating devices available for communicating with nursing staff. He stated he used a paper dictionary for translating some requests from Russian to English and writing them down. He revealed he asked to get his morning medication with food and med aides continue bring his morning medication before breakfast and he does not want to take medications on the empty stomach. He stated he was satisfied with nursing care in this facility: he gets his showers and food on time, and he liked it here, but he cannot participate in activities as nobody understands him. Resident #73 stated he participated in therapy where he received a printout with pictures/words in Russian/English. The social worker uses the Google translator with him and was trying to assist him with getting an iPad or new phone for using a google translator. He stated he was estranged from his family and only has one friend who visited him here and he can communicate his needs through her sometimes. He wanted to see a cardiologist for his cardiac conditions. The resident #73 provided the surveyor with written notes of his situation before and after admission to this facility with request to address the lack of communication available for him here at the facility. In an Interview on 07/30/2025 at 8:29 a.m., resident reported he was “frustrated” because staff fail to attempt to communicate with him and they do not understand his needs. Interview of LVN B on 7/30/25 at 11:47 a.m., revealed she provided speech therapy services to Resident #73 who stated she worked on improving problem solving to facilitate decision making skills for care/need using Google translator on her phone and her responded well to communication with use of electronic translator. Resident does not have any speech impairment and improved in swallowing food with being discharged on 7/11/25 from Speech therapy. Resident voiced his concern of not being able to communicate to nursing staff regarding his needs. She assisted him on communicating the need for itching medication to the nurse once. Speech therapist stated that not being able to communicate to nursing staff can cause medical decline and depression in this resident. Interview with the DOR on 7/30/25 at 10:45 a.m., revealed Resident #73 was seen by PT, OT, and Speech therapy from 6/17-7/11/25 for improving independence with ADLs. This resident participated well in therapy during this period. There was not a goal for improving functional communication with staff members in this facility for him, but he was provided with communication paper printouts of 10-20 words with Russian-English translation which he was able to utilize by pointing at words with pictures. The DOR stated Resident #73 was able to understand the therapy instructions with use of Google translator during therapy sessions. She stated the resident was physically independent with ADL tasks and able to communicate but needs a way to translate his needs from Russian to English. She was not aware of his frustration regarding inability of communicating his needs to nursing staff. She participated in staff meetings and was not aware it was an issue with this resident. Interview on 07/30/2025 at 2:55 p.m., CNA A on hall 300 revealed he provided Resident #73 with ADL assistance using gestures and not through verbal communication due to the resident's inability to communicate in English and never used Google translator with this resident. CNA A stated Resident #73 received all needed ADL care on the regular basis and seemed happy, but he does not know how other nursing staff communicate to this resident. CNA A stated if the resident were not able to commutate his needs with gestures and staff does not understand him, it could compromise his care. Interview with CMA C, on 7/31/2025 at 1:45 p.m., stated she administered medications to the Resident #73, but she does not use Google translator with him. She stated the resident can write in English and using gestures to communicate to staff. She was not aware about him not wanting medications before breakfast. She stated he usually took medications in front of her, and she does not leave medications at his bedside. She asked the surveyor to show how to use a Google translator stating she heard from DON that she needed to use it but does not know how to do it. CMA C stated she does not remember having an in service for using the Google translator with this resident CMA C was aware of potential negative consequences on resident's health status due to lack of communication with staff. Interview with LVN A on 07/31/2025 at 5:05 p.m., revealed she provided Resident #73 with ADL care. LVN A stated Resident uses hand gestures or he wrote in English to explain his needs. LVN A stated they communicate with Resident #73 by writing my questions out and then allowing Resident #73 to write his responses. LVN A stated she has started using a translation app to communicate with Resident #73. Interview with the AD on 07/30/2025 at 12:38 p.m., revealed the AD offered options for activities to Resident #73 include listening to music and watching movies in his room. The AD stated she tried to get Resident #73 to join in the community activities however, Resident #73 has declines repeatedly. Interview with the SW on 07/30/2025 at 10:16 a.m., revealed he was looking into training for the care staff to use a translator application on their cell phones to communicate with non- English-speaking residents. The SW stated they often have residents who do not speak English and some of our Staff do not speak English. Therefore, the translation application was a useful resource to solve the communication problem. The SW stated Resident #73 might feel lonely if he was not understood by staff and his needs may not be getting met. Interview with DON on 07/31/2025 at 4:30 p.m., revealed care should include speaking and communicating with each resident. The DON explained the resident has a right to be communicated with regarding aspects of his care and daily living. The DON stated the staff have now been in-serviced on communication with non- English-speaking residents. The DON stated, Social Worker communicated with her regarding setting up training for staff of how to use the Google translation application. Interview with Administrator on 7/31/2025 at 5:00 p.m., revealed the staff will receive in- service training by Senior staff on methods for communication with non- English-speaking Residents. Administrator explained the DON and Social Worker will be providing in- service training. Resident #47 Record review of Resident #47's Face Sheet dated 02/28/2025 revealed Resident #47 was admitted to the facility on [DATE] and was a [AGE] year-old male with diagnoses: Fracture of lateral malleolus or right fibula, Intracardiac thrombosis, Inguinal hernia, open wound, right foot, initial encounter, abrasion, right hip, hypertension, pain. Review of Resident #47's Quarterly MDS, dated [DATE] reflected the following: Section GG Functional Abilities, the resident was “Independent” for ADLs meaning, Resident completes the activity by themself with no assistance from a helper. Section C, (BIMS) Brief Interview for Mental Status is scored of 06 (indicates moderate cognitive functioning). Review of Resident #47's Comprehensive Care Plan dated 07/02/2025 reflected that Staff needs to assess and ensure adequate access to call bell, light, and personal items on the open side. Interview Resident # 47 on 07/29/2025 at 10:41 a.m., Resident #47 stated he eats in the dining room, receives medications from the staff nurses and facility assist him with bathing. Resident #47 stated, “he wants Bengay for his pain.” Resident #47 stated “call button was not hooked up”. Surveyor observed call light button at the top of Residents #47's headboard not within reach of Resident #47. Interview with Resident #47 on 07/31/2025 at 11:55 a.m., revealed Resident #47 had pain in both knees, feet, and shoulders. Resident #47 stated “I did not report my pain to the nurses when they came in my room to check on me because I forgot. Resident stated, “call button is not hooked up.” Observation on 07/31/2025 at 2:05 p.m., call light button was located on left side of bed, on the floor, under the bedside table and curled under a blue medical boot, trash can was in front of it. Call button was not within reach of resident. Interview on 07/31/2025 at 2:10 p.m., CNA C stated CNAs are responsible for the call button and she usually moved the call button closer to Resident #47. CNA C stated she will check on Resident # 47's call button location now. Interview on 07/31/2025 at 4:13 p.m., CNA D stated Resident #47 may not get the care he needs if he cannot reach the call light button, and a resident could be negatively affected if the resident did not have access to the call light. Record Review of Translation and/or Interpretation of Facility Services Policy dated May 2017 reveal the following information: “This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. It is understood that providing meaningful access to services provided by this facility requires also that the LEP resident's needs and questions are accurately communicated to the staff. Oral interpretation services therefore include interpretation from the LEP resident's primary language back to English. It is understood that to provide meaningful access to services provided by this facility, translation and/ or interpretation must be provided in a way that is culturally relevant and appropriate to the LEP individual.”

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents reviewed (Resident #1) for pharmacy services. The facility failed to: Provide pain medication ordered, for three consecutive months for different time frames, for resident with a diagnosis of malignant cancer who suffered from chronic pain. An Immediate Jeopardy (IJ) was identified on 04/23/2024. The IJ template was provided to the facility on [DATE] at 5:57 PM. While the IJ was removed on 04/26/2024, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A second IJ was identified on 05/15/2024 at 2:54 pm in the same area of non-compliance. The Administrator and the DON were notified. The Administrator was provided with an additional IJ template on 05/15/2024 at 2:54 pm. This failure could place residents at risk of not receiving the therapeutic benefits of medications which could lead to advanced injury, increased pain, and diminished quality of life. Findings included: Review of Resident #1s undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and most current re-admission 04/21/2024 diagnoses including malignant neoplasm of peripheral nerves and autonomic nervous system (rare cancers that start in the lining of the nerves), abrasion of lower back and pelvis, adrenocortical insufficiency (occurs when the adrenal glands don't make enough of the hormone cortisol) and pain. Review of Resident #1 's MDS dated [DATE] reflected a BIMS of 15 indicating no cognitive impairment. Review of Resident #1's Quarterly MDS dated [DATE] reflected, over the last 5 days she has had pain or hurting, over the last 5 days she experienced pain frequently, over the last 5 days pain had made it her for her to sleep occasionally. Verbal descriptor scale of pain over the last 5 days revealed the intensity of her pain has been severe. Over the last 5 days the resident had received a scheduled pain medication. Review of Resident #1's care plan dated 08/22/2023 revealed category of special care monitor for the presence of pain/intolerance during self-care activities. Category dated 08/22/2023 ADLs Functional Status/Rehabilitation Potential Monitor/record/report for presence of pain/intolerance during transfers. Review of hospital records dated 04/09/2023 until discharge of Resident #1 to the facility on [DATE] reflected patient endorsed worsening lower left extremity pain and swelling for the last couple of weeks. She lived at a skilled nursing facility, and they ran out of her pain medication 2-3 weeks ago and she presented to the ED for uncontrolled lower left extremity pain and leg wound. She had a history of malignant neoplasm of peripheral nerves of thorax and malignant peripheral nerve sheath tumor of chest (a type of cancer that can occur in various locations of your body). Patient's cancer was locally advanced and not curable. As a result of the cancer, she experienced chronic pain for which she was on chronic opiates (including methadone). Hospital records indicate they initially thought her uncontrolled pain on presentation was due to her cancer, but X-rays revealed her femur was broken in several places. Review of Resident #1's paper chart medication orders reflected methadone schedule II 5 mg. amount to administer: 1 tab; oral twice a day pain unspecified 02/02/2024 open ended. Review of Resident #1's paper chart medication orders reflected methadone schedule II 10 mg. amount to administer: 3 tablets; oral every 8 hours pain, unspecified, 02/08/2023 - open ended. Review of Resident #1's paper chart medication order reflected hydromorphone schedule II tablet 4 mg. amount to administer; 4 tabs, oral every 6 hours hold for sedation pain, unspecified, 02/08/2024 - open ended. In an interview on 04/22/2024 at 12:26 pm the DON revealed that medication administration documentation is completed in the paper chart for residents. If a medication is not given, the person who is responsible for administering the medication drew a circle around their initials indicating that the medication was not administered to the resident. DON further stated a note was written on the back of the paper medication administration record, or sometimes both a circle and a note was written on the back of the paper medication administration indicating on the paper medication record that a resident's medication was not given. Additionally, if there was a blank in the space that should indicate the time and date a medication was scheduled to be given, the medication was not given. The DON said that if R#1 was not given her pain medication, it was because the medication was not available to give to her. Review of handwritten notes on reverse side of Resident #1's paper medication admission record for February 2024 for Resident #1's order for methadone schedule II 10 mg. amount to administer: 3 tablets; oral every 8 hours pain, unspecified, 02/08/2023 - open ended reflected the pain medications were not available to administer to Resident #1. 02/20/2024 3:00 pm Methadone 10 mg. - not available 02/21/2024 3:00 pm Methadone 10 mg. - not available 02/22/2024 3:00 pm Methadone 10 mg. - not available 02/25/2024 3:00 pm Methadone 10 mg. - not available 02/26/2023 3:00 pm Methadone 10 mg. - not available Review of Resident #1's paper medication administration record for February 2024 beginning 02/08/2024 reflect methadone schedule II 10 mg. amount to administer: 3 tablets; oral every 8 hours pain, unspecified, 02/08/2023 - open ended. The handwritten circles around the initials of the staff member who was responsible to administer the medication and a blank space in a date and time box reflected that the ordered medication was not given to the resident 25 times because it was not available and therefore not administered. 02/09/2024 7:00 am 02/12/2024 3:00 pm 02/14/2024 11:00 pm 02/16/2024 3:00 pm 02/20/2024 7:00 am and 11:00 pm 02/21/2024 3:00 pm and 11:00 pm 02/22/2023 11:00 pm 02/23/2024 7:00 am, 3:00 pm, and 11:00 pm 02/24/024 11:00 pm 02/25/2024 11:00 pm 02/26/2024 7:00 am and 11:00 pm 02/27/2024 7:00 am, 3:00 pm, and 11:00 pm 02/28/2024 7:00 am, 3:00 pm, and 11:00 pm 02/29/2024 7:00 am, 3:00 pm, and 11:00 pm Review of Resident #1's paper medication administration record for February 2024 beginning 02/08/2024 reflected hydromorphone schedule II table 4 mg. amount to administer 4 tabs. oral every 6 hours hold for sedation pain unspecified 02/08/2024 - open ended. The handwritten circles around the initials of the staff member who was responsible to administer the medication reflected that the ordered medication was not given to the resident 16 times because it was not available and therefore not administered. 02/17/2024 - 02/20/2024 Review of the reverse side of Resident #1's paper medication administration record for February 2024 for hydromorphone reflected, 02/17/2024 hydromorphone on order (nurse notified). Review of Resident #1's paper medication administration record for March 2024 order beginning 02/08/2024 reflect methadone schedule II 5 mg. tab. oral twice a day 02/08/2023 - open ended. The handwritten circles around the initials of the staff member who was responsible to administer the medication reflected that the ordered medication was not given to the resident 20 times because it was not available and therefore not administered. 03/01/2024 11:00 am and 7:00 pm 03/02/2024 11:00 am and 7:00 pm 03/03/2024 - 03/10/2024 11:00 and 7:00 pm Review of Resident #1's paper administration medication for March 2024 order beginning 02/08/2024 reflected methadone schedule II 10 mg. amount to administer: 3 tablets; oral every 8 hours pain, unspecified, 02/08/2023 - open ended. The handwritten circles around the initials of the staff member who was responsible to administer the medication reflected that the ordered medication was not given to the resident 17 times because it was not available and therefore not administered. 03/01/2024 - 03/02/2024 03/03/2024 7:00 am 03/03/2024 3:00 pm 03/04/2024 - 03/06/2024 Review of reverse side of Resident #1's paper medication administration record for March 2024 for methadone schedule II 10 mg. reflected, date illegible, MD Notified. Review of Resident #1's paper medication administration record for March 2024 for order beginning 02/08/2024 reflected hydromorphone schedule II tablet 4 mg. amount to administer: 4 tabs; oral every 6 hours hold for sedation pain unspecified 02/08/24 - open ended. The handwritten circles around the initials of the staff member who was responsible to administer the medication reflected that the ordered medication was not given to the resident 38 times because it was not available and therefore not administered. 03/02/2024 1:00 pm 03/03/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/04/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/05/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/06/2024 1:00 pm, 7:00 am and 1:00 pm 03/16/2024 7:00 pm 03/17/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/18/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/19/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/20/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/21/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/22/2024 1:00 am Review of reverse side of Resident #1's paper medication administration record for March 2024 for hydromorphone schedule II tablet 4 mg schedule II reflected the following handwritten notes: 03/02/2024 awaiting pharmacy for methadone 5 mg., methadone 10 mg., and hydromorphone II, 03/16/2024 residents medication not given awaiting pharmacy see nurses notes, 03/17/2024 resident medication not given hydromorphone 4 tabs see nurses notes, and 03/19/2024 am hydromorphone 4 mg (4 tabs) not available will notify NP in AM. Review of Resident #1's paper medication administration record for April 2024 order beginning 02/08/2024 reflect methadone schedule II 5 mg. tab. oral twice a day 02/08/2023 - open ended. The handwritten circles around the initials of the staff member who was responsible to administer the medication reflected that the ordered medication was not given to the resident 4 times because it was not available and therefore not administered. 04/08/2024 11:00 am and 7:00 pm 04/09/2024 11:00 am and 7:00 pm Review of Resident #1's paper administration medication for April 2024 order beginning 02/08/2024 reflected methadone schedule II 10 mg. amount to administer: 3 tablets; oral every 8 hours pain, unspecified, 02/08/2023 - open ended. The handwritten circles around the initials of the staff member who was responsible to administer the medication reflected that the ordered medication was not given to the resident 10 times because it was not available and therefore not administered. 04/06/2024 11:00 pm 04/07/2024 7:00 am, 3:00 pm, and 11:00 pm 04/08/2024 7:00 am, 3:00 pm, and 11:00 pm 04/09/2024 7:00 am, 3:00 pm, and 11:00 pm Review of Resident #1's paper medication administration record for April 2024 for order beginning 02/08/2024 reflected hydromorphone schedule II tablet 4 mg. amount to administer: 4 tabs; oral every 6 hours hold for sedation pain unspecified 02/08/24 - open ended. The handwritten circles around the initials of the staff member who was responsible to administer the medication reflected that the ordered medication was not given to the resident 18 times because it was not available and therefore not administered. 04/05/2024 1:00 am, 7:00 am, and 1:00 pm 04/06/2024 1:00 am, 7:00 am, and 1:00 pm 04/07/2024 1:00 am, 7:00 am, and 1:00 pm, and 7:00 pm 04/08/2024 1:00 am, 7:00 am, and 1:00 pm, and 7:00 pm 04/09/2024 1:00 am, 7:00 am, and 1:00 pm, and 7:00 pm Interview with Resident #1 on 04/22/2024 at 11:27 am revealed she was feeling better since her return from the hospital, and she is getting her pain medications. She said that there have been several times she has not received her pain medications while living at the facility and it is because they have run out of them. She said occasionally they will give her Tylenol #3 when her pain medications are not available, but it does not help very much. She said she is always in pain at a constant level, on a pain level of a 6/10 - 7/10 all the time and she told the facility she was in pain. Prior to her last hospital admission on 04/09/2024 she said she had not been given pain medications for a long time but was unsure of how long she had not been receiving them. She said she told them that the pain was in her legs and that this was a different and terrible pain. She said her legs hurt very badly. The day she was admitted to the hospital she had a shower, and the pain was terrible, and she was crying from the pain and LVN A saw her crying. She called EMS herself to be taken to the hospital. Interview with LVN A on 04/24/2024 at 2:55 pm revealed Resident #1 sometimes did not get her pain medications because they could not get the prescription for the order filled. At times they would give her Tylenol #3, but it was not effective, and the hydromorphone helped her more. LVN A revealed Resident #1 was in pain every day, because of her condition, cancer. LVN A revealed Resident #1 was crying and Resident #1 told LVN A she had pain and Resident #1 told LVN A the pain is too much. LVN A called the NP for Tylenol #3 on 04/09/2024 (the day Resident #1 went to the hospital) and it was administered to Resident #1, but it did not help, and you could see from Resident #1's facial expressions and Resident #1's crying that the Tylenol #3 did not help. LVN A said she had never seen her crying that way. LVN A revealed she was in pain every day and it was important for her to give Resident #1 her pain medications because she was in pain, and she is a cancer patient. Interview with the DON on 04/24/2024 at 1:14 pm and 04/26/2024 at 3:09 pm revealed Resident #1 had a diagnosis for pain because she had cancer and Resident #1 had orders for prescription pain medications and the NP and MD took care of Resident #1's pain medication and that the facility had nothing to do with Resident #1's insurance, it was with the doctors. The DON said Resident #1 was in pain all the time, but the pharmacy could not get Resident #1's prescription filled because of insurance and paperwork delays, so there was nothing to do. The DON said that because Resident #1's medication was Schedule II controlled narcotics, they did not have them in the e-kit. The DON revealed it was not okay for Resident #1 to have gone even one day without her pain medication and the DON understood how high Resident #1's pain level was. The DON revealed she was not aware that Resident #1 was crying because of her pain. The staff did not bring it to her attention that she was crying except the day she went to the hospital. The orders from the doctor should have been filled. Resident #1 suffered from chronic pain and the facility was aware that she suffered from chronic pain. The DON is responsible for making sure medications are ordered and that there is a process in place to make sure residents receive the medication. Interview with the Administrator on 04/26/2024 ADM at 2:50 pm revealed he was aware that there was a struggle and an issue with obtaining Resident #1's pain medication and it was his understanding that her pain was addressed. He thought it was addressed because they contacted the MD, and another mediation was ordered that resolved the pain and that did not happen. If a resident goes without pain medication the resident could have severe pain and suffering. He revealed Resident #1's needs were not being meet and he knew she was in pain but did not know she was crying. He revealed he was aware Resident #1 called the EMS because of her pain and was surprised to hear that Resident #1 called the EMS as opposed to a staff member. He revealed the nursing staff and facility did not meet her needs. Facility Policy Administering Medications dated 04/2019 revealed the Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions. Medications are administered in accordance with prescribed orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication; b. Preventing potential medication or food interactions; and c. Honoring resident choices and preferences, consistent with his or her care plan. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. This was determined to be an Immediate Jeopardy (IJ) on 04/23/2024 at 5:57 pm. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 04/23/2024 at 5:57 pm. The following POR was accepted on 04/25/2024 11:01 am. PLAN OF REMOVAL On 4/19/2024 an abbreviated survey was initiated at [NAME] Woods 1 Nursing Center. On 4/23/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Threat states as follows: IJ Component: F 755 Pharmaceutical services Facility failed to issue prescription pain medications Hydromorphone and Methadone as ordered for [AGE] year-old female resident. Immediate Actions: 1. Resident returned to facility from the hospital on 4-21-24. Upon return, pain assessment was completed by licensed nurse, resident denied pain and was documented on 4-21-2024. 2. Resident returned to facility on 4-21-2024 with new order to discontinue hydromorphone and methadone and start morphine. Morphine medication was filled and dispensed 4-21-2024. A licensed nurse assured medication filled and assesses pain every shift. Completed 4-21-2024 Facility Plan to ensure compliance: 1. Licensed nurse to perform pain assessments on all current residents and address any pain that is identified. Completed 4/23/2024 2. DON/designee to re-educate licensed nurses in the process for unavailable medications and medications refusal to include steps to follow when medications are unavailable or refused by the resident. The Regional Nurse Consultant and [NAME] President of Operations provided in-service to DON and administrator. Staff that are on leave from the facility, as well as newly hired staff in the future will be given the pain medication education by the same individuals noted above before starting their next shift. This facility does not employ the use of agency personnel. Initiated on 4/23/2024. Completed 4/23/2024 3. DON/designee to re-educate licensed nurses on contacting physician for alternative pain medication to include obtaining a new order for an available pain medication from the E kit (facility's emergency medication kit). DON/designee to re-educate certified medication aides to notify licensed nurse when medication is not available. The Regional Nurse Consultant and [NAME] President of Operations provided in-service to DON and administrator. Staff that are on leave from the facility, as well as newly hired staff in the future will be given the pain medication education by the same individuals noted above before starting their next shift. This facility does not employ the use of agency personnel. Initiated on 4/23/2024. Completed 4/23/2024 4. The Medical Director was notified by Administrator on 4/23/2024 at 9:00 pm on the immediate jeopardy citation. 5. An Ad-hoc QAPI meeting was held on 4/23/2024 by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. Monitoring 1. DON/designee will perform medication reconciliation twice a week and ongoing to ensure and obtain pain medication is available for residents receiving pain medications. 2. DON/designee will review the 24-hour report daily to ensure residents pain is being documented and controlled, MD is being notified, and changes of condition are documented, and interventions are initiated for pain management. This process will be ongoing. 3. The above will be reviewed in the monthly facility QA meeting for no less than 60 days or until the Administrator determines substantial compliance has been achieved and maintained. On 04/26/2024 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Interview on 04/26/2024 with the DON at 3:09 pm revealed she was in serviced by RN C about the maintenance of resident pain control with the understanding of pain control management and communication. Interview on 04/26/2024 11:0 am with CMA A who said she attended an in-service about medication management and how early to let the DON and nurses know they are running out of medications and what to do if a resident refuses a medication. She revealed she was to tell the nurse or DON 7 days prior to a resident running out of medication. At day 7, prior to no more medications, she is going to let the charge nurse, the nurse manager, and the DON know the resident only has 7 days of medication left. She will let the charge nurse and the DON know immediately if the resident does not have any medication available for the resident. If a resident refuses medication, she will notify the nurse who will make the notation in the resident's chart. Interview on 04/26/2024 at 11:58 am with CMA B revealed he attended an in-service about medication ordering. He must let the DON and nurse know if they run out of any medication and have none to administer to a resident. If the resident has 8 days left of a medication, he needs to notify the nurse or DON so the pharmacy can be notified, or he needs to call the pharmacy. If it is a narcotic, he needs to tell a nurse or the DON that they only have 8 days left of medication and the resident needs a refill. If a resident refuses medication, he needs to let the nurse knows so he or she can put a note in the chart. Interview on 04/26/2024 at 1:12 pm with CMA C revealed he works 6:00 pm - 2:00 pm shift and was in-serviced on medication availability. At day 7, prior to the resident running out of a medication, you must tell the charge nurse and if resident refuses medication you tell the charge nurse. If there is no medication in the facility for a resident, they will tell the nurse and he or she will try and get it from the e-kit. If there are any medication problems he will inform the DON, especially if there is no medication in the facility for the resident. Interview on 04/26/2024 at 1:29 pm with CMA D revealed he works 2:00 pm - 10:00 pm shift and was in-serviced on ordering medications specific to pain management medications. CMAs are supposed to let the charge nurse know when they are down to a 7-day supply of medications. At day 7 they will re-order or let the ADON or charge nurse reorder medications. If the facility is out of a medication he needs to get with the supervisor and the charge nurse to see if they can get it from the e-kit and he will inform the DON that the medication was not available. If the resident refuses a medication, let the nurse know. Interview on 04/26/2024 at 2:01 pm with CMA E revealed she works the 2:00 pm - 10:00 pm shift and she was in-serviced about ordering medications. If you are out of medications, you do not circle it. You notify the nurse, and she will get it from the e-kit. If you are out of a medication, you report it to the nurse and DON. At the point that a resident has only 7 days left of a medication, inform the nurse so she can request it. If the resident is complete out of a medication, the DON needs to be informed. If a resident tells you they do not want a medication, if they refuse it, let the nurse know. Interview on 04/26/2024 at 11:26 am with RN A revealed she worked the 6:00 am - 2:00 pm shift and she was in-serviced on the process for unavailable medications and how to order them and when to go to the e-kit. She will let the DON know if there are any problems with ordering medication or a resident does not have a medication. She has been educated what to do if a resident refuses a medication. Interview on 04/26/2024 at 11:38 am with RN B revealed he works either 8:00 am - 5:00 pm or 6:00 am - 2:00 pm was in-serviced in making sure that the residents have all their prescribed medication, when and how to order them and when to use the e-kit. She will inform the DON if there are any problems with resident medications. She will make a note in the resident's record if they refuse medication. Interview on 04/26/2024 at 12:11 pm with LVN B revealed she attended an in-service about the correct way to order medications and let the DON know if there are any medication issues and to put a note in the residents record if they refuse a medication. Use the e-kit to get medication if you can if and you can't make sure to notify the DON. Interview on 04/26/2024 at 12:46 pm with LVN A revealed she works the 2:00 pm - 10:00 pm shift and the 10:00 pm - 6:00 am shifts and is PRN and she attended an in-service making sure residents have their medications and how to make sure they have them. Use the e-kit and if the medication is not available, let the DON know immediately. Interview on 04/26/2024 at 12:49 pm with LVN C revealed she is PRN she has worked all three of the facility shifts. She attended an in-service regarding ordering medications and making sure the resident has the necessary medications. It is good to use the e-kit and let the DON know if there are any medications issues. Put a note in the resident record if they refuse to take one of their medications. Interview on 04/26/2024 at 1:17 pm with LVN D revealed he works 10:00 pm - 6:00 am and was in-serviced about getting resident medications to make sure beforehand there is not a problem. Use the e-kit and if any issues, let the DON know. Interview on 04/26/2024 at 2:08 pm with LVN revealed he works the 10:00 pm - 6:00 am shift and she was in-serviced about obtaining the correct medications for a resident. It is important to let the DON know about any medications that are not available to the Resident and to use the e-kit and order medications before they run out. Interview on 04/26/2024 at 2:26 pm with RN C revealed he works either 6:00 am - 2:00 pm or 2:00 pm - 10:00 pm and she was in-serviced on getting resident medications ordered and how and when to use the e-kit and to write it in the resident chart if they refuse medications. Interview on 04/26/2024 at 2:36 pm with LVN F revealed he works 2:00 am - 10:00 pm and he attended some in-services about medications. He was told to let the DON know if there are not medications for the resident in the facility and to try and use the e-kit if something is missing. Interview on 04/26/2024 at 2: 05 pm with the Administrator revealed he received in-services on 4/23/24 from the RVPO about on pain management and pain and ensuring resident pain control needs are met by facility staff. He learned about symptoms of pain and making sure he understands the nurse's role for assessing for pain and to make sure the medical staff address resident pain immediately. Interview with the DON at 3:09 pm revealed she was in serviced by RNC about the maintenance of resident pain control with the understanding of pain control management and communication with her nursing staff. Reviewed the 04/23/2024 in-service given by RNC to the DON regarding pain assessment and management. Reviewed the 04/23/2024 in-service given by the RVPO to the Administrator regarding pain assessment and management. Reviewed the 04/23/2024 in-service given to the nursing staff by the DON regarding pain assessment and management. Reviewed Resident #1's pain assessment dated [DATE] completed by a licensed nurse. Interview and observation on 04/26/2024 at 2:50 pm of Resident #1 revealed she was out of bed, in her wheelchair, out of her room, visiting another resident and she said her pain was better and she was now taking morphine. Reviewed new order dated 04/21/2024 to discontinue hydromorphone and methadone and start morphine. Reviewed 04/23/2034 pain assessments performed by a licensed nurse on all current residents. Reviewed email dated 04/23/2024 from the Administrator notifying the Medical Director of the immediate jeopardy citation. Reviewed the Ad-hoc QAPI document that reflected a meeting was held on 4/23/2024 by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. Review of staff list and in service trainings reflected 80% of staff in serviced. The Administrator was informed the Immediate Jeopardy was removed on 04/26/2024 at 3:52 pm. While the IJ was removed on 04/26/2024, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Per administrative review, the investigation was reopened on 05/10/2024. A second IJ was identified and a new IJ template was provided to the facility on [DATE] at 2:54 PM. This was determined to be an additional Immediate Jeopardy (IJ) on 05/15/2024 at 2:54 pm in the same area of non-compliance. The Administrator and the DON were notified. The Administrator was provided with an additional IJ template on 05/15/2024 at 2:54 pm. An additional POR was required by the facility. The Facility failed to: Follow their facility policies and procedures and administer medication, pazopanib (chemotherapy medication), in accordance with Resident #1's prescribed orders who had a diagnosis of malignant terminal cancer. Resident #1 was never administered the medication, subsequently missing 24 doses. Review of the hospital discharge records dated 04/21/2024 reflected Resident #1 was prescribed pazopanib (chemotherapy medication) 200 mg. + 600mg oral once a day. Review of Resident #1's paper chart medication order reflected pazopanib (chemotherapy medication) 200 mg. + 600 mg. oral once a day. Review of Daily Skilled Nurse's Note (undated) reflected nurse spoke with the oncology office regarding the medication pazopanib and the pharmacist could not fill the medication until a pre-authorization was completed. The NP was notified and gave an order to hold the medication until available. Resident #1 was aware of the reason the pazopanib was on hold. Review of an order from the NP dated 04/24/2024 reflected pazopanib was on hold awaiting pre-authorization until the medication was available. Interview on 05/14/2024 at 11:33 am with the pharmacist, who was contacted by Resident #1's oncologist to fill Resident #1's pazopanib, revealed the pharmacy received an order from the oncologist on 05/09/2024 and the medication was ready to go except for insurance information. Interview on 05/16/2024 at 12:47 pm with Resident #1 revealed she knew she was not getting the medication because there was an insurance issue and the facility had to find a way to get the medication . Interview on 05/16/2024 at 1:07 pm with the Hospice Physician revealed the medication for pazopanib shoul [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident (Resident #1) reviewed for pain, in that: The facility failed to: Provide pain medication ordered for resident with a diagnosis of malignant cancer who suffered from chronic pain. An Immediate Jeopardy (IJ) was identified on 04/23/2024. The IJ template was provided to the facility on [DATE] at 5:57 PM. While the IJ was removed on 04/26/2024, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk for prolonged and unnecessary pain and suffering, decreased mobility, decreased quality of life, and decreased quality of care. Findings included: Review of Resident #1s undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and most current re-admission 04/21/2024 diagnoses including malignant neoplasm of peripheral nerves and autonomic nervous system (rare cancers that start in the lining of the nerves), abrasion of lower back and pelvis, adrenocortical insufficiency (occurs when the adrenal glands don't make enough of the hormone cortisol) and pain. Review of Resident #1 's MDS dated [DATE] reflected a BIMS of 15 indicating no cognitive impairment. Further review revealed over the last 5 days she had pain or hurting, experienced pain frequently, and pain had made it difficult for her to sleep occasionally. Verbal descriptor scale of pain over the last 5 days revealed the intensity of her pain has been severe. Over the last 5 days the resident had received a scheduled pain medication. Review of Resident #1's care plan dated 08/22/2023 revealed category of special care monitor for the presence of pain/intolerance during self-care activities. Category dated 08/22/2023 ADLs Functional Status/Rehabilitation Potential Monitor/record/report for presence of pain/intolerance during transfers. Review of hospital records dated 04/09/2023 until discharge of Resident #1 to the facility on [DATE] reflected patient endorsed worsening lower left extremity pain and swelling for the last couple of weeks. She lived at a skilled nursing facility, and they ran out of her pain medication 2-3 weeks ago and she presented to the ED for uncontrolled lower left extremity pain and leg wound. She had a history of malignant neoplasm of peripheral nerves of thorax and malignant peripheral nerve sheath tumor of chest (a type of cancer that can occur in various locations of your body). Patient's cancer was locally advanced and not curable. As a result of the cancer, she experienced chronic pain for which she was on chronic opiates (including methadone). Hospital records indicate they initially thought her uncontrolled pain on presentation was due to her cancer, but X-rays revealed her femur was broken in several places. Review of Resident #1's paper chart medication orders reflected the following: *methadone schedule II 5 mg. amount to administer: 1 tab; oral twice a day pain unspecified 02/02/2024 open ended. * methadone schedule II 10 mg. amount to administer: 3 tablets; oral every 8 hours pain, unspecified, 02/08/2023 - open ended. * hydromorphone schedule II tablet 4 mg. amount to administer; 4 tabs, oral every 6 hours hold for sedation pain, unspecified, 02/08/2024 - open ended. In an interview on 04/22/2024 at 12:26 pm the DON revealed that medication administration documentation was completed in the paper chart for residents. If a medication was not given, the person who was responsible for administering the medication drew a circle around their initials indicating that the medication was not administered to the resident. The DON further stated a note was written on the back of the paper medication administration record, or sometimes both a circle and a note was written on the back of the paper medication administration indicating on the paper medication record that a resident's medication was not given. Additionally, if there was a blank in the space that should indicate the time and date a medication was scheduled to be given, the medication was not given. The DON said that if Resident#1 was not given her pain medication, it was because the medication was not available to give to her. Record review of Resident #1's February 2024 paper MAR revealed the following: Handwritten notes on reverse side of Resident #1's of the MAR for methadone schedule II 10 mg. reflected the pain medications were not available to administer on the following dates. 02/20/2024 3:00 pm Methadone 10 mg. - not available 02/21/2024 3:00 pm Methadone 10 mg. - not available 02/22/2024 3:00 pm Methadone 10 mg. - not available 02/25/2024 3:00 pm Methadone 10 mg. - not available 02/26/2023 3:00 pm Methadone 10 mg. - not available Handwritten circles were around the initials of the staff member and a blank space in a date and time box reflected methadone schedule II 10 mg. was not given to the resident, 25 times because it was not available and therefore not administered. 02/09/2024 7:00 am 02/12/2024 3:00 pm 02/14/2024 11:00 pm 02/16/2024 3:00 pm 02/20/2024 7:00 am and 11:00 pm 02/21/2024 3:00 pm and 11:00 pm 02/22/2023 11:00 pm 02/23/2024 7:00 am, 3:00 pm, and 11:00 pm 02/24/024 11:00 pm 02/25/2024 11:00 pm 02/26/2024 7:00 am and 11:00 pm 02/27/2024 7:00 am, 3:00 pm, and 11:00 pm 02/28/2024 7:00 am, 3:00 pm, and 11:00 pm 02/29/2024 7:00 am, 3:00 pm, and 11:00 pm Handwritten circles were around the initials of the staff member which reflected hydromorphone schedule II table 4 mg. was not given to the resident, 16 times because it was not available and therefore not administered. 02/17/2024 - 02/20/2024 Handwritten notes on reverse side of Resident #1's of the MAR revealed hydromorphone reflected, 02/17/2024 hydromorphone on order (nurse notified). Handwritten circles around the initials of the staff member who was responsible to administer methadone schedule II 5 mg. tab. was not given to the resident, 20 times because it was not available and therefore not administered. 03/01/2024 11:00 am and 7:00 pm 03/02/2024 11:00 am and 7:00 pm 03/03/2024 - 03/10/2024 11:00 and 7:00 pm Record review of Resident #1's March 2024 paper MAR beginning 02/08/2024 revealed the following: Handwritten circles around the initials of the staff member who was responsible to administer methadone schedule II 10 mg. reflected that the ordered medication was not given to the resident, 17 times because it was not available and therefore not administered. 03/01/2024 - 03/02/2024 03/03/2024 7:00 am 03/03/2024 3:00 pm 03/04/2024 - 03/06/2024 Handwritten note on the reverse side of the methadone schedule II 10 mg. MAR reflected, date illegible, MD Notified. Handwritten circles around the initials of the staff member who was responsible to administer hydromorphone schedule II tablet 4 mg. reflected that the ordered medication was not given to the resident, 38 times because it was not available and therefore not administered. 03/02/2024 1:00 pm 03/03/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/04/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/05/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/06/2024 1:00 pm, 7:00 am and 1:00 pm 03/16/2024 7:00 pm 03/17/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/18/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/19/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/20/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/21/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/22/2024 1:00 am Handwritten notes of reverse side of Resident #1's hydromorphone schedule II tablet 4 mg schedule II MAR reflected the following handwritten notes : 03/02/2024 awaiting pharmacy for methadone 5 mg., methadone 10 mg., and hydromorphone II, 03/16/2024 residents medication not given awaiting pharmacy see nurses notes, 03/17/2024 resident medication not given hydromorphone 4 tabs see nurses notes, and 03/19/2024 am hydromorphone 4 mg (4 tabs) not available will notify NP in AM. Record review of Resident #1's April 2024 paper MAR beginning 02/08/2024 revealed the following: Review of Resident #1's paper medication administration record for April 2024 order reflect tab. oral twice a day 02/08/2023 - open ended. The handwritten circles around the initials of the staff member who was responsible to administer methadone schedule II 5 mg. was not given to the resident, 4 times because it was not available and therefore not administered. 04/08/2024 11:00 am and 7:00 pm 04/09/2024 11:00 am and 7:00 pm Handwritten circles around the initials of the staff member who was responsible to administer methadone schedule II 10 mg. was not given to the resident, 10 times because it was not available and therefore not administered. 04/06/2024 11:00 pm 04/07/2024 7:00 am, 3:00 pm, and 11:00 pm 04/08/2024 7:00 am, 3:00 pm, and 11:00 pm 04/09/2024 7:00 am, 3:00 pm, and 11:00 pm Handwritten circles around the initials of the staff member who was responsible to administer hydromorphone schedule II tablet 4 mg. was not given to the resident, 18 times because it was not available and therefore not administered. 04/05/2024 1:00 am, 7:00 am, and 1:00 pm 04/06/2024 1:00 am, 7:00 am, and 1:00 pm 04/07/2024 1:00 am, 7:00 am, and 1:00 pm, and 7:00 pm 04/08/2024 1:00 am, 7:00 am, and 1:00 pm, and 7:00 pm 04/09/2024 1:00 am, 7:00 am, and 1:00 pm, and 7:00 pm Interview with Resident #1 on 04/22/2024 at 11:27 am revealed she was feeling better since her return from the hospital, and she was getting her pain medications. She said there have been several times she had not received her pain medications while living at the facility and it was because they have run out of them. She said occasionally they will give her Tylenol #3 when her pain medications are not available, but it does not help very much. She said she was always in pain at a constant level, on a pain level of a 6 - 7 all the time and she told the facility she was in pain. Prior to her last hospital admission on 04/09/2024 she said she had not been given pain medications for a long time but was unsure of how long she had not been receiving them. She said she told them the pain was in her legs and that this was a different and terrible pain. She said her legs hurt very badly. The day she was admitted to the hospital she had a shower, and the pain was terrible, and she was crying from the pain and LVN A saw her crying. She called EMS herself to be taken to the hospital. Interview with LVN A on 04/24/2024 at 2:55 pm revealed Resident #1 sometimes did not get her pain medications because they could not get the prescription for the order filled. At times they would give her Tylenol #3, but it was not effective, and the hydromorphone helped her more. LVN A revealed Resident #1 was in pain every day, because of her condition, cancer. LVN A revealed Resident #1 was crying and Resident #1 told LVN A she said she was having pain and Resident #1 told LVN A the pain was too much. LVN A called the NP for Tylenol #3 on 04/09/2024 and it was administered to Resident #1, but it did not help, and you could see from Resident #1's facial expressions and Resident #1's crying that the Tylenol #3 did not help. LVN A said she had never seen her crying that way. LVN A revealed she was in pain every day and it was important for her to give Resident #1 her pain medications because she was in pain, and she was a cancer patient. Interview with the DON on 04/24/2024 at 1:14 pm and 04/26/2024 at 3:09 pm revealed Resident #1 had a diagnosis for pain because she had cancer and Resident #1 had orders for prescription pain medications and the NP and MD took care of Resident #1's pain medication and that the facility had nothing to do with Resident #1's insurance, it was with the doctors. The DON said Resident #1 was in pain all the time, but they could not get her prescription filled, so there was nothing to do. The DON revealed it was not okay for Resident #1 to even have gone a day without her pain medication and the DON understood how high Resident #1's pain level was. The DON revealed she was not aware that Resident #1 was crying because of her pain. The staff did not bring it to her attention that she was crying except the day she went to the hospital. The orders from the doctor should have been filled. Resident #1 suffered from chronic pain and the facility was aware that she suffered from chronic pain. The DON was responsible for making sure medications are ordered and that there is a process in place to make sure residents receive the medication. Interview with the Administrator on 04/26/2024 ADM at 2:50 pm revealed he was aware that there was a struggle and an issue with her Resident #1 her pain medication and it was his understanding that the pain was addressed. He thought it was addressed because they contacted the MD, and another mediation was ordered that resolved the pain and that did not happen. If a resident goes without pain medication the resident could have severe pain and suffering. He revealed Resident #1's needs were not being meet and he knew she was in pain but did not know she was crying. He revealed he was aware Resident #1 called the EMS because of her pain and was surprised to hear that Resident #1 called the EMS as opposed to a staff member. He revealed the nursing staff and facility did not meet her needs. Facility Policy Administering Medications dated 04/2019 revealed the Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions. Medications are administered in accordance with prescribed orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication . If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. This was determined to be an Immediate Jeopardy (IJ) on 04/23/2024 at 5:57 pm. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 04/23/2024 at 5:57 pm. The following POR was accepted on 04/25/2024 11:01 am. and included: On 4/19/2024 an abbreviated survey was initiated at [facility]. On 4/23/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Threat states as follows: IJ Component: F697 Pain Management Facility failed to issue prescription pain medications Hydromorphone and Methadone as ordered for [AGE] year-old female resident. Immediate Actions: 1. Resident returned to facility on 4-21-24. Upon return, pain assessment was completed by a licensed nurse and resident denied pain and was documented on 4-21-2024. 2. Resident returned to facility on 4-21-2024 with a new order to discontinue hydromorphone and methadone and start morphine. Morphine medication was filled and dispensed 4-21-2024. A licensed nurse assured medication filled and assesses pain every shift. Completed 4-21-2024. Facility Plan to ensure compliance: 1. DON/designee will re-educate pain management with emphasis on the assessing recognizing, identifying, and addressing the underlying cause of the pain as well as assuring medication is in the facility. The Regional Nurse Consultant and [NAME] President of Operations provided in-service to DON and Administrator. Staff that are on leave from the facility, as well as newly hired staff in the future will be given the pain management education by the same individuals noted above before starting their next shift. This facility does not employ the use of agency personnel. Initiated on 4/23/2024. Completed 4/24/2024. 2. Licensed nurse to perform pain assessments on all current residents and address any pain that is identified. Completed 4/23/2024 3. The Regional Consultant Nurse provided in-service to DON, ADON, and Administrator. DON/designee to re-educate licensed nurses on pain assessment, to include verbal and non-verbal signs of pain and reporting pain to provider (NP/MD). Licensed nurses will be in-serviced as needed thereafter. Licensed nurses will be in-serviced as needed thereafter. Staff that are on leave from the facility, as well as newly hired staff in the future will be given the pain education by the same individuals noted above before starting their next shift. This facility does not employ the use of agency personnel. Licensed nurses will be in-serviced as needed thereafter. Staff that are on leave from the facility, as well as newly hired staff in the future will be given the pain competency check off by the same individuals noted above before starting their next shift. This facility does not employ the use of agency personnel. Initiated on 4/23/2024. Completed 4/23/2024 4. The Medical Director was notified by Administrator on 4/23/2024 at 9:00 pm on the immediate jeopardy citation. 5. An Ad-hoc QAPI meeting was held on 4/23/2024 by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. Monitoring: 1. DON/designee will perform medication reconciliation twice a week and ongoing to ensure pain medication is available for residents receiving pain medications. 2. DON/designee will review the 24-hour report Monday through Friday, and RN designate will review the 24 hour report every Saturday and Sunday, to ensure residents pain is being documented and controlled, MD is being notified, and changes of condition are documented and interventions are initiated for pain management. 3. The above will be reviewed in the monthly facility QA meeting for no less than 60 days or until the Administrator determines substantial compliance has been achieved and maintained. On 04/26/2024 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Interview on 04/26/2024 at 11:26 am with RN A revealed she worked the 6:00 am - 2:00 pm shift and she was in-serviced on pain management and pain assessment. When she goes to a patient room, she is going to ask them if they are in pain and check their vitals and see if heart is elevated if they are in pain. She revealed that if you look at a patient, you can tell if they are pain. If the patient is in pain, ask where the pain is if they know what was causing it and when it started. Interview on 04/26/2024 at 11:38 am with RN B revealed he worked either 8:00 am - 5:00 pm or 6:00 am - 2:00 pm was in-serviced in pain assessment and management. He revealed all residents should be assessed for pain. Pain depends on the individual and was based on their diagnosis and if they have chronic pain. He revealed pain was individual for every person and should be prioritized as much as anything else if not more. If a resident cannot verbally tell you, they are in pain then he needs to see if the resident was grimacing or moaning. Staff need to look at resident's pain history. Interview on 04/26/2024 at 12:11 pm with LVN B revealed she attended an in-service about pain assessment in detail. She revealed there are two ways to assess a resident's pain one was to ask them and the second is to look at them. If they cannot tell them look at their diagnoses and assess residents completely if they can't respond. Pain is different for everyone. It can depend on their tolerance and their diagnoses. Interview on 04/26/2024 at 12:46 pm with LVN A revealed she works the 2:00 pm - 10:00 pm shift and the 10:00 pm - 6:00 am shifts and was PRN and she attended an in-service about pain. She said she received a copy of a document that discussed pain assessment and management and discussed the procedures of identify pain with a resident. Interview on 04/26/2024 at 12:49 pm with LVN C revealed she was PRN she has worked all there of the facility shifts. She attended an in-service regarding pain management. She learned about different types of pain and that residents may have different symptoms that may indicate that they need something different. She revealed nurses need to evaluate the individual needs and differences of each of the residents when evaluating for pain. Interview on 04/26/2024 at 1:17 pm with LVN D revealed he works 10:00 pm - 6:00 am and was in-serviced about pain management. If a resident can speak, you can ask them and they can tell you about their pain and a resident cannot speak you need to see if they are grimacing or frowning to assess their level of pain. Interview on 04/26/2024 at 2:08 pm with LVN revealed he works the 10:00 pm - 6:00 am shift and she was in-serviced about pain management. To assess a resident for pain she can look at the face of the resident for a grimace, ask if they are hurting, ask the severity of the pain and assess for all symptoms. She revealed nurses need to check their full body for their position and vitals. She revealed she does a head-to-toe assessment. Interview on 04/26/2024 at 2:26 pm with RN C revealed he works either 6:00 am - 2:00 pm or 2:00 pm - 10:00 pm and she was in-serviced on assessing pain. To assess pain, you look at the patient and ask how they are doing and if they say they are in pain ask questions about the pain including where did it start and how long has it lasted. If someone was nonverbal you must look at their facial expressions. The resident might be moaning or crying or be depressed. You can touch them and know if they are in pain or not. Interview on 04/26/2024 at 2:36 pm with LVN F revealed he works 2:00 am - 10:00 pm and he attended some in-services about medication. He received an in-service about pain assessment and pain management, and they discussed how to assess the resident's pain for both verbal and nonverbal residents and that pain is different and unique to all residents. Interview on 04/26/2024 at 2: 05 pm with the Administrator revealed he received in-services on 4/23/24 from the RVPO about on pain management and pain and ensuring resident pain control needs are met by facility staff. He learned about symptoms of pain and making sure he understands the nurse's role for assessing for pain and to make sure the medical staff address resident pain immediately. Interview with the DON at 3:09 pm revealed she was in serviced by RNC about the maintenance of resident pain control with the understanding of pain control management and communication with her nursing staff. Reviewed the 04/23/2024 in-service given by RNC to the DON regarding pain assessment and management. Reviewed the 04/23/2024 in-service given by the RVPO to the Administrator regarding pain assessment and management. Reviewed the 04/23/2024 in-service given to the nursing staff by the DON regarding pain assessment and management. Review of staff list and in service trainings reflected 80% of staff in serviced. The Administrator was informed the Immediate Jeopardy was removed on 04/26/2024 at 3:52 pm. While the IJ was removed on 04/26/2024, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 4 of 24 residents (Resident #71, #85, and #87 and Resident #73) reviewed for infection control, in that: 1 The facility failed to prevent Resident #71's, 85's and 87's wounds from getting infected. Resident #71 died in the local hospital [DATE] due to sepsis (a serious condition resulting from the presence of harmful microorganism in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death.) and infected wounds. Resident #85 was transferred to the local hospital on [DATE] and diagnosed with sepsis. Resident #87 was diagnosed with a wound infection on [DATE]. 2. TLVN S did not perform hand hygiene and change her gloves while performing wound care on Resident #87 and performed wound care on two wounds at the same time while performing wound care on Resident #87. 3. LVN M did not wash her hands with soap and water after picking up feces with gloves and discarding the feces and gloves on [DATE] at 9:05 .am. 4. CNA C and D failed to perform hand hygiene while serving lunch on [DATE] to Resident #31, 47, 75, 12, 25, 46, 392, 391, and 393. 5. TLVN S did not perform hand hygiene while performing wound care on Resident #73. An IJ was identified on [DATE] at 5:10 pm. The IJ template was provided to the facility on [DATE] at 5:03 pm. While the IJ was removed on [DATE] at 4:35 pm, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices placed residents at risk for infections, sepsis, and a diminished quality of life and death. Findings included: Record review of Resident #71's undated face sheet reflected a [AGE] year-old female who was originally admitted to the facility on [DATE], readmitted on [DATE] with diagnoses including history of stroke, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, pressure ulcer of left hip stage 3, pressure ulcer of unspecified heel unstageable, nutritional deficiency, unspecified pain, and type 2 diabetes mellitus with unspecified complications, and discharged on [DATE]. Record review of Resident #71's quarterly MDS, dated [DATE], reflected Resident #71 did not have any unhealed pressure ulcers/injuries and no other skin problems. Record review of Resident #71's quarterly MDS, dated [DATE], reflected Resident #71 had one unstageable pressure ulcer/injury and a diabetic foot ulcer. Staff were required to provide Resident #71 with nutrition or hydration intervention, pressure ulcer/injury care, application of nonsurgical dressings (with or without topical medications) other than to feet, applications of ointments/medications other than to feet, and application of dressings to feet (with or without topical medications). Record review of Resident #71's acute care plan, dated [DATE], reflected Resident #71 had pressure ulcer at her buttock, right lateral ankle and right knee. Record review of Resident #71's comprehensive care plan, edited [DATE], reflected Resident #71 will not develop skin breakdown related to incontinence. Record review of Resident #71's Braden scales for predicting pressure sore risk, dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE], reflected a score of 9 (with 9 or less indicating very high risk, ,d+[DATE] high risk, ,d+[DATE] moderate risk, ,d+[DATE] at risk for developing pressure ulcer or injuries). Record review of Resident #71's wound notes reflected Resident #71's foot wound developed on [DATE]. Record review of Resident #71's wound care notes, dated [DATE], reflected the following: Left Ischium unstageable measuring 4.6 x 3.4 cm. Left heel diabetic wound measuring 4x4 cm x unstageable. Right heel diabetic wound measuring 4 x 2.5 x unstageable. Record review of Resident #71's wound care notes, dated [DATE], reflected the following: Left Ischium unstageable measuring 4.5 x 3.5 cm. Left heel diabetic wound measuring 3.5 x 3.5 cm x unstageable. Right heel diabetic wound measuring 4 x 1.5 x unstageable. Resident #71's wound notes also reflected an order for cipro (Antibiotics are medicines that fight bacterial infections in people and animals) 500mg PO BID X 7 days for wound infection. Record review of Resident #71's wound care notes, dated [DATE], reflected the following: Right lateral ankle diabetic wound measuring 3 x 3 cm x unstageable. Left Ischium unstageable measuring 4.5 x 3.5 cm, note indicated the wound was deteriorating. Left heel diabetic wound measuring 3 x 3 x 2 cm. Right heel diabetic wound measuring 4 x 1.2 cm x unstageable. Resident #71's wound noted also reflected an order Doxycycline (Antibiotics are medicines that fight bacterial infections in people and animals.) 100 mg PO BID X 10 days for wound infection. Record review of Resident #71's wound care notes, dated [DATE], reflected the following: Right lateral ankle diabetic wound measuring 8 x 4.5 x unstageable. (Size was 2.6 times the previous week). note indicated the wound was deteriorating. Left Ischium unstageable measuring 4.5 x 3.5 cm, note indicated the wound was deteriorating. Left heel diabetic wound measuring 2 x 1 cm x unstageable. Right heel diabetic wound measuring 4 x 1.2 cm x unstageable, note indicated the wound was deteriorating. Resident #71's wound care notes also reflected an order Bactrim DS (Antibiotics are medicines that fight bacterial infections in people and animals.) PO BID X 7 days for wound infection. Review of Resident #71's wound care notes also reflected Bactrim DS (Antibiotics are medicines that fight bacterial infections in people and animals.) PO BID X 7 days was discontinued on [DATE] and new order for Keflex 500mg 1 tab PO every 12 hours x 10 days, wound culture to right ankle. Resident # 71's wound care notes dated [DATE] reflected, patient seen by facility treatment nurse for daily wound care, left foot has deteriorated a great deal: Record review of Resident #71's skilled wound care communication log for daily rounds, dated [DATE], reflected the following: Left ischium 4.5 x 3.5 x UTD. Right lateral ankle 8.1x 4.6 x UTD. Right anterior ankle 0.5 x 0.5 x UTD. Left heel 2 x 1 x UTD. Right knee 4 x 3 x UTD. Right Achilles heel 4.1 x 1.3 x 0.5. Record review of Resident #71's wound doctor's progress notes reflected the following: Record review of Resident #71's progress notes reflected Resident #71 was discharged to the local hospitalER on [DATE]. Record review of the Resident #71's nurse's notes, dated [DATE] at approximately 3:51 pm, reflected per Resident #71's family's request, Resident #71 was sent to the local hospitalER on [DATE] for further assessment of her right foot. Record review of Resident #71's hospital records, reflected Resident #71 was admitted to the local hospital on [DATE] with diagnoses including sepsis secondary to infected left buttock decubitus ulcer and right leg ulcer. Resident #71's hospital records also reflected, integumentary: Warm, Dry, multiple skin ulcers of the bilateral heels of the feet, right knee area medially. 4-inch diameter deep ulcerated wound on the left buttock, which is malodorous (smelling, very unpleasant), with exudative (he slow escape of liquids from blood vessels through pores or breaks in the cell membranes) drainage. minimal surrounding erythema at the wound edges . There was concern for foul-smelling exudate from the left buttock wound and internal medicine was asked to hospitalize. Records also reflected Resident #71 had status post right below-knee amputation dated [DATE]. Record review of Resident #71's WBC, dated [DATE], reflected a value of 22.0 mm (high), normal range 4XXX,d+[DATE].0 (WBC- defend your body against infections and disease. But, when there are too many white blood cells, it usually means you have infection or inflammation in your body): Albumin level 1.7 (low) normal range was 3.4 to 5.4 g/dL (If you have a lower albumin level, you may have malnutrition. It can also mean that you have an inflammatory disease, most cases of low albumin are caused by acute and chronic inflammatory responses.) Record review of Resident #71's death certificate reflected Resident #71 died on [DATE] with the causes of death being cerebral vascular accident, sepsis, infected hip, and foot pressure ulcer. Record review of Resident # 85's undated face sheet reflected a [AGE] year-old female who was admitted on [DATE] with diagnoses including anemia, unspecified, fracture of shaft of left tibia (the shinbone, the larger of the two bones in the lower leg.) and subsequent encounter for closed fracture with routine healing. Record review of Resident # 85's admission MDS assessment, dated [DATE], revealed a BIMS score of 15, which indicated she had no cognitive impairment. Record review of Resident # 85's acute care plan, dated [DATE], reflected Resident #85 had skin issue at her left tibia. Record review of Resident #85's wound doctor's notes, dated [DATE], reflected the following: Wound location- Left Tibia sign of infection -none measuring 6.6 x 8.0 cm x 0.2 cm exudate: scant, serous dressing used: Calcium Alginate with Honey, Dry Dressing Record review of Resident #85's wound doctor's notes, dated [DATE], reflected the following: Wound location- Left Tibia sign of infection -drainage measuring 6.1 x 8.1 x 1.3 cm. exudate: moderate, Serosanguineous, yellow Doxycycline 100mg 1 PO BID x 10 days. (Antibiotics are medicines that fight bacterial infections in people and animals.) Dressing used: Bactroban, Calcium Alginate Record review of Resident #85's wound doctor's notes dated [DATE] reflected: Wound location- Left Tibia sign of infection -drainage measuring 6.1 x 8.1 cm x 2.9 cm. exudate: moderate, Serosanguineous, yellow extend Doxycycline total 14 days. (Antibiotics are medicines that fight bacterial infections in people and animals.) dressing used--Collagen, Bacitracin and Cal alginate. Record review of Resident #85's NP progress notes dated [DATE] reflected the following: Chief Complaint/Reason for this Visit: Follow up on Left lower leg surgical wound infection. Patient was started on doxycycline for surgical wound infection. Wound care following. Vitals are stable per staff. Continue to monitor. Record review of Resident #85's progress noted, dated [DATE] at 10:00pm, reflected the following: Resident complained of increased drainage and warm to touch at wound care sight, upon assessing, removed bandage, wound care sight is red, warm to touch, pus, and has an odor . resident and family requested to go to the hospital. Another note with same date and time reflected the following, Resident family came to the nurses' station and asked if I could assess the resident's leg. The charge nurse from the hall and I assessed the resident, odor and brownish drainage leaking from the wound. After taking dressing out, scopious pus on the wound, this nurse did the treatment as order and charge nurse informed NP and sent Resident to ER. Record review of Resident #85's local hospital records, dated [DATE], reflected Resident # 85 was admitted due to sepsis (a serious condition resulting from the presence of harmful microorganism in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death.) of left lower extremity and bacteremia (the presence of bacteria in the blood). Resident #85's hospital records also reflected left lower extremity tissue culture was positive for MRSA, Klebsiella, and pseudomonas on [DATE]. Blood culture also positive for MRSA on [DATE]. Status post hardware removal, washout, and external fixation on [DATE], wound vac change on [DATE]. ORIF (Open reduction and internal fixation is a type of surgery used to stabilize and heal a broken bone) and PRS (Plastic and reconstruction surgery) closure was done [DATE]. Record review of Resident # 87's undated face sheet reflected a [AGE] year-old male who was admitted on [DATE] with diagnoses including unspecified open wound of left back wall of thorax without penetration into thoracic cavity, subsequent encounter, and pain unspecified. Record review of Resident # 87's admission MDS assessment, dated [DATE], reflected a BIMS score of 15, which indicated Resident #87 had no cognitive impairment. Record review of Resident # 87's acute care plan, dated, reflected Resident #87 had skin condition on his buttock, middle back and left Achilles. Record review of Resident #87's comprehensive care plan, dated [DATE], reflected Resident #87 required assistance with ADLs, he was at risk for pressure ulcer, and limited in mobility all or most of the time. Record review of Resident #87's wound care notes reflected the wound on Resident #87 buttocks was first noticed by staff seen on [DATE]. Record review of Resident #87's wound care notes, dated [DATE], reflected an order for Cipro 500 mg (Antibiotics are medicines that fight bacterial infections in people and animals.) PO every 12 hours x 7 days. Record review of Resident # 87's wound doctor's note, dated [DATE], reflected the following: Wound location: Bilateral Buttocks Sign of infection: None odor: None exudate: Mild, Serous measuring 8.0 x 7.1x 0.1 cm Wound location: middle back Sign of infection: None odor: None exudate: none measuring 2.5 x 0.5 cm x unstageable Record review of Resident # 87's wound doctor's note, dated [DATE], reflected the following: Wound location: Bilateral Buttocks Sign of infection: None odor: None exudate: mild, Moderate, Serous measuring 8.1 x 6.8 x 0.2 cm Wound location: middle back Sign of infection: None odor: None exudate: Mild, Moderate, Serous measuring 1.9 x 0.9 x 0.8 cm Record review of Resident # 87's wound doctor's note, dated [DATE], reflected the following: Wound location: Bilateral Buttocks Sign of infection: drainage odor: None exudate: moderate, serous, green measuring 8.1 x 5.1 x 0.3 Wound location: middle back Sign of infection: drainage odor: None exudate: mild moderate, serous, green measuring 2.2 x 0.6 x 0.7 cm Cipro 500mg (Antibiotics are medicines that fight bacterial infections in people and animals.) 1 PO q12 hrs x 7 days pending culture results. Review of undated Face Sheet for Resident #73 reflected she was admitted to the facility on [DATE] with diagnosis of Klebsiella pneumoniae (a type of gram-negative bacteria that can cause different types of healthcare-associated infections, including pneumonia, bloodstream infections, wound or surgical site infections, and meningitis), unspecified malignant neoplasm (history of cancer), Depression, Thrombocytosis (a disorder in which your body produces too many platelets), Nutritional deficiency, and Pressure ulcer of sacral region stage 4. Review of Resident #73's Care Plan for Pressure Ulcer/Injury dated [DATE] reflected Resident #73's ulcer will not exhibit signs of infection by keeping Resident #73 as clean and dry as possible and minimize skin exposure to moisture, and keep linens clean, dry, and wrinkle free. Review of the Quarterly MDS assessment for Resident #73 dated [DATE] reflected a BIMS Score of ,d+[DATE], which reflected moderate impairment in mental status. Resident #73 required one-person assistance for ADLs. An observation of a photograph from Resident #71's family, taken on [DATE] at 9:07 pm, reflected Resident #71's right foot. Resident #71's right foot was black and peeled from the bottom of her heel to above the ankle. Resident #71's right ankle bone was white and yellow and peeled. During an interview on [DATE] at 10:28am, Resident #71's family revealed Resident #71 expired on [DATE] at approximately 4:00 am due to sepsis and wound infection. Resident #71's family also revealed Resident #71 developed wound infections at the facility because she had no infections when she was admitted to the facility. Resident #71's family explained staff contacted them a few months ago (they could not indicate how many months or exact date of contact) and requested permission to treat Resident #71's wounds, which they granted permission. Resident #71's family revealed they did not know Resident #71 had a would on one of her feet. Resident #71's family explained they observed Resident #71's foot in the hospital on [DATE] and described the foot was black. During an interview on [DATE] at 11:06 am, TLVN S revealed she worked at the facility for five years. TLVN S explained she was responsible for providing daily wound care and cleaning, such as dressing changes and treatment, following wound care doctor's orders, and contacting the wound doctor and/or NP if there was an infection. TLVN S revealed a nurse (whose name she did not know) informed her several weeks ago (she could not provide the exact date or how many weeks ago it was) that Resident #71 had a spot on her heel. TLVN S explained Resident #71's spot on her heel worsened a few days later (she could not provide the exact date or how many days later it was). TLVN S explained she tried to apply triad paste to Resident #71's heel and placed Resident #71 on the wound doctor's rounds. TLVN S described Resident #71's heel was boggy (she did not define boggy). TLVN S explained Resident #71's wound began to get bigger. TLVN S revealed she observed Resident #71's right foot on [DATE] and described the ankle to front part of the foot as red, sloughy (yellow), boggy, macerated white skin, and the skin peeled back since her last observation on [DATE]. TLVN S revealed she did not observe Resident #71's wound as black on [DATE]. TLVN S also revealed Resident #71's family informed her on [DATE] that they were sending Resident #71 to the hospital. TLVN S revealed she received a photo from Resident #71's family on [DATE] in which she observed Resident #71's foot was black, and the infection spread from Resident #71's foot up to Resident #71's ankle. TLVN S also revealed she learned Resident #71 was septic and sepsis could cause an infection to spread. TLVN S did not know if Resident #71 had infections when Resident #71 was admitted to the facility. TLVN S revealed she first observed Resident #71's ankle and heel last week (she did not indicate the exact date or day). During an interview on [DATE] at 11:49 am, TLVN T revealed she worked at the facility for more than two years. TLVN T also revealed she was responsible for taking care of wounds and notifying residents' families, NP, and WCD of any changes of condition in residents' wounds. TLVN T revealed Resident #71 started off with wounds on her bilateral heel, ankle, interior ankle, and left ischium and TLVN T did not know when she first observed the wounds on Resident #71. TLVN T also revealed Resident #71 did not have the wounds when she was admitted to the facility. TLVN T did not know if Resident #71 was also admitted with infections. TLVN T revealed Resident #71 received daily wound care according to the physician's orders. TLVN T also revealed she last observed Resident #71 on [DATE], in which Resident #71's wounds were stable and had some necrotic tissue and slough. TLVN T revealed TLVN S informed her last week (she did not indicate the exact date or day) that Resident #71's wounds rapidly deteriorated. TLVN T also revealed the WCD visited the facility once a week. TLVN T did not know what cause Resident #71's ankle wound infection. During an interview on [DATE] at 1:20 pm, WCD revealed he worked for the facility under a contract for over one year. WCD also revealed he was responsible for managing residents' wound care. WCD revealed Resident #71 developed wounds on her legs. WCD also revealed Resident #71's wounds deteriorated. WCD did not know if Resident #71 was admitted to the facility with wounds and infections and when he started visiting and providing wound care to Resident #71. During an interview on [DATE] at 3:05 pm, RN I revealed she worked at the facility for five months. RN I also revealed she was trained and in-serviced on wound care and changing wound dressings. RN I also revealed she was responsible for monitoring and conducting wound care. RN I revealed she last observed Resident #71 on [DATE]. RN I explained Resident #71 had a wound on her right heel, right foot, left ankle, possibly left heel, possibly left knee, and hip sacral area. RN I also revealed she did not observe Resident #71 had wounds when she began her employment. RN I revealed she observed Resident #71 wounds had an odor, were dark colored, saggy, and had lots of drainage on [DATE]. RN I also revealed Resident #71 did not have any odors to her wounds, the wounds were smaller, and had no drainage on [DATE] or [DATE]). RN I did not know who the wound care nurse was who provided wound care to Resident #71 the week before [DATE] because TLVN T was out sick. RN I revealed wound care nurse A, her, and the other floor nurses were responsible for wound care. RN also revealed when she went to get a culture from Resident #71 on [DATE], she observed Resident #71 had drainage and the wound was bigger than on [DATE] or [DATE]. RN I did not know if Resident #71 was prescribed antibiotics and when Resident #71's wound developed. RN I revealed Resident #71's left foot and bottom hip area were treated; the right ankle and right heel wound were still present the first week of [DATE]. RN I also revealed Resident #71's right heel looked bigger when comparing first week of January to [DATE]. RN I revealed the other wounds did not have a change in status or condition when comparing first week of January to [DATE]. An observation of wound care performed by TLVN S on Resident #87 on [DATE] at about 7:45 am revealed TLVN S was assisted by a CNA. TLVN S gathered supplies outside the room. TLVN S and the CNA walked into Resident #87's room and performed hand hygiene. Resident #87 was rolled on his right side. TLVN S donned clean gloves, removed soiled dressing from the wounds on Resident #87's middle back and buttocks respectively, and had both soiled dressings on her hand. The soiled dressings from both of Resident #87's wounds contained serosanguineous drainages and was dated [DATE]. TLVN S did not change her soiled gloves or perform hand hygiene. TLVN S cleaned Resident #87's wound on his middle back with normal saline and a gauze with her soiled gloved hands and then moved to Resident #87's wound at his buttocks with the same normal saline and gauze. TLVN S again did not change her gloves or perform hand hygiene, applied medication med-honey to the wound bed at Resident #87's middle back using the same soiled gloved hand fingertips, and then moved to Resident #87's wound at the buttocks with same gloved hands applying med-honey to the wound bed and back to middle of the back. TLVN S then changed her soiled gloves, did not perform hand hygiene and donned clean gloves, and applied dressings on both wounds and dated the dressings. Both staff positioned Resident #87 in his bed, performed hand hygiene, and left Resident #87's room. An observation of 200 hall on [DATE] at 9:05 am revealed LVN M observed feces on the floor. LVN M put on gloves, picked up the feces, put the feces in a bag, discarded the bag of feces, discarded her gloves, used hand sanitizer, and entered a resident's room. LVN M was stopped before LVN M made physical contact with the resident in the room. During an interview on [DATE] at 9:05 am, LVN M revealed she worked at the facility for over one year. LVN M also revealed she was trained and in-serviced on infection control by the DON and ADON last week (she did not indicate the exact date). LVN M revealed she thought the hand sanitizer was enough hand hygiene to perform after discarding the gloves and feces. LVN M also revealed she usually washed and sanitized her hands and wore gloves before and after contact with each resident. LVN M explained that typically, if the feces was solid, she would try to wash her hands before and after. LVN M revealed she picked up the feces because she observed it on the ground. LVN M also revealed CNAs were responsible for picking up feces. LVN M also revealed if a nurse did not wear gloves and picked up feces, residents' health and wellbeing could be impacted. During an interview on [DATE] at 9:21 am, TLVN S revealed she was trained and in-serviced on infection control by the DON and ADON. TLVN S did not indicate when she was in-serviced. TLVN S also revealed she performed hand hygiene before and after contact with each resident. TLVN S revealed she would wash her hands with soap and water even if she used gloves to pick up a resident's feces and discarded the gloves and feces and used hand sanitizer before contacting another resident. TLVN S also revealed residents' health and wellbeing could be impacted, but it depended on the resident. TLVN S revealed a nurse should have washed their hands with soap and water before touching the next resident after picking up feces with gloves and discarding the feces and gloves. During an interview on [DATE] at 9:26 am, TLVN S stated, I know, I messed up on the first wound care with Resident #87. I read my binder after we were done and know exactly where I messed up. TLVN S explained when performing wound care on a resident with multiple wounds, it should be done one at a time. TLVN S further explained going back and forth from one wound to the other wound was cross contamination. TLVN S revealed after she took the soiled dressing from Resident #87's wounds, she was supposed to remove her soiled gloves, perform hand hygiene, and don clean gloves. TLVN S stated, Every time you remove gloves, hand hygiene is performed because of cross contamination. I was just putting the germ back in Resident #87's wounds, I did hand hygiene at the beginning and at the end of the procedure. TLVN S revealed she started rounding with the wound doctor on [DATE] and performed wound care on Resident #71 on [DATE]. TLVN S also revealed Resident #71's wound had gotten worst; the right foot was macerated (becomes soften by soaking in a liquid), and the dressing was saturated with a greenish drainage (like pseudomonas) with a foul odor. During an interview on [DATE] at 9:31 am, RN J revealed she worked at the facility for three years. RN J also revealed she was trained and in-serviced on infection control by the DON and ADON last week. RN J revealed she performed hand hygiene before and after contact with each resident and after resident care. RN J also revealed she would wash her hands with soap and water if she picked up feces with gloves and discarded the feces and gloves because it was feces and could go through gloves. RN J also revealed residents' health and wellbeing could be impacted if a nurse contacted them after picking up feces with gloves, discarding feces and gloves, and using hand sanitizer. During an interview on [DATE] at 9:37 am, LVN N revealed she worked at the facility for two and a half years. LVN N also revealed she was trained and in-serviced on infection control and hand hygiene by the ADON in [DATE] or [DATE]. LVN N revealed she performed hand hygiene all day and all the time. LVN N also revealed she washed her hands anytime she entered a resident's room and before and after contacting a resident. LVN N revealed she would wash her hands with soap and water if she picked up feces with gloves and discarded the feces and gloves because the feces could have gotten on the hands. LVN N also revealed residents' health and wellbeing could be impacted if a nurse picked up feces with gloves, discarded the feces and gloves, and used hand sanitizer because of the bacteria from the feces and the feces could have contaminated the nurse's hands. During an interview on [DATE] at 9:42 am, the DON revealed she had worked at the facility for 11 days. The DON also revealed she was trained on infection control and hand hygiene annually. The DON was not sure when staff were last in-serviced on hand hygiene and infection control. The DON revealed she expected staff to wash their hands before and after performing resident care and after resident care. The DON also revealed she expected staff to wash their hands with soap and water whenever their hands were soiled. The DON revealed staff were required to wash their hands with soap and water even after picking up feces with gloves, discarding the feces and gloves, and using hand sanitizer. The DON also revealed staff wore one pair of gloves when providing care to residents and were not allowed to wear two layers of gloves. The DON revealed the gloves staff used had the potential for wear and tear during use. The DON also revealed she encouraged staff to perform hand washing. The DON revealed she expected staff to wash their hands with soap and water if staff picked up feces with gloves, discarded the feces and gloves, and used hand sanitizer before entering another residents' room to provide care to another resident. During an interview on [DATE] at 9:43 am, the RNC revealed if a staff member's hands were not visibly soiled and they used gloves to pick up the feces, using alcohol-based hand rub after discarding the feces and gloves would be appropriate. The RNC also revealed staff wore one pair of gloves when providing care to residents and were not allowed to wear two layers of gloves. During an interview on [DATE] at 9:51 am, the ADM revealed he worked at the facility for over one year. The ADM revealed he was trained on infection control. The ADM also revealed he expected staff to wash their hands with soap and water when dealing with bodily fluids and fecal matter. The ADM revealed it was not proper hand hygiene for staff to pick up feces with gloves, discard the feces and gloves, and use hand sanitizer before contacting another resident. The ADM also revealed residents' health and wellbeing could be negatively impacted by a nurse contacting them after picking up feces with gloves, discarding the feces and gloves, and using hand sanitizer. The ADM revealed he expected staff to wash their hands with soap and water after picking up fecal matter. During an interview on [DATE] at 10:34 am, the DON revealed hand hygiene are to be done with each resident contact, with every glove change, and when the glove is visibly soiled, it should be changed, and hand hygiene performed. The DON stated, For residents with multiple wounds, wound care was done one at the time. You address one wound, once you were are done, you perform hand hygiene, changed gloves, and get to the other wound because you do not want to contaminate the wounds. The DON revealed hand hygiene was done for cross contamination prevention and to stop infection introduction into the wound. The DON stated, Once there was is not one dressing, the expectation was each wound should be treated individually. During an interview on [DATE] at 11:02 am, LVN N revealed she never performed wound care on Resident #71. LVN N did not know about Resident #71's infections. LVN N revealed Resident #71 had wounds. LVN N also revealed Resident #71 had wounds on the right heel, buttocks area, and lower legs. LVN revealed Resident #71's wounds were not deep. LVN N revealed she assessed Resident #71's dressings and made sure the dressings were dry, clean, and intact. LVN N revealed wound care nurses changed dressings and treated Resident #71's wounds. LVN N [TRUNCATED]

39269 Based on observations, interviews and record reviews, the facility failed to ensure nursing staff had the appropriate competencies and skills sets to provide nursing and related services in accordance with professional standards of practice for 1 (Resident # 87) of 2 residents observed for wound care by 1 (Wound care nurse A) of 1 wound care nurse reviewed for competency, in that: 1) TLVN S did not perform hand hygiene and change her gloves while performing wound care on Resident #87 on 01/19/2024. TLVN S also performed wound care on Resident #87's two wounds at the same time. The facility failed to ensure TLVN S, TLVN T and RN I had skills and competencies completed to perform wound care on 01/19/2024. An IJ was identified on 01/19/2024 at 5:10 pm. The IJ template was provided to the facility on [DATE] at 5:03 pm. While the IJ was removed on 01/21/2024 at 4:35 pm, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices placed residents at risk for infections, sepsis, a diminished quality of life and death. Findings included: Record review of Resident # 87's undated face sheet reflected a [AGE] year-old male who was admitted on [DATE] with diagnoses including unspecified open wound of left back wall of thorax without penetration into thoracic cavity, subsequent encounter, and pain unspecified. Record review of Resident # 87's admission MDS assessment, dated 01/02/2024, reflected a BIMS score of 15, which indicated Resident #87 had no cognitive impairment. Record review of Resident # 87's acute care plan reflected Resident #87 had skin condition on his buttock, middle back, and left Achilles. Record review of Resident #87's comprehensive care plan, dated 01/18/2024, reflected Resident #87 required assistance with ADLs, he was at risk for pressure ulcer, and limited in mobility all or most of the time. Record review of Resident #87's wound care notes reflected the wound on Resident #87 buttocks was first seen on 12/31/2023. Record review of Resident #87's wound care notes, dated 01/16/2024, reflected an order for Cipro 500 mg (Antibiotics are medicines that fight bacterial infections in people and animals.) PO every 12 hours x 7 days. Record review of Resident # 87's wound doctor's note, dated 01/16/2024, reflected the following: Wound location: Bilateral Buttocks Sign of infection: drainage odor: None exudate: moderate, serous, green measuring 8.1 x 5.1 x 0.3 Wound location: middle back Sign of infection: drainage odor: None exudate: mild moderate, serous, green measuring 2.2 x 0.6 x 0.7 cm Cipro 500mg (Antibiotics are medicines that fight bacterial infections in people and animals.) 1 PO q12 hrs x 7 days pending culture results. During wound care observation on 01/19/2024 at about 7:45 am by TLVN S on Resident # 87. TLVN S was assisted by CNA E. TLVN S gathered supplies outside the room, both staff walked into Resident # 87's room and performed hand hygiene. Resident # 87 was rolled on his right side. TLVN S donned (put on) clean gloves removed soiled dressing from the wounds on Resident #87's middle back and buttocks respectively and had both soiled dressing in her hand. Soiled dressings from both wounds contained serosanguineous (is a thin and watery fluid that is pink in color due to the presence of small amounts of red blood cells) drainages and dated 01/18/2024. TLVN S did not change soiled gloves or perform hand hygiene. TLVN S cleaned Resident #87's wound on his middle back with normal saline and gauze with soiled gloved hands then move to Resident # 87's wound at his buttocks with same normal saline and gauze. TLVN S again did not change gloves or perform hand hygiene, applied medication med-honey to the wound bed at Resident #87's middle back using same soiled gloved hands fingertips, then moved to Resident #87's wound at the buttocks with same gloved hands applying med-honey to wound bed and back to middle back. TLVN S then changed soiled gloves, did not perform hand hygiene and don clean gloves, and applied dressings on both wounds and dated the dressings. Both staff positioned Resident #87 in his bed, performed hand hygiene, and left Resident #87's room. During an interview on 01/19/2024 at 9:26 am, TLVN S started by saying, I know I messed up on the first wound care with Resident #87, I read my binder after we were done and know exactly where I messed up. TLVN S stated when performing wound care on a resident with multiple wounds, it should be done one at a time. TLVN S stated going back and forth from one wound to the other was cross contamination. TLVN S stated, after she took the soiled dressing from Resident #87's wounds, she was supposed to remove soiled gloves, perform hand hygiene, and don clean gloves. TLVN S stated every time you remove a gloves hand hygiene was performed because of cross contamination. TLVN S stated, I was just putting the germ back in Resident #87's wounds, I did hand hygiene at the beginning and at the end of the procedure. During an interview on 01/19/2024 at 10:34 am the DON stated hand hygiene was to be done with each resident's contact, with every glove change and when the glove was visibly soiled it should be changed and hand hygiene performed. The DON stated, for residents with multiple wounds, wound care is done one at the time. You address one wound, once you are done, you perform hand hygiene, change gloves, and get to the other wound because you do not want to contaminate the wounds. The DON stated hand hygiene id done for cross contamination prevention and stop infection introduction into the wound. She stated, once there is not one dressing, the expectation is each wound should be treated individually. During an interview on 01/19/2024 at 1:17 pm the RNC she was the providing supervision for the new DON. The RNC stated hand hygiene is done anytime a staff move from clean to dirty, prior to touching the clean, with glove changes to prevent the spread of infection. She stated, after removing the soiled dressing, remove gloves and perform hand hygiene to decrease the risk of infection, once the soiled dressing was removed, staff hands were considered dirty. The RNC stated when doing wound care with a resident with multiple wounds, each location should be treated as a separate treatment. The RNC stated moving from one wound to the other increase the risk of cross contamination. During an interview on 01/19/2024 at 2:01 pm the NP stated when performing wound care on a resident with multiple wounds, the staff should work on one wound complete it before going to the next, wound. She stated if one wound has infection, it will be transmitted to the next wound. The NP stated she expect the wound care nurse to follow the right procedure in wound. Record review of TLVN S, TLVN T and RN I 's personnel files revealed all 3 staff did not have competency skilled completed for wound care or hand hygiene. Interview on 01/19/2024 at 1:17 the RNC stated competencies skills check offs are done upon hiring and annually. She stated the DON or designee was responsible to ensure competencies were done for all staff. She stated competencies were to ensure the nurses were up to date on latest policy and procedure regarding a specific skill. The RNC stated she checked Wound care nurses A, B, and C's personnel's files and did not see competency check off for all 3 wound care nurses. Record review of facility's policy and procedure, revised May 2019, titled, Staff Development Program, reflected: All personnel must participate in initial orientation and regularly scheduled in-service training classes. Staff development is defined as initial orientation, followed by regularly scheduled in-service training. Programs. .The primary objective of our facility's Staff Development Program is to ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care. .All Staff Development classes attended by the employee are entered on the respective employee's Employee Training Attendance Record by the Department Director or other person(s) designated by that director. .Records are filed in the employee's personnel file or maintained by the Department Director. Record review of facility's undated competency check off, titled, Clean dressing change check off, reflected: Verify orders and assemble supplies and equipment needed. .Knock - Provide privacy and explain procedure. .Wash hands. .Set up clean and dirty areas. .Put on clean gloves. .Remove soiled dressing and discard. .Wash hands and put on clean gloves. .Clean wound using circular motion starting from the inside working outward. . Remove gloves and sanitize hands. .Put on clean gloves to continue with the dressing. .Discard used items. .Wash hands. . Sign TAR/Document observations. MUST MAINTAIN CLEAN TO CLEAN AND DIRTY TO DIRTY AREAS DURING PROCEDURE. Record review of facility's policy and procedure, dated August 2019, titled, Handwashing/Hand Hygiene, reflected: This facility considers hand hygiene the primary means to prevent the spread of infections. .All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Before and after direct contact with residents; Before donning sterile gloves; Before handling clean or soiled dressings, gauze pads, etc.; Before moving from a contaminated body site to a clean body site during resident care; After contact with a resident's intact skin; After contact with blood or bodily fluids; After handling used dressings, contaminated equipment, After removing gloves; These deficient practices resulted in the identification of an IJ on 01/19/2024 at 5:10 pm. The ADM was notified and provided with the IJ template on 10/19/2024 at 5:10 pm. The following Plan of Removal submitted by the facility and accepted on 01/21/2024 at 8:33 am: PLAN OF REMOVAL F726 The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the issues: Regional Director of Operations re-educated Administrator on ensuring competency of nursing staff completed 1/19/2024. Regional Nurse Consultant for facility reinforced and re-educated Director of Nursing and Assistant Director of Nursing on ensuring competency of nursing staff completed 1/19/2024. Licensed facility personnel to perform completion of competency evaluation as noted by competency skills checklist by 1/19/2024. DON/designee to have completion of competencies with emphasis on wound management on all licensed nursing personnel by 1/19/2024. Re-education of all licensed staff members began per DON/ADON and designees on areas of competencies noting concern following performance of skills checklist 1/19/2024. Interventions and Monitoring Plan to Ensure Compliance Quickly: o o The facility will have policy for competencies for nursing staff to be obtained on hire and at least annually with re-education to be performed as noted by competency check. Initiated: 1/19/2024 Completion: 1/20/2024. o o Audit of all existing and newly hired nursing staff to be performed weekly by DON and/or designee, as well as Human Resources Director to ensure completion of timely competency checks with documented competencies to be placed in employee files. Initiated: 1/19/2023 Completion: 1/20/2024. o o Any nursing staff identified through competency checks to require acute training or re-education will have education performed prior to presenting on shift until such time as competencies are adequate. Initiated: 1/19/2024 Completion: 1/20/2024. o Return demonstration of understanding will be noted by post competency check for each person educated with a written post-test administered by Director of Nursing, Assistant Director of Nursing, and/or designee for any nursing staff receiving re-education or training on competencies not found to be proficient. Staff that are on leave from the facility will be given the competencies check off by the same individuals noted above before starting their next shift. This facility does not employ the use of agency personnel. Initiated: 1/19/2024 Completion: 1/20/2024. o o The facility DON/ADON will act as monitoring liaison to coordinate completion of audits for competencies to include Administrator for continuum of care to be documented through signed attendance sheet in morning stand up. Initiated: 1/19/2024 Completed: 1/20/2024. o o Audit sheets for competencies on nursing staff to be reviewed by DON/ADON for completion at least weekly with indication of last performed check off. Initiated: 1/19/2024 Completed: 1/20/2024. o o The policy and procedure for competencies of licensed personnel to be reviewed by Regional [NAME] President of Operations and RNC with any changes to policies to be implemented. Initiated: 1/19/2024 Completed: 1/20/2024. o o Licensed nursing staff with direct involvement in the resident care in question during the time noted in the immediate jeopardy ruling will receive one on one education if still in employment of facility with return demonstration noted through verbal and written understanding in educational interactions and competency evaluation. Initiated: 1/19/2024 Completed: 1/20/2024. o o All licensed staff not on duty during competency check off will be checked as noted above prior to returning to the floor for their next scheduled shift. Initiated: 1/19/2024 Completed: 1/20/2024. o o The Medical Director was notified of Immediate Jeopardy and apprised of interventions and monitoring initiated with further updates to be given during QAPI meetings. Initiated: 1/19/2024 Completed: 1/19/2024. The survey team monitored the Plan of Removal on 01/21/2024 as followed: Record review of POR FOR 726 reflected the following: MD was notified of the IJ s on 1/19/2024. The Administrator and DON were both in-serviced by the VP for operation and Regional Nurse consultant on the competencies required of all licensed nursing staff to provide safe and proper care of residents. Re-education on proper procedure for wound care. Re-education on proper ways to prevent pressure ulcers and infections from developing. Re-education on abuse and neglect initiated on 01/19/2024. Staff competencies was initiated on 1/19/2024 for hand hygiene and wound care. Staff in-service on wound care, Wound care protocols, hand hygiene, skin and wound resources initiated on 1/19/2024. Infection control posttest initiated on 1/20/2024. During an interview on 01/21/2024 at 12:31 pm, RN I revealed she worked at the facility for five months. RN I also revealed staff were in-serviced every day by the DON, ADON, MDSN, RNC, and TLVN T about wound care, protocols, standing orders, and chain of command. RN I revealed staff were trained on what to do when they received new orders, new skin issues, relaying information to the nurse, and the nurse relaying information to all parties. RN I also revealed staff were trained on infection control concerning hand washing, wound care, and orders. RN I revealed staff also performed return demonstration and took a test that was scored. RN I also revealed staff were taught how to locate standing orders for pressure ulcers. During an interview on 01/21/2024 at 12:50 pm, CNA L revealed staff were in-serviced by the ADM, DON, and ADON about five times since the surveyors were at the facility. CNA L also revealed staff were required to be at the facility on 01/22/2024 for a meeting. CNA L revealed staff were also in-serviced on infection control and taught to wash their hands when working from one resident to another resident and when working on one task to another task. During an interview on 01/21/2024 at 1:04 pm, CNA K revealed she worked at the facility for four months. CNA K stated, We have been in-serviced on a lot of things. CNA K explained staff were in-serviced by the ADM, DON, and ADON on infection control related to keeping hands clean and washing hands with soap and water and using hand sanitizer. CNA K further explained staff had to demonstrate washing their hands while being monitored. CNA K stated, First was your hands before going to the resident and wash your hands after care. During an interview on 01/21/2024 at 1:16 pm, RN Q revealed he worked as a PRN RN for about one year. RN Q also revealed staff talked about the check offs that needed to be done. RN Q explained he completed the check off on hand washing. RN Q also revealed he was provided a handout about infection control that he had not complete yet. During an interview on 01/21/2024 at 1:28 pm, LVN O revealed she worked at the facility for about one year. LVN O also revealed she was in-serviced by the ADM on skin issues and pressure ulcers on 01/20/2024. LVN O revealed staff were also in-serviced by the DON and ADON about the new plan for skin and orders to use for skin. LVN O also revealed the DON and ADON also provided a detailed skin assessment. LVN O revealed the DON and ADON also covered infection control, hand hygiene, using hand sanitizer, washing hands when visibly soiled and using hand sanitizer when not visibly soiled. LVN O also revealed staff did a check off on wound care and hand hygiene. During an interview on 01/21/2024 at 1:40 pm, TLVN T revealed she was in-serviced by the DON and ADON on 01/20/24. TLVN T also revealed the DON and ADON talked about wound care and infection control. TLVN T revealed she also did a return demonstration on wound care and infection control protocols. TLVN T also revealed the DON and ADON also talked about the proper techniques based on the check list and a form for demonstration, wound care protocol, and orders. TLVN T revealed she sent a mass communication to all the nurses. TLVN T also revealed the DON and ADON talked about wound protocol related to nutritional status. TLVN T revealed she was working with the wound doctor to approve the protocol. TLVN T also revealed the DON and ADON reviewed the highlights where the nurses failed, reasons for not going from one wound to the other, better monitoring systems, treatments to suggest to the wound care nurses, changing gloves, hand hygiene, and cross contamination prevention. TLVN T revealed TLVN S and her were both part time wound care nurses. TLVN T also revealed the DON was new and put in place a lot. TLVN T revealed she performed a demonstration with staff on wound care, how to change gloves, when to wash hands, addressing wounds one at a time, and starting the process over when addressing each wound. During an interview on 01/21/2024 at 2:01 pm, the ADON revealed she was in-serviced by TLVN T and the DON on 01/19/2024. The ADON also revealed the DON went over with all the nurse on wound care, hand washing, and infection control. The ADON revealed staff did check offs on wound care and hand washing. The ADON also revealed staff had to also demonstrate to TLVN T on what to do. The ADON revealed staff also talked about the importance of gloving, hand hygiene, treating each wound as a separate entity due to cross contamination and the importance of changing the gloves for cross contamination. The ADON also revealed TLVN T was trained the night shift nurses and aides. The ADON revealed she had a copy of the new wound protocol, interventions and was taught to inform the WCD wounds were stageable. During an interview on 01/21/2024 at 2:18 pm, the DON revealed she was in-serviced by the RNC and trained on infection control during her hiring process and on 01/19/2024. The DON also revealed she started to in-service staff on hand hygiene, infection control, and wound care. The DON revealed hand hygiene was performed before and after resident care. The DON stated, Treat everybody's body fluid as infectious. The DON also revealed hand hygiene was performed when hands were soiled, removing barrels, and coming into contact with body fluid. The DON revealed hand hygiene was also performed before, during and after removing soiled dressings and before donning gloves during wound care. The DON also revealed staff were to use alcohol-based hand rub or soap and water before going to another resident. The DON revealed all nurses at the facility had been given wound care and infection control competency before their work shifts. An observation of 400 hall on 01/21/2024 at 3:20 pm revealed CNA P was sanitizing her hands with hand sanitizer along the hall. During an interview on 01/21/2024 at 3:20 pm, CNA P revealed she was in-serviced by the DON and ADM on 01/20/2024. CNA P explained the DON told her to notify a charge nurse if she saw anything related to skin, bruising, change of condition, or decreased PO intake. CNA P further explained the DON told her to notify the ADM or the DON if nothing is done after bringing the observations to the charge nurse's attention. CNA P revealed she was also trained on infection control and hand hygiene. CNA P stated, Protect yourself and the residents. Touch the residents with clean hands. During interviews on 01/21/2024 from 3:30 pm through 3:42 pm, two residents revealed staff performed wound care and completed a skin assessment. During an interview on 01/21/2024 at 3:59 pm, RN R revealed she worked at the facility for almost one year. RN R also revealed she completed skin assessments on shower days and was taught to inform the DON and perform skin care if she observed any skin changes. RN R revealed she was also taught how to identify residents at risk of developing skin breakdown. RN R also revealed she was taught infection control protocols, such as sanitizing her hands, washing her hands, and changing gloves before, during, and after care and whenever her gloves were soiled. RN R also revealed she was taught to treat one wound at a time to prevent the spread of infection when performing wound care on a resident with multiple wounds. RN R revealed she checked off on wound care, infection control, hand hygiene, and had to demonstrate the protocols and take a test after being in-serviced on the topics on 01/20/2024. During an interview on 01/21/2024 at 4:12 pm, the ADM revealed he was in-serviced by the VPFO and RNC on 01/19/2024 on staff competencies, infection control, pressure ulcer assessment prevention, and wound care. The ADM also revealed the DON, ADON, and TLVN T in-serviced staff on clinical topics and were trying to ensure all staff were in-serviced and trained before their work shift. The ADM revealed all residents had skin assessments and Braden Scales completed and new protocols for wound and skin care were implemented. The ADM also revealed the DON and designee would conduct the audit and he would verify daily. The ADM explained he and the DON would review weekly to make sure protocols and interventions were put in place and effective. The ADM also explained he and the DON decided to change specific treatment plans for each resident because the general care was not effective for all residents. The ADM revealed he notified the MD, and the next meeting was scheduled for 01/24/2024. The ADM was notified on 01/21/2024 at 4:35 pm that the IJ was removed. The facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. The survey team returned to the facility on [DATE] to complete a full recertification survey, and the following observations, interviews, and record reviews were conducted. Review of undated Face Sheet for Resident #73 reflected she was admitted to the facility on [DATE] with diagnosis of Klebsiella pneumoniae (a type of gram-negative bacteria that can cause different types of healthcare-associated infections, including pneumonia, bloodstream infections, wound or surgical site infections, and meningitis), unspecified malignant neoplasm (history of cancer), Depression, Thrombocytosis (a disorder in which your body produces too many platelets), Nutritional deficiency, and Pressure ulcer of sacral region stage 4. Review of Resident #73's Care Plan for Pressure Ulcer/Injury dated 12/06/23 reflected Resident #73's ulcer will not exhibit signs of infection by keeping Resident #73 as clean and dry as possible and minimize skin exposure to moisture, and keep linens clean, dry, and wrinkle free. Review of the Quarterly MDS assessment for Resident #73 dated 12/06/23 reflected a BIMS Score of 12/15, which reflected moderate impairment in mental status. Resident #73 required one-person assistance for ADLs. Observation on 01/24/2024 at 9:52am revealed TLVN S helped turn the resident to the resident's right side. It was observed that resident was laying on an uncovered mattress. TLVN S performed hand hygiene and wore a pair of clean gloves and removed the previous dressing on both the upper back and on the sacrum of the resident. Both dressing was not dated and initialed. Both dressings had trace of drainage on the outer side of the dressing. TLVN S discarded the removed dressing into the trash and disposed the gloves and performed hand hygiene with the use of hand sanitizer. No barrier was placed between the resident and mattress. TLVN S wore new pair of clean gloves and cleansed the upper back wound with saline and gauze. TLVN S disposed the gauze and saline into the trash and did not remove the glove and did not perform hand hygiene and continued to place new dressing onto the upper back wound. TLVN S then disposed the gloves into the trash and did not perform hand hygiene and walked out of the resident's room to gather more supplies to dress the sacrum wound. TLVN S touched the doorknob from inside of the room and touched the treatment cart to gather the supplies. TLVN S returned to the resident's bedside and placed the supplies on the side table with all the previous supplies that was gathered by the TLVN S. TLVN S then performed hand hygiene and wore pair of clean gloves and cleansed the wound on the sacrum. TLVN S dispose the gauze and saline into the trash and removed the gloves and performed hand hygiene with use of hand sanitizer. TLVN S then wore a new pair of clean gloves and dressed the wound and initialed and dated both the dressings. TLVN S repositioned the resident back to the uncovered mattress. In an interview on 1/25/24 at 4:05 PM, TLVN S stated she had worked at the facility consecutively for 1 year. TLVN S stated she had 2 years of additional wound care experience prior to that. TLVN S stated the facility had not initially given her training on the wound care role, and that training happened later. When asked who had provided her job description and responsibilities, TLVN S stated, I am not going to give you that. TLVN S further stated that the 2 old dressings removed from Resident 73's wound did not have a date or initial. TLVN S stated that she had trained another nurse the day before and that nurse had failed to label the dressings. TLVN S refused to name the nurse she had been training. TLVN S stated that she was at the bedside with the nurse in training, but she said, neither of us had a pen on us. TLVN S stated that labeling dressings was really important to know if a dressing was done daily and for drainage amount. TLVN S stated the date would indicate the when the dressing was last changed. TLVN S was asked why she did not remove her gloves between cleaning the wound with saline and applying the new dressing. TLVN S's response was, if you say I didn't, then I didn't, and I did not realize that. When asked why she did not sanitize after removing treatment gloves to go to the supply cart, TLVN S stated she did sanitize before she went to the treatment cart to gather more supplies. TLVN S then stated that before going to the treatment cart she should have sanitized and that I did not know that I didn't. TLVN S stated it is important to complete hand hygiene, so there was no contamination. TLVN S said', you don't know if something is growing in a wound and it can contaminate every surface we touch TLVN S agreed the treatment cart may have possibly been contaminated. TLVN S stated the mattress of the resident did not have a sheet because it was a low air loss mattress. When asked why there was no barrier placed between the draining wound and the mattress, TLVN S stated, I failed to do so and further stated that if copious drainage was on the mattress it could intermingle with the new dressing. TLVN S stated she was provided enough supplies and her last infection control in-service was Friday 1/19/24 with the DON. TLVN S stated the in-service was verbal and reading training with neither observation nor return demonstration completed. TLVN S stated the DON was the infection preventionist. TLVN S stated the initials on her badge were WSOC and that indicates she has a Wound, Skin, Ostomy Care Certification. In an interview on 1/25/24 at 4:25 PM with DON revealed the policy says to provide care and do good hand hygiene. DON stated her staff should use alcohol base hand care between residents or if hands visibly soiled, you should use soap and water. DON stated her expectation was staff should provide good hand hygiene when going from dirty to clean when providing wound care, and if hand hygiene was not done by staff, the potential outcome would be infection to a wound. DON stated infection control was not just for resident but for staff who can take infections home to their family members DON stated there was no excuse not to sanitize hands, as she gives them hand sanitizer. DON stated staff were in-serviced less than a week ago and last month. Interview on 1/26/24 at 11:05 AM with ADM revealed his expectation when wound care is completed, dirty PPE items are removed properly, and hand hygiene, including handwashing or sanitization, occurs. ADM stated once the staff hands were clean and sterile, he expects that they then go to the clean side. ADM stated his expectation is for this to repeat - when going from clean to dirty, they change their PPE, hand wash, or sanitize, and repeat. ADM stated a potential negative outcome of not following this process could be infection or disease. ADM stated staff have been in-serviced previously, and re-educated recently, on wound care hand hygiene and infection control to ensure they have the proper procedures in place. Review of facility policy for Wound Care (Revised October 2010) reflected, Use disposable cloth to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange supplies so they can be easily reached. Each wound is to be treated separately to prevent cross contamination. Wash and dry your hands thoroughly. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. Review of facility policy for Infection Control (Revised September 2017) reflected, Standard precautions are used for all resident care. They're based on a risk assessment and make use of common-sense practices and PPE (Personal Protective Equipment) that protect staff from infection and prevent the spread of infection among residents and staff. Standard precautions include Practicing Hand Hygiene. Page 9 reflected, Hand hygiene refers to cleaning your hands by using hand washing techniques (washing hands with soap and water), antiseptic hand wash, antiseptic hand rub (i.e., alcohol-based hand sanitizer, ABHR, including foam or gel), or surgical hand antisepsis. The Administr [TRUNCATED]

Based on interview and record review, the facility failed to ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance for 1 of 8 residents (Resident #71) reviewed for nutrition. The facility failed to ensure dietitian interventions of increased tube feedings and speech therapy were implemented when Resident #71 had a 10% weight loss in [DATE], leading to an overall weight loss of 32% from [DATE] to [DATE]. Resident #71 also developed pressure wounds on her foot and hip that worsened, and she died on [DATE]. The noncompliance was identified as PNC. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. The failure placed residents at risk of unplanned weight loss, malnutrition, worsening of wounds, and death. Findings included: Review of the undated face sheet for Resident #71 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of cerebral infarction (death of brain tissue), hemiplegia (paralysis on one side of the body), aphasia (loss of speech), dysphagia (swallowing difficulties), diabetes mellitus, and Bell's palsy (weakness or paralysis of facial muscles). Review of the quarterly MDS for Resident #71 dated [DATE] reflected she could not participate in the BIMS assessment. The Swallowing and Nutrition section included a trigger for 5% or more weight loss in the previous month or 10% in the previous six months. It reflected she received nutrition by feeding tube and had a mechanically altered diet. It reflected she received 25% or less of her daily nutrition by tube. The section for Skin Conditions reflected she had one unstageable pressure ulcer. Review of the care plan for Resident #71 dated [DATE] reflected the following: Category: Nutritional Status Resident is at risk for trending weight loss. Resident will consume ,d+[DATE]% of meals over the 90-day review period. 1. Serve resident food preferences. 2. Assess resident for food preferences. 3. Monitor dietary intake. 4. Offer supplements between meals to enhance caloric intake. 5. Offer substitute if less than 50% of meal is consumed. 6. Offer oral hygiene before meals. Category: Feeding Tube Resident requires feeding tube R/T PRN use for bolus secondary to poor appetite. Resident will not exhibit signs of complications from feeding tube or enteral feeding solution. Check placement and patency of feeding tube before each feeding or medication administration. Check placement and patency of feeding tube every shift and PRN. If tube should become clogged follow protocol and notify MD. Category: Nutritional Status Resident requires a mechanically altered diet R/T dysphagia/aphasia. Resident will eat ,d+[DATE]% of meal. Diet: Puree with NTL. Encourage oral intake of food and fluids. Monitor and record intake of food. Review of weights for Resident #71 reflected the following, which constituted a 32% weight loss over the six-month period: [DATE] 156 lbs. [DATE] 143 lbs. [DATE] 148 lbs. [DATE] 143 lbs. [DATE] 130 lbs. [DATE] 125 lbs. [DATE] 118 lbs. Review of the LD notes for resident #71 dated [DATE] reflected the following: Follow up regarding significant weight loss times 30, 90, 180 days; diet: puree NTL (may have moist, minced texture with supervision upon request); has varied 50 to 100%; previously had a nocturnal feeding, but D/C due to being too full from feeding to be able to eat PO. Eats meals in main dining room, sometimes requests for mech soft when nurse present for supervision and set up help; scoop plate added [DATE] at all meals; Receives one can ensure daily by mouth. Weight: November weight 132 pounds, down 9 pounds X 30 days; -7.69% X 30 days, -13.16% X 90 days, -18.01 X 180 days; BMI 23.4 within normal limits; this week is down to 128 pounds [DATE] Labs [DATE] CMP reviewed glucose 115+ Plan: 1. SLP to evaluate and consult family for signing waiver for mechanical 2. Add one can Glucerna 1.2 bolus QID at p.m. between meals, regardless of meal intake. Goal: to halt, weight, loss, maintain weight; improved intake, at least 75% or more daily. Review of the LD notes for Resident #71 dated [DATE] reflected the following: [DATE] pounds, down 5.3% times 30 days, -15.54% times 90 days, -21.88% times 180 days; BMI 22.1 WNL; weight loss of 23 pounds in the past three months. Glucerna 1.2 bolus QID provides 1140 kcal, 57 g PO, 768,CH20+150 CQ shift equals 1368 cc water minimum. Review of the physician orders for Resident #71 dated [DATE] reflected the following: Monitor and document meal intake, breakfast luncheon dinner three times a day after meals if less than 50% of meal eaten give one carton of Glucerna 1.2 Cal via nutrition bolus start date [DATE]. Review of all the speech therapy notes for Resident #71 from [DATE] through [DATE] reflected she was discharged from services most recently on [DATE]. Review of the hospital records for Resident #71 dated [DATE] reflected she weighed 118 lbs. at hospital admission. The records reflected she had a surgical history of insertion of feeding device into stomach and introduction of nutritional substance into upper GI started [DATE]. Lab results from the hospital reflected an albumin level of 1.7 g/dl (reference range 3XXX,d+[DATE].4 g/dl), indicating malnutrition. Review of the death certificate for Resident #71 reflected she died on [DATE] in the hospital. Her cause of death was listed as due to or as a consequence of: cerebral vascular accident, sepsis, and infected hip and foot pressure ulcers. During an interview on [DATE] at 03:05 PM, the LD stated she had been made aware that Resident #71 had several nursing concerns related to wound care and that she went to the hospital and died . The LD stated she had been stressing with nursing department to get her recommendations to the physician so they could be ordered. The LD stated she frequently recommended interventions, but she was limited in that she could not write orders, so implementation had been a challenge. The LD stated Resident #71 triggered as having significant weight loss over several months with the first occurrence of significant weight loss in [DATE]. She stated each week the clinical team met Mondays for weight meetings, and the LD was not in the facility on Mondays, so the LD met the previous Director of Nursing on a different day of the week, depending on the week. The LD said she met with the DON each week and went through everybody with her and asked questions about how her residents had been, and they talked about interventions. The LD stated she had this procedure with the previous Director of Nursing who was on probation and let go. The LD stated Resident #71 would not eat well on pureed foods, and the LD recommended Resident #71 see the SLP to evaluate for mechanical soft meals with one-to-one supervision. The LD stated Resident #71 would have eaten better on that, but she needed to be supervised, as she had some dysphagia. The LD clarified that her recommendations during that period were for Resident #71 to meet with SLP, have her diet upgraded if the family agreed, have the family sign a waiver for an upgraded diet if they need a waiver, and to make sure that regardless of her meal intake, she would get a bolus feeding between meals. The LD stated during interviews with staff, she determined that, when the bolus feedings were dependent on percentage eaten, Resident #71 was not getting them frequently. The LD stated she wanted to make sure Resident #71 received the feedings regardless of intake, because there was still weight loss. She stated she added the recommendation, and it should have become and diet order change on [DATE] from based on meal intake to scheduled no matter what. When the LD came back the following month, Resident #71 was still losing weight, as much as 10 lbs per month, so the LD determined Resident #71 should go back on full controlled bolus feedings four times per day. The LD stated she made this recommendation on [DATE]. The LD stated the facility did not request any additional consults with her in December, and Resident #71 continued to lose weight. The LD stated when the current DON started on [DATE], she had to have done an audit immediately, because the LD was called the next day and informed her recommendations had not been implemented for Resident #71. The LD stated in turn, she performed an in-service for all management staff related to the procedure for requesting a consult and the procedure for implementing her recommendations. The LD stated she reminded them about the policy and procedure of contacting her, what issues needed contact and how urgently, and her recommendations: who would be putting them in the system and who was responsible for implementing them. She stated she felt the nursing staff were now on the right page with her. She stated the previous DON seemed burned out, and the LD would go back and check to make sure things had been implemented, and they would not have been implemented. The LD stated the responsibility for placing the orders was with the previous Director of Nursing. The LD stated when she spoke to the previous Director of Nursing and said, hey I've asked you a couple times, this hasn't gone through, the previous Director of Nursing said, don't worry we are placing it. The LD stated the SLP evaluation, and both the increases in bolus feedings for Resident #71 were not implemented when she made the recommendations. She stated she performed an audit of all her recommendations on [DATE], and those for Resident #71 were the only ones that had not been implemented. During an interview on [DATE] at 09:49 AM, the SLP stated Resident #71 had been on speech therapy from her admission to the facility in [DATE] until [DATE]. The SLP stated there had not been another request for an evaluation since then. She stated she was aware from their meetings that the family was unsure whether Resident #71 should upgrade to a mechanical soft diet and finally refused to sign a waiver allowing Resident #71 to eat mechanical soft foods. She stated that was the family's decision and she would have liked the opportunity to educate the family but that did not happen. The SLP said the way she usually found out that she needed to conduct an evaluation for therapy services was that nursing would notify her. She stated no one notified her from any department that the LD had recommended an evaluation for services for Resident #71. During an interview on [DATE] at 10:23 AM, the MDSN stated Resident #71 did not like the puree food and wanted to eat regular food. The MDSN stated the family was educated about the risks of upgrading her diet to mechanical soft and did not want to sign a waiver. The MDSN stated they noticed the weight loss at the end of [DATE] and early [DATE]. The MDSN stated after the new DON started on [DATE], one of the first things she looked at was weight loss in the facility, and they discovered there had been a miscommunication with who was handling the dietitian interventions. The MDSN stated, as a result of the miscommunication, Resident #71 did not receive the interventions recommended by the dietitian. The MDSN stated prior to the new DON discovering this problem, the MDSN's part was to input the weights and report to the rest of the clinical team who triggered for significant weight loss. She stated the former DON was supposed to be doing the rest, which included referring for a dietitian consult, referring to speech therapy, requesting the physician order supplements or additional tube feedings. The MDSN stated since thy discovered the problem, they had developed a plan where the MDSN handled all the communication to and from the dietitian and speech therapy. The MDSN stated the DON would take over if the MDSN was unavailable. The MDSN stated she was responsible for the entire weight loss monitoring program since [DATE]. She stated the outcome of a failure to identify and address unplanned weight loss for residents could be infection, immunocompromise, skin breakdown, heart failure, kidney failure, or death. During an interview on [DATE] at 10:26 AM, the RNC stated she had started working in the facility in [DATE] and began going through several system audits. She stated she quickly discovered unplanned weight loss in the facility was higher than the national average and developed a PIP to address the weight loss. The RNC stated the former Director of Nursing at the time was responsible for the weight loss program and was struggling to maintain oversight on the program. The RNC stated after their PIP was put in place, the former Director of Nursing, who was on a probationary status, was terminated. The RNC stated when they hired the current DON, she began reviewing the systems and paid particular attention to the weight loss program, as there was already a PIP in place. The RNC stated the DON immediately discovered the issue with Resident #71, unfortunately the discovery came after the resident had already lost so much weight. The RNC stated they found dietitian recommendations from November and [DATE] that had not been implemented for Resident #71. The RNC stated when the failure was identified, the LD immediately did in-servicing, they added the failure to the PIP, and assigned the entire weight loss program to the MDSN with the DON as a backup. During an interview on [DATE] at 10:43 AM, the DON stated she had started in her position on [DATE] and had immediately looked over systems and programs and discovered that Resident #71 had several dietitian recommendations that had not been implemented. She stated after completing her audit, she did not identify any other residents who went without the LD recommendations being audited, but Resident #71 had already lost additional weight at that point. The DON stated the tube feedings for Resident #71 should have increased in November to be scheduled regardless of meal intake and instead the order remained tube feedings between meals only if Resident #71 ate less than 50% of her meal. The DON stated she did not remember exactly how much weight loss Resident #71 had, but it was a lot. The DON stated at that point, she worked with the RNC to develop a new program that had the MDSN responsible for the entire weight loss system. The DON stated the MDSN had already been responsible for inputting weights and communicating to the rest of the IDT if there was significant weight loss, but under the new plan, the MDSN would also be responsible for requesting the dietitian consults, communicating the dietitian recommendations to the physician, and ensuing the orders were entered and started after the physician approved them. She stated the system had been fully in place since [DATE] with all pertinent staff in-serviced. She stated she in-serviced the nursing, therapy, and kitchen staff on the new plan as well as several other related in-services such as identifying changes in skin color and turgor, wound care, abuse and neglect protocol, and resident rights. During an interview on [DATE] at 03:57 PM, the ADON stated she had been in-serviced on or around [DATE] by the LD on the dietitian communication process and by the DON on supplements, nutrition, weight loss, reporting changes, and skin conditions. During an interview on [DATE] at 04:01 PM, the MD stated she had been notified of the failures related to Resident #71's nutrition and had participated in creation of the PIP related to weight loss in the facility as well as the additions when it was discovered that Resident #71 did not have her dietitian recommendations ordered. She stated she had reviewed all the dietitian recommendations as part of the plan to correct the issue, and all recommendations had been ordered. She stated she could not think of any recommendations she did not agree with. She stated the plan to correct the failures was effective to the best of her ability to tell, though they would continue monitoring for effectiveness. Review of a PIP dated [DATE] with a revision on [DATE] and a target date of [DATE] reflected the following: Problem We have a high rate of acute weight loss for the month of September. 6.7%. Goals To decrease the rate of weight loss. Benchmark goal is less than 2%. Action 1. Monthly weights to be obtained and analyze by the fifth of each month. 2. Data that meets the significant change criteria will be addressed within variance report with documentation of interventions, notification of RP/family and position. New form created an in-service [NAME] administrative nursing staff. 3. Weekly weights will be reviewed and analyze by DON or designate timely and intervene accordingly. 4. DON or designee to hold a monthly IDT meeting by the 12th of each month. 5. DON to send monthly meeting to Regional Nurse Consultant by the 15th of each month. 6. Admin to ensure monthly meeting is being held. 7. Admin to place action plan in QPI for three months 8. Communication with RD to coordinate recommendations for November, December 9. Weight monitoring to correspond with dietitian and report Review of in-services provided by the LD on [DATE] reflected the following two in-services dated [DATE], each signed by management staff: 1. Upon completion of the report, the consultant dietitian will email a copy to the facility, staff, as well as the assessments. The report includes: -Cover sheet -Internal compliance -Recommendations -Assessments The entire report will be printed and filed in the designated facility binder under the appropriate month. A copy of the fax recommendations is to be placed in the designated physicians box to be evaluated and signed off on. After the recommendation is signed on by the physician, it is to be ordered and then placed in the resident medical chart under the dietary tab. 2. Facility nursing staff is to notify the consultant dietitian when: -There are physician orders for a dietitian consult -A resident has significant weight loss -Changes in diet or supplementation -A new admission and readmission -A resident has a new area to skin -Any other dietary comments/concerns Ways to contact: Email went not urgent and would like the consultant to review on next visit Examples: -New tube feed patient with orders -Physician order for dietitian consult -Diet or supplementation change -Monthly significant weight loss report -Monthly skin report -Dietary questions/concerns Text or phone call when Examples: -New to feed patient without orders -Family member present at facility with more urgent concern -State surveyors are present Your current consultant dietitians: (Contact information for the LD and an alternative if cannot contact primary for any reason). Review of the facility audits for significant weight loss [DATE] reflected six residents still having significant weight loss. Review of a facility audit performed on [DATE] for orders for all six residents still triggering for Weight Loss in [DATE] reflected all dietitian recommendations had been ordered and implemented. Review of the physician orders cross-referenced with dietitian recommendations for the six residents triggering for Weight Loss on the facility CMS-802 matrix dated [DATE] reflected all recommendations had been ordered. Review of a facility audit of all residents in the facility with pressure wounds conducted on [DATE] reflected three residents with sounds had not been ordered supplements such as protein supplement and multivitamins. Each of these three residents received new orders for supplements between [DATE] and [DATE]. Review of physician orders dated [DATE] for all residents with pressure ulcers in the facility reflected they each had orders for protein and vitamin supplements. Review of facility policy dated [DATE] and titled Nutrition (Impaired)/Unplanned Weight Loss reflected the following: Assessment and Recognition 1. The nursing staff will monitor and document, the weight and dietary intake of residents in a format which permits comparisons overtime. 2. The staff and physician will define the individuals, current nutritional status (weight, food/fluid intake, and pertinent laboratory values) and identify individuals with anorexia, weight, loss or gain, and significant risk for impaired nutrition. 3. The physician will consider whether any assessment including additional diagnostic testing is indicated to help clarify the severity or consequences of weight loss and/or impaired nutrition. 4. The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline, appetite, or food intake. Treatment/Management 1. The staff and physician will identify pertinent intervention based on identified causes and overall resident condition, prognosis, and wishes. a. Treatment decisions should consider all [NAME] evidence and relevant issues. (e.g. food intake, resident/patient wishes, overall condition and prognosis, etc.) and should not be based solely on lab or diagnostic test results. 2. The physician will authorize appropriate interventions, as indicated. a. This may include tapering, stopping, or switching medications known to be associated with undesirable weight gain or anorexia or weight loss. b. The physician will document specific interventions could not be identified or not feasible. 3. The staff and physician will review and consider existing dietary restrictions and modified consistency diets. Monitoring 1. The physician and staff will monitor nutritional status, and individuals, response to interventions, and possible complications of such interventions. The Administrator was informed the of the past noncompliance at the Immediate Jeopardy level on [DATE] at 04:30 PM.

Based on observations, interviews and record reviews, the facility failed to ensure based on the comprehensive assessment of a resident the resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 (Residents # 71, 85 and 87) of 5 residents reviewed for pressure ulcer care. The facility failed to ensure Resident #s 71, 85 and 87 were ordered nutritional supplements to promote wound healing based on risk factors based on standard of care. The facility failed to prevent Resident #71's, 85's and 87's wounds from getting infected. Resident #71 died in the local hospital 01//2024 due to sepsis (a serious condition resulting from the presence of harmful microorganism in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death.) and infected wounds. Resident #85 was transferred to the local hospital on 01//2024 and diagnosed with sepsis. Resident #87 was diagnosed with a wound infection on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE] at 5:10 pm. The IJ template was provided to the facility on [DATE] at 5:10 pm. While the IJ was removed on [DATE] at 4:35 pm the facility remained out of compliance at a scope of pattern and a severity of potential for more than minimal harm that is not immediate jeopardy due to all staff not being trained by [DATE] at 4:35 pm. These failures placed residents at risk for infections, sepsis, and a diminished quality of life and death. Findings included: Record review of Resident #71's undated face sheet reflected she was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including history of stroke, cerebral infarction due to unspecified occlusion (blockage or closing) or stenosis (narrowing) of unspecified cerebral artery, pressure ulcer of left hip stage 3, pressure ulcer of unspecified heel unstageable, nutritional deficiency (vitamin deficiency), unspecified pain, and type 2 diabetes mellitus with unspecified complications. Record review of Resident #71's quarterly MDS, dated [DATE], reflected Resident #71 did not have any unhealed pressure ulcers/injuries and no other skin problems. Record review of Resident #71's quarterly MDS, dated [DATE], reflected Resident #71 had one unstageable pressure ulcer/injury and a diabetic foot ulcer. Staff were required to provide Resident #71 with nutrition or hydration intervention, pressure ulcer/injury care, application of nonsurgical dressings (with or without topical medications) other than to feet, applications of ointments/medications other than to feet, and application of dressings to feet (with or without topical medications). Record review of Resident #71's acute care plan, dated [DATE], reflected Resident #71 had pressure ulcer at her buttock, right lateral ankle and right knee. Review of Resident #71's comprehensive care plan dated [DATE] reflected Nutritional Status for Resident #71 was at risk for trending weight loss, edited [DATE] reflected Resident #71 will not develop skin breakdown related to incontinence. Record review of Resident #71's Braden scales for predicting pressure sore risk, dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE], reflected a score of 9 (with 9 or less indicating very high risk, ,d+[DATE] high risk, ,d+[DATE] moderate risk, ,d+[DATE] at risk for developing pressure ulcer or injuries). Record review of Resident #71's weight reflected the following: [DATE] weight of 160 pounds [DATE] weight of 148 pounds, -5 pounds in a month [DATE] weight of 143 pounds, - 17 pounds in 4 months [DATE] weight of 130 pounds, -13 pounds with 9.9% within a month [DATE] weight of 125 pounds, -5 pounds in 1 month [DATE] weight of 118 pounds, -7 pounds in 1 month Resident had a total of 42 pounds weight loss from [DATE] to [DATE]. Record review of Resident # 71's Dietician note, dated [DATE], reflected: Resident with continued weight loss; Significant weight loss -8.33% x 90 days Record review of Resident #71's wound notes reflected Resident #71's foot wound developed on [DATE]. Record review of Resident #71's acute Care Plan dated [DATE] revealed Resident #71 had pressure ulcer at her buttock, right lateral ankle and right knee. Record review of Resident # 71's physician orders reflected Resident #71 was not ordered any supplements for wound healing. Record review of Resident #71's wound care notes dated [DATE] reflected: Left Ischium unstageable measuring 4.6 x 3.4 cm. Left heel diabetic wound measuring 4x4 cm x unstageable. Right heel diabetic wound measuring 4 x 2.5 x unstageable. Record review of Resident #71's wound care notes dated [DATE] reflected: Left Ischium unstageable measuring 4.5 x 3.5 cm. Left heel diabetic wound measuring 3.5 x 3.5 cm x unstageable. Right heel diabetic wound measuring 4 x 1.5 x unstageable. Resident #71's wound notes also reflected an order for cipro (Antibiotics are medicines that fight bacterial infections in people and animals) 500mg PO BID X 7 days for wound infection. Record review of Resident #71's wound care notes dated [DATE] reflected: Right lateral ankle diabetic wound measuring 3 x 3 cm x unstageable. Left Ischium unstageable measuring 4.5 x 3.5 cm, note indicated the wound was deteriorating. Left heel diabetic wound measuring 3 x 3 x 2 cm. Right heel diabetic wound measuring 4 x 1.2 cm x unstageable. Resident #71's wound noted also reflected an order Doxycycline (Antibiotics are medicines that fight bacterial infections in people and animals.) 100 mg PO BID X 10 days for wound infection. MAR reflected the medication was given from [DATE] through [DATE]. Record review of Resident #71's wound care notes dated [DATE] reflected: Right lateral ankle diabetic wound measuring 8 x 4.5 x unstageable. (Size is 2.6 times the previous week). note indicated the wound was deteriorating. Left Ischium unstageable measuring 4.5 x 3.5 cm, note indicated the wound was deteriorating. Left heel diabetic wound measuring 2 x 1 cm x unstageable. Right heel diabetic wound measuring 4 x 1.2 cm x unstageable, note indicated the wound was deteriorating. Resident #71's wound noted also reflected an order Bactrim DS (Antibiotics are medicines that fight bacterial infections in people and animals.) PO BID X 7 days for wound infection. Bactrim was discontinued and Keflex 500mg 1 PO X 10 days started on [DATE]. Review of Resident #71's physician orders reflected nutritional supplements to promote wound healing were not stated until [DATE]. Record review of Resident #71's Medication administration record reflected the following: Prostat 30ml to promote wound healing 1 x day dated [DATE]. Multivitamin with mineral 1 x day dated [DATE]. Vitamin C 1 x day dated [DATE]. Record review of Resident #71's wound care notes also reflected Bactrim DS (Antibiotics are medicines that fight bacterial infections in people and animals.) PO BID X 7 days was discontinued on [DATE] and new order for Keflex 500mg 1 tab PO every 12 hours x 10 days, wound culture to right ankle. Resident # 71's wound care notes dated [DATE] reflected, patient seen by facility treatment nurse for daily wound care, left foot has deteriorated a great deal: Record review of Resident #71's progress reflected Resident #71 was discharged to the local hospitalER on [DATE]. Record review of the Resident #71's nurse's notes dated [DATE] at approximately 3:51pm written by LVN Y reflected per Resident #71's family's request, Resident #71 was sent to the local hospital ER [DATE] for further assessment of her right foot. Record review of Resident #71's hospital records, reflected Resident #71 was admitted to the local hospital on [DATE] with diagnoses including sepsis secondary to infected left buttock decubitus ulcer and right leg ulcer. Resident #71's hospital records also reflected, integumentary: Warm, Dry, multiple skin ulcers of the bilateral heels of the feet, right knee area medially. 4-inch diameter deep ulcerated wound on the left buttock, which is malodorous, with exudative drainage. minimal surrounding erythema at the wound edges . There was concern for foul-smelling exudate from the left buttock wound and internal medicine was asked to hospitalize. Records also reflected Resident #71 had status post right below-knee amputation dated [DATE]. Record review of Resident #71's [NAME] blood Cell count (WBC) dated [DATE] reflected a value of 22.0 mm (high), normal range 4XXX,d+[DATE].0 (White blood cells- they defend your body against infections and disease. But, when there are too many white blood cells, it usually means you have infection or inflammation in your body): Albumin level 1.7 (low) normal range is 3.4 to 5.4 g/dL ( If you have a lower albumin level, you may have malnutrition. It can also mean that you have an inflammatory disease, most cases of low albumin are caused by acute and chronic inflammatory responses.) During an interview with Resident #71's family member on [DATE] at 10:28am, Resident #71's family revealed Resident #71 expired on [DATE] at approximately 4:00am. Review of Resident #71's death certificate reflected Resident #71 died on [DATE] with causes of death being cerebral vascular accident, sepsis, infected hip, and foot pressure ulcer. Review of Resident # 85's undated face sheet revealed a [AGE] year-old female with admitted [DATE]. Diagnoses include anemia, unspecified, fracture of shaft of left tibia (the shinbone, the larger of the two bones in the lower leg.) subsequent encounter for closed fracture with routine healing. Review of Resident # 85's admission MDS assessment dated [DATE] revealed a BIMS score of 15, indicating no impairment. It was also reflected Resident #85 was at risk of developing pressure ulcer, dependent for lower body dressing and putting on or removing footwear. Review of Resident # 85's acute Care Plan revealed dated [DATE] reflected Resident #85 had skin issue at left tibia. Record review of Resident #85's wound doctor's notes dated [DATE] reflected: Wound location- Left Tibia sign of infection -none measuring 6.6 x 8.0 cm x 0.2 cm exudate: scant, serous dressing used: Calcium Alginate with Honey, Dry Dressing Record review of Resident #85's wound doctor's notes dated [DATE] reflected: Wound location- Left Tibia sign of infection -drainage measuring 6.1 x 8.1 x 1.3 cm. exudate: moderate, Serosanguineous, yellow Doxycycline 100mg 1 PO BID x 10 days. (Antibiotics are medicines that fight bacterial infections in people and animals.) Dressing used: Bactroban, Calcium Alginate Record review of Resident #85's wound doctor's notes dated [DATE] reflected: Wound location- Left Tibia sign of infection -drainage measuring 6.1 x 8.1 cm x 2.9 cm. exudate: moderate, Serosanguineous, yellow extend Doxycycline total 14 days. (Antibiotics are medicines that fight bacterial infections in people and animals.) dressing used--Collagen, Bacitracin and Cal alginate. Record review of Resident #85's NP progress notes dated [DATE] reflected: chief Complaint/Reason for this Visit: Follow up on Left lower leg surgical wound infection. Patient was started on doxycycline for surgical wound infection. Wound care following. Vitals are stable per staff. Continue to monitor. Record review of Resident #85's progress notes dated [DATE] at 10:00pm written by RN I reflected: Resident complained of increased drainage and warm to touch at wound care sight, upon assessing, removed bandage, wound care sight is red, warm to touch, pus, and has an odor . resident and family requested to go to the hospital. Another note with same date and time reflected, Resident family came to the nurses' station and asked if I could assess the resident's leg. The charge nurse from the hall and I assessed the resident, odor and brownish drainage leaking from the wound. After taking dressing out, scopious pus on the wound, this nurse did the treatment as order and charge nurse informed NP and sent Resident to ER. Record review of Resident #85's local hospital records dated [DATE] reflected Resident # 85 was admitted due to sepsis of left lower extremity and bacteremia (the presence of bacteria in the blood). Resident #85's hospital records also reflected left lower extremity tissue culture was positive for MRSA (Methicillin-resistant Staphylococcus aureus- infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics used ), Klebsiella (infections commonly occur among sick patients in healthcare settings who are receiving treatment for other conditions) and pseudomonas on [DATE]. Blood culture also positive for MRSA on [DATE]. Status post hardware removal, washout, and external fixation on [DATE], wound vac change on [DATE]. ORIF (Open reduction and internal fixation is a type of surgery used to stabilize and heal a broken bone) and PRS (Plastic and reconstruction surgery) closure was done [DATE]. Review of Resident # 87's undated face sheet revealed a [AGE] year-old male with admitted [DATE]. Diagnoses include Unspecified open wound of left back wall of thorax without penetration into thoracic cavity, subsequent encounter, pain unspecified. Review of Resident # 87's admission MDS assessment dated [DATE] revealed a BIMS score of 15. It also reflected Resident #58 was dependent for upper and lower body dressing, at risk for developing pressure ulcer. Review of Resident # 87's acute Care Plan dated revealed Resident #87 had skin condition on his buttock, middle back and left Achilles. Review of Resident #87's comprehensive care plan dated [DATE] revealed Resident #87 required assistance with ADLs, resident at risk for pressure ulcer, resident is limited in mobility all or most of the time. Review of Resident #87's wound care notes reflected wound on Resident #87 buttocks was first seen on [DATE]. Review of Resident #87's wound care notes dated [DATE] reflected an order for Cipro 500 mg (Antibiotics are medicines that fight bacterial infections in people and animals.) PO every 12 hours x 7 days. Record review of Resident # 87's wound doctor's note dated [DATE] reflected: Wound location: Bilateral Buttocks Sign of infection: None odor: None exudate: Mild, Serous measuring 8.0 x 7.1x 0.1 cm Wound location: middle back Sign of infection: None odor: None exudate: none measuring 2.5 x 0.5 cm x unstageable Record review of Resident # 87's wound doctor's note dated [DATE] reflected: Wound location: Bilateral Buttocks Sign of infection: None odor: None exudate: mild, Moderate, Serous measuring 8.1 x 6.8 x 0.2 cm Wound location: middle back Sign of infection: None odor: None exudate: Mild, Moderate, Serous measuring 1.9 x 0.9 x 0.8 cm Record review of Resident # 87's clinical records revealed he was not ordered nutritional supplements until [DATE]. Record review of Resident #87's physician orders reflected an order dated [DATE] for: Liquid Protein Fortifier (protein hydrolysate, milk) liquid; 1 gram-4 kcal/6 ml; amt: 30ml; oral Vitamin C (ascorbic acid (vitamin c)) tablet; 500 mg; amt: 1 tab; oral Twice A Day Zinc-220 (zinc sulfate) capsule; 50 mg zinc (220 mg); amt: 1 tab; oral Once A Day Record review of Resident # 87's wound doctor's note dated [DATE] reflected: Wound location: Bilateral Buttocks Sign of infection: drainage odor: None exudate: moderate, serous, green measuring 8.1 x 5.1 x 0.3 Wound location: middle back Sign of infection: drainage odor: None exudate: mild moderate, serous, green measuring 2.2 x 0.6 x 0.7 cm Cipro 500mg (Antibiotics are medicines that fight bacterial infections in people and animals.) 1 PO q12 hrs. x 7 days pending culture results. During an interview on [DATE] at 10:28 am, Resident #71's family revealed Resident #71 passed away at the hospital on [DATE] at 4:00 am due to sepsis and wound infection. Resident #71's family also revealed Resident #71 had no infections when she was admitted to the facility and developed infections at the facility. Resident #71's family revealed they did not know Resident #71 had wounds on one of her feet. Resident #71's family also revealed they requested staff to send Resident #71 out to the hospital because they felt Resident #71 was in pain, TLVN S informed her that Resident #71 was crying in pain, felt Resident #71 needed pain relief, and did not want to wait for the culture test results to determine if Resident #71 needed to be sent out. Resident #71's family also revealed they observed Resident #71's foot on [DATE], it was black and the tendons were exposed when hospital staff observed her foot. During an interview on [DATE] at 11:06 am, TLVN S revealed she worked at the facility for five years. TLVN S also revealed she was responsible for providing daily wound care, such as changing dressings, daily cleanings, following MD's orders, providing treatment and contacting the NP and/or WCD if there was an infection. TLVN S did not know if Resident #71 had any infections when she was admitted to the facility. TLVN S revealed a nurse informed her that Resident #71 had a spot on her several weeks ago. TLVN S explained Resident #71's heel spot worsened a few days later. TLVN S revealed she tried to apply triad paste to Resident #71's heel and place Resident #71 on the WCD's rounds. TLVN S described Resident #71's wound as boggy. TLVN S revealed Resident #71's wound began to get bigger. TLVN S also revealed the WCD last rounded on Resident #71 on [DATE]. TLVN S also revealed she last observed Resident #71's wound when she was treating the heel and necrotic ankle on the right foot on [DATE]. TLVN S revealed she observed Resident #71's right foot, from ankle to the front part of the foot, turned into one big wound that was red, sloughy (yellow), boggy, and the skin was macerated white and peeled back on [DATE]. TLVN S revealed she did not observe black on Resident #71's wound, but she did observe black on the wound areas treated. TLVN S also revealed Resident #71's family informed her that they were sending Resident #71 out to the hospital on [DATE]. During an interview on [DATE] at 11:39 am, TLVN T revealed she worked at the facility for almost three years. TLVN T also revealed she was responsible for taking care of residents' wounds, notifying residents' families, NP, WCD, and MD of any changes of condition in residents' wounds, and communicating updates with wound care. TLVN T revealed Resident #71 did not have wounds on her bilateral heel, ankle, interior ankle, and left ischium when she was admitted to the facility. TLVN T did not know if Resident #71 had any infections when she was admitted to the facility. TLVN T also did not know when she first observed those wounds. TLVN T revealed Resident #71 started off with wounds on her bilateral heel, ankle, interior ankle, and left ischium. TLVN T revealed daily wound care was given to Resident #71 according to physician's orders. TLVN T revealed she last observed Resident #71's wound on [DATE], which were stable and had some necrotic tissue and slough. TLVN T revealed there were no culture tests taken to determine how Resident #71 developed wounds and infections. TLVN T revealed TLVN S informed her last week that Resident #71's wounds rapidly deteriorated. TLVN T revealed RN I, who covered for wound care nurses during their absence, took a wound culture of Resident #71's foot on [DATE]. TLVN T revealed the root cause for Resident #71 developing wounds was due to nutrition. TLVN T was not sure what caused Resident #71's ankle infection. During an interview on [DATE] at 1:20 pm, the WCD revealed he worked for the facility for a little over one year. The WCD also revealed he was responsible for managing residents' wound care and measuring wounds. The WCD did not know if Resident #71 was admitted with wounds and infections. The WCD revealed Resident #71 was very unhealthy, morbidly obese and developed wounds on legs and buttocks. The WCD did not know he started rounding Resident #71's wounds. The WCD revealed Resident #71 had pretty bad wounds and possibly severe PAD. The WCD revealed Resident #71's wounds deteriorated. The WCD also revealed Resident #71 was not eating or drinking well. During an interview on [DATE] at 3:05 pm, RN I revealed she worked at the facility for five months. RN I revealed she was responsible for monitoring and conducting wound care when the wound care nurses were absent. RN I explained TLVN S and the other floor nurses were also responsible for wound care. RN I revealed she was trained in wound care. RN I did not know when she was last in-serviced on wound care. RN I revealed she was in-serviced on dressing changes in [DATE] by TLVN T. RN I also revealed she did not observe Resident #71 had wounds when she started her employment. RN I did not know when Resident #71's wounds developed. RN I revealed Resident's left foot and bottom hip area were treated and the right ankle and right heel wounds were present the first week of [DATE]. RN I revealed she observed Resident #71 did not have any odors to her wounds, the wounds were smaller, and had no drainage on either [DATE] or [DATE]. RN I did not know who was the wound care nurse who provided care to Resident #71 on [DATE]. RN I also revealed she last observed Resident #71's wounds on the right heel, right foot, left ankle, possibly left heel, possibly left knee, and hip sacral area on [DATE]. RN I revealed Resident #71's wound had an odor, was bigger, dark colored, saggy and had lots of drainage on [DATE]. RN I also revealed she was informed by TLVN T that she had an order to obtain a wound culture from Resident #71's foot on [DATE]. RN I revealed Resident #71 had weight loss. RN I explained Resident #71 ate and had an appetite, but she sometimes did not eat because of the food. RN I explained Resident #71 was still losing weight. RN I revealed staff addressed Resident #71's weight loss with the NP, wound care nurses, and family. RN I revealed Resident #71 was given health shakes by medication aides and nurses. An observation of wound care performed by TLVN S on Resident #87 on [DATE] at about 7:45 am revealed TLVN S was assisted by a CNA E. TLVN S gathered supplies outside the room. TLVN S and the CNA E walked into Resident #87's room and performed hand hygiene. Resident #87 was rolled on his right side. TLVN S donned clean gloves, removed soiled dressing from the wounds on Resident #87's middle back and buttocks respectively, and had both soiled dressings on her hand. The soiled dressings from both of Resident #87's wounds contained serosanguineous drainages and was dated [DATE]. TLVN S did not change her soiled gloves or perform hand hygiene. TLVN S cleaned Resident #87's wound on his middle back with normal saline and a gauze with her soiled gloved hands and then moved to Resident #87's wound at his buttocks with the same normal saline and gauze. TLVN S again did not change her gloves or perform hand hygiene, applied medication med-honey to the wound bed at Resident #87's middle back using the same soiled gloved hand fingertips, and then moved to Resident #87's wound at the buttocks with same gloved hands applying med-honey to the wound bed and back to middle of the back. TLVN S then changed her soiled gloves, did not perform hand hygiene and donned clean gloves, and applied dressings on both wounds and dated the dressings. Both staff positioned Resident #87 in his bed, performed hand hygiene, and left Resident #87's room. During an interview on [DATE] at 09:26 am, TLVN S said she started about 2 months ago. She rounded with the wound doctor [DATE] and did wound care on Resident #71 on [DATE]. TLVN S stated Resident #71's wound had gotten worse, the right foot was macerated, and the dressing was saturated with greenish drainage (like pseudomonas) with foul odor. Resident #71 was not on any supplements for wound healing since her foot wound started two months ago. She also stated the new DON brought to her attention that Resident #71 needed to be on protein supplement and vitamins to aid in her wound healing. TLVN S stated Residents #71, 85, and 87 were at risk for developing pressure ulcers due to her medical conditions such as immobility. TLVN S also stated Resident #71, 85 and 87 should have been on supplements for her wound healing. During an interview on [DATE] at 10:34 am, the DON stated Braden scale assessment should be done upon admission, monthly, when there is check skin issues, nutritional changes to make sure the individual was not declining. The DON stated, if a Resident's Braden scale reflects high risk for pressure ulcer development, the facility should consult the dietician for recommendation for supplement due to increased need for protein. The Resident should be turned/repositioned frequently, staff should ensure the Resident is eating, labs such are albumin levels should be check for wound healing. The DON stated nutrition, turning and repositioning play a big role in wound prevention and healing. She stated when she started work at the facility sometimes after [DATE], while reviewing wound care documents, she realized Residents with wounds were not on nutritional supplements for wound healing and recommended that those Residents be order supplements. She stated she was not sure why those residents were not on nutritional supplements. During an interview on [DATE] at 1:17 pm, the RNC said she was the providing supervision for the new DON. The RNC stated the Braden Scales was used to identify resident at risk for skin breakdown, less than 12 is high risk, the lower the number the higher the risk. The RNC stated the categories of the Braden scale were, moisture, activity, mobility, nutrition, friction, and shear. She also stated, when a resident is at high risk, a look back at the category that was triggered to determine the intervention. The RNC stated Braden scale were done upon admission, quarterly and with change of condition. She stated Resident #71's Braden Scales scores were 9 throughout her stay in the facility, Resident #71 was contracted and unable to move for a long time. The RNC stated for a resident with weight loss who developed a wound, the dietician needed to be notified of the wound development, but the dietician was not made aware of Resident #71's wound development. She stated Residents with pressure ulcer required supplemented protein to promote wound healing and Resident #71 had nutritional deficit and so she needed more protein. During an interview on [DATE] at 4:42 pm, TLVN T revealed she provided wound care to Resident #85. TLVN T also revealed Resident #85 was sent to the hospital on [DATE] because staff thought her wound was infected. TLVN T revealed Resident #85 did not return since being discharged to the hospital. TLVN T also revealed Resident #85 had a wound in her left leg. TLVN T did not know what interventions were implemented for Resident #85's wound care. During an interview on [DATE] at 2:01 pm, the NP stated she usually do not order medications or treatments for wounds because there was a wound doctor. The NP also stated for Residents with wounds, were ordered Vitamin C, liquid protein, and zinc. The Dietitian was also made aware to ensure the resident was getting the right intake. The NP stated once the wounds were developed and identified those medications should have started. The NP stated she ordered Remeron (Appetite stimulant) to help with nutrition as well. During an interview on [DATE] at 3:05 pm, the Licensed Dietitian stated she visited the facility on [DATE], and the wound on Resident #71's foot was identified on [DATE], but no one told her about it then. The LD stated she received a wound report from the facility on [DATE], and Resident #71's wound was not on it. The LD stated If she had known Resident #71 had a wound, she would have looked at protein by adding prostat (liquid protein) during medication administration, started multivitamins and seeing if the facility was doing CBC and BMP. Review of facility's policy dated [DATE] titled Pressure Ulcers/Skin Breakdown - Clinical Protocol reflected: the nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). .In addition, the nurse shall describe and document/report the following: .Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. Pain assessment; Resident's mobility status; Current treatments, including support surfaces; and All active diagnoses. .The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. .Beyond trying to maintain a stable weight and providing approximately 1XXX,d+[DATE].5 gm/kg protein daily, there are no routine pressure ulcer-specific nutritional measures for those with or at risk for developing a pressure ulcer. .Any nutritional supplementation should be based on realistic appraisal of an individual's current nutritional status and minimizing any medications and conditions that may be affecting appetite and weight. Review of facility's policy dated [DATE] titled Prevention and Screening - Clinical Protocol reflected: Where medically indicated and accepted by the resident or a substitute decision-maker, the attending physician will identify primary, secondary, and tertiary preventive and screening measures. .The physician will order lab screening tests that are relevant to monitoring the individual's treatment regimen or identifying modifiable risks and complications. .The staff and physician will address ethical issues related to situations where residents decline, to receive, or are unlikely to benefit from screening, preventive measures, or aggressive medical interventions. Review of facility's policy dated [DATE] titled Pressure Injuries Overview reflected: The purpose of this procedure is to provide information regarding definitions and clinical features of pressure injuries. .A pressure injury will present as intact skin and may be painful. .A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful. .Pressure ulcers/injuries occur 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 skin temperature and moisture, nutrition, perfusion, co-morbidities and condition of the soft tissue. Review of facility's policy dated [DATE] titled Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol reflected: The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. The staff and physician will define the individual's current nutritional status (weight, food/fluid intake, and pertinent laboratory values) and identify individuals with anorexia, weight loss or gain, and significant risk for impaired nutrition; for example, high risk residents with acute symptoms such as vomiting, diarrhea [TRUNCATED]

39269 Based on observation, interview and record review the facility failed to ensure residents were free from neglect for 3 (Residents # 71, 85 and 87) of 5 residents reviewed for neglect. The facility failed to ensure Resident #s 71, 85 and 87 were ordered nutritional supplements to promote wound healing based on risk factors based on standard of care. The facility failed to prevent Resident #71's, 85's and 87's wounds from getting infected. Resident #71 died in the local hospital on [DATE] due to sepsis (a serious condition resulting from the presence of harmful microorganism in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death.) and infected wounds. Resident #85 was transferred to the local hospital on [DATE] and diagnosed with sepsis. Resident #87 was diagnosed with a wound infection on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE] at 5:10 pm. The IJ template was provided to the facility on [DATE] at 5:10 pm. While the IJ was removed on [DATE] at 4:35 pm the facility remained out of compliance at a scope of pattern and potential for more than minimal harm that is not immediate jeopardy, due to all staff not being trained by [DATE] at 4:35 pm. These failures placed residents at risk for infections, sepsis, and a diminished quality of life and death. Findings includes: Record review of Resident #71's undated face sheet reflected she was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including history of stroke, cerebral infarction due to unspecified occlusion (blockage or closing) or stenosis (narrowing) of unspecified cerebral artery, pressure ulcer of left hip stage 3, pressure ulcer of unspecified heel unstageable, nutritional deficiency (vitamin deficiency), unspecified pain, and type 2 diabetes mellitus with unspecified complications. Record review of Resident #71's Braden scales for predicting pressure sore risk dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] reflected a score of 9 (with 9 or less indicating very high risk, ,d+[DATE] high risk, ,d+[DATE] moderate risk, ,d+[DATE] at risk for developing pressure ulcer or injuries). Record review of Resident #71's weight reflected the following: [DATE] weight of 160 pounds [DATE] weight of 148 pounds, -5 pounds in a month [DATE] weight of 143 pounds, - 17 pounds in 4 months [DATE] weight of 130 pounds, -13 pounds with 9.9% within a month [DATE] weight of 125 pounds, -5 pounds in 1 month [DATE] weight of 118 pounds, -7 pounds in 1 month Resident had a total of 42 pounds weight loss from [DATE] to [DATE]. Review of Resident #71's comprehensive care plan dated [DATE] reflected Nutritional Status for Resident #71 was at risk for trending weight loss, edited [DATE] reflected Resident #71 will not develop skin breakdown related to incontinence. Record review of Resident # 71's Dietician note dated [DATE] reflected: Resident with continued weight loss; Significant weight loss -8.33% x 90 days Add 1 ensure shake QD to aid in further meet needs. Record review of Resident #71's wound notes written by TLVN S dated [DATE] reflected Resident #71's foot wound developed on [DATE], right lateral ankle, right heel with necrotic, hard area. Paint with betadine daily at this time. Record review of Resident #71's acute Care Plan dated [DATE] revealed Resident #71 had pressure ulcer at her buttock, right lateral ankle and right knee. Record review of Resident # 71's physician orders reflected Resident #71 was not ordered any supplements for wound healing since the wound developed on [DATE]. Record review of Resident #71's wound care notes dated [DATE] reflected: Left Ischium unstageable measuring 4.6 x 3.4 cm. Left heel diabetic wound measuring 4x4 cm x unstageable. Right heel diabetic wound measuring 4 x 2.5 x unstageable. Record review of Resident #71's wound care notes dated [DATE] reflected: Left Ischium unstageable measuring 4.5 x 3.5 cm. Left heel diabetic wound measuring 3.5 x 3.5 cm x unstageable. Right heel diabetic wound measuring 4 x 1.5 x unstageable. Resident #71's wound notes also reflected an order for cipro (Antibiotics are medicines that fight bacterial infections in people and animals) 500mg PO BID X 7 days for wound infection. Record review of Resident #71's wound care notes dated [DATE] reflected: Right lateral ankle diabetic wound measuring 3 x 3 cm x unstageable. Left Ischium unstageable measuring 4.5 x 3.5 cm, note indicated the wound was deteriorating. Left heel diabetic wound measuring 3 x 3 x 2 cm. Right heel diabetic wound measuring 4 x 1.2 cm x unstageable. Resident #71's wound noted also reflected an order Doxycycline (Antibiotics are medicines that fight bacterial infections in people and animals.) 100 mg PO BID X 10 days for wound infection. MAR reflected the medication was given from [DATE] through [DATE]. Record review of Resident #71's wound care notes dated [DATE] reflected: Right lateral ankle diabetic wound measuring 8 x 4.5 x unstageable. (Size is 2.6 times the previous week). note indicated the wound was deteriorating. Left Ischium unstageable measuring 4.5 x 3.5 cm, note indicated the wound was deteriorating. Left heel diabetic wound measuring 2 x 1 cm x unstageable. Right heel diabetic wound measuring 4 x 1.2 cm x unstageable, note indicated the wound was deteriorating. Resident #71's wound noted also reflected an order Bactrim DS (Antibiotics are medicines that fight bacterial infections in people and animals.) PO BID X 7 days for wound infection. Bactrim was discontinued and Keflex 500mg 1 PO X 10 days started on [DATE]. Review of Resident #71's physician orders reflected nutritional supplements to promote wound healing were not stated until [DATE]. Record review of Resident #71's Medication administration record reflected the following: Prostat 30ml to promote wound healing 1 x day dated [DATE]. Multivitamin with mineral 1 x day dated [DATE]. Vitamin C 1 x day dated [DATE]. Record review of Resident #71's wound care notes also reflected Bactrim DS PO BID X 7 days was discontinued on [DATE] and new order for Keflex 500mg 1 tab PO every 12 hours x 10 days, wound culture to right ankle. Resident # 71's wound care notes dated [DATE] reflected, patient seen by facility treatment nurse for daily wound care, left foot has deteriorated a great deal: Record review of Resident #71's progress notes written by LVN Y dated [DATE] reflected Resident #71 was discharged to the local hospitalER on [DATE] at about 4:05 pm. Record review of Resident #71's nurse's notes dated [DATE] at approximately 3:51pm reflected per Resident #71's family's request, Resident #71 was sent to the local hospital ER [DATE] for further assessment of her right foot. Record review of Resident #71's hospital records, reflected Resident #71 was admitted to the local hospital on [DATE] with diagnoses including sepsis secondary to infected left buttock decubitus ulcer and right leg ulcer. Resident #71's hospital records also reflected, integumentary: Warm, Dry, multiple skin ulcers of the bilateral heels of the feet, right knee area medially. 4-inch diameter deep ulcerated wound on the left buttock, which is malodorous, with exudative drainage. minimal surrounding erythema at the wound edges . There was concern for foul-smelling exudate from the left buttock wound and internal medicine was asked to hospitalize. Records also reflected Resident #71 had status post right below-knee amputation dated [DATE]. Record review of Resident #71's [NAME] blood Cell count (WBC) dated [DATE] reflected a value of 22.0 mm (high), normal range 4XXX,d+[DATE].0 (White blood cells- they defend your body against infections and disease. But, when there are too many white blood cells, it usually means you have infection or inflammation in your body): Albumin level 1.7 (low) normal range is 3.4 to 5.4 g/dL (If you have a lower albumin level, you may have malnutrition. It can also mean that you have an inflammatory disease, most cases of low albumin are caused by acute and chronic inflammatory responses.) During an interview with Resident #71's family member on [DATE] at 10:28am, Resident #71's family revealed Resident #71 expired on [DATE] at approximately 4:00am. Review of Resident #71's death certificate reflected Resident #71 died on [DATE] with causes of death being cerebral vascular accident, sepsis, infected hip, and foot pressure ulcer. Resident #85 Review of Resident # 85's undated face sheet revealed a [AGE] year-old female with admitted [DATE]. Her diagnoses include anemia, unspecified, fracture of shaft of left tibia (the shinbone, the larger of the two bones in the lower leg.) subsequent encounter for closed fracture with routine healing. Review of Resident # 85's admission MDS assessment dated [DATE] revealed a BIMS score of 15, indicating no impairment. It was also reflected Resident #85 was at risk of developing pressure ulcer, dependent for lower body dressing and putting on or removing footwear. Review of Resident # 85's acute Care Plan dated [DATE] reflected Resident #85 had skin issue at left tibia. Record review of Resident #85's wound doctor's notes dated [DATE] reflected: Wound location- Left Tibia sign of infection -none measuring 6.6 x 8.0 cm x 0.2 cm exudate: scant, serous dressing used: Calcium Alginate with Honey, Dry Dressing Record review of Resident #85's physician orders reflected an order dated [DATE] for: Pro-Stat AWC (amino acids- protein hydrolys) liquid; ,d+[DATE] gram-kcal/30 ml; amt: 30 ml; oral Record review of Resident #85's wound doctor's notes dated [DATE] reflected: Wound location- Left Tibia sign of infection -drainage measuring 6.1 x 8.1 x 1.3 cm. exudate: moderate, Serosanguineous, yellow Doxycycline 100mg 1 PO BID x 10 days. (Antibiotics are medicines that fight bacterial infections in people and animals.) Dressing used: Bactroban, Calcium Alginate Record review of Resident #85's wound doctor's notes dated [DATE] reflected: Wound location- Left Tibia sign of infection -drainage measuring 6.1 x 8.1 cm x 2.9 cm. exudate: moderate, Serosanguineous, yellow extend Doxycycline total 14 days. (Antibiotics are medicines that fight bacterial infections in people and animals.) dressing used--Collagen, Bacitracin and Cal alginate. Record review of Resident #85's NP progress notes dated [DATE] reflected: chief Complaint/Reason for this Visit: Follow up on Left lower leg surgical wound infection. Patient was started on doxycycline for surgical wound infection. Wound care following. Vitals are stable per staff. Continue to monitor. Record review of Resident #85's progress noted dated [DATE] at 10:00pm written by RN I reflected: Resident complained of increased drainage and warm to touch at wound care sight, upon assessing, removed bandage, wound care sight is red, warm to touch, pus, and has an odor . resident and family requested to go to the hospital. Another note with same date and time reflected, Resident family came to the nurses' station and asked if I could assess the resident's leg. The charge nurse from the hall and I assessed the resident, odor and brownish drainage leaking from the wound. After taking dressing out, scopious pus on the wound, this nurse did the treatment as order and charge nurse informed NP and sent Resident to ER. Record review of Resident #85's local hospital records dated [DATE] reflected Resident # 85 was admitted due to sepsis of left lower extremity and bacteremia (the presence of bacteria in the blood). Resident #85's hospital records also reflected left lower extremity tissue culture was positive for MRSA(Methicillin-resistant Staphylococcus aureus- infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics used ), Klebsiella (infections commonly occur among sick patients in healthcare settings who are receiving treatment for other conditions) and pseudomonas on [DATE]. Blood culture also positive for MRSA on [DATE]. Status post hardware removal, washout, and external fixation on [DATE], wound vac change on [DATE]. ORIF (Open reduction and internal fixation is a type of surgery used to stabilize and heal a broken bone) and PRS (Plastic and reconstruction surgery) closure was done [DATE]. Resident #87 Review of Resident # 87's undated face sheet revealed a [AGE] year-old male with admitted [DATE]. His diagnoses included Unspecified open wound of left back wall of thorax without penetration into thoracic cavity, subsequent encounter, pain unspecified. Review of Resident # 87's admission MDS assessment dated [DATE] revealed a BIMS score of 15. It also reflected Resident #58 was dependent for upper and lower body dressing, at risk for developing pressure ulcer. Review of Resident # 87's acute Care Plan dated revealed Resident #87 had skin condition on his buttock, middle back and left Achilles. Review of Resident #87's comprehensive care plan dated [DATE] revealed Resident #87 required assistance with ADLs, resident at risk for pressure ulcer, resident is limited in mobility all or most of the time. Review of Resident #87's wound care notes reflected wound on Resident #87 buttocks was first seen on [DATE]. Review of Resident #87's wound care notes dated [DATE] reflected an order for Cipro 500 mg (Antibiotics are medicines that fight bacterial infections in people and animals.) PO every 12 hours x 7 days. Record review of Resident # 87's wound doctor's note dated [DATE] reflected: Wound location: Bilateral Buttocks Sign of infection: None odor: None exudate: Mild, Serous measuring 8.0 x 7.1x 0.1 cm Wound location: middle back Sign of infection: None odor: None exudate: none measuring 2.5 x 0.5 cm x unstageable Record review of Resident # 87's wound doctor's note dated [DATE] reflected: Wound location: Bilateral Buttocks Sign of infection: None odor: None exudate: mild, Moderate, Serous measuring 8.1 x 6.8 x 0.2 cm Wound location: middle back Sign of infection: None odor: None exudate: Mild, Moderate, Serous measuring 1.9 x 0.9 x 0.8 cm Record review of Resident # 87's clinical records revealed he was not ordered nutritional supplements until [DATE]. Record review of Resident #87's physician orders reflected an order dated [DATE] for: Liquid Protein Fortifier (protein hydrolysate, milk) liquid; 1 gram-4 kcal/6 ml; amt: 30ml; oral Vitamin C (ascorbic acid (vitamin c)) tablet; 500 mg; amt: 1 tab; oral Twice A Day Zinc-220 (zinc sulfate) capsule; 50 mg zinc (220 mg); amt: 1 tab; oral Once A Day Record review of Resident # 87's wound doctor's note dated [DATE] reflected: Wound location: Bilateral Buttocks Sign of infection: drainage odor: None exudate: moderate, serous, green measuring 8.1 x 5.1 x 0.3 Wound location: middle back Sign of infection: drainage odor: None exudate: mild moderate, serous, green measuring 2.2 x 0.6 x 0.7 cm Cipro 500mg (Antibiotics are medicines that fight bacterial infections in people and animals.) 1 PO q12 hrs. x 7 days pending culture results. During an interview on [DATE] at 09:26 am, TLVN S started Resident # 71's wounds started about 2 months ago. She stated she rounded with the wound doctor [DATE] and did wound care on Resident # 71 on [DATE]. TLVN S stated Resident #71's wound had gotten worse, the right foot was macerated (soft like soak in a liquid), and the dressing was saturated with greenish drainage (like pseudomonas) with foul odor. She Resident #71 was not on any supplements for wound healing since her foot wound started two months ago. She also stated the new DON brought to her attention that Resident #71 needed to be on protein supplement and vitamins to aid in her wound healing. TLVN S stated Residents #71, 85, and 87 were at risk for developing pressure ulcers due to her medical conditions such as immobility. TLVN S also stated Resident #s 71, 85 and 87 should have been on supplements for wound healing. During an interview on [DATE] at 10:34 am, the DON stated Braden scale assessment should be done upon admission, monthly, when there was skin issues, nutritional changes to make sure the individual was not declining. The DON stated, if a Resident's Braden scale reflects high risk for pressure ulcer development, the facility should consult the dietician for recommendation for supplement due to increased need for protein. The Resident should be turned/repositioned frequently, staff should ensure the Resident was eating, labs such as albumin levels should be check for wound healing. The DON stated nutrition, turning and repositioning play a big role in wound prevention and healing. She stated when she started work at the facility sometimes after [DATE], while reviewing wound care documents, she realized Residents with wounds were not on nutritional supplements for wound healing and recommended that those Residents were ordered supplements. She stated she was not sure why those residents were not on nutritional supplements. During an interview on [DATE] at 1:17 pm, the RNC stated she was providing supervision for the new DON. The RNC stated the Braden Scales was used to identify resident at risk for skin breakdown, less than 12 was high risk, the lower the number the higher the risk. The RNC stated the categories of the Braden scale were, moisture, activity, mobility, nutrition, friction, and shear. She also stated, when a resident was at high risk, a look back at the category that was triggered to determine the intervention. The RNC stated Braden scale were done upon admission, quarterly and with change of condition. She stated Resident #71's Braden Scales scores were 9 throughout her stay in the facility, Resident #71 was contracted and unable to move for a long time. The RNC stated for a resident with weight loss who developed a wound, the dietician needed to be notified of the wound development, but the dietician was not made aware of Resident #71's wound development. She stated Residents with pressure ulcer required supplemented protein to promote wound healing and Resident #71 had nutritional deficit and so she needed more protein. During an interview on [DATE] at 2:01 pm, the NP stated she usually do not order medications or treatments for wounds because there was a wound doctor. The NP also stated for Residents with wounds, were ordered Vitamin C, liquid protein, and zinc. The Dietitian was also made aware to ensure the resident was getting the right intake. The NP stated once the wounds were developed and identified those medications should have started. The NP stated she ordered Remeron (Appetite stimulant) to help with nutrition for Resident #71. Review of Resident #71's MAR reflected no evidence of Remeron being administered. During an interview on [DATE] at 3:05 pm, the Licensed Dietitian stated she visited the facility on [DATE], and the wound on Resident #71's foot was identified on [DATE], but no one told her about it then. The LD stated she received a wound report from the facility on [DATE], and Resident #71's wound was not on it. The Licensed Dietitian stated If she had known Resident #71 had a wound, she would have looked at protein by adding prostat (liquid protein) during medication administration, started multivitamins and seeing if the facility was doing CBC and BMP. Review of facility's policy revised [DATE] titled Abuse and Neglect - Clinical Protocol reflected: Neglect, as defined at S483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Assessment and Recognition .The nurse will assess the individual and document related findings. Assessment data will include: injury assessment (bleeding, bruising deformity, swelling etc.); Pain assessment; Current behavior; Patient's age and sex; All current medications, Vital signs; Behavior over last 24 hours. All active diagnoses; and any recent labs. The nurse will report findings to the physician. As needed, the physician will assess the resident/patient to verify or clarify such findings, especially if the cause or source of the problem is unclear. .The physician and staff will help identify risk factors for abuse within the facility; significant injuries in physically dependent individuals; issues related to staff knowledge and skill; or performance that might affect resident care. .Along with staff and management, the physician will help identify situations that might constitute or could be construed as neglect; for example, inadequate prevention or care of pressure ulcers, inattention to advance directives and resident wishes, inappropriate management of problematic behavior, recurrent failure to provide incontinence care, failure to report or evaluate significant weight loss, repeated failure to check for correct application of restraints, etc. Review of facility's policy dated [DATE] titled Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol reflected: The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. The staff and physician will define the individual's current nutritional status (weight, food/fluid intake, and pertinent laboratory values) and identify individuals with anorexia, weight loss or gain, and significant risk for impaired nutrition; for example, high risk residents with acute symptoms such as vomiting, diarrhea, fever and infection, or those taking medications that may be causing weight gain or increasing the risk of anorexia or weight loss. Review of facility's policy dated [DATE] titled Pressure Ulcers/Skin Breakdown - Clinical Protocol reflected: the nursing staff and practitioner will assess and document an individual's significant risk actors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). .In addition, the nurse shall describe and document/report the following: .Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. Pain assessment; Resident's mobility status; Current treatments, including support surfaces; and All active diagnoses. .The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. .Beyond trying to maintain a stable weight and providing approximately 1XXX,d+[DATE].5 gm/kg protein daily, there are no routine pressure ulcer-specific nutritional measures for those with or at risk for developing a pressure ulcer. .Any nutritional supplementation should be based on realistic appraisal of an individual's current nutritional status and minimizing any medications and conditions that may be affecting appetite and weight. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 5:10 pm. The Administrator was notified. The Administrator was provided with the IJ template on [DATE] at 5:10 pm The following Plan of Removal submitted by the facility was accepted on [DATE] at 8:33 am. PLAN OF REMOVAL F600 The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the issues: Regional Director of Operations re-educated Administrator on wound prevention and care to include infection control and supplemental incorporation of interventions. [DATE]. RNC for facility reinforced and re-educated Director of Nursing and Assistant Director of Nursing on wound prevention and care to include infection control and supplemental incorporation of interventionsXXX[DATE]. Complete skin assessment of all residents performed throughout facility as well as Braden scales to ensure they match resident status. [DATE] All residents found to have wounds or Braden scores falling within scope of intervention were audited for implementation of supplements, prophylactic skin measures and treatment appropriate orders for wounds or skin issues noted. [DATE] One on one education of all licensed staff members began per DON/ADON and/or designees on areas of wound prevention and treatment to ensure protocols followed as put in place. [DATE]. Interventions and Monitoring Plan to Ensure Compliance Quickly: o The facility will ensure infection control education to include hand hygiene and wound care measures on all new hires and at minimum annually or upon audit findings. Initiated: [DATE] Completion: [DATE] o DON/designee will perform random audits of Braden scales for 4 residents 3x/week for 4 weeks to ensure adequate assessment and documentation with appropriate measures in place. Initiated: [DATE] Completion: [DATE] o All residents noted to have current wounds will be audited Q week x4 weeks by DON and/or designee to ensure all supplements, consultations and treatments are in line with standard protocols as ordered by practitioner. Initiated: [DATE] Completion: [DATE] o Return demonstration of understanding will be noted by post competency check for each person educated with a written post-test administered by Director of Nursing, Assistant Director of Nursing, and/or designee for any nursing staff receiving re-education or training on competencies not found to be proficient. Staff that are on leave from the facility will be given the competencies check off by the same individuals noted above before starting their next shift. This facility does not employ the use of agency personnel. Initiated: [DATE] Completion: [DATE]. o The facility DON/ADON will act as monitoring liaison to coordinate completion of audits for accurate assessment of resident status in relation to Braden scale and skin monitoring to ensure proper care, training competency and immediate initiation of interventions and treatments are enacted for all residents requiring. This will be relayed to the Administrator during weekly CAR meetings for continuum of care to be documented through signed attendance sheet. Initiated: [DATE] Completed: [DATE] o The policy and procedure for infection control to be reviewed by Regional [NAME] President of Operations and RNC with any changes to policies to be implemented. Initiated: [DATE] Completed: [DATE] o Licensed nursing staff with direct involvement in the resident care in question during the time noted in the immediate jeopardy ruling will receive one on one education if still in employment of facility with return demonstration noted through verbal and written understanding in educational interactions and competency evaluation. Initiated: [DATE] Completed: [DATE] o All licensed staff not on duty during above wound prevention, intervention, and treatment education will be checked as noted above prior to returning to the floor for their next scheduled shift. Initiated: [DATE] Completed: [DATE] o Proper wound care treatment, interventions and prevention as well as staff training competency in wound care and immediate implementation of skin/wound needs will be reviewed by the QAPI committee x 3 months and changes to the plan will be made as needed. Initiated: [DATE] Completed: [DATE] o The Medical Director was notified of Immediate Jeopardy and apprised of interventions and monitoring initiated with further updates to be given during QAPI meetings. Initiated: [DATE] Completed: [DATE] Monitoring of the plan of removal was completed on [DATE] and revealed the following: Review of the facility's POR for F600 reflected: Administrator and DON were both in-serviced by the VP for operation and RNC on prevention of pressure ulcer and infection from developing dated [DATE]. In-services initiated on [DATE] for identification of pressure injury risk factor and interventions for risk factors. Documentation of Resident's Braden scale and Resident's skin assessments initiated on [DATE]. Post test was conducted on [DATE] covering Infection control, identifying pressure injury risk factors and interventions, Braden Scale, abuse and neglect. During an interview on [DATE] at 12:31 pm, RN I revealed she worked at the facility for five months. RN I also revealed staff have been in-serviced every day. RN I explained staff were in-serviced by the DON, ADON, MDSN, RNC, and TLVN T. RN I revealed staff were in-serviced on wound care, protocols, standing orders, chain of command, what to do when new orders were received, new skin issues, relaying communications to the nurse, nurse relating communications to all reporting parties, and infection control related to handwashing, g-tube medication administration, wound care and orders. RN I revealed staff were required to perform a return demonstration in which they took a test and were scored on performance. RN I also revealed staff took exams on abuse and neglect after given examples of abuse and neglect. RN I explained staff talked about how not catching something could affect a resident, such as nutrition affecting wound healing, not redirecting, and not educating residents. RN I further explained the body would shut down with poor nutrition. RN I also revealed staff were taught how not performing assessments or observing residents could affect the resident. RN I revealed staff were also taught the Braden scale (a scale used to determine who was at risk for developing pressure ulcers) and preparing the scale when there was a change of condition or new change of condition observed during skin assessment. RN I also revealed staff were taught how to locate standing orders for pressure ulcers. RN I revealed she performed a skin assessment on a newly admitted resident and taught a new employee how to perform the protocol. During an interview on [DATE] at 12:50 pm, CNA L revealed staff have been in-serviced by the ADM, DON, and ADON about five times since the surveyors entered the facility on [DATE]. CNA L revealed staff were in-serviced on abuse, letting management know if observed something and did not report, skin care, skin change, reporting to nurses when residents did not eat or drink, infection control, such as making sure staff checked residents' skin during showers, immediately reporting any skin changes to the charge nurse, and making sure staff washed their hands when working from one resident to another and performing one task to another. CNA L also revealed nurses were required to check on residents' skin. During an interview on [DATE] at 1:04 pm, CNA U revealed she worked at the facility for four months. CNA U also revealed staff were in-serviced by the ADM, DON, and ADON on infection control, always changing residents, keeping residents clean, washing hands, using hand sanitizer, and not leaving residents soiled. CNA U also revealed staff were trained on abuse and neglect, not attending to residents who need staff was neglect, observing and reporting skin to nurses when showering and changing residents. CNA U revealed staff were also trained on assisting residents to eat, encouraging residents to eat and documenting food and fluid intake, and notifying the nurse if residents w [TRUNCATED]

Based on interview, and record review the facility failed to ensure adequate supervision to prevent accidents for 1 (Resident #1) of 5 residents reviewed for accidents and supervision. 1. On 08/10/2023 resident was admitted by ambulance to the facility after an acute hospital stay with a diagnosis of altered mental status. 2. On 08/12/2023 at approximately 12:30 pm resident R#1 eloped from the facility. R#1 was returned by a staff member to facility on 08/12/2023 at approximately 3:00 pm. Resident was assessed, and no injuries found. 3. On 08/12/2023 at approximately 9:45 pm R#1 eloped a 2nd time from the facility. He was found by police who returned him to the facility. R#1 was not assessed for injuries, and he left AMA. An (IJ) Immediate Jeopardy was identified on An IJ was identified on 08/22/2023. While the IJ was removed on 08/25/2023 at 6:30 PM, the facility remained out of compliance at a severity level of actual harm with the potential for more than minimal harm that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place all residents at risk for accidents and harm. Findings included: Review of R#1's undated face sheet reflected R#1 was a [AGE] year-old male, admitted to the facility on [DATE] at 2:04 pm and discharged on [DATE] at 12:00 am. R#'s face sheet did not list a diagnosis. Review of R#1's Baseline Care Plan reflected an admitting DX of altered mental state (Altered mental status is a change in mental function. It stems from certain illnesses, disorders and injuries affecting your brain. The change is often temporary, but can quickly become life-threatening), tachycardia (an irregular electrical signal (impulse) starting in the upper or lower chambers of the heart causes the heart to beat faster), pancytopenia (low levels of red blood cells, white blood cells and platelets), problems - falls and used an electric wheelchair. ElopementBased on interview and record review the facility failed to ensure adequate supervision to prevent accidents for 1 (Resident #1 ) of 5 residents reviewed for accidents and supervision. - On 08/12/2023 at approximately 12:30 p.m. Resident #1 (R#1) eloped from the facility. R#1 was returned by a staff member to facility on 08/12/2023 at approximately 3:00 pm. Resident #1 was assessed, and no injuries found. - On 08/12/2023 at approximately 9:45 p.m., R#1 eloped a 2nd time from the facility. He was found by police who returned him to the facility. R#1 was not assessed for injuries, and he left AMA. An (IJ) Immediate Jeopardy was identified on 08/22/2023 at 5:25 pm While the IJ was removed on 08/24/2023 at 6:30 PM, the facility remained out of compliance at a scope of isolated with no actual harm with the potential for more than minimal harm that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place all residents at risk for harm requiring hospitalization and/or death. Findings included: Review of R#1's undated face sheet reflected R#1 was a [AGE] year-old male, admitted to the facility on [DATE] at 2:04 p.m. and discharged on [DATE] at 12:00 a.m. R#1's face sheet did not list a diagnosis. Review of R#1's Baseline Care Plan reflected an admitting DX of altered mental state (Altered mental status is a change in mental was not listed as a problem. Record review of hospital records dated 07/16/2023 reflected that R#1 was admitted on [DATE] found down at a gas station with DX of sepsis (a serious condition in which the body responds improperly to an infection) due to acute colitis (Infections caused by a virus or a parasite) and metabolic encephalopathy (a problem in the brain), homeless and unable to state where he lives. Review of hospital record dated 07/18/2023 of consultation for purposes of capacity to make medical decisions reflected that the patient (R#1) was very confused, he actually believed he was in Michigan on two occasions in my interaction. He was unable to identify any kind of date time or situation. He was also very confused about events. The record reflected patient showed poor higher level of thinking as well and processing. R#1 revealed he had been having energy difficulties, concentration concerns, sleep disruption, and psychological factors that impacted his functioning. His affect was blunted, and mood appeared depressed. He was oriented to person, place, and time period with no observable signs of psychosis noted. R#1received a 11 out of 30 on PHQ - 9 (PHQ-9 Quick Depression Assessment) which placed him in mild range of depression. He received a 12 out of 30 on the MSE (mental status exam) which indicated moderate cognition. R#1 struggled with any higher-level processing or understanding of recent medical events. A quick review of his medical issues was provided to the patient; however, the patient could not remember any of these issues after a short delay of interference. Record reflected diagnostic impression of 1. delirium secondary to his general medical condition and to rule out dementia/neural cognitive defects 2. anxiety order, not otherwise specified 3. rule out adjustment disorder 4. alcohol use disorder- in full remission per patients report Treatment recommendations. 1. Followed with one-to-one psychotherapy for management of mood while hospitalized . 2. Progress will be assessed with the patient and the staff support. 3. Patient was also assessed for adherence to psychological treatment plan - the patient's mood could impact adherence and consequentially cognitive behavioral therapy will be used to address any issues with adherence 4. The patient is not showing capacity to make medical decisions at this time. Review of hospital record dated 07/24/2023 of psychotherapy one-to-one reflected patient (Resident #1) still is as confused as the last interaction and only able to identify he was in the hospital accurately. He still believes he is in Michigan and could not identify place or any aspect time or date. He continued to be confused about why he's in the hospital and recent events. Patient still unable to do any higher-level thinking and could not remember any of the discussion about his medical care after short delay with interference. Mental Status Exam revealed appearance disheveled, oriented to self, mood depressed, affect flat, attitude inhibited, thought content non elicited, insight and judgment both limited and poor. DX assessment plan to rule out [NAME]-Korsakoff syndrome (an unusual type of memory disorder due to a lack of thiamin (vitamin B1) requiring immediate treatment. It most often happens in people with alcohol use disorder and malnutrition. While there isn't a cure, healthcare providers can recommend treatments to manage your symptoms), apparently patient had a long history of neurocognitive deficits noted at a local homeless shelter and likely patient had at least pre-existing dementia. Patient still not showing capacity make to make medical decisions. Review of hospital progress note dated 08/07/2023 reflected, remains confused. Review of hospital progress note dated 08/08/2023 reflected diagnosis assessment of early dementia/anxiety likely a manifestation of B12 deficiency. Patient did not show capacity to make medical decisions, this is likely his baseline cognitive function (measures your brain function in a healthy state). Record review of 08/10/2023 at 2:20 pm, admission nurses note by RN 1 reflect R#1 had a DX upon admission of altered mental status and was A&OX3 (alert and oriented to person, place, and time) and had no other concerns at that time. Record review of 08/10/2023 at 9:00 pm nurses note by RN 1 reflect R#1 expressed wanting to leave the facility. R#1 expressed he needed to leave because of a personal reason. Note reflected that R#1 was redirected back to his room and assured that there would be additional assistance in the morning. Note reflected he said he would stay the night but would need to leave in the morning. Note reflected that management was notified of his behavior. There are no nurses notes from the facility for 08/11/2023. Interview with RN 1 revealed on 08/21/23 at 1:10 pm that at 9:00 pm on 08/10/2023 R#1 began to talk about eloping and started wandering and said he had to go but RN 1 said it was nighttime and it was unsafe for him to leave. She said she texted the ADM that R#1, on admission, did not show any signs of wanting to leave but at approximately 9:00 pm, R#1 said he wanted to leave. When asked what ADM's reply was to her text, she said ADM said to redirect him and he would see R#1 in the morning. RN 1 said she does not know if the ADM went to see R#1 the next morning. She revealed she told the charge nurse for the next shift that R#1 wanted to leave and to keep an eye on him. RN 1 said it is fair to say that there were some concerns about R#1 and elopement. She revealed she did not know about his mental status, but she did try to call the hospital and obtain information, but the hospital did not return her call. When asked why his possession inventory admission sheet was blank, she said he did not have any clothes, he was admitted to the facility from the hospital in a hospital gown and had no belongings to list. Interview on 08/12/2023 at 5:05 pm with LVN 2 revealed LVN 2 observed R#1 walk the 300-hallway on the 08/11/2023 and he looked confused. LVN 2 revealed R#1 was walking the hallway and the nurses' station near the dining area and when LVN #2 last saw R#1, he was in his bed. Interview with LVN 1 on 08/12/2023 at 4:32 pm revealed she worked with R#1 on 08/12/2023 in the morning prior to his elopement at approximately 12:30 pm that day. She revealed R#1 was walking around on 400-hallway and pushed up against the bar of the front door. She approached him and she said he could not go out. When asked about his mental status she said he was AX3, but he was slow and acted like he did not understand everything she told him. She did not look at his DX but said she thought that he had a DX of dementia or Alzheimer's, and she told the receptionist, who is seated in front of the main entry/exit door, to keep an eye on him. She said all the staff were aware that he was exit seeking. LVN 1 said she knew he seemed anxious and wanted to leave. LVN 1 said that when he returned from the first elopement, she texted the NP who ordered labs, to keep him hydrated, issue a WG and conduct Q 15 minutes. When asked again about his mental state, LVN 1 said R#1 answered all her questions correctly and knew he was in a nursing home but there was something about him that made her think he had cognition issues. Interview with CMA 1 on 08/12/2023 at 11:28 pm revealed she observed R#1 trying to find his way out and when she asked him about why he wanted to leave he said his home was in Michigan and he knew he was not in Michigan. He said that he came to the facility to use the rest room then they would not let him leave. CMA 1 said she felt that he seemed confused she told nurse (nurses name unknown). Interview on 08/25/2023 at 4:14 pm with RN 2 revealed she worked the 2:00 pm to 10:00 pm shift on 08/12/2023, after R#1's first elopement, and had an order from the NP for a WG for R#1. RN 2 revealed she asked permission from R#1 to place the WG (there was no policy in place for the resident or RP to sign for wander guard placement) on his R leg by his ankle and R#1 agreed. RN 2 revealed NP also placed an order for labs, to make sure he was hydrated, and for Q15-minute checks. RN 2 said each time she checked R#1 she said she confirmed he was wearing the WG. Interview with maintenance manager on 08/24/2023 at 10:34 pm revealed that he has worked at the facility for approximately seven years and every Monday he opened the doors that are alarmed with both regular alarms and combination WG and regular alarms and confirmed that they alarmed for at least 20 seconds. He also revealed that after R#1 eloped, he checked all the door alarms and the facility windows and screens. He revealed that he thinks R#1 walked out with facility visitors because he has no clue how else R#1 eloped. Record review of facility Accident/Incident Report for Falls, Injury, Elopement, Behaviors, Allegation dated 08/12/2023 and signed by LVN 1 for R#1's first elopement reflected R#1 was A&OX2 and revealed cognitive factors of memory impairment and decision making impaired. Record review of facility Accident/Incident Report for Falls, Injury, Elopement, Behaviors, Allegation dated 08/12/2023 and signed by the DON for R#1's second elopement reflected under Type of Injury other, no Head-to-Toe assessment and that physician was notified on 08/12/2020 (believe the 2020 is a type and should be 2023) at 9:45 pm. Record review of facility Accident/Incident Report for Falls, Injury, Elopement, Behaviors, Allegation dated 08/13/2023 completed for R#1's first and second elopements and signed by the ADM reflected Head to Toe Assessment A&Ox3 and NP was notified on 08/12/2023 with no time of notification documented. Record revealed R#1 left building at around 12 pm and was found by staff member and brought back. Then at around 9:30 R#1 left again and was found. Record review of facility policy Review of Risk of Elopement/Wandering Review undated in R#1's paper file and completely blank revealed: Instructions Complete upon admission, thirty days after admission, quarterly and at significant change, or per facility policy. Review potential risk factors and resident status including is the resident cognitively impaired with poor decision-making skills, does the resident have a history of leaving the facility without informing staff, has the resident expressed a desire to go home, and admitted or readmitted and not accepting the situation. On 8/22/2023 at 5:25 pm, the the ADM and the DON were notified of the Immediate Jeopardy (IJ) due to the above failures and the IJ template was provided at that date and time. The following Plan of Removal was submitted by the facility and was accepted on 08/24/2023 at 10:51 am: Table of Contents F689 On 8/22/23, [NAME] Woods 1 Nursing Center failed to adequately supervise and prevent accidents for one resident. The facility failed to prevent R1 from eloping from the facility two times in less than a 24-hour period. All resident at risk for elopement. 1. Regional [NAME] President of Operations performed education on 8.22.23 for Administrator on accidents and hazards processes including elopement program. 2. Regional Nurse Consultant performed further education on 8.22.23 for Director of Nursing on accidents and hazards processes including elopement program. 3. The DON/Designee immediately assessed all residents for elopement risk on 8/22/23. 4 Residents who were found to be high risk for elopement and care plan and orders were updated by DON/designee. No new residents were found at risk. Elopement Assessments were dated and signed by evaluator. 4. MDS coordinator reviewed and updated Comprehensive care plan for all residents who scored yes in the Risk of Elopement/Wandering Review on 8.22.23. 5. The DON/Designee immediately in-serviced all staff on the elopement program and exit seeking behaviors on 8.22.23. If behaviors are noted, report to DON/designee. Education included licensed nurses to complete elopement risk assessment upon admission, quarterly and change of condition. All staff education on when and how to respond to door alarms and what to do if a resident leaves the facility and what to do when the resident returns. All staff not present, including agency, shall be in-serviced by DON/Designee before start of shift and new hires will be educated by DON/designee. 6. DON/designee presented post tests on 8/23/23 for knowledge retention after the education was presented. All staff who scored <80% was re-educated. 7. Administrator/designee to perform random checks of residents with wander guard bracelets, wander guard door system, and fire exit alarms via one-on-one observation 3x/week for 4 weeks and 1x/week for 3 months to assure wander guard system and doors are working properly. This shall be documented on the administration's audit sheet for wandergaurd, fire door exit alarm. Start 8.22.23 and end 12.12.23. Any issues with the system or doors will be immediately addressed and corrected Administrator/Designee. Results of the audits will be reviewed and discussed by the interdisciplinary team and medical director in QAPI and implement new interventions if needed. Results of the audits will be reviewed and discussed by the interdisciplinary team and medical director during QAPI and implement new interventions if needed 3 times a week for 4 weeks then once a week for 3 months. Started 8/22/23. 8. DON/designee will have a weekly at-risk meeting with interdisciplinary team to include review of the incident and accident reports and interventions including elopements. Start date is 8.22.23 and will be conducted 3 times a week for 4 weeks then once a week for 3 months and once a month there after. Any issues with the reports and interventions will be immediately addressed and corrected. 9. Admin/designee will hold a QAPI meeting with the interdisciplinary team q week for 3 weeks to discuss elopement program progress. Any issues found within the meeting will be immediately addressed and corrected by DON/designee which includes further education and replacement of equipment if needed. Start 8.22.23 and end on 9.12.23. 10. Electronic notification of Medical Director notification of IJ and QAPI meetings given 8/22/23 at 5:43 p.m. Medical director attended via telephone conference. 11. Admin/designee will keep the elopement system in QAPI meeting with the interdisciplinary team for 3 months following the initial 3-week meetings. Start 8.22.23 and end 12.12.23. Any issues found within the meeting will be immediately addressed and corrected which includes further education and replacement of equipment if needed. Monitoring of the plan of removal from 08/25/2023 through 08/25/2023 included the following: 1. Confirmed that the Regional [NAME] President of Operations performed education on 08/22/2023 for Administrator on accidents and hazards processes including elopement program. 2. Confirmed Regional Nurse Consultant performed further education on 08/22/2023 for Director of Nursing on accidents and hazards processes including elopement program. 3. Confirmed the DON/Designee immediately assessed all residents for elopement risk on 08/22/2023. 4. Confirmed MDS coordinator reviewed and updated Comprehensive care plan for all residents who scored yes in the Risk of Elopement/Wandering Review on 08/22/2023. 5. Reviewed in-service attendance sheet and materials dated 08/22/2023 given by the DON and ADM to staff subjects WG protocol, admission protocol, incident/accident protocol, exit searching, and discharge. 6. Reviewed in-service attendance sheet dated 08/22/2023 given by the DON and ADM on head count for residents on all shifts incoming and outgoing, check when you put your eyes on the residents, nurses check your residents when you come in from your shifts. 7. Reviewed in-service given by DON on wanderguard Use Protocol to check placement of WG, check and ensure skin integrity, and document every shift. 8. Reviewed in-service given by DON and ADM to all staff on abuse and neglect, elopement/wandering, and wanderguard. 9. Interviewed LNV, LVN nurse manager, and CMA from different shifts who stated they participated, understood, and felt comfortable with the information given regarding WG, admissions, incidents/accidents and discharge, and keeping eyes on the residents. The ADM and DON were informed the Immediate Jeopardy was removed on 08/24/2023 at 6:30 PM., however the facility remained out of compliance at a scope of isolated nd a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy, 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 the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. 1. R#1 was a resident at the facility for approximately 52 hours (08/10/2023 at 2:30 pm admission through 08/13/23 at midnight AMA) and displayed exit seeking, confused, and questionable cognitive behavior during his admission. 2. R#1 eloped two times within a 24-hr. period, and he was discharged AMA without an assessment and without consulting the facility MD or NP or obtaining an order. An (IJ) Immediate Jeopardy was identified on 08/22/2023 at 5:25 pm While the IJ was removed on 08/24/2023 at 6:30 PM, the facility remained out of compliance at a scope of isolated with no actual harm with the potential for more than minimal harm that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place all residents at risk for accidents, harm, and/or death. Findings included: Review of R#1's undated face sheet reflected R#1 was a [AGE] year-old male, admitted to the facility on [DATE] at 2:04 pm and discharged on [DATE] at 12:00 am. R#1's face sheet did not list a diagnosis. Review of R#1's Baseline Care Plan reflected an admitting DX of altered mental state (Altered mental status is a change in mental function. It stems from certain illnesses, disorders and injuries affecting your brain. The change is often temporary, but can quickly become life-threatening), tachycardia (an irregular electrical signal (impulse) starting in the upper or lower chambers of the heart causes the heart to beat faster), pancytopenia (low levels of red blood cells, white blood cells and platelets), problems - falls and used an electric wheelchair. Elopement was not listed as a problem. Record review of hospital records dated 07/16/2023 reflect that R#1 was admitted on [DATE] found down at a gas station with DX of sepsis (a serious condition in which the body responds improperly to an infection) due to acute colitis (Infections caused by a virus or a parasite) and metabolic encephalopathy (a problem in the brain), homeless and unable to state where he lives. Review of hospital record dated 07/18/2023 of consultation for purposes of capacity to make medical decisions reflected that the patient was very confused, he actually believed he was in Michigan on two occasions in my interaction. He was unable to identify any kind of date time or situation. He was also very confused about events. The record reflected patient showed poor higher level of thinking as well and processing. R#1 revealed he had been having energy difficulties, concentration concerns, sleep disruption, and psychological factors that impacted his functioning. His affect was blunted, and mood appeared depressed. He was oriented to person, place, and time period with no observable signs of psychosis noted. R#1received a 11 out of 30 on PHQ - 9 (PHQ-9 Quick Depression Assessment) which placed him in mild range of depression. He received a 12 out of 30 on the MSE (mental status exam) which indicated moderate cognition. R#1 struggled with any higher-level processing or understanding of recent medical events. A quick review of his medical issues was provided to the patient; however, the patient could not remember any of these issues after a short delay of interference. Record reflected diagnostic impression of 5. delirium secondary to his general medical condition and to rule out dementia/neural cognitive defects 6. anxiety order, not otherwise specified 7. rule out adjustment disorder 8. alcohol use disorder- in full remission per patients report Treatment recommendations. 5. Followed with one-to-one psychotherapy for management of mood while hospitalized . 6. Progress will be assessed with the patient and the staff support. 7. Patient was also assessed for adherence to psychological treatment plan - the patient's mood could impact adherence and consequentially cognitive behavioral therapy will be used to address any issues with adherence 8. The patient is not showing capacity to make medical decisions at this time. Review of hospital record dated 07/24/2023 of psychotherapy one-to-one reflected patient still is as confused as the last interaction and only able to identify he was in the hospital accurately. He still believes he is in Michigan and could not identify place or any aspect time or date. He continued to be confused about why he's in the hospital and recent events. Patient still unable to do any higher-level thinking and could not remember any of the discussion about his medical care after short delay with interference. Mental Status Exam revealed appearance disheveled, oriented to self, mood depressed, affect flat, attitude inhibited, thought content non elicited, insight and judgment both limited and poor. DX assessment plan to rule out [NAME]-Korsakoff syndrome (an unusual type of memory disorder due to a lack of thiamin (vitamin B1) requiring immediate treatment. It most often happens in people with alcohol use disorder and malnutrition. While there isn't a cure, healthcare providers can recommend treatments to manage your symptoms), apparently patient had a long history of neurocognitive deficits noted at a local homeless shelter and likely patient had at least pre-existing dementia. Patient still not showing capacity make to make medical decisions. Review of hospital progress note dated 08/07/2023 reflected, remains confused. Review of hospital progress note date 08/08/2023 reflected diagnosis assessment of early dementia/anxiety likely a manifestation of B12 deficiency. Patient did not show capacity to make medical decisions, this is likely his baseline cognitive function (measures your brain function in a healthy state). Record review of 08/10/2023 2:20 pm admission nurses note by RN A reflect R#1 had a DX upon admission of altered mental status and was A&O X 3 (alert and oriented to person, place, and time). Record review of 08/10/2023 9:00 pm nurses note by RN A reflect R#1 expressed wanting to leave the facility because of a personal reason. Note reflected he said he would stay the night but would need to leave in the morning. Note reflected that management was notified of his behavior. There are no nurses notes from the facility for 08/11/2023. Interview with RN A revealed on 08/21/23 at 1:10 pm that at 9:00 pm on 08/10/2023, R#1 began to talk about eloping and started wandering and said he had to go but RN A said it was nighttime and it was unsafe for him to leave. She said she texted the ADM that R#1, on admission, did not show any signs of wanting to leave but at approximately 9:00 pm, R1 said he wanted to leave. When asked what ADM's reply was to her text, she said ADM said to redirect him and he would see R1 in the morning. RN A said she does not know if the ADM went to see R1 the next morning. RN A said it is fair to say that there were some concerns about R#1 and elopement. She revealed she did not know about his mental status, but she did try to call the hospital and obtain information, but the hospital did not return her call. When asked why his possession inventory admission sheet was blank, she said he did not have any clothes, he was admitted to the facility from the hospital in a hospital gown and had no belongings to list. Interview with LVN A on 08/12/2023 at 4:32 pm revealed she worked with R#1 on 08/12/2023 in the morning prior to his elopement at approximately 12:30 pm that day. She revealed R#1 was walking around on 400-hallway and pushed up against the bar for the door. She approached him and she said he could not go out. When asked about his mental status she said he was AX3, but he was slow and acted like he did not understand everything she told him. She did not look at his DX but said she thought that he had a DX of dementia or Alzheimer's, and she told the receptionist, who is seated in front of the main entry/exit door, to keep an eye on him. She said all the staff were aware that he was exit seeking. LVN A said she knew he seemed anxious and wanted to leave. LVN A said that when he returned from the first elopement, she texted the NP who ordered labs, to keep him hydrated, issue a WG and conduct Q 15 minutes. When asked again about his mental state, LVN A said R#1 answered all her questions correctly and knew he was in a nursing home but there was something about him that made her think he had cognition issues. Interview with CMA 1 on 08/12/2023 at 11:28 pm revealed she observed R#1 trying to find his way out and when she asked him about why he wanted to leave he said his home was in Michigan and he knew he was not in Michigan. He said that he came to the facility to use the rest room then they would not let him leave. CMA 1 said she felt that he seemed confused she told nurse (nurses name unknown). Interview on 08/25/2023 at 4:14 pm with RN 2 revealed she worked the 2:00 pm to 10:00 pm shift on 08/12/2023, after R#1's first elopement, and had an order from the NP for a WG for R#1. RN 2 revealed she asked permission from R#1 to place the WG (there was no policy in place for the resident or RP to sign for WG) on his R leg by his ankle and R#1 agreed. RN 2 revealed NP also placed an order for labs, to make sure he was hydrated, and for Q15-minute checks. RN 2 said each time she checked R#1 she said she confirmed he was wearing the WG. Interview on 08/22/23 at 11:41 am with the RNC said there was absolutely concern about R#1 eloping and he exhibited clear wandering and exit seeking behaviors. She feels the WG could have helped with his safety. She said that if he agreed to wear the WQ, it would not feel like his rights were being violated. If he eloped once, particularly because they were not sure how he eloped the first time, he could elope a second time. Interview on 08/21/2023 at 10:23 pm with ADM revealed R#1 eloped from the facility on 08/12/2023 between12:30 pm and 1:00 pm. Facility elopement policies were followed and approximately 2.5 hrs. R#1 was located about 2 miles away, in a heavy metropolis area, by a facility nurse, who was looking for him in her car. R#1 returned to the facility at approximately 3:00 pm. ADM told him that it is not okay to leave without telling someone. R#1 was assessed and was fine. ADM said they suspected R#1 followed someone out of the facility. ADM revealed that they checked the fire exit doors, and they were all working. R#1 eloped again at approximately 9:45 pm on 08/12/2023, facility elopement policies here followed, and R#1 was located approximately 1.75 hrs. later approximately 1.2 miles away in a heavy metropolis area. He was returned to the facility by the police. ADM revealed that he told R#1 if you want to leave, that's fine. R#1 signed AMA papers at midnight on 08/13/2023 and left the facility. ADM revealed that when he eloped the second time on 08/11/2023, he was not wearing a WG. ADM said that he consulted with his superiors who said that R#1 was fine to sign AMA paperwork and let him be on his way. ADM revealed he was not assessed the 2nd time he was returned by the police to the facility because he just came into the facility from outside with the police to AMA paperwork. Interview on 08/24/2023 at 9:08 pm with the ADM who revealed, when asked what could happen if a resident was improperly discharged , ADM said the resident could become injured or possibly die. When asked if ADM was aware that R#1 had a DX of altered mental status and hospital records repeatedly, over several days, revealed R#1 thought he was in the state of Michigan he said he was not very familiar with reading clinical records, so he sent them to his corporate office for review and asked for guidance from his corporate bosses. When asked who is responsible for the residents at the facility where he is the ADM, he revealed he was responsible for the safety of the residents, and he might have made some assumptions about R#1's cognition. When asked why he allowed R#1 to leave AMA, he said that he relied on the advice of his bosses at the corporate office. When asked if he called the NP or MD and asked them about R#1 leaving AMA, he said he did not. Interview on 08/23/2023 at 2:14 pm with DON revealed she said she was not informed that R#1 left AMA and she would have liked to have been given notice of the situation because she is the main care giver and wants to know what is going on with the patients. When asked to see the order from the NP or MD for the AMA as is required by facility policy, the DON revealed that is no order from either the NP or the MD because neither were consulted or informed about the AMA until after R#1 discharged AMA. Interview on 08/22/23 at 9:45 am with the ADM revealed he did not communicate with the NP or MD if it was okay for R#1 to be discharged AMA if R#1 requested, but the ADM did ask his corporate nurse. ADM said he sent all the hospital and clinical referral information to the CP asked if R#1 could be discharged AMA. He revealed that he explained to the CP that R#1 eloped and his concerns, anytime a resident went missing or eloped, was the resident's BIMS score and cognitive level. He revealed he sent the hospital and clinical records to the CP to review and evaluate because he is not familiar with hospital paperwork. When asked if ADM was aware that R#1's medical records contained the name and a location to obtain R#1's daughter's name and telephone number as an SDM information (SDM a process whereby clinicians collaboratively help patients to reach evidence-informed and value-congruent medical decisions. This process is especially relevant in screening for conditions in which there is a close trade-off between harms and benefits) ADM revealed he searched the initial few pages of R#1's admission hospital records but did not see R#1's daughter's name listed as a SDM. The ADM revealed that he notified the NP and MD after the AMA was signed and did not call either the NP or the MD to discuss R#1 and a possible AMA after R#1's elopements. The ADM revealed his is not sure why he did not notify either the NP or the MD sooner, he would have to look into that, and no response was given. When asked why no BIMS was conducted, the ADM replied, he would have to look into that, and no response was given. ADM revealed he did not either contact or notify the ombudsman about R#1's AMA discharge. Interview on 08/24/2023 at 9:08 am with the ADM revealed he does not know why there is no physical order for the WG. He revealed that he knew there was an order for the WG when the investigation began because RN 2 told him she put a WG on R#1. ADM was not aware that the NP was phoned when R#1 eloped the 1st time, but he did know that the NP should be notified if a resident elopes. ADM said he initially told staff to conduct 30-minute safety checks, but they were already doing 15-minute safety checks as ordered by the NP. ADM revealed he communicated to RN 2 that the WG was not necessary to give R#1. The ADM never personally asked R#1 if it was okay for him to get a WG. R#1 did tell the ADM that he was sad, and he wanted to go for a walk. The ADM revealed that he told R#1 that if he wanted to leave, to let someone know and he could leave. ADM revealed that R#1 was eating his lunch during this conversation and R#1 seemed content and receptive of the conversation. ADM revealed to R#1 that it was probably best if he stayed but he was welcome to leave. ADM revealed that the total amount of conversation with R#1 was probably ten minutes. ADM revealed he did not ask the staff who had cared for him what they thought about his mental capacity and did not talk to his staff about R#1's exit seeking behaviors. ADM revealed he was not aware that RN 2 asked R#1 permission to place a WG on R#1. ADM revealed that the CP and RVPO made the assumption, even though they did not speak to R#1 about a WG placement, that it was against his rights to put a AG on R#1. ADM revealed his superiors said it would be some form of resident restraint. ADM believed that R#1's cognition was the key factor regarding the WG placement. The ADM and his superiors felt that R#1's cognition was intact, and the ADM relied on the information of his superiors who had never seen or spoken to R#1 when making the judgment of a WG placement after R#1 had already eloped from the facility. ADM revealed he was not aware that he needed to talk to the MD or NP before considering a resident AMA. ADM revealed that when R#1 was told he could leave AMA, the ADM said he did not ask R#1 if he had a place to obtain his prescribed medicine or if he was homicidal or suicidal. Interview on 08/23/2023 at 12:20 pm with MD revealed he did not learn about R#1's discharge AMA until 08/23/203 from the facility NP. Interview on 08/23/2023 at 12:20 pm with NP revealed she was told at 2:20 pm that R#1 eloped, they found him, and he returned. She gave verbal orders for STAT labs, for a WG, and Q-15-minute checks. She revealed the facility did not communicate to her R#1's exit seeking behavior prior to his elopement. She revealed she would have liked to have known about R#1's exit seeking behaviors because, had she known, she might have been able to prescribe a medication to relieve R#1's anxiety or other arrangements to keep him safe. NP revealed that, of course R#1's elopement was a safety concern. When she was informed of R#1's second elopement she said she thought to herself, how did this happen again particularly because he had a WG. NP revealed she did not know about R#1's AMA discharge until Monday, 08/14/2023 when she went to the facility for her regular visit. She revealed she did not write an AMA order. She revealed that R#1's discharge was not the most safe or appropriate and should have been kept more in the loop at to what happened. NP said R#1 would be homeless with no stable housing and no knowledge or how to get his medications and because his cognitive status was unknown, R#1 was unable to understand the risks. Record review of R#1's hospital records dated 08/07/2023 revealed that R#1's daughter's name and telephone number was in the EMR records. Record review of R#1's orders reflect no NP order for the WG. Record review of R#1's orders reflect no order from the NP or MD for AMA approving R#1's release from the facility AMA. Record review of R#1's nurses notes reflect not records indicating any communication with the NP or MD involving R#1 leaving AMA. Record review of facility Accident/Incident Report for Falls, Injury, Elopement, Behaviors, Allegation dated 08/12/2023 and signed by LVN A for R#1's first elopement reflected R#1 was A&OX2 and revealed cognitive factors of memory impairment and decision making impaired. Record review of facility Accident/Incident Report for Falls, Injury, Elopement, Behaviors, Allegation dated 08/12/2023 and signed by the DON for R#1's second elopement reflected under Type of Injury other, no Head-to-Toe assessment and that physician was notified on 08/12/2020 (believe the 2020 is a type and should be 2023) at 9:45 pm. Review of Release of Responsibility for Discharge Against Medical Advice dated 08/13/2023 reflected, This is to certify that I, R#1, wish to discharge myself from this facility at my own insistence and against the advice or authority of my physician. Record review of facility Accident/Incident Report for Falls, Injury, Elopement, Behaviors, Allegation dated 08/13/2023 completed for R#1's first and second elopements and signed by the ADM reflected Head to Toe Assessment A&Ox3 and NP was notified on 08/12/2023 with no time of notification documented. Record revealed R#1 left building at around 12 pm and was found by staff member and brought back. Then at around 9:30 R#1 left again and was found. Record review of facility policy Review of Risk of Elopement/Wandering Review undated in R#1's paper file and completely blank revealed: Instructions Complete upon admission, thirty days after admission, quarterly and at significant change, or per facility policy. Review potential risk factors and resident status including is the resident cognitively impaired with poor decision-making skills, does the resident have a history of leaving the facility without informing staff, has the resident expressed a desire to go home, and admitted or readmitted and not accepting the situation. Record review of facility Discharging a Resident without a Physician's Approval dated October 2012 revealed a physician's order should be obtained for all discharges unless a resident or representative is discharging himself or herself against medical advice. The order for approved discharge must be signed and dated by a physician and recorded in the resident's medication record not later than seventy-two (72) hours after the discharge. Record review of facility Wandering, and Elopements dated March 2019 revealed Policy Statement - The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation 1. If identified as a risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. If a resident is missing, initiate the elopement/missing resident emergency procedure: If the resident is not located in the building or premises notify the Attending Physician, and the DON services, the resident's legal representative, when the resident returns to the facility, the DON or charge nurse shall examine the resident for injurie, contact the attending physician and report findings and conditions of the resident, document relevant information in the resident's medical record. Review of facility Admission Criteria dated March 2019 reflected Policy and Interpretation and Implementation - 1. The objectives of our admission criteria policy are to: a. Admit residents who can be cared for adequately by the facility. e. assure that the facility receives appropriate medical and financial records prior to or upon the resident's admission. 5. Prior to or at the time of admission, the resident's Attending Physician provides the facility with information needed for the immediate care of the resident, including orders covering at least: routine medical care orders to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive assessment and develop a more detailed Interdisciplinary Care Plan. 6. Residents are admitted to this facility as long as their needs can be met adequately by the facility. Review of facility Nursing Services Policy and Procedure manual for Long-Term Care Behavior, Mood, and Cognition dated April 2018 reflected all new admissions are screened for mental disorders, intellectual disabilities or delated disorders per the Medicaid Pre-Admission Screening and Resident Review Process. On 8/22/2023 at 5:25 pm, the the ADM and the DON were notified of the Immediate Jeopardy (IJ) due to the above failures and the IJ template was provided at that date and time. The following Plan of Removal was submitted by the facility and was accepted on 08/24/2023 at 10:51 am: Table of Contents F 600 On 8/22/23, [NAME] Woods 1 Nursing Center failed to adequately supervise and prevent accidents for one resident. The facility inappropriately discharged R1 with notifying MD or obtaining AMA discharge order. All residents are at risk for inappropriate discharge. 1. Regional [NAME] President of Operations performed education on 8.22.23 for Administrator on discharge processes including discharging AMA and the requirements. 2. Regional Nurse Consultant performed further education on 8.22.23 for Director of Nursing on discharge processes including discharging AMA and the requirements 3. The DON/Designee immediately in-serviced licensed nurses on the discharge process on 8.22.23. Education includes to start discharge planning upon admission, the information required in the medical record including obtaining a physician's order for all discharges, and the process of discharging a resident without a physician approval. All present and newly hired licensed nurses and agency staff will complete education prior to beginning a shift. 4. DON/designee presented posttests 8/23/23 for knowledge retention after the education was presented. All staff who scored <80% will be reeducated by DON /designee. 5. DON/designee to monitor all discharges for documentation and notification of physician 3xwk for 4 wks. then 1xw for 3 months. Start 8.22.23 and end 12.12.23. Any issues with the discharge process will be immediately addressed and corrected by DON/designee. Results of the audits will be reviewed and discussed by the interdisciplinary team and medical director during QAPI and implement new interventions if needed 3 times a week for 4 weeks then once a week for 3 months which started 8/23/23 6. DON/designee will have a weekly at-risk meeting, a meeting with IDT to review fall, skin, weight, infection, and discharges, with interdisciplinary team to include review of all discharging residents. Start date is 8.22.23 and will be ongoing. Any issues with the discharge will be immediately addressed and corrected DON/designee. 7. Admin/designee will hold a QAPI meeting with the interdisciplinary team q week for 3 weeks to discuss discharge process. Any issues found within the meeting will be immediately addressed and corrected which includes further education by DON/designee. Start 8.22.23 and end on 9.12.23. 8. Electronic notification of Medical Director notification of IJ and QAPI meetings given 8/22/23 at 5:43 p.m. Medical Director attended meeting. Ad Hoc meeting held 8/23/23 at 2:00 p.m. discussing the citations received and process of POR. 9. Admin/designee will keep the discharge process in QAPI meeting with the interdisciplinary team for 3 months following the initial 3-week meetings. Start 8.22.23 and end 12.12.23. Any issues found within the meeting will be immediately addressed and corrected DON/designee which includes further education and replacement of equipment if needed. Monitoring of the plan of removal from 08/25/2023 through 08/25/2023 included the following: 1. Confirmed the Regional [NAME] President of Operations performed education on 08/22/2023 for Administrator on discharge processes including discharging AMA and the requirements. 2. Confirmed the Regional Nurse Consultant performed further education on 08/22/2023 for Director of Nursing on discharge processes including discharging AMA and the requirements. 3. Reviewed the in-service on for licensed nurses on the discharge process on 08/22/2023 with education that included to start discharge planning upon admission, the information required in the medical record including obtaining a physician's order for all discharges, and the process of discharging a resident without a physician approval and interviewed LVN and charge nurse on understanding. 4. Reviewed the staff posttests 08/23/2023 for knowledge retention after the education was presented. 5. Interviewed LVNs regarding the education received on in-services for discharges including when to start discharge planning and the information required from medical record including obtaining a physician's order for all discharges, and the process of discharging a resident without a physician approval. 6. Facility had no discharges for the start date of 08/22/2023 to document for notification of physician. 7. Reviewed QAPI meeting notes 08/22/2023 with the interdisciplinary team to discuss discharge process. The ADM and DON were informed the Immediate Jeopardy was removed on 08/24/2023 at 6:30 PM., however the facility remained out of compliance at a scope of isolated nd a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review the facility failed to identify and take measures to maintain the usual body weight and prevent further weight for one (1) of four (4) residents reviewed for weight loss. Resident #14 has had a significant weight loss since being admitted to the facility on [DATE] (two months ago). This failure could place all five (5) residents with significant weight loss at risk for avoidable weight loss, increase risk for pressure sores, and failure to maintain optimal nutritional status as determined by lab values which could lead to dehydration, pain and unnecessary hospitalization . Findings include: Review of Resident #14's Face Sheet reflected an [AGE] year old male admitted on [DATE]. Resident [DIAGNOSES REDACTED]. Review of Resident #14's MDS (minimum data set) dated 8/24/17, reflected a weight of 213 pounds (#). Review of the facility's Weight Change Report, reflected Resident #14 weighed 193 #s on 9/5/17 and 183 #s on 10/5/17. Review of Resident #14's Registered Dietitian's note dated 10/9/17, reflected the resident had a 29 # weight loss since admit and a stage 2 pressure ulcer. Recommendation to add Med Pass 2.0, 60 cc's with each medication pass and adding a multivitamin with mineral. There was no assessment of the resident's current calorie or protein requirements to maintain weight and promote healing of ulcer. Review of Resident #14's current physician orders, reflected a puree diet, thin liquids, plate guard and divided plate. Resident had orders for stage 2 sacral ulcer wound treatment. Observation on 10/10/17 at 10:30 pm, Cook A added the shredded pork to the blender, added less than a cup of water from the faucet and then added thickener. Cook A blended the pork, added some more thickener, blended again and poured into the steamtable pan. At 11:05 am, the DA A pureed the pineapple upside down cake with apple juice and poured into dessert cups. At 11:25 am, Cook A added the boiled cauliflower with water from the boiling pot into the blender, pureed the cauliflower and poured into steamtable pan. Cook A had green handle scoop in the puree foods. Observation on 10/10/17 at 1:05 pm, a test tray revealed pureed pork was warm, not hot, and little flavor. The pureed cauliflower was hot, but tasted bland and watery. The pureed sweet potato was warm, with no seasoning and watery tasting. The puree cake was runny, nectar thick at best and very sweet. There was no bread. Observation on 10/11/17 at 12:07 pm, revealed during trayline Cook A was using a green handled scoop for the puree potato and vegetable. During an interview on 10/10/17 at 1:03 pm, Cook A stated, I forgot to use the puree bread. Observation on 10/12/17 at 1:00 pm, revealed Resident #14 being fed by a staff member a puree diet, single serving, and 1 glass of lemonade. The resident ate 100 percent. The resident was not offered a second portion. During an interview on 10/12/17 at 12:35 pm, the Speech Therapist stated Resident #14 should be NPO (nothing per oral) but the family wants him to had a p.o. (per oral) diet. She stated the resident should be fed small bites, giving ample time for resident to swallow, and sip of drink every other bite. She stated, I have trained some of the nursing staff to fed him. She stated, I was not aware he had lost so much weight, but he could have double portions, healthshakes, magic cup with meals and snacks between meals. During an interview on 10/12/17 at 2:00 pm, the Dietary Manager stated the green handle scoop is a #12 (3 oz), the cook should have used a #8 (4 oz). Review of the facility's recipes for Pureed Pasta and Vegetable reflected a #8 scoop portion size. During the same interview on 10/12/17 at 2:00 pm, the DM stated, I saw Cook A add water to the meat and knew that was not the correct liquid to use. She stated, I was a cook at another facility so I know not use water and vegetables don't typically need any extra liquid. She stated, I see now I need to retrain the cooks. During a Family Interview on 10/12/17 at 2:20 pm, via telephone, Resident #14's daughter stated she was not aware the resident had lost weight. She stated the resident liked chicken and hamburgers. During an interview on 10/12/17 at 4:45 pm, the ADON stated, I have just received the telephone order to add Med pass 2.0 (a protein supplement) and a multivitamin with mineral. Review of Resident #14's Medical Record, reflected no acute care plan for significant weight loss nor a care plan for nutritional risk due to dysphagia. The facility's CMS form 672 reflected 5 residents with weight loss.