Every finding on record at Greenhill Villas

Based on interviews and record reviews, the facility failed to ensure that the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for 3 (Resident #10, Resident #11, and Resident #46) of 23 residents reviewed for timing and revision.1. The facility failed to ensure Resident #10's comprehensive care plan was updated and accurate by not resolving the care plan for IV antibiotic administration that resident no longer had an order for and an indwelling catheter that he no longer had an order for as of 09/01/2026 at 9:18 AM. 2. The facility failed to ensure Resident #11's comprehensive care plan was updated and accurate by not resolving IV fluid therapy and IV access that she no longer received as of 09/03/2026 at 9:05 AM. 3. The facility failed to ensure Resident #46's comprehensive care plan was revised to reflect the discontinuation of IV access to accurately guide the provision of care on 08/31/2026 of 10:50 AM. These failures could place residents at risk of not receiving the care and services to meet their needs. Findings included: 1. Record review of Resident #10's face sheet, dated 09/01/2026, indicated he was a [AGE] year-old male, re-admitted [DATE], with the diagnoses which included dementia (a decline in metal ability sever enough to interfere with everyday life), depression (common serious mood disorder that causes a persistent feeling of sadness, emptiness, and loss of interest in daily activities), diabetes mellitus (disease in which the body cannot produce or properly use insulin resulting in high blood sugars), high blood pressure and obstructive and reflux uropathy (blockage that stops urine from flowing normally through the urinary tract). Record review of Resident #10's quarterly MDS assessment, dated 06/16/2026, indicated he understood others and he made himself understood. The MDS also indicated Resident #10 had a BIMS score of 12 which meant he had moderate cognitive impairment. The MDS also indicated Resident #10 required total assistance from staff for dressing, toileting, and transfers, maximal assistance from staff for bathing, moderate assistance for bed mobility, and set up assistance for eating. The MDS also indicated he required intermittent catheterization (catheter insertion and removal used to be placed in the bladder to drain urine). Record review of Resident #10's comprehensive care plan, revised 05/11/2026, indicated he had an indwelling catheter as of 5/5/2026 with interventions to position catheter bag below the level of bladder, empty drain bag as ordered and ensure catheter strap in place. Record review of Resident #10s comprehensive care plan, revised on 05/19/2026, indicated Resident #10 was on IV medications (vancomycin), an antibiotic used for infection, with intervention to check dressing site daily. Record review of Resident #10's physicians order summary report, dated as of 09/03/2026, indicated he had orders that included:1) straight catheter every 6 hours as needed for retention with a start date of 08/13/2026 and no end date. 2) straight catheter four times a day for retention with a start date of 08/13/2026 and no end date. The order summary report did not indicate Resident #10 had an indwelling catheter nor did it indicate he had an IV or an order for IV medications During an observation and interview on 09/01/2026 at 9:18 AM, Resident #10 was sitting in his room in his wheelchair and he had no IV access, nor did he have a urinary catheter in place. Resident #10 said he was waiting on his nurse to provide intermittent catheterization. 2. Record review of Resident #11's face sheet, dated 09/03/2026, indicated she was a [AGE] year-old female, re-admitted [DATE], with diagnoses which included cerebral palsy (a group of permanent disorders that appear in early childhood and affect body coordination, balance, and posture), epilepsy (a chronic brain disorder characterized by recurring, unprovoked seizures caused by sudden bursts of abnormal electrical activity in the nerve cells), gastrostomy status (indicating a person has a current functioning gastrostomy tube in place), and aphasia (language disorder caused by damage to parts of the brain that control how you speak, write, read, and understand words). Record review of Resident #11's annual MDS assessment, dated 07/28/2026, indicated she rarely understood others and rarely made herself understood. The MDS also indicated she could not complete a BIMS assessment, and her daily cognitive decision making was severely impaired. The MDS also indicated she was dependent on staff for all ADLs and she received 51% or more calories and 501 cubic centimeters per day through her gastrostomy tube. Record review of Resident #11's comprehensive care plan, dated 07/28/2026, indicated she required IV infusion therapy related to her labs on 07/22/2026 with interventions to provide IV fluids as ordered, monitor for adverse reactions, and to monitor the IV site for redness, swelling, and warmth. Record review of Resident #11's physicians order summary report as of 09/02/2026 did not indicate an order for IV fluids or IV access. During an observation on 09/03/2026 at 9:05 AM, Resident #11 was lying in her room in her bed and she had no IV access. During an interview on 09/03/2026 at 4:07 PM, the DON said all the IDT team employees were responsible for ensuring all the resident care plans were updated according to resident orders, but ultimately the DON was responsible. The DON said she expected the care plans to be accurate for the care of the residents at the present time, and the failure placed residents at risks of their needs not being met. During an interview on 09/03/2026 at 4:19 PM, the Administrator said she expected all the resident care plans to always reflect the actual care for each individual resident. The Administrator said the failure placed residents at risk for staff not providing proper care. 3. Record review of Resident #46's face sheet, dated 09/03/2026, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with a primary diagnosis of wedge compression fracture of T9-T10 vertebra (fracture of spine). Record review of Resident #46's care plan, dated 07/30/2026, revealed Resident #46 had a care plan for intravenous access (IV) with an intervention stating Resident #46 had peripheral IV access and PICC line access. The care plan did not address when the IV access and the PICC line access was discontinued. The care plan did not address the location, monitoring after discontinuation and monitoring for further infection signs and symptoms. Record review of Resident #46's comprehensive MDS assessment, dated 7/30/2026, revealed Resident #46 had a BIMS of 06 indicating severe cognitive impairment. The Comprehensive MDS assessment indicated Resident #46 was able to make herself understood and understood others clearly. The Comprehensive MDS assessment revealed Resident #46 had an IV access. Record review of Resident #46's quarterly MDS assessment, dated 8/7/2026, revealed Resident #46 was receiving IV medications and antibiotics on admission and while a resident. Record review of Resident #46's physicians order summary, dated 9/3/2026, revealed Resident #46 had an order to remove IV from right forearm dated 08/06/2026. Order summary did not address the discontinued IV PICC line access. During an observation and interview on 08/31/2026 at 10:50 a.m., Resident #46 stated she had lived in the facility for about 2 months and during her stay she had sepsis (severe infection). Resident #46 stated she was not receiving IV medications. Observation revealed no IV access on Resident #46. During an interview on 09/03/2026 at 1:30 p.m., LVN L revealed Resident #46 was not on an IV medication and no longer had an IV access. LVN L stated she was unsure of the date she had the IV. LVN L stated that the intradisciplinary team were responsible for care plans and she stated that she would have expected the care plan to reflect the care Resident #46 was currently receiving. LVN L stated that revision of the care plan would allow all nursing staff to know what the plan of care was for Resident #46 and Resident #46 was at risk of not having an accurate care plan. During an interview on 09/03/2026 at 2:17 p.m., the ADON revealed she was unaware Resident #46's care plan stated that she was on IV medication and had an IV access and PICC line. The ADON stated that she was a part of the IDT but she did not revise the care plan. The ADON stated t she expected Resident #46's care plan to have been revised when her IV access and PICC line were discontinued to reflect the care she was currently receiving. The ADON stated there was a risk of Resident #46 receiving care that was no longer ordered. During an interview on 09/03/2026 at 3:02 p.m., the DON stated she was unaware Resident #46 care plan stated she was on an IV medication, had an IV access and PICC line. The DON stated she was responsible for ensuring Resident #46's care plan reflected the care she was currently receiving because she was responsible for ensuring the nursing staff complete care plans. The DON stated that the IDT meeting was used to update the care plan to reflect Resident #46's care on a quarterly basis. The DON stated that she expected Resident #46's care plan to be revised to reflect when the IV access and PICC line access were discontinued. The DON stated she did not see the risk of harm to Resident #46 other than not having an accurate care plan. The DON stated that the care plan was used to collaborate Resident #46's plan of care. During an interview on 09/03/2026 at 3:17 p.m., the Administrator stated nursing was responsible for revising care plans. The Administrator stated she was not aware that Resident #46's care plan stated that she had an IV access or PICC line. The Administrator stated that she expected Resident #46's care plan to match the current care orders. The Administrator stated that Resident #46 was at risk of her care plan not reflecting the care she was receiving. Record review of the facility policy titled, Comprehensive Care Plan, undated, revealed, Residents' preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan. A comprehensive care plan will be review after each admission, quarterly, annual and/or significant change MDS assessment, and revised based on changing goals, preferences and needs of the resident in response to current interventions.

Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain grooming and personal hygiene for 2 of 23 residents reviewed for ADLs. (Resident #10 and Resident #20)The facility failed to ensure Resident #10 received his baths as scheduled on Mondays, Wednesdays, and Fridays as of 09/01/2026 at 9:18 AM. The facility failed to ensure Resident #20 received her baths as scheduled on Mondays, Wednesdays, and Fridays as of 09/01/2026 at 8:52 AM. This failure could place residents at risk for embarrassment, discomfort, decreased self-esteem, or decreased quality of life. Findings included: 1. Record review of Resident #10's face sheet, dated 09/01/2026, indicated he was a [AGE] year-old male who re-admitted to the facility on [DATE] with diagnoses which included dementia (a decline in metal ability sever enough to interfere with everyday life), depression (common serious mood disorder that causes a persistent feeling of sadness, emptiness, and loss of interest in daily activities), diabetes mellitus (disease in which the body cannot produce or properly use insulin resulting in high blood sugars), high blood pressure and obstructive and reflux uropathy (blockage that stops urine from flowing normally through the urinary tract). Record review of Resident #10's quarterly MDS assessment, dated 06/16/2026, indicated he understood others and he made himself understood. The MDS also indicated Resident #10 had a BIMS score of 12 which meant he had moderate cognitive impairment. The MDS also indicated Resident #10 required total assistance from staff for dressing, toileting, and transfers, maximal assistance from staff for bathing, moderate assistance for bed mobility, and set up assistance for eating. The MDS also indicated he required intermittent catheterization. Record review of Resident #10's comprehensive care plan dated 02/23/2026 indicated he had an ADL self-care deficit with interventions for staff to assist with personal hygiene as required and he required 1 staff assistance with bathing. Record review of Resident #10's shower log for August 2026 indicated a three day per week shower schedule on Mondays, Wednesdays, and Fridays. Review of the shower log indicated Resident #10 did not receive a shower on Wednesday 08/05/2026, Monday 08/10/2026, Wednesday 08/12/2026, Friday 08/14/2026, Wednesday 08/19/2026, Friday 08/21/2026, Monday 08/24/2026, Wednesday 08/26/2026, and Friday 08/28/2026. During an interview on 09/01/2026 at 9:18 AM, Resident #10 said he was supposed to get his showers on Mondays, Wednesdays, and Fridays but he had not had his showers as scheduled. Resident #10 said he did not get his shower the week of August 9th, the week of August 10th through the 14th, the week of August 16th 2026 through the August 20th 2026, as well as August 25, 2026-August 28, 2026. Resident #10 said he liked to have his showers as scheduled because he did not like going around dirty and he should not have to put clean clothes on a dirty body. 2. Record review of Resident #20's face sheet, dated 09/02/2026, revealed an [AGE] year-old female admitted [DATE] and readmitted [DATE] with diagnoses which included CHF (a condition where the heart does not pump the blood efficiently) Afib (a condition characterized by rapid, irregular heart contractions), Hypertension (high blood pressure), cerebral infarction (blood vessel blockage in the brain that can cause brain damage or death), Osteoarthritis (occurs when protective cartilage that cushions the ends of the bones wears down over time), MDD (persistent feelings of sadness and loss of interest in activities), anxiety (a feeling or worry, nervousness or unease). Record review of Resident #20's Quarterly MDS assessment, dated 06/03/2026, revealed Resident #20 had no speech, hearing or communication deficits and a BIMS score of 15 which indicated intact cognition. Resident #20 had upper and lower extremity impairment, required the use of a wheelchair for mobility, setup assistance in eating, moderate assistance in bathing, bed mobility, transfers, upper body dressing, maximum assistance in lower body dressing and was totally dependent for toileting. Record review of Resident #20's care plan, reviewed 06/03/2026, revealed Resident #20 had an ADL self-care performance deficit and required assistance of one staff member for bathing and required personal hygiene assistance for hair management, shaving and oral care. Record review of Resident #20's shower log for July 2026 revealed a three day per week shower schedule on Mondays, Wednesday, and Fridays. Further review of the shower log indicated Resident #20 did not receive a shower on Wednesday, 07/15/2026, and Friday, 07/17/2026. Record review of Resident #20's shower log for August 2026 revealed Resident # 20 did not receive a shower on 08/07/2026, 08/14/2026 and 08/17/2026. During an observation and interview on 09/01/2026 at 8:52 a.m., Resident #20 was seated in her wheelchair, presented clean, odor free and appropriately dressed. Resident #20 stated that since she voiced a grievance on 06/17/2026, Things had gotten better, but still missed some showers. Resident #20 stated that she probably would not get a shower today (09/01/2026) because one of the girls called in, and she hoped she received a shower on Friday morning (09/04/2026) because she had an appointment. During an interview on 08/02/2026 at 10:37 a.m., LVN C stated that the shower schedules were located in the nurse aide tasks and they were able to access the schedule at the start of their shift. LVN C stated that the nurse aids let her know if they were unable to complete the assigned resident showers and she would notify the oncoming nurse at the end of the shift. LVN C stated she was not aware of any residents who had voiced that they were not receiving showers and did not recall any specific information regarding missed showers for Resident #10 and Resident #20. During an interview on 09/02/2026 at 9:00 a.m., LVN D stated that the nurse aids were able to access the shower schedule in their tasks program and she was able to view completed tasks to ensure showers were given. LVN D stated that the ADON assigned the shower schedule for each resident and if she had a resident who wanted a different schedule, LVN D would let the ADON know to adjust the schedule. LVN D did not recall any specific information regarding missed showers for Resident #10 or Resident #20. During an interview on 09/02/2026 at 2:10 p.m., LVN F stated was an ADON, and that she was working as a nurse aide today and that she was aware of the shower schedule by accessing the tasks list. LVN F stated that the shower schedule is determined by date of admission, stated they try to give the shower on the day the resident admitted to the facility and then the schedule is made every other day accordingly. LVN F stated showers were scheduled for [NAME]/Wednesday/Friday or Tuesday/Thursday/Saturday. LVN F stated that one of her roles as the ADON is to input the shower schedules for her residents. LVN F did not recall any specific information regarding missed showers for Resident #10 or Resident #20. During an interview on 09/03/2026 at 2:20 p.m., CNA E stated that she checked her tasks on each day to learn who was scheduled for shower that day. Stated there is kind of a schedule, and because she had worked her for a while, she knew who was scheduled for showers. Stated she would tell the charge nurse if she was not able to complete all the scheduled showers or if a resident refused a shower. Stated that sometimes a resident would tell her that they did not get their shower and she would try to squeeze them in if she could. CNA E did not recall any specific information regarding missed or refused showers for Resident #10 or Resident #20. During an interview on 09/03/2026 at 9:15 a.m., CNA B stated that she checked the task system to determine who was scheduled for showers. Stated that there is a system, but usually all the showers fall on the day shift and sometimes we have 8, and sometimes we have 20. CNA B stated that one of the nursing administration staff put the schedule in the task system. CNA B did not recall any specific information regarding missed or refused showers for Resident #10 or Resident #20. During an interview on 09/03/2026 at 3:05 p.m., the DON stated she believed the showers were being completed, but the nurse aids did not document accurately. The DON stated she had provided multiple in-services regarding shower needs and that either she or the ADON's input the schedules into the nurse aid tasks. The DON stated Resident #20 addressed her concern that showers were not being provided on 06/17/2026 and a grievance was completed and resolved in that Resident #20 had received her shower. The DON was not aware that Resident #20 was still not receiving her scheduled showers. During an interview on 09/03/2026 at 3:20 p.m., the Administrator stated she did not feel showers were not happening because they reviewed the nurse aid tasks during the weekday morning meeting and any showers that were not completed were added for the next day. The Administrator stated she would interview the staff and provide coaching or additional training, as needed, to ensure showers were being done and would monitor showers completed through resident interviews. Record review of the facility policy titled, Bath, tub/shower, undated, revealed the process for providing a shower, but did not reflect the number or showers that should be provided or the facility's system and schedule for providing showers.

Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for the secure unit (female secure unit) reviewed for activities. The facility failed to ensure activities were provided to the residents on the female secure unit 08/31/2026-09/03/2026. This failure could place residents at risk of not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being. Findings included: During observations made between 08/31/26-09/03/26 at different times of the day there were no activities provided to the residents on the female secure unit of 18 residents. During attempted interview and observation on 08/31/2026 at 10:00 a.m., an activity calendar for August revealed scheduled activity for the facility only and BINGO listed as off unit once a week. A group of residents on the secure unit. Residents were observed sitting around the television at the dining table. Observed several residents getting up and sitting down, moving along the couch and changing chairs. Resident #32 was observed getting a stuffed animal off of the mantle and another resident tried to take it out of her hand. Attempted interview with Resident #8 revealed they did not do activities on the unit. During an interview on 08/31/26 at 10:15 a.m., CNA R stated there were no activities provided for the female secure unit. CNA R stated the residents on the unit sat and watched television all day. CNA R stated often the female were agitated because of the lack of things to do. CNA R stated it was difficult to keep the residents calm on the unit with no activities being provided. During an interview on 08/31/26 at 10:30 a.m., RN S stated that herself and one CNA R were responsible for the residents on the female secure unit. RN S stated that three residents were allowed to go off of the unit to attend scheduled BINGO with the rest of the facility, however, the other 14 residents that resided on the unit were not offered activities. RN S stated she did her best to keep the residents calm throughout the day with no activities. RN S stated that she tried to redirect the residents, and it was increasingly difficult in the afternoons. During an interview on 09/03/26 at 11:50 a.m., the Activity Director stated that she had one activity calendar used for the entire facility. The Activity Director stated that she invited a couple of the residents that resided on the unit to BINGO that happened once a week, but she did not have scheduled activities on the unit. The Activity Director stated that for as long as she had been in the position (unknown time period) she had not provided activities on the secure unit. The Activity Director stated there were no one on one activities provided to the residents on secure unit. The Activity Director stated she felt it would benefit the women on the unit to provide scheduled activities that were located on the unit. The Activity Director stated that it was her responsibility to provide activities to the residents and she had provided puzzles to the secure unit but not all residents liked puzzles and only 3 residents were allowed off of the unit activities. The Activity Director stated residents on the unit were at risk of low quality of life and increased behaviors due to lack of activities. During an interview on 09/03/26 at 12:15 PM, the DON said the Activity Director was responsible for ensuring activities were conducted on the secure units. He said the Administrator was responsible for providing oversight to the Activity Director. The DON said not having activities had the potential for extreme boredom. During an interview on 09/03/26 at 2:14 PM, the Administrator said she expected the Activity Director to have an individualized calendar for the women's secure unit to cater for what their needs were, and she expected the activities to be provided. The Administrator said not having activities could affect the resident's quality of life as far as enjoyment, socialization, and their mood and happiness. Record review of facility's Resident Rights policy undated revealed that the facility must care for each resident in a manner and environment that promotes maintenance or enhancement of his or her quality of life while recognizing the resident's individuality.The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, plan of care and other applicable provision of this part.The Resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

Based on observations, interviews and record reviews, the facility failed to ensure that the resident environment remains as free of accident hazards as possible for 3 of 6 residents (Resident's #63, #56, and #57) reviewed for accidents.1.The facility failed to ensure Resident #63, did not have shaving cream in his bathroom on 09/03/26.2.The facility did not ensure [NAME] Nail Polish Remover was not stored on Resident #56's dresser. 3. The facility failed to ensure Resident #57 did not have a throw rug, an air freshener, and a hair dryer plugged in her bathroom. These failures could place residents at risk of injury or harm. Findings included: 1. Record review of Resident #63's face sheet, dated 09/03/26, reflected Resident #63 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included stroke (a medical emergency that occurs when blood supply to the brain is blocked or when a blood vessel bleeds in the brain), dementia (memory loss), depression(sadness), and high blood pressure (means the force of blood pushing against your artery walls is too high). Record review of Resident #63's quarterly MDS assessment, dated 06/19/26, reflected Resident #63 made himself understood, and was understood by others. Resident #63's BIMs score was a 15 which indicated he was cognitively intact. The MDS indicated Resident #63 required assistance with toileting, bathing, oral hygiene, and eating. Record review of Resident #63's comprehensive care plan revised 12/19/25 reflected Resident #63 had an activity of daily living self-care performance deficit related to his stroke. The care plan interventions were for staff to assist with personal hygiene as required: hair, shaving, oral care as needed. During an observation on 09/03/26 at 1:50 p.m., a can of shaving cream which read keep out of reach of children was sitting on Resident #63's bedside table in the bathroom. During an interview on 09/03/26 at 1:53 p.m., Resident #63 said he used the shaving cream with the help of staff. He said he had not been told he could not have the shaving cream in his room. During an interview on 09/03/26 at 1:55 p.m. CNA D said she was the aide for Resident #63. She verified the shaving cream was in the room. She said she was not sure if the shaving cream was allowed or not, but since it read keep out of reach of children, she said it should not be in the room for safety. During an interview and observation on 09/03/26 at 2:01 p.m., LVN L said all staff were responsible for ensuring items were stored properly and securely. LVN L verified Resident #63 had shaving cream in his bathroom. She said no residents should have shaving cream in their room. She said she had not noticed the shaving cream on Resident #63's bedside table. LVN L said it was important to ensure items were not left on the resident table for all residents' safety. During an interview on 09/03/26 at 4:07 p.m., the DON said all staff were responsible for ensuring items were stored properly and securely. The DON said she monitored rooms with random spot checks. The DON said it was important to ensure items were not left on the resident's table for residents' safety. During an interview on 09/03/26 at 4:41 p.m., the Administrator said she expected shaving cream to be behind a locked door or not assessable by the residents. The Administrator said she did random spot checks of rooms, but she expected all staff to round. The Administrator said it was important for residents' safety to ensure no items were left on the residents' table or in bathroom that were not safe. 2. Record review of Resident #56's face sheet, dated 09/03/26, reflected Resident #56 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnosis which included Dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of Resident #56's quarterly MDS assessment, dated 06/21/26, reflected Resident #56 made herself understood and understood others. Resident #56's BIMS score was 8, which reflected her cognition was moderately impaired. Record review of Resident #56's comprehensive care plan, revised on 10/30/25, reflected Resident #56 had impaired cognitive function. The care plan interventions included: keep the residents' routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. During an observation and interview on 08/31/26 at 1:20 p.m., there was a plastic bottle labeled [NAME] Nail Polish Remover on Resident #56's dresser. Resident #54 stated a staff member provided the remover to her, but she was unable to recall the name. During an interview on 09/03/26 at 1:32 p.m., CNA B stated nursing staff were responsible for ensuring items were stored properly and securely. CNA B stated she noticed the fingernail polish on Resident #56's dresser but it did not cross her mind to remove it from her. CNA B stated fingernail polish remover should be stored in the activity director office. CNA B stated it was important to ensure items were not left on the resident's dresser for residents' safety. During an interview on 09/03/26 at 2:04 p.m., the BOM stated she was responsible for daily champion rounds for Resident #56. The BOM stated during her rounds twice a day she looked for items that should not be in the resident's room such as fingernail polish remover. The BOM stated she did not notice the remover on Resident #56's dresser. The BOM stated the nail polish remover should be stored in the activity director office. The BOM stated it was important to ensure items were not left on the resident's dresser for residents' safety. During an interview on 09/03/26 at 3:40 p.m., the DON stated she expected the fingernail polish remover to be stored in the activity area. The DON stated all staff were responsible for ensuring items were stored properly and securely. The DON stated she monitored compliance by ensuring champion rounds were completed by the assigned department head and daily rounds conducted by her. The DON stated she had noticed issues in the past and in serviced staff verbally. During an interview on 09/03/26 at 4:26 p.m., the Administrator stated she expected fingernail polish remover to be stored in the activity director office. The Administrator stated all staff were responsible for ensuring items were stored properly and securely. The Administrator stated she did random spot checks, but she expected champions rounds to be done daily by the assigned department head. The Administrator stated it was important to ensure items were not left on the residents' dresser for residents' safety. 3. Record review of Resident #57's face sheet dated 09/03/26 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses which included Alzheimer's disease (progressive brain disorder that gradually destroys memory, thinking skills, and the ability to carry out simple daily tasks), major depression (a common mood disorder that causes a lasting sadness, emptiness, and loss of interest in daily activities ), personal history of transient ischemic attack(mini stroke), and chronic kidney disease (long term disorder in which the kidneys are damaged and cannot filter). Record review of Resident #57's annual MDS assessment date 08/08/26 indicated she was usually understood and usually understood others. The MDS also indicated she had a BIMS score of 11 which meant she had moderately impaired cognition. The MDS also indicated she was independent with all ADLs except eating and hygiene required setup assistance from staff. Record review of Resident #57's comprehensive care plan dated 09/01/22 indicated she had a fall impaired cognitive function and had with goals to not sustain serious injury and interventions to ensure a safe environment with even floors and free from spills and personal items within reach. During an observation and interview on 08/31/26 at 12:37 p.m., Resident #57 was sitting in her room in recliner and said she doesn't have a memory, but she does a lot of things on her own. Resident #57 had a throw rug in front of her toilet, an air freshener on the assist bar, and a blow dryer plugged in the wall under her sink and sitting next to the toilet on a plastic set of drawers. During an observation on 09/01/26 at 10:32 a.m., Resident #57 continued to have a throw rug in front of her toilet, an air freshener on the assist bar, and a blow dryer plugged in the wall under her sink and sitting next to the toilet on a plastic set of drawers. During an observation on 09/03/26 at 1:51 p.m., Resident #57 was sitting on her bed reading a book and she continued to have a throw rug in front of her toilet, an air freshener on the assist bar, and a blow dryer plugged in the wall under her sink and sitting next to the toilet on a plastic set of drawers. During an interview on 09/03/26 at 2:18 p.m., LVN C said she was aware of the throw rug and the hair dryer, but she was unsure policy wise if Resident #57 should have had the items in her bathroom. LVN C said Resident #57 was at risk of falling with the rug being in her bathroom. LVN C said the hair dryer being in her bathroom and she was unsure because it depended on the cognitive level of the resident and if they were short-term with the facility. During an interview on 09/03/26 at 3:22 p.m., ADON E said the hair dryer should not have been in Resident #57's bathroom because of the fire hazard, the throw rug should not have been in her bathroom because it was a fall risk for Resident #57. ADON E said the air freshener should not be in the bathroom because it placed a risk for ingestion by any resident. ADON E said all staff were responsible for ensuring hazardous items were not in resident rooms and bathrooms. During an interview on 09/03/26 at 4:05 p.m., the DON said all staff were responsible for completing rounds in the facility and ensuring no items were left in the rooms that could cause harm. The DON said Resident #57 should not have a hair dryer in her bathroom and she thought it may have been the hair dryer an aide left in the room from her office, but it was not. The DON said she did not know Resident #57 had the hair dryer and it placed a risk for Resident #57 shocking herself. The DON said Resident #57 should not have had a throw rug in her bathroom because it placed her at risk for falls. During an interview on 09/03/26 at 4:20 p.m., the Administrator said her expectation was for all the hazardous items to be kept out of resident rooms. The Administrator said all staff were responsible when they completed rounds. The Administrator said the failure of Resident having a throw rug placed a risk for falls and the hair dryer placed a risk of electrocution or burns. Record review of the facility policy, dated May 6, 2005, Nursing Home List of Items Not Allowed in Resident Room (This list is not all inclusive) indicated: Medications: (includes all Prescription and Over-the-Counter drugs, except emergency items like nitro-glycerin, which must be ordered by the doctor through the Nursing Home.) and in certain situations where the resident is allowed to self-administer as per care plan. SAFETY HAZARDS: AEROSOL CANS of any product are combustible GLASS ITEMS which can be broken and cause cuts. ELECTRICAL APPLIANCES - No coffee pots, toaster, electric blankets, heaters, hair dryers, curling irons, microwaves etc. Heating pads only by order of the physician and they must be UL approved. No electronic ovens under any circumstances. ROOM DEODORIZERS - Not allowed.

Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 5 medication carts (North Nurse Medication Cart) and 2 of 23 resident rooms (Resident #56 and Resident #63) reviewed for drugs and biologicals. 1.The facility failed to ensure the North Nurse Medication Cart was secured when LVN L entered a resident room on 08/31/2026. 2. The facility did not ensure Nystatin powder (used to treat yeast and fungal infection) was properly secured and not left in Resident #56's room. 3.The facility failed to ensure staff did not leave Ketoconazole shampoo (a medicated antifungal treatment used to eliminate scalp fungus, control stubborn dandruff, and reduce flaking or seborrheic dermatitis) in Resident #63's room on 08/31/26 and 09/3/26. This failure could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion. Findings Included: 1.During an observation on 08/31/2026 at 10:05 a.m., LVN L placed the North Nurse Medication Cart at the door of a resident room leaving it unlocked with draws accessible when pulled to open facing the hallway and entered resident room for approximately 5 minutes with the door shut. LVN L exited the room and noticed another resident hospice staff member standing by her cart. During an interview on 08/31/2026 at 10:10 a.m., LVN L stated she entered the resident's room to replace an oxygen humidifier and forgot to lock her cart. During an interview on 09/03/2026 at 10:00 a.m., LVN L stated that she unintentionally left her cart unlocked when she went into a resident room. LVN L stated that she should have locked her cart when she walked away from the cart. LVN L stated that her cart was at risk of being tampered with. LVN L stated residents were at risk of getting into her cart and consuming any over the counter or prescribed medication in the pill blister pack that was in the cart. During an interview on 09/03/2026 at 2:27 p.m., the ADON stated she expected LVN L to lock her nurse medication cart when she stepped away from the cart. The ADON stated LVN L's medication cart should have been locked to prevent harm to the residents, consumption of medications and tampered with the medication cart. The ADON stated that she did spot check randomly and LVN L left her cart unlocked she locked it and notified them to lock their cart when they stepped away. During an interview on 09/03/2026 at 3:09 p.m., the DON stated she was unaware that LVN L left her medication cart unlocked. The DON stated that she expected all nursing staff to lock their cart when they step away or take their hands and eyes off the cart. The DON stated she expected LVN L to lock her cart to prevent theft of medications and for LVN L to provide a safe environment for the residents. During an interview on 09/03/2026 at 3:18 p.m., the Administrator stated that it was the DON's responsibility to ensure that the Nurse Medication Cart always remained locked when unattended. The Administrator stated that the medication cart should have been locked to prevent drug diversion and someone consuming a medication on the cart that could be harmful and cause adverse effects such as overdose. 2. Record review of Resident #56's face sheet, dated 09/03/26, reflected Resident #56 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnosis which included Dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of Resident #56's quarterly MDS assessment, dated 06/21/26, reflected Resident #56 made herself understood and understood others. Resident #56's BIMS score was 8, which reflected her cognition was moderately impaired. Record review of Resident #56's comprehensive care plan, revised on 10/30/25, reflected Resident #56 had impaired cognitive function. The care plan interventions included: keep the residents' routine consistent and try to provide consistent care-givers as much as possible in order to decrease confusion. Record review of Resident #28's order summary report, dated 09/03/26, reflected an active order for Nystatin Topical Cream 100000 unit/gm: apply to affected area topically three times a day for yeast with a start date 08/04/26. During an observation and interview on 08/31/26 at 1:20 p.m., there was a plastic bottle labeled Nystatin Powder on Resident #56's dresser. Resident #56 stated a staff member gave her the powder to place under her abdominal folds twice a day. Resident #56 was unable to recall staff name. During an interview on 09/03/26 at 1:32 p.m., CNA B stated nursing staff were responsible for ensuring items were stored properly and securely. CNA B stated she noticed the medication on Resident #56's dresser but it did not cross her mind to remove it from her. CNA B stated medication should be stored on the nurse's cart. CNA B stated it was important to ensure items were not left on the resident's dresser for residents' safety. During an interview on 09/03/26 at 2:04 p.m., the BOM stated she was responsible for daily champion rounds for Resident #56. The BOM stated during her rounds twice a day she looked for items that should not be in the resident's room such as medication. The BOM stated she did not notice the medication on Resident #56's dresser. The BOM stated the medication should be stored on the nurse's medication cart. The BOM stated it was important to ensure items were not left on the resident's dresser for residents' safety. During an interview on 09/03/26 at 3:40 p.m., the DON stated she expected medications to be stored on the nurse's cart. The DON stated Resident #56 was not allowed to self-administer the powder. The DON stated all staff were responsible for ensuring items were stored properly and securely. The DON stated she monitored compliance by ensuring champion rounds were completed by the assigned department head and daily rounds conducted by her. The DON stated she had noticed issues in the past and in- serviced staff verbally. During an interview on 09/03/26 at 4:26 p.m., the Administrator stated she expected medications to be stored on the nurse's cart. The Administrator stated all staff were responsible for ensuring items were stored properly and securely. The Administrator stated she did random spot checks, but she expected champions rounds to be done daily by the assigned department head. The Administrator stated it was important to ensure items were not left on the residents' dresser for residents' safety. 3. Record review of Resident #63's face sheet, dated 09/03/26, reflected Resident #63 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included Seborrheic dermatitis (a common, chronic inflammatory skin condition that causes scaly, greasy patches and stubborn dandruff on oily areas of the body), stroke(a medical emergency that happens when blood flow to part of the brain is blocked or a blood vessel in the brain bursts, causing brain cells to die), dementia (memory loss), depression(sadness), and high blood pressure(occurs when the force of blood pushing against your artery walls is consistently too high). Record review of Resident #63's quarterly MDS assessment, dated 06/19/26, reflected Resident #63 made himself understood, and was understood by others. Resident #63's BIMs score was a 15 which indicated he was cognitively intact. The MDS indicated Resident #63 required assistance with toileting, bathing, oral hygiene, and eating. Record review of Resident #63's physician's order dated 09/27/25 indicated: Ketoconazole External Shampoo 2 percent, apply to scalp topically every 72 hours for seborrheic dermatitis. The order did not indicate that Resident #63 was able to self-medicate. Record review of Resident #63's Medication Administration Record dated 09/01/26 through 09/30/26, indicated LVN T signed she administrated Ketoconazole External Shampoo 2 percent to Resident #63 on 09/01/26 (Tuesday). Record review of Resident #63's comprehensive care plan revised 02/20/26 reflected Resident #63 had a rash to his scalp, ears, face, and chest related to seborrheic dermatitis. The intervention was to apply Ketoconazole External Shampoo 2 percent (Ketoconazole (Topical)) as ordered. During an observation on 08/31/26 at 12:02 p.m., a prescription medication of Ketoconazole shampoo was sitting on Resident #63's bedside table in the bathroom. During an observation on 09/03/26 at 1:51 p.m., a prescription medication of Ketoconazole shampoo was sitting on Resident #63's bedside table in the bathroom. During an interview on 09/03/26 at 1:53 p.m., Resident #63 said he used the prescription medication of Ketoconazole when he had a shower on 09/01/26. He said the nurses had left the medication in his room at an unknown date. He said he did not know he was not supposed to have prescription medication in his room. During an interview on 09/03/26 at 1:55 p.m. CNA D said she was the aide for Resident #63. She verified the prescription medication was in the bathroom. She said prescription medication should not be in the bathroom or anywhere in the resident's room. She said the nurses were supposed to ensure they did not leave medication in the room for safety. During an interview and observation on 09/03/26 at 2:01 p.m., LVN L said all nurses were responsible for ensuring prescription medication was stored properly and securely. LVN L verified the prescription medication of Ketoconazole was in the bathroom and said no residents should have prescription medication in their room. She said Resident #63 did not have orders to self-medicate any medication. LVN L said it was important to ensure prescription medication was not left on the resident table or bathroom for all residents' safety. During an interview on 09/03/26 at 4:07 p.m., the DON said nurses were responsible for ensuring items were stored properly and securely. The DON said she monitored rooms with random spot checks. The DON said it was important to ensure items were not left on the resident's table for residents' safety. During an interview on 09/03/26 at 4:41 p.m., the Administrator said she expected all prescription medication to be locked and secured by the nurses. The Administrator said she expected staff to round and if they saw things that should not be in a resident's room to remove it. The Administrator said it was important for residents' safety to ensure no items were left unattended that could hurt or harm a resident. Record review of the facility's policy titled, Medication Storage in the Facility Policy, from Pharmcare USA Policy and procedure, dated 2025, indicated, Policy: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on interviews and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 3 of 6 residents (Resident #12, Resident #36, and Resident #32) reviewed for administration.1.The facility failed to maintain Resident #12's hospice binder with form 3074 (Texas Medicaid Physician Certification of Terminal Illness form. In which a doctor used it to state that a patient has a terminal illness with a life expectancy of six months or less), 3071 (past Texas Medicaid Hospice Recipient Election/Cancellation form) benefit recertification period, and Interdisciplinary group meetings (IDG).2. The facility failed to maintain Resident #36's hospice binder with the Interdisciplinary group meetings held every 2 weeks.3. The facility failed to obtain Resident #32's current and past Texas Medicaid Hospice Recipient Election/Cancellation form (3071), Physician certification of terminal illness (3074), Hospice Plan of Care and current interdisciplinary notes for current hospice certification period. These deficient practices could place residents who receive hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. Findings included: 1. Record review of Resident #12's face sheet, dated 09/03/26, reflected Resident #12 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included dementia (a decline in mental ability that interferes with daily life),Parkinson (a progressive brain disorder that affects movement, balance, and other body functions due to the loss of dopamine-producing neurons), and depression (a common mental health condition characterized by persistent sadness and a loss of interest in activities, significantly impacting daily life). Record review of Resident #12's quarterly MDS assessment, dated 07/29/26, reflected Resident #12 understood, and was usually understood by others. Resident #12's BIMs score was a 00 which indicated she was severely cognitively impaired. The MDS indicated Resident #12 was on hospice services. Record review of Resident #12's physician's orders dated 01/18/26 indicated an order for hospice. Record review of Resident #12's comprehensive care plan revised 04/02/26 indicated Resident #12 had a terminal prognosis and was on hospice services. The intervention was to work cooperatively with hospice team to ensure the residents' spiritual, emotional, intellectual, physical and social needs were met. Record review of Resident #12's hospice binder on 09/03/26 at 11:09 a.m., revealed it did not have the Physician certification of the terminal illness form 3074, Texas Medicaid Hospice Recipient Election/Cancellation form 3071, the IDG meetings or benefit recertification period. During a phone call on 09/03/26 at 4:15 p.m., the hospice company said Resident #12's beneficial period ended 09/01/26 and they met every 2 weeks for the IDG meeting. He said he was not aware of the process and the facility binders but would have the DON or the hospice nurse to call back. A return call was not received a call prior to exit. 2. Record review of Resident #36's face sheet, dated 09/03/26, reflected Resident #36 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included dementia (a decline in mental ability that interferes with daily life), anxiety (a feeling of unease, worry, or fear, often experienced as a normal reaction to stress), and depression (a common mental health condition characterized by persistent sadness and a loss of interest in activities, significantly impacting daily life). Record review of Resident #36's admission MDS assessment, dated 06/26/26, reflected Resident #36 understood, and was understood by others. Resident #36 BIMs score was an 08 which indicated she was severely cognitive impairment. The MDS indicated Resident #36 was on hospice services. Record review of Resident #36's comprehensive care plan dated 06/17/26 indicated Resident #36 had a terminal prognosis and was on hospice services. The intervention was to work cooperatively with the hospice team to ensure the residents' spiritual, emotional, intellectual, physical and social needs were met. Record review of Resident #36's physician's orders dated 06/17/26 indicated an order for hospice for senile degeneration of the brain. Record review of Resident #36's hospice binder on 09/03/26 at 11:09 a.m., revealed the IDG meeting in the chart was dated 07/24/26. During a phone interview on 09/03/26 at 3:58 a.m., the hospice nurse said the binders at the facility should contain supporting notes or documentation needed for Resident #36. She said the binder should at least have the face sheet, election form, code status, certification of terminal illness, plan of care, and medications. She said they met every two weeks on Friday for the Interdisciplinary group meetings and said the documentation should be updated at least the following week after the Interdisciplinary group meetings. She looked at the office's records and said Resident #36's last Interdisciplinary group meeting was 08/21/26. She said she would email over the information to the facility. She said it was important to have the binders at the facility updated to help the facility know the care and services the hospice staff were providing. During an interview on 09/03/26 at 10:39 a.m., LVN N said she was not sure of all the information that needed to be included in the hospice binder. She said she thought the hospice binder should include the name of the hospice, diagnosis, face sheet, and code status. She said management was responsible for ensuring the hospice binders were updated. She said any information the hospice company had for Resident #12 and Resident #36 should be at the facility for effective communication because their care was combined. During an interview on 09/03/26 at 4:07 p.m., the DON said she expected the hospice binders or electronic medical records to be updated with all required material. She said medical records were responsible for making sure the hospice information was in the electronic records. She said hospice should correlate with the facility nurses to see about any changes in resident care. She said she was responsible for periodically ensuring the hospice binder or electronic medical records were updated. She said she reviewed the residents' charts periodically but was not aware Resident #12 nor Resident #36 did not have all required information in the binder or electronic medical records. She said the risk could be miscommunication on care between hospice and the facility. During an interview on 09/03/26 at 4:47 p.m., the Administrator said any information the hospice company had should be updated in the facility's hospice binder or electronic medical records. She said she expected all information needed to be in the hospice binder or electronic medical records. She said the DON was responsible for ensuring all hospice documents were up to date. She said the binder or electronic medical records should be updated for effective communication and continuity of care. 3.Record review of face sheet dated 9/3/2026 revealed Resident #32 was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of Alzheimer's disease with late onset (impaired cognitive functioning). Record review of quarterly MDS dated [DATE] revealed Resident #32 had severe impairment for cognitive skill for daily decision making. The MDS assessment indicated Resident #32 was receiving hospice care. Record review of the care plan dated 10/23/2025 revealed Resident #32 was care planned for terminal prognosis and was receiving hospice services. The care plan revealed an intervention to work cooperatively with hospice team to ensure Resident #32 spiritual, emotional, intellectual, physical, and social needs were met. Record review of an order summary dated 9/3/2026 revealed Resident #32 had an order to admit to hospice for diagnosis of Alzheimer's. Record review of Resident #32's hospice binder did not have the certification for services, any intradisciplinary group meeting notes, care plan, no #3071 form, no #3074 form, and most recent certification period of 01/06/2026 that was placed in the binder. During an interview on 09/03/2026 at 9:49 a.m., revealed Hospice Case Manager was responsible for printing all missing documents and placing them in the binder for Resident #32. The Hospice Case Manager stated that she was unaware of the need for the 3071, 3074, IDG meetings, and the plan of care for certification period. Teh Hospice Case Manager stated she had not been contacted requesting the documents for Resident #32 from the facility. The Hospice Case manager stated that it was the facility's responsibility to let her know the documents needed. The Hospice Case Manager stated that Resident #32's binder was to be updated every 2 weeks with each IDG meeting, certification period, certification of terminal illness, and recertification period for coordination of care. The Hospice Case Manager stated that the hospice staff and facility used the binder to collaborate care for Resident #32 and Resident #32 was at risk of not receiving the intended hospice case. During an interview on 09/03/2026 at 1:40 p.m., LVN L stated that she was unsure who was responsible for Resident #32 hospice binder. LVN L stated that she did not check the binder to ensure the documentation was up to date, but she did call hospice to collaborate care. LVN L stated that the binder was to ensure both the facility and the hospice services were on the same page with care. LVN L stated that Resident #32 was at risk of not having collaborated care with hospice due to no recertification in the binder. LVN L stated that no one would know Resident #32 was still receiving hospice services. During an attempted interview on 09/03/2026 at 1:55 p.m., Resident #32 was unable to provide any information regarding the hospice service she was receiving. During an interview on 09/03/2026 at 2:30 p.m., the ADON stated that she did not have a process to ensure Resident #32's hospice binder had the 3071, 3074, IDG meeting notes, or recertification period. The ADON stated that she was unsure what was needed in the binder and had not instructed the nursing staff to check the binder. The ADON stated that she did not ensure the binder was updated with current records for hospice services for Resident #32 and Resident #32 was at risk of not having collaborated care. During an interview on 09/03/2026 at 3:10 p.m., the DON stated that she thought medical records was responsible for Resident #32's hospice binder. The DON stated that she did not have a process in place to check Resident #32's binder for updated hospice records. The DON stated that the hospice binder was used to ensure care was provided and the team was on the same page for Resident #32's care. The DON stated that Resident #32 was at risk of not receiving hospice services. During an interview on 09/03/2026 at 3:19 p.m., the Administrator revealed she was unaware of the missing documents for Resident #32's hospice binder. The Administrator stated that she expected nursing to ensure the binder was up to date for the care Resident #32 was receiving in a timely manner. The Administrator stated that Resident #32 was at risk of not receiving or receiving unintended care. The Administrator stated that the binders were intended to collaborate with the hospice services for Resident #32. Record review of the facility Hospice Services policy dated 02/13/2007 revealed The DON or designee will be responsible for ensuring that documentation is part of the current clinical record. At a minimum, the documentation will include: The current and past Texas Medicaid Hospice Recipient Election/Cancellation form (#3071),Texas Medicaid Hospice-Nursing Facility assessment form (#3073), Physician certification of terminal illness (#3074),Medicare Election Statement (if dual eligible),Verification that the recipient does not have Medicare part A, Hospice Plan of Care, and Current interdisciplinary notes to include nurses notes/summaries, physician orders and progress notes, and medications and treatment sheets during the hospice certification period.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #2) and 3 of 3 staff reviewed for infection control.1. The facility did not ensure COTA Q and CNA wore gloves prior to picking up dirty linen off the floor. 2. The facility did not ensure the Treatment Nurse followed EBP while measuring Resident #2 wound located on her left heel. These failures could place residents at risk for cross contamination and the spread of infection. Findings included: 1. During an observation and interview on 08/31/26 at 12:40 p.m., COTA Q was observed picking up dirty linen from the floor without wearing gloves in front of room [ROOM NUMBER]. COTA Q placed the dirty linen into a plastic bag. COTA Q stated she was supposed to wear gloves to prevent contamination. COTA Q stated she did not wear gloves because she was in a hurry. During an observation and interview on 09/01/26 at 9:34 a.m., CNA B was observed picking up dirty linen from the floor without wearing gloves, using a plastic bag to pick up the linen in front of room [ROOM NUMBER]. CNA B placed the dirty linen into a plastic bag. CNA B stated she should have worn gloves, but she used the plastic bag as gloves. CNA B stated it was important to ensure gloves wear worn to prevent the spread of infection.2. Record review of Resident #2 face sheet, dated 09/03/26, reflected Resident #2 was an [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included pressure ulcer (localized injury to the skin and underlying tissue caused by prolonged pressure, friction, or shear) of left heel, Stage 4 (full thickness loss of tissue that exposes underlying muscle tendon, ligament, or bone). Record review of Resident #2's quarterly MDS assessment, dated 07/24/26, reflected Resident #2 made herself understood and understood others. Resident #2's BIMS score was 10, which reflected her cognition was moderately impaired. Resident #2 was at risk for developing pressure ulcers/injuries and did have any skin problems. Record review of Resident #2's comprehensive care plan, initiated 04/22/26, reflected Resident #2 was on enhanced barrier precautions. The care plan interventions included gloves and gown should be donned (on) if any of the following activities are to occur wound care. Record review of Resident #2's physician's order summary, dated 09/03/26, reflected an active order for stage 4 pressure to left heel: clean with wound cleanser, pat dry, medi honey (topical treatment used to manage and heal wounds), and cover with dry dressing every Tuesday, Thursday and Friday with a start date 08/07/26. During an observation and interview on 09/01/26 at 9:31 a.m., the Treatment Nurse was observed measuring Resident #2's wound to her left heel without wearing a gown. The Treatment nurse stated she should have put on a gown prior to measuring the wound. The Treatment Nurse stated she was nervous due to the surveyor being present. The Treatment Nurse stated Resident #2 was on EBP due to her wound to her left heel. The Treatment Nurse stated it was important to ensure infection control practices were done to prevent the spread of infection. During an interview on 09/03/26 at 3:40 p.m., the DON stated she was the Infection Control Preventionist for the facility. The DON stated gloves should be worn prior to picking up linen off the floor. The DON stated a gown should have been worn prior to measuring Resident #2's wound to her left heel. The DON stated she monitored infection control practices by random spot checks, skill checks and in-services. The DON stated it was important to ensure infection control practices were followed to prevent the spread of infection. During an interview on 09/03/26 at 4:26 p.m., the Administrator stated she expected staff to wear gloves when picking up linen from the floor. The Administrator stated she expected a gown to be worn prior to measuring Resident #2's wound. The Administrator stated the DON was responsible for monitoring infection control practices. The Administrator stated it was important to ensure infection control practices were followed to prevent the spread of infection. Record review of the facility's undated policy titled Infection Control Plan: Overview, reflected, The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.Linens.Personnel will handle, store, process and transport linens so as to prevent the spread of infection. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities.EBP are indicated for residents with any of the following: Wounds.

Based on observation, interview, and record review, the facility failed to establish policies regarding smoking areas, and smoking safety for 1 of 1 smoking area.The facility failed to provide an ashtray of safe design that would prevent a lit cigarette from coming into contact with a discarded cigarette butt. These failures could place residents and staff at risk of fire and burn injury.Findings included: During an observation on 09/02/26 at 10:02 a.m., during the scheduled smoke break, revealed there was an ash tray hanging on the wall in which it did not have a proper place to put the cigarette out. It only had a hole where someone could place their cigarette but not to ensure the cigarette was out completely. During an interview on 09/02/26 at 10:15 a.m., Housekeeper N said she was not sure if the gray ashtray hanging on the wall, was a safe ashtray. She said the residents had placed their cigarettes and ashes in it before. She said she did empty the weighted flip-top ashtray on the table and the grey ashtray on the wall in the trash dumpster located outside after the residents smoked at times. She said she tried to ensure the cigarettes were out before she placed the butts/ashes in the trash dumpster outside but was not sure of the proper way to discard the cigarette butts. She did not say if she put any type of liquid on the ashes or butts before throwing them in the trash dumpster. She did say after thinking about it that if the cigarettes were not completely out there was a risk of fire with putting the cigarette butts and trash in the same receptacle.During an interview and observation on 09/03/26 at 3:55 p.m., the Maintenance Supervisor said he was aware of the grey ash tray on the wall. He said he thought it was an approved ashtray. Observation and interview of the ashtray with the Maintenance Supervisor revealed he realized there was no way for the residents, staff or visitors to ensure their cigarettes were completely out before disposing it in the ashtray. The Maintenance Director removed the ashtray. The Maintenance Supervisor said he was not aware of any training required to take the residents out to smoke. The Maintenance Supervisor said he was responsible for cleaning out the cigarette butts every morning. He said he was not aware other staff emptied the ashtrays. He said he did put water on the ashes/butts before he threw them in the trash dumpster outside. He said he could see the potential risk of fire because the grey ashtray hanging on the wall did not have a way to ensure cigarette ashes/butts that were dropped inside the receptable were completely out.During an interview on 09/03/26 at 4:07 p.m., the DON said she was aware of the ashtray on the table and on the wall in the smoking area. She said she was not aware if they were the approved ashtrays or not but assumed they were. She said the Maintenance Supervisor was the overseer of the smoking area. The DON said there was a risk of fire if staff were putting cigarettes in the trash dumpster and were not sure if the cigarettes were out and if residents, staff, or visitors were dropping lit cigarettes in a container and was unsure if the cigarette was completely out.During an interview on 09/03/26 at 4:41 p.m., the Administrator said she was aware of the ashtrays out in the smoking area. She said residents, staff, and visitors should be placing their butts/ashes in the ashtrays. She said she was not sure if the gray ashtray hanging on the wall was of a safe design or not. The Administrator said it was the Maintenance Supervisor's responsibility to ensure the ashtrays in the smoking area were approved ashtrays. She said if the ashtray was not safe then she could see the potential for a fire hazard. She said she was okay with staff emptying the cigarettes in the dumpster outside as long as they ensured the cigarettes ashes/butts were completely out.Record review of the facility policy titled, Smoking dated 10/12/22, indicated, It is the policy of this community to accommodate residents who desire to smoke, including electronic cigarettes by taking reasonable precautions, providing a safe environment for them, and protecting the non-smoking residents. Procedure:.2. Smoking by residents is allowed outside in designated, marked smoking areas with the following safety measures readily available: a. Ashtrays made of noncombustible material and safe design; b. Metal containers with self-closing covers into which ashtrays can be emptied. 5. The community will develop a smoking schedule to ensure a safe environment.

Based on observation, interview, and record review, the facility failed to treat residents with respect and dignity and cared for them in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 1 of 23 residents (Resident #24) reviewed for resident rights. The facility did not ensure LVN A fed Resident #24 while sitting down on 08/31/26 at 1:24 p.m. This failure could place residents at risk of embarrassment, isolation, and diminished quality of life. Findings included: Record review of Resident #24's face sheet, dated 09/03/26, reflected Resident #24 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnosis hypertensive heart disease with heart failure (unmanaged high blood pressures forced the heart to work too hard, causing the heart muscle to thicken, weaken and fail to pump blood efficiently). Record review of Resident #24's significant change in status MDS assessment, dated 05/29/26, reflected Resident #24 made herself understood, and understood others. Resident #24 BIMS score was 15, which reflected her cognition was intact. Resident #24 required set-up clean up assistance with eating. Record review of Resident #24's comprehensive care plan, initiated 09/12/25, reflected Resident #24 had an ADL Self Care Performance Deficit. The care plan interventions included: assistance with personal hygiene as required; hair, shaving, oral care as needed. During an observation on 08/31/26 at 1:24 p.m., LVN A was standing up while feeding Resident #24 her lunch meal. During an interview on 08/31/26 at 1:38 p.m., LVN A stated she should have sat at eye level while feeding Resident #24. LVN A stated it was important to treat residents with dignity and respect. During an interview on 08/31/26 at 1:40 p.m., Resident #24 stated she did not know if staff were supposed to sit or stand but she would like them to sit. During an interview on 09/03/26 at 3:40 p.m., the DON stated she expected LVN A to sit at eye level while assisting Resident #24 with lunch. The DON stated she conducted random rounds during meal service to ensure dignity and respect were provided while residents were being assisted with meals. The DON stated there were no issues in the past. The DON stated it was important to treat residents with dignity and respect. During an interview on 09/03/26 at 4:26 p.m., the Administrator stated she expected LVN A to sit at eye level while assisting Resident #24 with her meal. The Administrator stated the DON, or designee, was responsible for monitoring meal service. The Administrator stated it was important to treat residents with dignity and respect. Record review of the facility's undated policy titled, Resident Rights, reflected, A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Respect and dignity - The resident has a right to be treated with respect and dignity.

Based on observation, interview, and record review, the facility failed to ensure that each resident has a right to secure and confidential personal and medical information for 1 of 11 (Resident #64) resident reviewed for personal privacy and confidentiality of records.The facility failed to maintain personal privacy and confidentiality of records in that an employee received resident specific information to include name and identifying social history information describing Resident #64 from a person who was not associated with Resident #64 and was related to another staff member. This failure could place residents at risk of personal information being exposed to unauthorized individuals.Findings included:Record review of Resident #64's face sheet, dated 09/02/2026, revealed an [AGE] year-old female admitted [DATE] and readmitted [DATE] with diagnoses which included ASCHD (narrowing or blockage of coronary arteries), Hypertension (high blood pressure), PVD (condition of build-up fatty material inside the blood vessels), COPD (a progressive lung disease that makes it difficult to breathe), Osteoarthritis (occurs when protective cartilage that cushions the ends of the bones wears down over time), dementia (general term that describes decline in cognitive function that is severe enough to interfere with daily life) and psychosis (a severe mental condition that results in loss of contact with external reality).Record review of Resident #64's Comprehensive MDS Assessment, dated 06/10/26, revealed Resident #64 had minimal hearing difficulty, was understood by others and understood others, severely impaired vision with a BIMS score of 15 which indicated intact cognition. Resident #64 required the use of a wheelchair for mobility, set-up assistance with bed mobility, supervision with eating, upper body dressing, moderate assistance in bathing, lower body dressing, transfers, and maximum assistance in toileting. Record review of Resident #64's care plan, reviewed 06/11/26, revealed Resident #64 had impaired visual function, impaired hearing function, ADL self-care deficit and received medications for anxiety and depression.During an observation and interview on 09/01/26 at 7:59 a.m., Resident #64 was sitting at side of her bed waiting for breakfast. Resident #64 was clean, odor free and appropriately dressed. Resident #64 stated she had a history of financial exploitation in the past from a family member prior to admission, had no concerns of exploitation since she admitted to the facility and refused to further discuss her personal finances. Resident #64 stated she felt safe at the facility and that she would not want her personal information or financial affairs to be discussed with people who had no business knowing my business.During a confidential interview on 08/31/26 at 11:56 a.m., Confidential Person G revealed they received a call on 08/18/2026 (time unknown) from the family member of Employee V and that family member shared specific information to include name and financial social history about Resident #64. Confidential Person G stated they did not know if the information provided was true but stated they believed Resident #64's privacy was violated and informed the Administrator. A telephone interview was attempted 09/01/26 at 9:39 a.m. with the non-employee, non-family member who shared resident specific information about Resident #64 and was unsuccessful. Attempts were made to three different contact numbers on 09/01/2026 at 9:39 a.m., 9;40 a.m., and 9;41 a.m. to confirm if the family member had confidential information about Resident #64. During an interview on 09/02/26 at 8:46 a.m., the Employee V stated she had not intentionally shared any resident specific information with non-employees and understood the importance of privacy and confidentiality regarding resident information and data. Employee V stated to her knowledge Resident #64 was being assisted by legal aid for exploitation concerns that occurred prior to her admission to the facility and no concern of current exploitation was identified to her. Employee V stated she received training on HIPAA and understood how to protect residents' privacy.Record review of Employee V's personnel file revealed she had signed the facility Privacy Acknowledgement & Non-Disclosure Agreement upon hire on 06/23/2026.During an interview on 09/02/26 at 9:52 a.m., the SW stated Resident #64 was a victim of exploitation from a family member prior to admission but never expressed concern of exploitation since admission to this facility on 02/12/2026. The SW stated she was assisted by the court system to identify a competent person to manage her financial affairs and voiced no concerns about exploitation since she was admitted to this facility. During an interview on 09/02/2026 at 3:20 p.m., the Administrator stated the concern of a HIPAA violation was brought to her attention by Confidential Person G on an unknown date, but she was unable to validate that it occurred because the family member in question was trespassed from the facility on 08/16/2026 for causing a disturbance and would not respond to telephone contact. The Administrator stated all staff received HIPAA privacy and confidentiality training upon hire, annually and as needed and she did not feel any staff intentionally shared resident specific information. The Administrator stated that she was ultimately responsible for ensuring resident's privacy was protected. Record review of the facility policy titled, Resident Rights, undated, revealed. Privacy and confidentiality - The resident has a right to personal privacy and confidentiality of his or her personal and medical records, and 2. The facility must respect the resident's right to personal privacy.Record review of the facility's, Privacy Acknowledgement & Non-Disclosure Agreement, undated, that iswas provided to the employees upon hire revealed, As a condition of my employment or work at the facility, I agree that I: Will not verbally or in any written form disclose confidential resident information to any unauthorized person.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 23 (Resident #60) residents reviewed for care plans.The facility failed to implement identified care plan interventions related to the use of the assist bars on 08/26/26. This failure could place residents at risk of not receiving appropriate interventions to meet their current needs.Findings included:Record review of Resident #60's face sheet, dated 09/03/26, reflected Resident #60 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnosis of acute respiratory failure with hypoxia (not enough oxygen in blood. Record review of Resident #60's admission MDS assessment, dated 08/25/26, reflected Resident #60 usually made herself understood and understood others. Resident #60's BIMS score was 14, which reflected her cognition was intact. Record review of Resident #60's comprehensive care plan, revised on 08/27/26, reflected Resident #60 used a bed rail to assist themselves with ADLs. The care plan interventions included: grab/assist bar to be used and the resident used rail on the left and right of the bed. Record review of Resident #60's physician's order summary report, dated 09/03/26, reflected an active order for grab/assist bar to both sides of bed to assist with ADLs and transfers, dated 08/27/26. During an interview and observation on 08/31/26 at 1:05 p.m., Resident #60's family member stated he asked ADON E to place an assist bar to assist with positioning. Resident #60's family member stated he was told by ADON E it would be placed on 08/28/26 but it was never done. Observation reflected no assist bars were installed on either side of Resident #60's bed. During an interview on 09/01/26 at 12:28 p.m., the Maintenance Supervisor stated that ADON E informed him on 08/28/26 she needed him to place an assist bar on each side of Resident #60's bed. The Maintenance Supervisor stated he was tied up in the kitchen on 08/28/26 and could not place the assist bars and on 08/31/26 he had other work that needed to be done. The Maintenance Supervisor stated he did not know the medical part of why it was important for the assist bars to be installed. During an interview on 09/02/26 at 10:07 a.m., the DOR stated it would be helpful for Resident #60 to have the assist bars because Resident #60 was not strong enough to get out of bed on her own. The DOR stated if she did not have the assist bars and needed it there was a high risk of falls. During an interview on 09/03/26 at 3:14 p.m., ADON E stated Resident #60's family member asked on 08/27/26 for an assist bar to help with positioning and transfer in bed. ADON E stated she had Resident #60's family member to sign a consent, obtained an order and ensured it was on the care plan. ADON E stated she notified the Maintenance Supervisor on 08/28/26 that an assist bar needed to be installed on Resident #60's bed. ADON E stated it was important to ensure that the assist bars were installed to help with ADLs. During an interview on 09/03/26 at 3:40 p.m., the DON stated her expectation was for the assist bars to be placed on 08/28/26. The DON stated once the device was placed she monitored compliance by daily rounds. The DON stated she could not recall if Resident #60's needing an assist bar was addressed in the morning meeting. The DON stated she did not conduct rounds on Monday (08/31/26). The DON stated it was important to ensure that the assist bars were installed for mobility. During an interview on 09/03/26 at 4:26 p.m., the Administrator stated she expected the assist bars to be installed when the Maintenance Supervisor was told. The Administrator stated the DON, or designee, was responsible for monitoring to ensure the assist bars were installed. The Administrator stated it was important to ensure that the assist bars were installed to prevent injury. Record review of the facility's undated policy titled, Comprehensive Care Planning, reflected, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with. Includes measurable objectives and timeframes to meet a resident's medical, nursing needs.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable based on the comprehensive assessment and consistent with the resident's needs and choices for 2 of 5 residents (Resident #25 and Resident #60) reviewed for activities of daily living. 1. The facility failed to provide a communication assistance device to effectively communicate with Resident #25 on 08/31/26 and 09/01/26. 2. The facility failed to provide translation assistance to effectively communicate with Resident #60 from 08/31/26 through 09/03/26. This failure could place residents at risk for declining and diminishing quality of life. Findings included: Record review of Resident #25's face sheet, dated 09/03/26, reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis which included aphasia (a disorder that affects how you communicate). Record review of Resident #25's admission MDS assessment, dated 8/26/26, reflected Resident #25 usually made himself understood, and understood others. Resident #25's BIMS score was 0 which indicated severe cognitive impairment severe problems with thinking and memory. Record review of Resident #25's care plan, revised on 08/31/26, reflected Resident #25 had a communication problem related to aphasia following cerebral infarction, stroke. The care planned interventions included: to anticipate his needs, communicate with resident by asking yes/no questions, and give resident time to show/point to what he was needing. During an interview and observation on 09/01/26 at 10:03 a.m., Resident #25 was sitting in bed awake with no distress noted. The surveyor began talking to Resident #2 and asked if his needs were being met. Resident #25 waved his index finger and never replied. There was no communication device observed in his room. During an interview on 09/02/26 at 2:34 p.m., CMA N said Resident #25 mumbles when he wants something, hits the table, or points to things. CMA N said images would help in his care. CMA N said it was important to have effective communication because you may not always know what Resident #25 was talking about. During an interview on 09/02/26 at 2:41 p.m., the ADON said Resident #25 would point at things and shake his head. The ADON said if he had a picture board it would help. She said effective communication was important to meet Resident #25's needs and give him a good quality of life. During a telephone interview on 09/02/26 at 3:33 p.m., CNA D said Resident #25 does not say anything besides baba. CNA D said Resident #25 pointed to objects. CNA D said she thought a communication board would be helpful because it was important to make sure Resident #25's needs were met. During an interview on 09/02/26 at 3:24 p.m., LVN C said she communicated with Resident #25 by having him point and using the process of elimination. LVN C said a picture board would be effective for him. LVN C said effective communication was important to prevent the resident from becoming frustrated and to meet his needs. During an interview on 09/03/26 at 4:34 p.m., the Administrator said she has not had a conversation with Resident #25. The Administrator said effective communication was important to help the staff understand what the residents were trying to say and be able to meet their needs. She said it was also important for the residents' dignity. Record review of Resident #60's face sheet, dated 09/01/26, reflected Resident #60 was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of type 2 diabetes mellitus (a chronic condition in which the body doesn't use insulin properly), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), essential hypertension (condition in which the force of blood pushing against the artery walls was consistently too high), and acute kidney failure (a condition in which the kidneys suddenly cannot filter waste products from the blood). Record review of Resident #60's face sheet, dated 09/01/26, reflected Resident #60's primary language was Spanish. Record review of Resident #60's admission MDS assessment, dated 08/25/26, reflected her preferred language was Hispanic. Resident #60's MDS reflected usually made self-understood and understood others. Resident #60's BIMS was 14, which indicated intact cognition normal thinking and memory. Record review of Resident #60's care plan, revised on 8/31/26, reflected Resident #60 had a communication problem related to Spanish speaking. The care plan interventions included: anticipate and meet needs, staff to use translation application when no Spanish speaking employee was unavailable, and use alternative tools as needed, such as communication book/board, writing pad, gestures, signs, and pictures. During an interview and observation on 08/31/26 at 1:05 p.m., Resident #60 was sitting in the recliner with her family members at the bedside. The state surveyor began talking to Resident #60 in English and asked if her needs were being met. Resident #60 did not reply. Resident #60's family member said Resident #60 did not speak English and understood very little. Resident #60's family member said when staff could not communicate with Resident #60, they called another family member to communicate Resident #60's needs. Resident #60's family member would call the facility to let them know what Resident #60 needed. There was no communication device observed in the room. There was no translation services number posted or sign to use translation applications observed in the room. During an interview on 09/01/26 at 9:20 a.m., Resident #60's family member asked the state surveyor to translate a letter from the facility that was provided to him that morning. Resident #60's family member said he did not know how to read English and was not provided with the letter in Spanish. During an interview on 09/02/26 at 2:34 p.m., CMA N said she communicated with Resident #60 through the resident's family member. CMA N said if Resident #60's family member was not available; she would get help from a nurse. The CMA N said a communication board would be helpful in Resident #60's care. CMA N said it was important to have effective communication because if they do not communicate well, they may not always know what the residents were talking about. During a telephone interview on 09/02/26 at 3:33 p.m., CNA D said she communicated with Resident #60 through the resident's family member. CNA D said Resident #60's family member spoke broken English. CNA D said she knew Resident #60's family members responses were appropriate because during meal tray passes when he asked for something, CNA D listed things to find what he needed. CNA D said she had never used a translator. CNA D said this was not effective communication and it was important to make sure the residents' needs were being met. During an interview on 09/02/26 at 2:41 p.m., the ADON said Resident #60 understood what the ADON was saying but cannot speak English. She said Resident #60's husband speaks English. The ADON said she would call a translator or use Google Translate if there were no Spanish speaking staff available. She said effective communication was important to meet Resident #60's needs and give them a good quality of life. During an interview on 09/03/26 at 4:34 p.m., the Administrator said she had never had a conversation with Resident #60. The Administrator said she was not aware Resident #60 received a letter from the facility in English. The Administrator said translation devices or Spanish speaking staff were able to help communicate with Resident #60. The Administrator said effective communication was needed to help the resident. She said it was important to understand what they were trying to say to meet the residents' needs and maintain dignity. Record review of the facility's undated policy titled, Resident Rights, reflected, . A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Information and communication:1. The facility must ensure that information is provided to each resident in a form and manner the resident can access and understand, including in an alternative format or in a language that the resident can understand. Summaries that translate information may be made available to the patient at their request and expense in accordance with applicable law.

Based on observation, interview, and record review the facility failed to provide appropriate treatment and service of care for 1 resident (Resident #10) reviewed for intermittent catheters. 1. The facility failed to ensure LVN C inserted Resident #10's intermittent catheter (tube inserted into bladder to drain urine) using the proper sterile technique on 09/01/26. 2. The facility failed to ensure LVN C provided hand hygiene between glove changes while inserting Resident #10's intermittent catheter on 09/01/2026.These failures could affect residents with an intermittent urinary catheter and place them at risk of urethral tears, discomfort, infection, and lack of dignity.Findings included: 1. Record review of Resident #10's face sheet dated 09/01/2026 indicated he was a [AGE] year-old male who re-admitted to the facility on [DATE] with the diagnoses which included dementia (a decline in metal ability sever enough to interfere with everyday life), depression (common serious mood disorder that causes a persistent feeling of sadness, emptiness, and loss of interest in daily activities), diabetes mellitus (disease in which the body cannot produce or properly use insulin resulting in high blood sugars), high blood pressure and obstructive and reflux uropathy (blockage that stops urine from flowing normally through the urinary tract). Record review of Resident #10's quarterly MDS assessment dated [DATE] indicated he understood others and he made himself understood. The MDS also indicated Resident #10 had a BIMS score of 12 which meant he had moderate cognitive impairment. The MDS also indicated Resident #10 required total assistance from staff for dressing, toileting, and transfers, maximal assistance from staff for bathing, moderate assistance for bed mobility, and set up assistance for eating. The MDS also indicated he required intermittent catheterization. Record review of Resident #10s comprehensive care plan dated 02/23/2026 indicated he had an ADL self-care deficit with interventions for staff to assist with personal hygiene as required and he required 1 staff assistance with toileting and to straight catheterize three times a day as needed. Record review of Resident #10's order summary report dated as of 09/03/2026 indicated he had orders that included:1)straight catheter every 6 hours as needed for retention with a start date of 08/13/2026 and no end date. 2)straight catheter four times a day for retention with a start date of 08/13/2026 and no end date.During an observation and interview on 09/01/2026 at 11:01 AM LVN C inserted an intermittent catheter to relieve Resident #10's urine. LVN C donned gown and gloves and setup her table with the supplies for the catheter insertion. LVN K said she forgot her hand sanitizer she was supposed to use between glove changes but continued the procedure and removed her dirty gloves. LVN K then donned her sterile gloves. LVN K touched the package of the intermittent catheter to open it for insertion with her sterile hands. LVN K also touched the urinal for collection prior to inserting the catheter. LVN K then inserted the intermittent catheter with contaminated hands. LVN K allowed urine to flow and removed sterile gloves and donned clean gloves without providing hand hygiene. During an interview on 09/01/2026 at 11:20 AM LVN K said she knew she did not complete the intermittent catheter insertion correctly. LVN K said she should have opened all of her supplies prior to donning her sterile gloves. LVN K said she should have also grabbed her hand sanitizer to use between glove changes prior to continuing the procedure. LVN K said her not using the hand sanitizer between glove changes placed Resident #10 at risk for infection and completing the insertion of the catheter with contaminated gloves placed Resident #10 at risk for contamination and urinary tract infections. During an interview on 09/03/2026 at 11:05 AM LVN K said she would guess she had a skills check off for catheter insertion upon hire and annually, but she could not remember. LVN K said all she could remember was videos the facility provided upon hire. LVN K said her annual was approaching in September 2026 but unsure of the exact date. During an interview on 09/03/2026 at 3:18 PM ADON E said she had completed one skills proficiency check off for staff in the past but LVN K's check off was not one of her duties, so she was unsure if LVN K had been checked off or not. ADON E said her expectation was for all of the nurses to complete the procedures of catheter insertion and hand hygiene the proper way. ADON E said the failure placed Resident #10 at risk for urinary tract infections or other infections. During an interview on 09/03/2026 at 4:03 PM the DON said she expected the LVN K to maintain sterile field while inserting a catheter and the failure could cause infection. The DON said she was sure LVN K had been checked off for catheter insertion but would have to find the proficiency form for her. The DON said she expected all staff to use hand hygiene between glove changes. The DON said she was responsible for ensuring the staff provided proper care and techniques. The DON said the failure placed Resident #10 at risk for infection. During an interview on 09/03/2026 at 4:19 PM the Administrator said she expected LVN K to follow the proper procedure for catheters and the failure placed Resident #10 at risk for infection. Record review of the undated facility policy Catheter insertion, Male/Female indicated: Female and male catheterization is the insertion of a catheter into the urinary bladder via the urethra to drain the bladder of urine. Catheterization can be performed using s straight catheter to drain urine from the bladder and then removing or, or by using an indwelling catheter that provides continuous drainage. Sterile technique is utilized as the bladder is a sterile cavity and infection associated with catheterization is common.

Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 resident (Resident #11) reviewed for quality of care.The facility failed to ensure LVN K properly flushed Resident #11's gastrostomy tube (tube placed in the belly walldirectly into the stomach used to provide liquid, medications, and nutrition) with 50cc's of water before and after her medication was administered on 09/03/26.This failure could affect residents receiving enteral nutrition and hydration and place them at risk of dehydration and health complications.Findings included:1. Record review of Resident #11's face sheet dated 09/03/26 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses which included cerebral palsy (a group of permanent disorders that appear in early childhood and affect body coordination, balance, and posture), epilepsy (a chronic brain disorder characterized by recurring, unprovoked seizures caused by sudden bursts of abnormal electrical activity in the nerve cells), gastrostomy status (indicating a person has a current functioning gastrostomy tube in place), and aphasia (language disorder caused by damage to parts of the brain that control how you speak, write, read, and understand words). Record review of Resident #11's annual MDS assessment dated [DATE] indicated she rarely understood others and rarely made herself understood. The MDS also indicated she could not complete a BIMS assessment, and her daily cognitive decision making was severely impaired. The MDS also indicated she was dependent on staff for all ADLs, and she received 51% or more calories and 501 cubic centimeters per day through her gastrostomy tube.Record review of Resident #11's comprehensive care plan dated 5/19/21 indicated she had a potential fluid deficit and was dependent on staff for all intake with interventions administer medications as ordered. Record review of Resident #11's order summary report as of 09/02/26 indicated:1) Enteral Feed Order every shift flush tube with 50 ml water before and after medication administration and feedings with a start date of 03/05/2025 and no end date. 2) Enteral Feed Order every shift Flush with at least 5mls of water between each medication with a start date of 08/21/2023 and no end date. During an observation on 09/03/26 at 09:05 AM LVN K provided Resident #11 her morning medications via her gastrostomy tube using aseptic technique with gloves and gown on with 5cc's of water between each medication but failed to flush Resident #11's gastrostomy tube with 50 cc's of water before the medications and 50 cc's of water after the medications were completed. During an observation and interview on 09/03/26 at 11:55 AM LVN K said she remembered flushing the gastrostomy tube with about 5cc of water between each of Resident #11's medications. LVN K said she did not recall the order to flush 50cc of water before and after medication but then LVN K looked in the electronic record system and located the order for 50cc flush before and after the medications. LVN K said she had just flushed 200 cc for a flush order, but she did not see the 50 cc before and after medications. LVN K said she was going to miss something. LVN K said she just did not see the order. LVN K said the failure could potentially place a risk for dehydration, but she said she gave Resident #11 extra water on days she was up in her chair. During an interview on 09/03/26 3:20 PM ADON E said her expectation was for all of the nurses to flush Resident #11's gastrostomy tube before and after medication administration using the correct amount of water to ensure proper water intake and ensure they were following the doctor's orders. ADON E said the failure placed a risk for the gastrostomy tube not being patent and the medication not being received correctly. ADON E said the failure could have also placed Resident #11 at risk for dehydration or electrolyte imbalance. During an interview on 09/03/26 at 4:06 PM the DON said she expected the nurses to follow the doctor's orders for Resident #11's medication and her flushes. The DON said the nurses were responsible for ensuring they followed doctor's orders. The DON said the failure placed a risk for dehydration and preventing Resident #11's gastrostomy tube maintaining patency. During an interview on 09/03/26 at 4:19 PM the Administrator said her expectation was for the nurses to provide the flushes to Resident #11's gastrostomy tube properly. The Administrator said the DON was responsible for ensuring the nurses were properly giving the gastrostomy tube medications. The Administrator said the failure placed a risk for dehydration and clogging of the tube. Record review of the facility's undated policy PCU035-Enteral Tube Medication Administration indicated: Policy Safely and accurately administer oral medications through an enteral tube.Procedure.8. Flush the tube with 30ml of water. 9. Administer liquid medication first, then those that need to be diluted.11. Flush the tube with 30ml of water and clamp. *Prevents the medication from clogging the lumen tube.

Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 6 residents (Resident #64 and Resident #81) reviewed for respiratory care.1.The facility failed to ensure Resident #64's oxygen concentrator filter did not contain grey like substance on 08-31/26 through 09/02/26. 2. The facility failed to ensure Resident #81's oxygen concentrator filter did not contain grey like substance on 08-31/26 through 09/02/26 These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.Findings included: 1. Record review of Resident #64's face sheet, dated 09/03/26 indicated she was an [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses which included Chronic obstructive pulmonary disease also known as COPD (a lung disease that makes it hard to breathe), dementia (memory loss), and diabetes(a chronic health condition that happens when your blood sugar, also called blood glucose, gets too high).Record review of Resident #64's quarterly MDS assessment, dated 06/10/26, indicated Resident #64 understood and was understood by others. The MDS assessment indicated she had a BIMS score of 15 indicating she was cognitively impaired. Resident #64 required assistance with bathing, toileting, dressing, bed mobility, personal hygiene, and eating. The MDS indicated she required oxygen.Record review of Resident #64's comprehensive care plan, dated 08/26/26, indicates Resident #64 required oxygen therapy related to COPD. The intervention of the care plan was for staff to administer oxygen as ordered. Record review of Resident #64's physician's order dated 09/03/26 indicated: May have oxygen at 2 liters per minute continuously for shortness of breath. May titrate to 4 liters.During an observation on 09/02/26 at 9:10 a.m., revealed Resident #64 was lying in her bed with oxygen at 2 liters per nasal cannula. Resident #64 had some grey-like substance on her concentrator filter.2. Record review of Resident #81's face sheet, dated 09/03/26 indicated she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included Chronic obstructive pulmonary disease also known as COPD (a lung disease that makes it hard to breathe),anxiety (normal emotion of fear, tension, or worry about future events), and Schizophrenia (a serious mental illness that changes how a person thinks, feels, and behaves, often making it hard to tell what is real and what is not).Record review of Resident #81's quarterly MDS assessment, dated 07/08/26, indicated Resident #81 understood and was understood by others. The MDS assessment indicated she had a BIMS score of 14 indicating she was cognitively impaired. Resident #81 required assistance with bathing, toileting, dressing, bed mobility, personal hygiene, and eating. The MDS indicated she required oxygen.Record review of Resident #81's comprehensive care plan, dated 03/12/25, indicates Resident #81 required oxygen therapy. The intervention of the care plan was for staff to administer oxygen as ordered. Record review of Resident #81's physician's order dated 04/12/26 indicated: May have oxygen at 2-4 liters per minute while in bed and at night for COPD. During an observation on 09/02/26 at 9:32 a.m., revealed Resident #81 was lying in her bed with oxygen at 2 liters per nasal cannula. Resident #81 had some grey-like substance on her concentrator filter.During an observation and interview on 09/02/26 at 2:45 p.m., revealed Resident #81 was sitting up in her chair with oxygen set at 2 liters and Resident #64 was lying in her bed with oxygen tubing placed in her nose at 2 liters. LVN K came into the room and verified Resident #64 and Resident #81's oxygen concentrator filter was dirty. She said tubing for the oxygen was supposed to be changed on the Sunday night shift, but she was not sure when the concentrators filters should have been changed or cleaned. She said the filters should be cleaned to help the residents breathe in clean air and prevent infection control issues.During an interview on 09/03/26 at 4:07 p.m., the DON said the nurses were responsible for ensuring oxygen concentrators filters were cleaned weekly on Tuesday. She said she did random rounding to check on oxygen filters. She said she was not aware of Resident 64 and Resident #81's oxygen filters were dirty. She said it was important to keep oxygen concentrators filters clean for cleaner air and prevent respiratory issues.During an interview on 09/03/26 at 4:41 p.m., the Administrator said nurses were responsible for ensuring the oxygen concentrator filters were clean. She said nurse management were the overseers. She said failure to keep clean oxygen concentrators filters could affect the residents' health and cause breathing issues.Record review of the facility's undated policy titled Oxygen Administration, indicated, Goals:1. The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen. 2. The residents will maintain an effective breathing pattern with administration of oxygen. 3. The residents will be free from infection. Procedure:16. Change or clean oxygen concentrator filter to the manufactures' recommendations.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services to determine that drug records are in order and that an account of all controlled drugs was maintained and periodically reconciled for 3 of 8 medication carts (East Hall medication cart, East Hall nurse's cart and Unit medication cart) reviewed for pharmacy services.1. The facility did not ensure LVN K, RN S, and LVN T counted controlled drugs every shift change on 09/02/2026. These failures could result in an inaccurate controlled medication count, drug diversion, and decreased therapeutic effects from medications. Findings included: 1. During a record review, interview, and random count observation of the East Hall medication cart and the Eats Hall nurse's cart with LVN K on 09/02/2026 at 1:50 PM indicated missing signatures for On duty and Off duty for 09/02/2026 of the narcotic count sheet and signatures in place for Off duty prior to the shift complete. LVN K said she always counted the carts, but she was aware the cart should not be signed off until it was recounted. LVN K said she relieved LVN T and LVN T did not sign the narcotic sheet. LVN K said she could not say if other nurses counted but the failure could place a risk of miscounts. During a record review, interview, and random count observation of Unit medication cart with RN S on 09/02/2026 at 2:10 PM indicated missing signatures for On duty and Off duty for 09/02/2026 of the narcotic count sheet and signatures in place for Off duty prior to the shift complete. RN S said she always signed the sheets that way, but the failure could cause risk of assumption that the cart already been counted and the count of narcotic medications being incorrect causing drug diversion. During a record review of the facility schedule indicated LVN T worked the night shift of 09/01/2026 from 6:00 PM until 09/02/2026 at 6:00 AM.An attempted telephone interview on 09/03/2026 at 3:11 PM with LVN T, the night nurse who was responsible for counting and signing the narcotic sheets for East Hall medication cart, East Hall nurse's cart and Unit medication cart on 09/02/2026 was unavailable and a voicemail was left.During an interview on 09/03/2026 at 4:01 PM, the DON stated she expected the medication aides and nurses to sign the narcotic count sheet at the beginning after counting the narcotic medications and end of each shift after counting the narcotic medications. The DON stated that she was overall responsible for ensuring the narcotic count sheets were completed and occasionally checked the sheets. The DON said she was not aware the narcotic sheets were not signed. The DON stated it was important to count and sign the narcotic sheets before and after their shifts to prevent a medication error and drug diversion and oncoming nurses may not know if there was a discrepancy with the narcotic medications. During an interview on 09/03/2026 at 4:18 PM, the Administrator stated she expected the nurses and medication aides to sign the narcotic sheet at the beginning and end of their shift after counting the narcotic medications. The Administrator stated she was not aware the narcotic sheets were not signed off. The Administrator stated it was important to count and sign the narcotic sheets before and after their shifts to prevent a drug diversion. Record review of the facility's policy titled PCU019 - Controlled Medications - Administration reviewed 04/06/2026, indicated, 8. At each shift change, a physical inventory of all controlled medications is conducted by two licensed nurses and/or one nurse and a CMA, QMAP, Med Tech or equivalent as allowed by your State regulatory agency and is documented on an audit record. Alternatively, the shift change audit may be recorded on the accountability record if there is a designated column for the audit. 9. Current controlled medication accountability records and audits records are kept on the medication cart, either in the MAR or in a separate folder. When completed, audit and accountability records are submitted to the Director of Nursing and kept on file for three years at the facility. 10. Any discrepancy in controlled substance medication counts is reported to the Director of Nursing immediately.

Based on observation, interview, and record review, the facility failed to ensure it was free from medication error rate of less than 5%. 1 of 3 staff (CMA U) made 2 errors out of 37 opportunities. This resulted in a 5.41% medication error rate for 1 resident (Resident #59) of 5 reviewed for medication errors.The facility failed to ensure CMA U administered a Bupropion HCL ER XL 300mg tab to Resident #59 on 09/02/2026 during the morning medication pass according to physician's order.The facility failed to ensure CMA U did not administer Resident #59 his Risperdal(risperidone) 3mg tab during the morning medication pass on 09/02/2026 when it was not due until bedtime.These failures placed the residents at risk of harm or not receiving desired outcomes from medications not administered according to physician's orders and manufacturer's specifications. Findings included:Record review of Resident #59's face sheet dated 09/02/2026 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses which included cerebral infarction (a stroke in which the blocked blood vessel in the brain cuts off blood and oxygen causing brain tissue to die), major depressive disorder (a common mood disorder that causes a lasting sadness, emptiness, and loss of interest in daily activities), paranoid schizophrenia (prominent paranoid and delusions with disorganized speech), and seizures. Record review of Resident #59's annual MDS assessment dated [DATE] indicated he understood others and made himself understood. The MDS also indicated he had a BIMS score of 10 which indicated he had moderate cognitive impairment. Record review of Resident #59's order summary report dated as of 09/03/2026 indicated he had an order for:1. Bupropion HCL ER XL tablet extended release 24-hour 300 mg (antidepressant). Give 1 tablet by mouth one time a day for depression with a start date of 09/12/2023 with no end date.2. Risperdal tablet 3mg (antipsychotic). Give 1 tablet by mouth at bedtime related to paranoid schizophrenia with a start date of 09/12/2023 and no end date. During an observation and interview on 09/02/2026 at 8:33 AM CMA U prepared Resident #59's medication for administration. She removed the blister pack for Risperdal 3mg tab and placed 1 tablet in the cup. CMA U prepared the rest of the scheduled oral medications and placed them in the cup. The Bupropion HCL ER XL tablet extended release 24-hour 300mg tablet (antidepressant) was not in the cup. CMA U was questioned as she was entering Resident #59's room with medication to administer to him, about the Risperdal (risperidone) and she said the Risperdal was given at night. CMA U then looked at the medication and removed the Risperdal tab and administered the other medications. CMA U said she was going to give Resident #59 the Risperdal on accident and that she was just nervous. CMA U said the failure placed Resident #59 at risk for a possible overdose. During a record review of the scheduled medications in the cup during the observation on 09/02/2026 at 8:33 AM and medication reconciliation on 09/03/2026 at 9:30 AM the Bupropion HCL ER XL tablet extended release 24-hour 300mg tablet (antidepressant) was not given. The scheduled medications in the cup during the observation on 09/02/2026 at 8:33 AM did not include bupropion HCL ER XL tablet.During an attempted telephone interview on 09/03/2026 at 10:44 AM CMA U was unavailable. During an interview on 09/03/2026 at 3:57 PM the DON said her expectation was for the medication aide to read the orders and follow the 5 rights of medication. The DON said overall she was responsible for ensuring the medications were passed correctly and all the medication aides and nurses had been checked off for proficiency. The DON said she expected the medication error rate to be below 5%. The DON said the failure placed a risk for residents not getting the medications correctly and causing harm, but the side effects depended on the medication. The DON said bupropion could have caused behaviors and the Risperdal could have caused harm. The DON said she considered the Risperdal (risperidone) a significant medication error because it was an antipsychotic medication. The DON said the failure placed Resident #59 at risk for harm from being given early and the night dose would have been given after causing more harm. During an interview on 09/03/2026 at 4:15 PM the Administrator said her expectation was for the medication aides and the nurses to follow the medication administration policy, keep the med error rate below 5% and the to follow the 5 rights of medications. The Administrator said the failure placed a risk for adverse reactions for Resident #59 and the severity depended on the type of medications. Record review of the facility's policy titled PCU018 - Medication Administration and General Guidelines dated 2025, indicated, Policy: Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so. Procedure:1. Medications are prepared, administered, and recorded only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications. 2. Medications are administered in accordance with written orders of the attending physician.9. At the end of each medication pass, the person administering the medications reviews the MAR to ascertain that all necessary doses were administered and documented. Checklist for completing proper steps in the administration of medications:. Ensures identity of the right resident. Adheres to the 6 Rights of Medication Administration:1) Right Dose, 2) Right Route, 3) Right Resident, 4) Right Medication, 5) Right Time, 6) Right Documentation, Observes the resident take the medications, and Documents the administration of each medication on the MAR & Controlled Medications on the Control Sheet.

Based on observation, interview, and record review the facility failed to accommodate residents' food preferences for 1 of 1 resident (Resident #58) reviewed for meal choices. The facility failed to honor Resident #58's preferences for no beans/legumes for the lunch menu on 08/31/26. This failure could place residents at risk for decreased resident choices, diminished interest in meals, and weight loss. Findings included: Record review of Resident #58's face sheet, dated, 09/03/26, reflected Resident #58 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included cognitive communication deficit (disorders involve a problem with communication due to a disruption in cognitive processes), unspecified intellectual disabilities (a condition that limits intelligence and disrupts abilities necessary for living independently), essential hypertension (condition in which the force of blood pushing against the artery walls is consistently too high), and mixed hyperlipidemia (condition where both your LDL cholesterol and triglycerides are elevated at the same time). Record review of Resident #58's quarterly MDS, dated [DATE], reflected Resident #58 usually makes himself understood, and usually understands others. Resident #58's BIMS score was 9, which reflected his cognition was moderately impaired. Resident #58 required setup or clean-up assistance with eating. Record review of Resident #58's care plan, revised on 08/31/26, reflected Resident #58 had an ADL self-care performance deficit. The care plan interventions included supervision as needed. Record review of Resident #58's meal ticket on 08/31/26 reflected Resident #58 disliked beans/legumes. During a dining observation on 08/31/26 at 12:30 p.m., Resident #58 received a portion of field peas with snaps. Resident #58 said he could not eat beans; he did not like them. During an interview on 09/03/26 at 2:41 p.m., the Dietary Manager said the cook was responsible for ensuring Resident #58 did not receive beans. She said when the staff made the meal ticket, it should have been removed so Resident #58 did not receive the peas and green beans. She said it was important to not give residents their dislikes because it was their preference. During a telephone interview on 09/03/26 at 3:12 p.m., an attempt was made to contact [NAME] P about Resident #58 likes or dislikes. [NAME] P did not answer. During an interview on 09/03/26 at 3:41 p.m., the DON said she was the nurse checking the resident meal trays. The DON said she was aware that Resident #58 did not like green beans. The DON said she did not see the green beans on the tray, so they were not removed. The DON said it was important to make sure the residents were receiving what they wanted. The DON said it could make Resident #58 feel like they were not honoring his wishes. A policy on preference was requested but was not received prior to exit. During an interview on 09/03/26 at 4:32 p.m., the Administrator said the cook plated the tray and then the nurse checked the tray before it went to the resident. The Administrator said it was important to honor the residents' likes and dislikes.

Based on observation, interview, and record review the facility failed to ensure that 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 13 (Resident #1) residents reviewed for pharmaceutical services. RN A failed to reconcile Resident #1's medication orders as instructed from the discharging hospital on 7/30/26 including the reconciliation of the anti-seizure medication Keppra (also known by the generic name levetiracetam). On 8/3/26 Resident #1 had a seizure and was sent to hospital. The noncompliance was identified as Past Noncompliance. The noncompliance began on 7/30/26 and ended on 8/3/26. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving needed medications to manage signs and symptoms of health conditions and could lead to significant health complications including seizures. Findings included: Record review of Resident #1's face sheet dated 8/20/26 indicated Resident #1 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses including portal vein thrombosis (a blood clot that blocks or narrows the portal vein, which is the major blood vessel carrying blood from your digestive organs to your liver), down syndrome (genetic condition caused by an extra copy of chromosome 21, which changes how a person's body and brain develop), obstructive reflux uropathy (a condition where blocked or hindered urine flow causes urine to back up into the kidneys, often combined with backward flow from the bladder), conversion disorder with seizures or convulsions (a condition where a person experiences real physical seizure-like movements or unresponsiveness that are caused by a functional disruption in how the brain works rather than abnormal electrical brain activity), and convulsions (medical condition where your body's muscles contract and relax rapidly and repeatedly, causing uncontrolled shaking). Record review of the admission MDS dated [DATE] indicated Resident #1 admitted to the facility from a hospital on 7/27/26. The MDS indicated Resident #1 was absent of speech, rarely/never made himself understood and rarely/never understood others. Resident #1 was dependent on staff for all ADLS (oral hygiene; toileting, showering/bathing, dressing of the upper/lower body, putting on footwear and personal hygiene) with the exception of eating for which he required supervision or touching assistance. Resident #1 required partial to moderate assistance with rolling from left to right, sit to lying position, and lying to sitting position at the side of the bed. Resident #1 required substantial/ maximal assistance with sit-to-stand positioning, bed-to-chair transfers, toilet transfers, tub/shower transfers, and car transfers. Resident #1 was dependent on staff for locomotion in his manual wheelchair. The MDS indicated Resident #1 had an indwelling urinary catheter and was always continent of bowel. The MDS indicated Resident #1 had a diagnosis of Seizure disorder or epilepsy. The MDS indicated Resident #1 had not been administered an anticonvulsant medication during the 7-day look back period. Record review of the care plan initiated on 7/28/26 indicated Resident #1 had a seizure disorder. The care plan interventions included post seizure treatment (in the event of seizure [Turn on side with head back; hyper-extended to prevent aspiration; keep airway open; after seizure take vital signs and perform neuro check; monitor for aphasia (absence of speech), headache, altered level of consciousness , paralysis, weakness, pupillary changes.]); document (in the event of seizure) the location of seizure activity, type of seizure activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state (the recovery period that happens immediately after a seizure); Provide seizure precautions; do not leave resident alone during a seizure. Protect resident from injury (If resident is out of bed, help to the floor to prevent injury; remove or loosen tight clothing); Do not restrain resident during a seizure; and protect from onlookers. The Care plan was revised on 8/3/26 with the following interventions; administer Keppra (also known by the generic name levetiracetam, is a medication used to treat and control seizures) as ordered. The Care plan was revised on 8/5/26 with the following intervention, draw Keppra level as ordered. Record review of the nursing progress note for Resident #1 dated 7/29/26 at 7:45 pm stated attempted to insert foley catheter into resident using 18 french catheter per sterile technique protocol with assistance of (charge nurse). Talked to resident and explained what and why the procedure needed to be done. Resident became very agitated, aggressive pulling this nurse's arms and hands and hitting at stomach. This nurse stopped the attempt to insert due to resident's behaviors. (Provider) notified. (Provider gave) new order to send to hospital for foley catheter insertion. This note was written by RN B. Record Review of the nursing progress note for Resident #1 dated 7/29/26 at 7:55 p.m. reported EMS services were contacted as ordered and Resident #1 was transported by EMS services to the hospital at 8:20 p.m. This note was written by RN B. Record review of the hospital AVS dated 7/29/26 (printed on 7/30/26 at 12:31 a.m.) instructed to ask primary provider about the medication levetiracetam (also known by the brand name Keppra) 500 mg by mouth twice daily. Record review of the nursing progress notes for July 2026 found there were no nursing progress notes for 7/30/26. Record review of the nursing progress note dated 7/31/26 stated Recd (received) order from medical doctor for urology referral, obtain Prostate specific antigen and Urine analysis, and start Flomax 0.4 milligrams QHS (every night at hour of sleep). This note was written by RN A. Record Review of the nursing progress note dated 8/3/26 at 7:57 a.m., stated (Resident #1) was transferred to a hospital on [DATE] 8:00 AM related to 3 minute seizure. This note was written by the DON. During an observation on 8/20/26 at 3:55p.m., Resident #1 laid in his bed. Resident #1 was non-verbal. Resident #1 smiled when asked how he was feeling. During an interview on 8/21/26 at 10:15 am RN A said he was the nurse that originally admitted Resident #1 to the facility on 7/27/26. RN A said a few days later Resident #1 went to the local emergency room for urinary retention (7/29/26). RN A said Resident #1 did not leave for the hospital on his shift but did return on his shift on 7/31/26. RN A said his shift was 6:00 a.m. to 6:00 p.m. RN A said at the start of his shift on 7/31/26 Resident #1 was still at the hospital. RN A said he received report from RN B that Resident #1 was sent out to the hospital on the night shift (6:00 p.m. to 6:00 a.m.) because he (Resident #1) had not voided and became combative with the attempted insertion of a foley catheter. RN A said RN B reported to him that she (RN B) had received a report from the hospital ER that Resident #1 had his catheter placed, was awaiting EMS transfer back to the facility and there were no changes. RN A said when Resident #1 arrived he had not received a report from hospital ER and thought nothing of it. RN A said he was provided the AVS from the hospital (which notes if there are any medication changes) from the EMS services upon Resident #1's return. RN A said he looked at the first page of the document (the AVS from the hospital visit) and stated usually if there are medication changes, those changes are noted on the front page of the document with the full list with instructions on any further changes back in the document. RN A said he did not see any noted changes on the front page and did not review the medication list further back in the document. RN A stated he understood the gravity of what has happened (when asked if it was important to review medications on AVS from hospitals after a resident's visit to the ER). RN A said he did not review the medication list on the AVS for reconciliation and did not ask the provider about the medication Keppra. RN A said he had changed his nursing practice as a result of Resident #1 having had a seizure on 8/3/26 with the AVS from the hospital on days prior indicating to ask the provider about Keppra 500 mg BID. RN A said in the future he would always review discharge instructions or AVS after a resident's visit to the ER. RN A said he no longer worked at the facility and was terminated as a result of failing to reconcile Resident #1's medication list after his ER visit. During an interview on 8/21/26 at 10:28 am RN B said Resident #1 was sent out to the ER on [DATE] because the Resident had not voided after the discontinuation of his foley catheter. RN B said when she attempted to place a new foley catheter Resident #1 became combative and hit her. RN B said Resident #1's bladder was distended and Resident #1 needed to have the catheter placed. RN B said she knew at the hospital Resident #1 would be provided medication to sedate him in order for the procedure to be performed. RN B said she notified the provider of the situation and was given an order to send Resident #1 to the local ER. RN B said in the early morning hours, (she could not recall the exact time) she received a call from the local ER. RN B said the ER nurse told her Resident #1 had his foley catheter placed and for the facility not to remove the current catheter. RN B said she was told by the ER nurse told Resident #1 was ready to come back to the facility, but it could be a while before the EMS transported him back to the facility. RN B said she was not told anything about his medications and that the ER nurse reported she would call back with a full report when EMS was ready to transport the Resident back to the facility. RN B said she did not receive an additional call from the ER and that Resident #1 had not returned to the facility by the end of her shift at 6:00 a.m. on 7/30/26. RN B said she gave report to RN A providing him with the information she had received from the ER nurse. RN B said it was extremely important to ensure a resident's medication was reconciled after an emergency room visit. During an interview on 8/21/26 at 12:17 p.m., Resident #1's family member said Resident #1 had been on Keppra since December 18, 2023. Resident #1 said she had assumed Resident #1 was continued on his Keppra after his admission to the facility on 7/27/26. Resident #1's family member explained Resident #1 had been hospitalized from [DATE] -7/26/26 at two different hospitals. The family member said he was at hospital 1 initially, then transferred to hospital 2 and then returned to hospital 1 before his admission to the facility. Resident #1 said when the facility notified her of Resident #1's seizure on 8/3/26 she said she was surprised because Resident #1 had not had a seizure since he had been started on Keppra. Resident #1's family member said something to that effect when the facility notified her of Resident #1's seizure. Resident #1's family member said she knew Resident #1 received Keppra while he was at hospital #2 because she had a conversation with staff about it. During an interview on 8/21/26 at 5:00 p.m. the DON said RN A should have reconciled Resident #1's medications after his ER visit. The DON said had he (RN A) asked the provider about the medication Keppra as instructed by the ER AVS, Resident #1 would have been started back on Keppra 500 mg and may not have had a seizure. The DON said RN A was terminated on 8/5/26 as a result of the facility investigation into the incident. The DON said the facility self-reported the incident to the State, notified the physician and obtained and order for the Keppra 500 mg BID. The DON said in-services were initiated and completed with all nursing staff over the importance of medication reconciliation. The DON said the audits were performed to ensure no other resident had failed to have medications reconciled on admission, re-admission or ER visit. The DON said she and the ADONs provide oversight to ensure medications are reconciled but the oversight was dependent on nurses documenting medication reconciliation in the facility's computer records system or on noting medication changes on the 24-hour nursing report. The DON said RN A had not completed documentation in either place. During an interview on 8/21/26 at 5:20 p.m., the Administrator said she expected nursing staff to ensure medications were reconciled and after an ER visit. The Administrator said it was important for medications to be reconciled after ER visits because there may be new medications or medications that need to be discontinued. The Administrator said the facility reported the incident and investigated it. The Administrator said RN A was initially suspended and then terminated as result of the facility investigation. The facility policy and procedure dated 11/14/26, titled Medication Reconciliation, stated, Medication reconciliation is the process of creating the most current, complete and accurate list of possible patient medications comparing that list against medication orders at each stage of the patient's stay in the facility and resolving discrepancies.it is common for changes to made to a patient's medications when he or she is hospitalized . Upon transition back to the SNF ( skilled nursing facility), medication reconciliation should be performed again. The facility had corrected the noncompliance prior to entrance by the following: *Keppra 500 mg BID ordered for Resident #1 and administered since 8/3/26 (date of his return from hospital). *Suspension and subsequent Termination of RN A on 8/5/26 *Off cycle Quality Assurance meeting held on 8/3/26 *Notification of the Medical Director *Audit of recent resident hospitalization admissions for medication reconciliation on 8/3/26. *In-service completed with nursing staff regarding medication reconciliation on 8/3/26. *Ongoing monitoring by DON initiated on 8/3/26 to ensure all new admissions and readmission from previous day(s) performed by DON Confirmed the facility had corrected the non-compliance prior to survey starting by: *Record review of the physician order summary dated 8/21/26 found Resident #1 had an active order for Keppra 500 mg BID with a start date of 8/3/26. An active order for a Keppra level every month was also noted with a start date of 8/3/26. *Record review of Record of Employee File for RN A found he was terminated on 8/5/26. * Record review of in-services dated 8/3/26 indicated nursing staff were in-serviced regarding medication reconciliation. The sign-in sheet found every nurse at the facility had received the in-service. Record review of a Quality Assurance (QA) Meeting Sign-in Sheet dated 8/3/26 indicated the facility had an ad hoc Quality Assurance meeting regarding the incident on 8/3/26. The QA Meeting Sign-in Sheet indicated the physician and nurse practitioner had been notified of the incident on 8/3/26. Record review of the monitoring sheets initiated 8/3/26 found the DON was performing ongoing monitoring to ensure all new admissions and readmission from previous day(s) had medication reconciliation completed. Staff interviewed (LVN C, LVN, D , LVN E, LVN F, LVN G, LVN H) on 8/21/26 between 3:54 p.m. and 4:53 p.m. reported medication reconciliation must be performed for every resident upon admission, readmission and post ER visits to ensure all medication changes, recommendations or questions were addressed by the Resident's provider. Record review of the sampled residents hospital discharge records (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12 and Resident #13) found all medications were reconciled after admission, readmission or ER visit as applicable. The noncompliance was identified as past noncompliance. The noncompliance began on 7/30/26 and ended on 8/3/26. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, and record review, the facility failed to ensure that appropriate information was communicated to the receiving health care institution to include Advance Directive information for 1 of 1 (Resident #3) resident reviewed for advance directives. Resident #3's Advance Directive information was inaccurately documented on the transfer form, and a copy of the advance directive was not provided to the EMS staff or hospital staff upon transfer to the emergency room. This deficient practice could place residents at risk for not having their wishes followed according to advance care planning. The findings were:Record review of Resident #3's face sheet, dated [DATE] revealed an [AGE] year-old male admitted [DATE] and discharged [DATE] with diagnoses that included: Alzheimer's Disease (a progressive irreversible brain disease and the most common cause of dementia), Chronic Obstructive Pulmonary Disease (a progressive lung disease that causes long term breathing problems), Benign Prostatic Hyperplasia (an enlargement of the prostate gland related to a growth that squeezes the urethra), Hypertension (high blood pressure) and Hyperlipidemia (high levels of fats).Record review of Resident #3's Annual MDS dated [DATE] revealed resident was understood by others and understood what was said to him and had a BIMS Score of 8 indicating moderate cognitive impairment. Further review of the Annual MDS revealed resident required the use of a walker for mobility, was independent in bed mobility, transfers and gait and required set up assistance with eating, toileting, upper and lower body dressing.Record review of Resident #3's EMR revealed a valid Directive to Physician's and Family or Surrogates dated [DATE] that elected all treatments other than those needed to keep him comfortable be withheld, no ventilator and no feeding tube. Record review of Resident 3's physician's orders revealed an order for Full Code dated [DATE]. Record review of Resident #3's care plan revealed a focus area dated [DATE] indicating Resident is a Full Code; and Interventions to include: Initiate BLS (Basic Life Support) CPR (Cardiopulmonary Resuscitation) if the resident is without a heartbeat and Notify EMR. Record review of Resident #3's transfer form dated [DATE] revealed 6. Advance Directives, 1. Does the resident have any of the following advanced directives indicated yes for DNR in direct contradiction to his completed and valid Directive to Physicians and Family or Surrogates. During an interview on [DATE] at 1:30 p.m., LVN D confirmed she made an error of the transfer form because Resident #3 was Full Code, not DNR. LVN D stated she should have provided the EMS staff a copy of his Advance Directives to provide to the emergency room staff. LVN D stated that failure to provide correct information at time of transfer could result in the resident receiving life sustaining support that he did not desire or not obtaining treatment he did desire. During an interview on [DATE] at 5:32 p.m., the physician stated that he expected the nursing staff to relay the appropriate advance directive information on all transfers to include a hard copy of documents in order to ensure continuity of care and to ensure that the resident's wishes are honored. The physician stated Resident #3's directive did not specifically indicate DNI (Do Not Intubate) and although the documents were not sent, his wishes were not violated as he was no placed on a ventilator. During an observation on [DATE] at 8:02 a.m., Resident #3 was in bed, eyes closed, unlabored breathing with bandage to his tracheal site indicating intubation tubing had been removed. Resident #3 did not respond to verbal or tactile stimuli to complete interview. During an interview on [DATE] at 8:15 a.m., Resident #3's responsible party stated that she had been contacted by the nursing facility at time of transfer and verbalized to the discharge nurse to remember to send Resident #3's advance directive. Resident #3's responsible party stated that after discussion with the hospital physician and conversation with other family members had elected to remove the intubation tube to honor resident's wishes not to remain on life support as per his directive. During an interview on [DATE] at 3:22 p.m., the DON stated that she expected the nursing staff to provide a copy of Advance Directives to EMS staff for all hospital transfers to ensure the resident's wishes are honored. The DON stated it is important that external entities are provided with accurate information to ensure the resident's and/or responsible parties wishes are honored. The DON stated that she had completed an Inservice training for the nursing staff on accurate completion of all transfer / discharge documents. During an interview on [DATE] at 3:50 p.m., the Administrator stated the adverse effect of not providing accurate documentation on hospital transfers and all discharges could be negative outcomes for the resident if the care did not match the treatment orders. The Administrator stated she expected the nursing staff to provide accurate information on transfers and discharges and that the DON is responsible for ensuring the nursing staff are trained on the discharge process and that she as the Administrator is ultimately responsible for monitoring the accuracy of documentation for discharges. Review of facility policy titled, Self Determination End of Life Measures, undated, revealed Policy: 3. The facility will respect the wishes of the resident as outlined in the advance directive.The primary nurse will note the resuscitation status of the resident on all applicable clinical records.and also, document whether or not the resident has executed the advance directive.

Based on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services was provided, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 3 resident (Resident #1) reviewed for pressure injuries. 1. The facility failed to ensure CNA B and CNA C provided incontinent care, and turning and repositioning for Resident #1 on 10/09/25 and 10/10/25 causing Resident #1's wounds to worsen. 2. The facility failed to identify a wound prior to a PRN hospice visit on 10/11/2025, where the hospice nurse identified a stage ll sacral wound closed and dark in color, and by 10/13/2025 there was, per the evidence, a right heel abrasion, a left heel blister, and a sacral wound with eschar. 3. The facility failed to initiate wound care orders on 10/11/2025 and 10/12/2025. An Immediate Jeopardy (IJ) situation was identified on 10/29/2025. The IJ template was provided to the facility on [DATE] at 1:37 PM. While the IJ was removed on 10/30/2025 at 1:57 PM, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk for worsening of existing pressure injuries, pain, and infection. Findings included: Record review of Resident #1's face sheet, dated 10/27/25, indicated an [AGE] year-old female who admitted to the facility on [DATE]. Resident #1 had diagnoses which included artherosclerotic heart disease (plaque buildup in arterial walls causing them to narrow), anxiety (excessive worry, fear, and nervousness), depression (persistent feelings of sadness and loss of interest in things), and high blood pressure. Record review of Resident #1's admission MDS assessment dated [DATE] indicated she could make herself understood and she was able to understand others. The MDS also indicated she had a BIMS score of 5 which meant she had severe cognitive loss. The MDS also indicated she required moderate assistance with toileting, bathing, transfers, and dressing, and supervision for eating and bed mobility. The MDS indicated she was at risk for pressure ulcers but did not have any unhealed pressure ulcers. Record review of Resident #1's care plan dated 08/18/25 indicated she had bladder incontinence and would remain free from skin breakdown with interventions to provide incontinent care at least every 2 hours. Record review of Resident #1's Braden scale for predicting pressure sore risk dated 08/26/25 indicated she was at a low risk for developing pressure sores. Record review of Resident #1's nurse progress notes dated 09/27/25-10/28/25 indicated there were no progress notes on 10/10/25, 10/11/25, nor 10/12/25. Record review of Resident #1's skin assessment dated [DATE] indicated she had no pressure, venous, arterial, or diabetic ulcers, but she did have redness to her buttocks with barrier cream applied. Record review of Resident #1's hospice note dated 10/11/25 indicated a hospice RN KK came for an as needed visit and observed a wound to Resident #1's sacral area dark in color. Record review of Resident #1's skin assessment dated [DATE] indicated she had an abrasion to her right heel that measured 3.0 cm X 3.0 cm with skin prep daily and offloading heels, a wound to her sacrum that measures 4.0 cm x 3.5 cm x 0.1 with 2.7 cm x 2.4 cm eschar and treatment of calcium alginate, medihoney and cover with hydrocolloid dressing every Monday and Thursday, and a blister to her left heel that measured 5.0 cm X 8.5 cm with skin prep daily and to offload heels. Record review of Resident #1's care plan dated 10/13/25 indicated she had an actual wound to her sacrum, an abrasion to her right heel, and a blister to her left heel with interventions in place to encourage resident to get into bed and off sacrum, resident would be see by the wound doctor weekly, monitor wounds and report changes to the doctor, and heels would be floated at all times. Record review of Resident #1's order summary report dated 10/28/25 with orders since the admission date of 08/05/25 indicated an order for:1. May apply barrier cream as needed every shift with a start date of 08/05/25 and no other skin or wound care orders were noted until 10/13/25. Record review of Resident #1's order summary report, dated 10/28/25, indicated orders since the admission date of 08/05/25 reflected an order to:1 Apply skin prep to the abrasion on the right heel daily one time a day for Wound Healing with a start date of 10/13/2025 but now discontinued on an unknown date. 2 Apply skin prep to the blister on the left heel daily one time a day for Wound Healing with a start date of 10/13/2025 but now discontinued on an unknown date. 3 Cleanse the stage 3 on the left heel with wound wash, pat dry, and apply collagen powder, and cover with gauze island dressing every Monday, Wednesday, Friday and PRN if soiled or dislodged one time a day every Monday, Wednesday, Friday for Wound Healing with a start date of 10/24/2025 and no end date. 4 Apply skin prep to the unstageable DTI (deep tissue injury) on the right heel 3 times a week one time a day every Mon, Wed, Fri for Wound Healing with a start date of 10/29/2025 but now discontinued on an unknown date. 5 Apply skin prep to the unstageable DTI (deep tissue injury) on the right heel daily one time a day every Monday, Wednesday, Friday for Wound Healing with a start date of 10/29/2025 and no end date. 6 Cleanse wound to sacrum with normal saline pat dry, apply medihoney, calcium alginate, and cover with hydrocolloid every Monday and Thursday, and PRN if soiled or dislodged one time a day every Monday and Thursday for wound healing with a start date of 10/16/2025 but now discontinued on an unknown date. 7 Cleanse unstageable wound to sacrum with normal saline pat dry, apply medihoney, calcium alginate, and cover with hydrocolloid every Monday and Thursday, and as needed if soiled or dislodged one time a day every Monday, Thursday for wound with a start date of 10/20/2025 but now discontinued on an unknown date. 8 Cleanse unstageable wound to sacrum with normal saline pat dry, apply medihoney, calcium alginate, and cover with hydrocolloid every Monday, Wednesday and Friday, and as needed if soiled or dislodged one time a day every Monday, Wednesday, Friday for wound healing with a start date of 10/24/2025 but now discontinued on an unknown date. 9 Cleanse unstageable wound to sacrum with normal saline pat dry, apply med honey, Flagyl, and cover with hydrocolloid every Monday, Wednesday and Friday, and PRN if soiled or dislodged one time a day every Monday, Wednesday, Friday for wound healing with a start date of 10/29/2025 and no end date. Record review of Resident #1's administration record for October 2025 indicated there was no administration of the order:1. May apply barrier cream as needed every shift with a start date of 08/05/25 and no other skin or wound care orders were noted until 10/13/25. Record review of the facility schedule dated 10/09/25 and 10/10/25 for the 6:00 PM-6:00 AM shift indicated LVN QQ, CNA HH, CNA D, CNA B, and CNA C were scheduled to work on the east wing which was Resident #1's location. Observation of Resident #1's video camera footage dated from 10/9/25 at approximately 7:00 PM until 10/10/25 at approximately 6:51 AM indicated she was not turned, repositioned, nor provided incontinent care. Observation of Resident #1's video camera footage dated from 10/10/25 at approximately 7:41 PM until 10/11/25 at approximately 6:25 AM indicated she was not turned, repositioned, nor provided incontinent care. During an observation on 10/27/25 at 3:33 PM Resident #1 was sitting up in bed with a low-pressure loss mattress being utilized. Resident #1 had a wedge under her left side and both feet floated on two pillows. The Treatment Nurse donned gloves and assisted by hospice sitter they rolled Resident #1 over, removed her brief to expose bandage (large Tegaderm bandage in place dated 10/27/25 with initials). The Treatment Nurse peeled back bandage to expose wound. It appeared to be an unstageable, full thickness wound to Resident #1's sacrum present. The wound measured (Length x Width x Depth) 6.0 cm x 6.5 cm x not measurable due to necrosis (death of tissue due to no blood supply). The Eschar (thick layer of dead skin that forms over a wound, often appearing black) measurement was 3 cm x 2.5 cm x not measurable (due to necrosis). There was a tunnel at 12 o'clock that was 0.7 cm. and a tunnel at 2 o'clock that was 0.5 cm. The Treatment Nurse placed the bandage back over wound and then re-enforced with another bandage. The Treatment Nurse failed to use other PPE during care. There was no sign for PPE use visible. During an interview on 10/27/25 at 3:46PM the Treatment Nurse said the Wound NP came every Thursday and he had been seeing Resident #1. The Treatment Nurse said the Wound NP measured weekly and Hospice nurse measured Resident #1's wounds on Mondays when she came to visit and received the reports on Thursdays. The Treatment Nurse said Resident #1 had a wound to her Sacrum and then to the right buttocks that appeared as 1 wound. She said Resident #1's wound had worsened and had places where it is tunneling on 10/27/25 but last Thursday (10/23/25) it was not. The Treatment Nurse said the CNAs, to her knowledge, were supposed to be turning her and repositioning her every 2 hours. The Treatment Nurse said she had not had any complaints specifically but at times night and day staff say each other do not turn and reposition residents and clean them as they were supposed to. The Treatment Nurse said they do not have a system in place to ensure that the CNAs were turning and repositioning the residents but when she works the floor as a charge nurse, she did monitor to ensure the CNAs were turning and repositioning the resident by rounding on the hallways. The Treatment Nurse said charge nurses were responsible for ensuring the CNAs were turning and repositioning all the residents to prevent skin breakdown.During an interview with the facility doctor on 10/28/25 at 10:12 AM he said he was familiar with Resident #1, but he was unable to elaborate on her wounds, the status, or the cause because he was not notified of the wounds or involved in the care of the wounds. During an interview on 10/28/25 at 10:35 AM Hospice RN LL said she saw Resident #1 on Mondays and Thursdays weekly. She said on 10/6/25 Resident #1 had some breakdown noted but it was only excoriation, and she notified the unknown facility nurse at the time to ensure to apply the barrier cream when providing incontinent care and to ensure the CNAS were turning and repositioning Resident #1. She said she said Resident #1 on 10/9/25 and the area to her bottom continued to require just barrier cream. Hospice Rn LL said there were no openings to her buttocks and no wounds to her heels. Hospice RN LL said she had talked to the Administrator and the DON about Resident #1 and the staff needing to turn and reposition her, and about her brief not being changed in a timely manner. Hospice RN LL said Resident #1's buttocks went from excoriation to an unstageable wound in 2 weeks, which she saw on 10/13/25. Hospice RN LL said the wound would have been preventable if the staff had been turning, repositioning and providing incontinent care as they were supposed to. During an interview on 10/28/25 at 2:56 PM, LVN A said she worked on 10/10/25 and 10/11/25 from 6:00 AM- 6:00 PM on the east wing with Resident #1. She said she placed a call to Resident #1's hospice company about a change in condition and Hospice RN KK came out to see Resident #1. LVN A said she talked to Hospice RN KK and got orders from her, but she could not remember what the orders were. LVN A said she also called the Treatment Nurse about orders. LVN A said the nurses always called hospice and the hospice nurse called the hospice doctor. She said they never called the facility NP since Resident #1 was on hospice. LVN A said she missed placing a progress note and inputting the orders for Resident #1's wound care on 10/11/25[. She said the failure placed the risk for no one else knowing the resident had wounds or treatments in place and could place the resident at risk for infection or wounds worsening. During an interview on 10/29/25 at 11:23 AM the Administrator said she expected the CNAs to be rounding the halls during the shift every 2 hours and to provide incontinent care as needed. She said she was not aware of the staff not providing any care for Resident #1 on 10/09/25 and 10/10/25. The Administrator said she had talked to Resident #1's family member on an unknown date but she never notified her of any nights with no care being provided. She said the failure placed a risk for skin breakdown. During an interview on 10/29/25 at 11:25 Am the DON said her expectation was for the charge nurse to round and for the CNAs for round the halls every 2 hours and turn and reposition residents as well as provide incontinent care as needed. She said Resident #1's family member did notify her of the CNAs going in the room and turned and repositioned her on some nights but did not check her bed or provide incontinent care. The DON said at the time she thought Resident #1 was not urinating as much die to a decline in status and may that be why they did not change her. She said the CNAs were responsible for ensuring the residents were provided care and clean and dry throughout the shift and the failure placed residents at risk for skin breakdown or skin worsening. She said she had never looked at any of the videos from the camera in Resident #1's room. The DON said she was not aware of the wounds being in place until 10/13/25 when she was notified by the Treatment Nurse. She said the facility discussed wounds daily in the morning meetings. During an interview on 10/29/25 at 12:18 PM CNA C said sometimes she was by herself and could not change the residents every 2 hours. CNA C said she did recall times when she was not able to go into Resident #1's room every 2 hours. She said she could not remember not going in there at all but she thought they were short staffed 10/9/25 and 10/10/25. CNA C said the failure placed Resident #1 and others at risk for bed sores, rashes, abuse and neglect. CNA C said she did not call anyone because she worked the night shift. CNA C said the charge nurse helped her with rounds on the hall. She said she was unsure if the charge nurse or herself told anyone how they were short staffed on the nights of 10/9/25 and 10/10/25 so that was considered neglect. CNA C said on 10/9/25 she was by herself until 10pm. She said she guessed she forgot to check on Resident #1. CNA C said she was busy answering call lights and putting other residents to bed. CNA C said the failure placed Resident #1 at risk for abuse and neglect and getting a bed sore. She said she knew Resident #1 had sores now, but she did not report the short staff and lack of care because she was not thinking about calling since it was nighttime. CNA C said she was watching the baby camera for Resident #1 that was at the nurse's station for if Resident #1 was getting up at times. During an interview on 10/30/25 at 12:16 PM CNA B said there had not been times that she had not taken care of Resident #1. CNA B said she recalled on 10/9/25 night shift it was super busy, and she came in late about 9:00 PM instead of 6:00 PM and did not get to see Resident #1 as much as she was supposed to. CNA B said it was really busy, and her and CNA C did not get to go in the room as much. When the surveyor mentioned the camera in the room showing the staff did not come in at all, CNA B said she did not realize she did not go in there at all. CNA B said the failure to change residents was neglect, and she said it could cause skin breakdown and bed sores. She said she was not aware that the resident had bed sores, but she knew Resident #1 was still going to the restroom the last time she worked. CNA B said she was unsure if she told anyone that she could not care for Resident #1 on the night of 10/9/25 and 10/10/25 but it placed the risk was for care being missed again. Record review of the facility's, undated, policy Pressure Injury: Prevention, Assessment and Treatment indicated:Procedure:1. Nursing personnel will continually aim to maintain the skin integrity, tone, turgor and circulation to prevent breakdown, injury and infection. 3. Upon assessment and identification of a pressure sore the staff nurse will notify the treatment nurse/designee. The treatment nurse/designee will:1. Notify the physician of pressure sore and obtain and follow any orders as directed by the physician. 2.Notify family and dietary department. Document Notification 4. Causes of Pressure Injuries:6. Nursing Action/Rationale:1. Prevention: The nurse can assist in the prevention of pressure injuries by performing the following nursing interventions: NOTE: Add any interventions to care plan. 1. Determine resident's skin tolerance to pressure and develop a turning schedule; residents should be turned every two (2) hours or more often if necessary and notify the Treatment Nurse/designee of any potential problems.3. Keep the bed clean, dry and free of wrinkles. 9. Assess for early signs of skin breakdown and report any abnormal findings. Early signs of pressure sores include redness, tenderness and swelling of the skin. Notify Treatment Nurse/designee of any potential problems by completing Skin Concern Notification Worksheet 10. Treatment Nurse/designee or Director of Nursing will assess site and evaluate for appropriate stage as listed in this procedure. Notify physician; obtain an order and monitor the site. Sign off on treatment sheet any treatment completed.11. Director of Nursing or designee to in-service nurses and CNA's on above prevention. This was determined to be an Immediate Jeopardy (IJ) on 10/29/25 at 1:31 PM. The Administrator was notified. The Administrator was provided with the IJ template on 10/29/25 at 1:37 PM. The following Plan of Removal submitted by the facility was accepted on 10/29/2025 at 05:30 PM. Plan of RemovalOctober 29, 2025F686 Treatment and Services to Prevent/Heal Pressure UlcersInterventions1. Resident #1 was assessed from head to toe by the DON and ADON. No additional skin issues were identified. Completed on 10/28/25. 2. Resident's #1 pressure wound was assessed, measured, and documented by the DON and ADON. The DON and ADON documented the measurements in PCC on the weekly ulcer assessment. Completed on 10/28/25.3. Resident #1's treatment orders, supplements, and care plan were reviewed by the Regional Compliance Nurse and DON for the appropriate intervention. Completed 10/28/25. 4. Head-to-toe assessments were completed on all residents by the DON and ADON. No additional pressure wounds were identified. Completed as of 10/28/25.5. All residents with pressure wounds were measured by DON and ADON as of 10/28/25. The MD was notified of all changes in measurements by the DON and ADON on 10/28/25. All measurements were documented in the chart by the DON and ADON as of 10/28/25. The physician was notified and all orders are current. 6. All residents with skin issues including pressure wounds had their care plans reviewed by the Regional Compliance Nurse, DON, ADON, and MDS Coordinator for appropriate interventions to prevent additional wounds and promote healing. All interventions were updated and implemented. Completed 10/28/25. 7. The MD was notified of the immediate jeopardy citation on 10/29/25 by the Administrator. 8. An ADHOC QAPI meeting with the IDT Team and Medical Director was held on 10/29/25 to discuss the immediate jeopardy and plan of removal. 9. The Administrator, DON and ADON were in-serviced 1:1 on the following topics below by the Regional Compliance Nurse. Completed 10/29/25. A. Pressure Prevention Policy- to include assessments, the causes of pressure injuries, interventions such as pressure relieving devices, providing incontinent care, turning and repositioning and treatments for the residents. B. Skin Assessment Policy- performing a head-to-toe assessment, measuring and documenting all skin issues including wounds. Skin assessments will be completed upon admission, readmission, weekly and as needed for any new skin issues. C. Documentation- to include accuracy and completeness of documentation. All skin issues including wounds will be documented accurately on the weekly skin assessment and/or weekly ulcer assessment.D. Notifying Change in Condition- the charge nurses will notify the MD and RP immediately of all changes in conditions to include any changes in wounds. Charge nurses will notify the MD for additional orders. Any additional orders by the MD will be implemented immediately by the charge nurse. If the charge nurse cannot notify the MD/RP immediately, the charge nurse will inform the DON or ADON to assist with notification. The nurse will notify the physician of any changes to wounds.E. Abuse/Neglect Policy- failure to provide incontinent care, turning and repositioning can be considered neglect and cause further skin breakdown. In-services 10. All staff will be in-serviced regarding the following topics below by the Regional Compliance Nurse, DON, and ADON. All staff who are not present will not be allowed to assume their duties until in-serviced. All PRN staff will be in-serviced prior to their next assignments. All new hires will be in-serviced on their date of hire, during facility orientation. All agency staff will be in-serviced prior to the start of their assignment. Completed 10/29/25.A. Pressure Prevention Policy- to include assessments, the causes of pressure injuries, interventions such as pressure relieving devices, providing incontinent care, turning and repositioning, and treatments for the residents. B. Skin Assessment Policy- performing a head-to-toe assessment, measuring and documenting all skin issues including wounds. Skin assessments will be completed upon admission, readmission, weekly and as needed for any new skin issues. C. Documentation- to include accuracy and completeness of documentation. All skin issues including wounds will be documented accurately on the weekly skin assessment and/or weekly ulcer assessment. orders by the MD will be implemented immediately by the charge nurse. D. Notifying Change in Condition- the charge nurses will notify the MD and RP immediately of all changes in conditions to include any changes in wounds. Charge nurses will notify the MD for additional orders. Any additional orders by the MD will be implemented immediately by the charge nurse. If the charge nurse cannot notify the MD/RP immediately, the charge nurse will inform the DON or ADON to assist with notification. The nurse will notify the physician of any changes to wounds.E. Abuse/Neglect Policy- - failure to provide incontinent care, turning and repositioning can be considered neglect and cause further skin breakdown. If you identify abuse or neglect, then you need to report it to the abuse coordinator/Administrator. Staff that worked from October 10th and 11th have been educated by the DON and Administrator on rounding, providing incontinent care, turning and repositioning as it can be considered neglect and cause further skin breakdown if these tasks are not provided to the resident. Completed on 10/29/2025. Monitoring of the POR included the following:Interview 10/30/25 at 9:22 AM with MD of the facility indicated the facility notified him of the immediate jeopardy citations on 10/29/25. During interviews conducted on 10/30/25 at 9:59 AM- 10/30/25 at 1:57 PM with the Administrator, DON, ADON, Business Office Manager, Activity Director, Social Worker, Dietary Manager, LVN A, CNA B, CNA C, CNA D, Housekeeping E, LVN F, CNA G, LVN H, LVN K, CMA L, CNA M, CMA N, LVN O, COTA P, Medical Records Director, Laundry R, Maintenance Director S, LVN T, CNA U, CNA V, Housekeeping Supervisor W, Housekeeping Supervisor X, CNA Y, CMA Z, CMA AA, CNA BB, CNA CC, Dietary cook DD, Floor Maintenance EE, ADON FF, CNA GG, and CNA HH indicated they had been in-serviced on the facilities abuse and neglect policy, the pressure prevention policy, the skin assessment policy, documentation, notifying change of condition, and rounding to be completed in the facility. Record review of Resident #1's skin assessment indicated it was completed on 10/28/25 with no new skin issues noted and signed by the DON. Record review of Resident #1's pressure ulcer assessment indicated it was completed on 10/28/25 with no new concerns and signed by the DON. Record review of Resident #1's treatment orders, supplements, and care plan indicated they were completed with orders in place and care plan updated as of 10/28/25. Record review of all resident head-to-toe assessments completed by the DON and ADON with no concerns noted as of 10/28/25. Record review of 6 residents with pressure ulcers with completed ulcer assessments completed with no concerns noted on 10/28/25. Record review completed on10/30/25 of copies of all residents with updated care plans with interventions put in place for wounds. Record review of the signature sheet for the ADHOC QAPI meeting that was held on 10/29/25 indicated the medical director and the IDT team were in attendance. Record review of the 1:1 in-service provided to the Administrator, DON, and ADON completed on 10/29/25 indicated they were in-serviced over the pressure prevention policy, the skin assessment policy, documentation, notifying change of condition, abuse and neglect, and rounding in the facility. Record review of the staff in-services related to the IJ provided indicated the staff that had been to work were in-serviced over the pressure prevention policy, the skin assessment policy, documentation, notifying change of condition, abuse and neglect, and rounding in the facility. The Administrator was informed that the Immediate Jeopardy was removed on 10/30/2025 at 1:57 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy and a scope of isolated due to the facility's need to monitor the implementation of the plan of removal. Evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for quality of care. 1. The facility failed to ensure Resident #1 was adequately supervised which resulted in Resident #1 leaving the facility on 08/22/24 and being found at a gas station in a town 38.1 miles east of the facility. 2. The facility failed to monitor and put measures in place to keep Resident #1 who was high risk for elopement from eloping from the facility on 08/22/24. 3. The facility failed to do a search of the surrounding area when they discovered a door alarm sounded on 08/22/24. The noncompliance was identified as PNC. The IJ began on 08/22/24 and ended on 08/23/24. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of potential accidents, injuries, harm or death. Findings include: Record review of Resident #1's face sheet, dated 08/29/24, indicated an [AGE] year-old female who admitted to the facility on [DATE]. Resident #1 had diagnoses which included dementia (memory loss) with behaviors, delusional disorder (a mental health condition characterized by persistent, false beliefs that are not based on reality), hallucinations (false perceptions), psychosis (mental health condition characterized by a loss of contact with reality), depression (persistent feeling of sadness), anxiety (mental health condition characterized by excessive worry, fear, and nervousness), and chronic obstructive pulmonary disease (group of lunch diseases that cause airflow obstruction and breathing problems). Record review of Resident #1's elopement risk assessment, with an effective date of 07/30/24, indicated Resident #1 was not bedfast, in a Geri-chair, or unable to self-propel wheelchair. Resident #1 was able to ambulate independently or with a device, cognitive skills for daily decision making was moderately impaired, understood, and verbalized acceptance of need for nursing home care. Resident #1 had no history of previous attempts to leave own residence/facility. The assessment indicated Resident #1 had an elopement risk score of 10. Record review of Resident #1's elopement risk assessment, with an effective date of 08/07/24, indicated Resident #1 was not bedfast, in a Geri-chair, or unable to self-propel wheelchair. Resident #1 was able to ambulate independently or with device, cognitive skills for daily decision making was moderately impaired, and verbalized anger and frustration related to placement. Resident #1 had no history of previous attempts to leave own residence/facility. The assessment indicated Resident #1 had an elopement risk score of 15. Record review of Resident #1's Admission MDS assessment, dated 08/09/24, indicated Resident #1 was understood and understood others. Resident #1 had a BIMS score of 12, which indicated her cognition was moderately impaired. Resident #1 did not have behaviors, refused care, or wandered. Resident #1 required supervision or touching assistance with oral hygiene, toileting, showering, lower body dressing and personal hygiene. Record review of Resident #1's progress note, dated 08/10/24 and signed by LVN S, indicated Resident #1 stated she wanted to go home, she did not feel good and was requesting a family member to take her home. The note indicated Resident #1's family member was notified where she voiced the resident was taking an antidepressant at home. The Nurse Practitioner was notified with an order for the antidepressant medication. The progress note did not indicate Resident #1 was attempting to leave the facility. Record review of Resident #1's progress notes, dated 08/11/24-08/21/24, did not indicate Resident #1 had voiced wanting to leave the facility or made any attempts to leave the facility. Record review of Resident #1's comprehensive care plan, revised on 08/22/24, indicated Resident #1 had an elopement or elopement attempt, where she left the facility unattended. The care plan interventions included to admit to MCU upon arrival to facility per MD, assess/record/report to MD risk factors for potential elopement such as: resident's elopement or attempted elopement, wandering, repeated requests to leave facility, statements such as I'm leaving .I'm going home, attempts to leave facility, elopement attempts from previous facility, home, or hospital, and to determine the reason the resident is attempting to elope. The care plan interventions also included to distract resident from elopement attempts by offering pleasant diversions, structured activities, food, conversation, television, books, and if the resident was exit seeking to stay with the resident and notify the charge nurse by calling out, sending another staff member, or using the call system. Record review of Resident #1's order summary report, dated 08/01/24-08/31/24, indicated Resident #1 had the following orders: o quetiapine fumarate 25 mg give one tablet by mouth one time a day related to psychosis with a start date of 08/11/24. o Refer to behavioral health to evaluate and treat as indicated one time only related to dementia with behaviors with a start date of 08/01/24. o Fluoxetine 40 mg one capsule daily for depression with a start date of 08/11/24. Record review of Resident #1's progress note, dated 08/22/24 at 4:56 PM, signed by LVN A, indicated At around 1:00 PM-1:30 PM trays were being passed on hall, upon entering her room she wasn't in it, staff started looking in dining room and all rooms up and down 200 west, 300 north and south, all bathrooms, closets, under bed anywhere any one could be hiding was looked, upon not finding her we call code orange and all other staff started looking for her thru (through) out facility, some went outside of facility looking, police notified, staff started reviewing camera. Record review of Resident #1's progress note, dated 08/22/24 at 5:35 PM, and signed by the previous DON, indicated At approximately 1730 [5:30 PM], [Resident #1] arrived back to facility via nursing home transportation bus. This DON accompanied resident back to facility at approximately Mile Marker 170. Upon arrival to assist van driver, resident was sitting in the front seat on the passenger side of the van. The resident was exit seeking by trying to unlock the front passenger side door. Resident was also trying to unlatch the seat belt. When this DON interviewed the resident and asked how did she end up at the gas station in [another town], the resident answered 'I don't know what you are talking about!' This DON then asked the resident, 'so are you getting into cars with strangers?' The resident stated, 'I never get into the cars with strangers!' This DON then asked the resident 'SO what happened?' And the resident stated, 'I'm not saying another word, I have already said too much!' Resident refused to say anything else. This DON asked resident was she hungry, resident stated 'no.' This DON went to the kitchen and received a dietary tray for resident and offered the meal to the resident. The resident refused. Resident was assisted to the restroom to toilet. Resident is currently on the secure unit sitting on the couch watching T.V. without any concerns at this time. No exit seeking noted at this time. Resident placed on one-on-one observation. Record review of Resident #1's hospital records, dated 08/22/24, indicated .Patient presents per paramedics. She eloped from her extended care facility dementia unit in [town nursing facility located]. She somehow got a ride up to [town that was 38.1 miles east of the facility] where she was found and brought here to meet her facility transport to go back home. Patient has no acute complaints. She denies trauma altered mental status relative to baseline. Paramedics state her vital signs were stable and patient has had no complaints with them as well . The hospital records also indicated . spoke with DON at [facility], she requested that pt be asked if she was harmed in any physical, emotional, or sexual way. Informed that pt is currently AAOx2. Nurse talked with pt and pt denied being harmed in any way and stated, 'That man that drove me here was just helping me get out of there' Record review of the [town resident was found] police call sheet report, date 08/22/24 at 2:06 PM, indicated the call was received from a gas station for a welfare check. The reporter advised a female came in with dementia and does not know where she is and then gave Resident #1's name. The report indicated Resident #1 arrived in a vehicle with a male who was scared to death and left, she did not know a number to call for help and was sitting in the store in the dining area. Record review of the [town facility located] police call detail report, dated 08/22/24 at 2:16 PM, indicated the DON had called regarding a missing person. The report indicated the missing person was Resident #1. Record review of the [town facility located] police department narrative by the corporal indicated .on 08/22/24 at approximately 1449 hours (2:49 PM) I, [name of corporal] was dispatched to the [facility] in reference to a UUMV. Prior to receiving this call, I was dispatched to the same address at approximately 1416 hours (2:16PM) in reference to a missing person. On the previous call, staff from the [facility] reported a dementia resident [Resident #1] had snuck out of the location through the west side laundry room door. While on scene searching for [Resident #1] a member of the staff advised officers [Resident #1] was located at the [gas station in the town located 38.1 miles east of the facility]. Upon my arrival, I made contact with [Laundry Aide C]. [Laundry Aide C] advised she works in the laundry room at the [facility]. [Laundry Aide C] advised after helping search for [Resident #1] when she was missing, she was getting ready to leave work. [Laundry Aide C] advised when she arrived to work that day, she parked her [car model] near the laundry room on the west side of the facility. [Laundry Aide C] advised she left her car keys in the vehicle. [Laundry Aide C] advised around 1200 hours (12:00 PM) she went to lunch with a co-worker and rode with them in their vehicle and arrived back around 1230 hours (12:30 PM). [Laundry Aide C] told me when she went to leave, she noticed her vehicle was no longer parked where she left it. Due to the timing of [Resident #1] going missing and the time of the vehicle was taken, staff member believed the two incidents could be related . I spoke with Human Resource, and she advised she spoke with an employee from the [gas station name]. [Human Resource] advised [gas station employee] observed [Resident #1] arrive at the location in a gold SUV with an unknown male. [Human Resource] said [gas station employee] was able to get ahold of [Resident #1's] family member who informed him she was supposed to be at the [facility name]. [Human Resource] advised that is how the facility was notified she was found in [town located 38.1 miles east of facility]. [Human Resource] told me they contacted [the other town's police department] and had an officer take [Resident #1] to the [hospital name] to be checked out. I watched the surveillance footage and observed at approximately 1222 hours (12:22 PM), [Resident #1] walked out of the building from the west hall (laundry room side). I observed at approximately 1234 hours (12:34 PM), [Laundry Aide C's car] could be seen going east on the southwest side of the building. No other camera captured [Laundry Aide C's car] Record review of Resident #1's consent for secure unit, with an effective date of 08/22/24, indicated Resident #1's representative verbally or by phone gave consent for Resident #1 to be placed in the secure unit. During an interview on 02/10/25 at 1:39 PM, LVN A said the day of the elopement incident she was in the dining room assisting with feeding since she was assigned to lunch duty. LVN A said she saw Resident #1 walking around in the dining room around noon and then went walking down the hall. LVN A said Resident #1 ate sometimes in the dining room or her room. LVN A said she did not remember if Resident #1 had been trying to exit seek prior or had voiced she wanted to leave the facility. LVN A said when the staff passed trays, approximately an hour after she last saw her, Resident #1 could not be found. LVN A said management was notified and everyone started looking for her. LVN A said they reviewed the cameras and noticed Resident #1 left through the back door, near the laundry room. LVN A said there was a code to exit the door, but also had a sign to hold for 15 seconds and the door would unlock. LVN A said Resident #1 could read and probably held the door for it to unlock. During an interview on 2/10/25 at 1:47 PM, the DON said when the staff reported Resident #1 could not be found they searched everywhere, even the neighbor's house. The DON said when they could not find her, they called the police. The DON said they reviewed the cameras and they saw she had left the building. The DON said they did not have a camera facing where the car was parked so was unsure if Resident #1 drove or someone took her. The DON said Resident #1 was found in another town and she asked the paramedics to take her to the hospital to be checked out. Laundry Aide C's car was found at the location where Resident #1 was found and Resident #1 had the keys. The DON said at the gas station, someone had said Resident #1 was dropped off. The DON said Resident #1 was brought back to the facility and placed in the secured memory care unit. The DON said she was unable to recall if Resident #1 had verbalized wanting to leave the facility and had made no prior attempts of leaving. The DON said Resident #1 was referred to psych services as well due to her hallucinations. The DON said two staff members answered the door alarm and had checked but saw no one there. The DON said they completed elopement risk assessments for all residents in the building at the time of the incident, completed daily monitoring of doors, and performed elopement drills. During an interview on 02/10/25 at 2:14 PM, the AIT said the day of the incident she was not at the facility, but staff called her and reported Resident #1 could not be found. The AIT said she returned to the facility to assist. The AIT said they told her Resident #1 left in a car, and police found her in another town. The AIT said the previous Maintenance Supervisor and the previous Medical Records staff had answered the door alarm but did not know there was a resident involved as each one thought the other one set the door alarm. The AIT said when Resident #1 returned to the facility she was not confused but it took forever to get her to come down off the facility van as she did not want to come inside. The AIT said they completed in-services, monitoring, placed Resident #1 in the unit, completed elopement assessments on all residents, safety assessments, and elopement drills. The AIT said Resident #1 voiced once wanting to go home but made no attempts of leaving the facility. The AIT said the staff was also educated on not leaving their keys in their vehicles. During an interview on 02/10/25 at 10:52 PM, LVN B said she worked the 6:00PM-6:00AM shift and was the nurse who had taken care of Resident #1. LVN B said Resident #1 had not voiced wanting to leave the facility or made any attempts of wanting to leave the facility prior to her elopement on 08/22/24. During an interview on 02/10/25 at 11:17 PM, Laundry Aide C said the day of Resident #1's elopement, she went to her car to get something out because she was leaving to go eat lunch with a friend and left her keys on the seat when she placed them down. Laundry Aide C said around 2:00 PM, she was getting ready to leave and her car was no longer where she parked it. Laundry Aide C said her car was found at a gas station in [town 38.1 miles east of the facility]. Laundry Aide C said Resident #1 had her keys on her when she arrived back to the facility. Laundry Aide C said the facility in serviced her on parking, not leaving the keys inside the car, code orange, answering the door alarms and checking to see if no one was outside. Laundry Aide C said she had not heard Resident #1 wanting to go home and had not seen her make any attempts to leave the facility. During an interview on 02/10/25 at 11:28 PM, CNA D said she had been Medical Records at the time of Resident #1's elopement. CNA D said she was putting up medical supplies when she heard the door to the laundry exit alarming. CNA D said she went to the door and looked around but had not seen anyone. CNA D said there were no residents outside, and no one was leaving. CNA D said she had not heard of Resident #1 voicing wanting to leave the facility or seen Resident #1 make any attempts to leave the facility. CNA D said the facility in-serviced her when answering an alarming door, they need to ensure no residents were leaving the building. She said she was instructed to check outside and around the building. CNA D said when there was a code orange it indicated there was a missing person and everyone had to help in locating the missing resident. Interviews on 02/10/25 between 1:39 PM and 11:54 PM with (LVN A, DON, AIT, LVN B, Laundry Aide C, CNA D, LVN E, CNA F, CNA G) and interviews with (CNA H, CNA K, Maintenance Supervisor, CNA R, CMA Q, LVN P, Speech Therapist, Treatment Nurse, MDS Coordinator, Housekeeping Supervisor, LVN S, Housekeeping L, LVN M, Dietary Aide N) on 02/11/25 between 12:11 AM and 1:12 PM revealed they were able to answer questions regarding in-services on abuse and neglect, immediately notifying the abuse coordinator for any abuse allegations, response on what to do when a resident was exit seeking which was to notify nurse and management staff, responding to the door alarms, checking to ensure no residents had left the building, if no residents were seen they were to notify the nurse and do a count of residents to ensure no one had left, code orange was for a missing resident that was unable to be located and not leaving their keys in their vehicles. During an interview on 02/11/25 at 10:32 AM, the Regional Compliance Nurse said when a resident had an elopement risk score of 10 or higher, they were considered at risk for elopement. She said they updated the residents care plan to reflect their risk of elopement and if the residents wandered, they educated staff. The Regional Compliance Nurse said all doors at the facility were locked and required a code to get in or out. The Regional Compliance Nurse said when a resident was actually exit seeking, they ruled out any underlying medical condition, found placement, or placed them in their secure unit. She said Resident #1 was placed in the memory care secure unit upon her return to the facility and her care plan was updated. Record review of the in-services dated 08/22/24 indicated the staff was in-serviced on elopement prevention policy, abuse and neglect policy, not leaving their keys in their vehicle, if a resident was exit seeking to stay with the resident and notify the DON, ADON and the Administrator. Record review of the in-services dated 08/23/24 indicated the staff was in-serviced on responding to door alarms by walking outside to check to see if any resident may have exited the door and would need to be directed back inside, once it was determined that a resident had not exited the door, the code was pressed to turn the alarm off, code orange (missing resident) and the steps to take if a code orange was called, elopement prevention policy, and the abuse and neglect policy. Record review of the missing resident/elopement monitoring check off indicated the following had been completed: Ensuring the locking mechanism and alarm were functioning properly on all exit doors of the facility 5 days a week. Conducted at least 3 elopement drills weekly. 5 staff members were asked weekly on what to do if a resident was exit seeking, the process to follow if a door alarm was sounding, and what to do if a resident was discovered missing. Record review of the elopement drills revealed they were completed three times a week with no concerns noted with a start date of 08/22/24. Record review of the Assessment History Elopement Risk Assessment Report indicated 76 assessments were completed on 08/22/24. Three residents with an elopement risk assessment score of 10 or higher were reviewed. The three residents resided in the memory care secure unit and their care plan indicated they were a high risk for elopement. Record review of Safe Assessments completed on 08/22/24 for residents residing on Resident #1's hall. Record review of the facility's policy Elopement Prevention revised January 2023 indicated Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. 1. The Elopement Risk Assessment will be completed upon admission . at least quarterly, after an elopement attempt, upon new exit seeking behavior, and upon change of condition .4. The residents' care plan will be modified to indicate the resident is at risk for elopement episodes. Interventions into elopement episodes will be entered onto the resident's care plan and medical records . 7. If a resident is discovered to be missing, a search shall begin immediately . Record review of the facility's policy Elopement Response revised January 2023 indicated Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or is suspected, our elopement response plan will be immediately implemented. 1. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical 2. Determination of missing resident either by routine nursing rounds or door alarms: A. Note: A resident is determined to be missing when he/she leaves the facility without the staff's knowledge . 4. Should an employee discover the resident is missing from facility (Code Orange), he/she should: A. Report to the charge nurse, B. Determine if the resident is out on authorized leave or pass. If not; C. Make a thorough search of the building (s) and premises, If not located; D. Notify the Administrator and the Director of Nursing; E. Notify the resident's responsible party. Notify the attending physician; G Notify VP of Risk Management, ADO, COO, Divisional VP of clinical, Director of Secure Care Services, Compliance Nurse, and Sr, VP of Clinical Services .J. Make an extensive search of the surrounding area.5. Deployment Procedure: A. Charge nurse on each unit send staff down each hall to check each room, including bathroom closet and bed for correct resident. B. Check all rooms on the hall including tub and bathrooms, linen closets and any recreations rooms. Check all common areas and offices. 6. If unable to locate resident in the building, proceed as follows: A. Unaffected Area- Charge nurse designates one CNA per hall to remain on unit along with him/himself and sends remaining staff to affected area. B. Affected Area- Charge Nurse assigns to specific outside areas to ensure that all surrounding areas are searched. C. After 30 minutes, if the resident has not been found, the following call must be made: report missing resident to the police, update responsible party . The noncompliance was identified as PNC. The IJ began on 08/22/24 and ended on 08/23/24. The facility had corrected the noncompliance before the survey began.

Based on observations, interviews, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 3 (Resident #1) residents reviewed for quality of care. 1. The treatment nurse failed to transcribe Resident #1's physician orders for wound care and provide wound care (clean with normal saline/wound wash, pat dry, apply collagen powder, med honey pad and secure with gauze island adhesive border once daily) to Resident #1's right lower shin from 08/23/24-08/31/24 as ordered resulting in hospitalization with a diagnosis of cellulitis (bacterial skin infection). 2. The facility failed to assess, document, and monitor for Resident #1's wound. An IJ was identified on 09/09/24. The IJ template was provided to the facility on [DATE] at 12:05 p.m. While the IJ was removed on 09/09/24, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents of risk for not receiving appropriate care and treatment, a decreased quality of life, or death. Findings included: Record review of Resident #1's face sheet, dated 09/09/24, indicated Resident #1 was originally admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), and laceration without foreign body (an object originating outside the body if an organism), right lower leg. Record review of the quarterly MDS assessment, dated 07/08/24, indicated Resident #1 made herself understood and usually understood others. Resident #1's BIMS score was 5, which indicated her cognition was severely impaired. Resident #1 required substantial/maximal assistance with upper and lower body dressing and taking off footwear. Resident #1 required setup or clean-up assistance with eating, supervision with oral hygiene and partial/moderate assistance with personal hygiene. Resident #1 was at risk for developing pressure ulcers/injuries and did not have any skin problems. Record review of Resident #1's comprehensive care plan dated 07/23/2024 did not reveal a care plan for the laceration to her right lower leg. Record review of Resident #1 event nurses' note dated 08/22/24 completed by RN A indicated Resident was sitting in her wheelchair a doorway. Resident has a laceration to right lower leg, shin, with horizontal laceration noted with gross amount of blood puddled at feet and around the room, pressure applied with towel. Resident unable to provide description of accident. EMS called and resident transferred to a local hospital for further evaluation and treatment. Record review of Resident #1 after-visit summary dated 08/22/2024 discharge instructions indicated to keep wound clean and dry, apply pressure dressings as needed for bleeding. Keep the bandage and ace wrap (wound care supplies) on the wound for the next 24 hours before changing. Follow up with PCP or return to the ER in 10-14 days for suture removal. Record review of a text message dated 08/23/24 beginning at 3:18 p.m. between the treatment nurse and wound care NP indicated a picture of the laceration to Resident #1's right shin was sent to the wound care NP informing of the wound and requesting treatment orders. The wound care NP sent back an order for medi-honey, collagen powder, and gauze island border QD. Record review of Resident #1's electronic monitoring records dated 09/07/24 did not indicate there was documentation the ordered that was text from the wound care NP was transcribed to the MAR. Record review of the order listing report dated 09/09/2024 indicated Resident #1 had an order with a start date 08/30/24 to cleanse with normal saline/wound wash, pat dry, apply collagen powder (wound healing product), med honey pad (wound healing product) and secure with gauze island adhesive border once daily to her right lower shin. Record review of Resident #1's WAR between 08/23/24-08/31/24, did not indicate she received any treatments to her right shin. Record review of Resident #1's initial skin assessment dated [DATE] completed by the treatment nurse, indicated Resident #1 had a laceration that required stitches to her RLE. Record review of Resident #1's weekly skin assessment dated [DATE] completed by the treatment nurse indicated a laceration to lower leg resulting in ER visit and stitches with compression bandage in place with orders to not remove for 24 hours. Record review of Resident #1's weekly skin assessment dated [DATE] indicated a laceration and stitches to right lower leg. The assessment failed to include the size of the laceration, drainage, or treatment. Record review of Resident #1 initial wound evaluation and management summary dated 08/29/24 completed by the wound care NP indicated a dressing treatment plan to Resident #1 right lower shin was to apply collagen powder and leptospermum honey and secure with gauze island with boarder daily for 30 days. Record review of Resident #1 wound evaluation and management summary dated 09/05/24 completed by the wound care NP indicated a dressing treatment plan to Resident #1 right lower shin was to apply collagen powder, leptospermum honey, gauze packing strips and secure with gauze island with boarder daily for 23 days. The wound care NP also ordered labs, x-rays, and doxycycline (antibiotics) 100 mg po bid x 10 days related to wound healing. Record review of a progress note dated 09/06/24 completed by LVN B indicated Resident #1 was admitted to a local hospital for an infected wound. Record review of the hospital medical records dated 09/06/24 indicated Resident #1 had a diagnosis of cellulitis and was started on ceftriaxone (antibiotic) in the ED. During an interview on 09/07/24 at 10:55 a.m., Resident #1 was currently at a local hospital. The hospital nurse stated Resident #1 was admitted to the hospital with cellulitis. The hospital nurse stated Resident #1 had received IV antibiotics (Rocephin) up until the IV accidently came out. The hospital nurse stated Resident #1 refused to be sticked again. The hospital nurse stated she was currently received amoxicillin 875-125 mg by mouth at this time. During an observation and interview on 09/07/24 at 10:57 a.m., Resident #1 was lying in bed with family at bedside. An attempted interview with Resident #1, indicated she was non-interview able. Resident #1's family member stated her wound was horrible. Resident #1's family member stated that there was a concern of the wound not been treated correctly. Resident #1's family member removed the sheet from her right leg and Resident #1 was noted to have a dark black tissue covering the wound bed that appeared to be dead tissue. The wound bed appeared to have depth, unable to measure. The wound edges had a red purplish discoloration with 5 visible sutures. During an interview on 09/07/24 at 12:33 p.m., the treatment nurse stated it was reported to her by LVN E that Resident #1 had an incident that required her to be sent to the local hospital for treatment and evaluation. The treatment nurse stated when Resident #1 returned from theER on [DATE] she had orders to leave the dressing in place for 24 hrs. The treatment nurse stated on 08/23/24 she removed the dressing and assessed the laceration but failed to take measurements or document the laceration. The treatment nurse stated after she removed the bandage, she took her personal cell phone and sent a picture of the laceration to the wound care NP. The treatment nurse stated he replied with an order for medi-honey, collagen powder, and gauze island border QD. The treatment nurse stated she provided wound care Monday-Friday off the text message that was given but forgot to input the orders in PCC and document she completed wound care. The treatment nurse stated the weekend RN supervisor would have not none to provide wound care since she did not transcribe the wound care order from 08/23/24. The treatment nurse stated her and the charge nurses that performed the wound care should have checked off the wound care on the WAR as completed if the resident was provided wound care. The treatment nurse stated if it was not checked off on the WAR that meant the wound care was not completed. When asked why the order was not placed in PCC on 08/23/24, the treatment nurses stated, I forgot, no excuse. The treatment nurse stated the process when an order was given from the NP or MD, she should have clarified the order, enter the order in PCC, and notify the charge nurses, ADON and DON of all changes of wounds and treatments. The treatment nurse stated when the wound care NP came in to see Resident #1 on 08/29/24 after he completed his notes, she should have placed the orders in PCC on 08/29/24 not 08/31/24 and notified Resident #1's charge nurse, ADON and DON of the treatment. The treatment nurse stated this failure put Resident #1 at risk for an infection. During a telephone interview on 09/07/24 at 1:28 p.m., RN C stated she was the weekend RN supervisor. RN C stated she provided wound care to residents on the weekend. RN C stated she did not perform wound care to Resident #1 on 08/24/24 or 08/25/24 because there were no orders in PCC. RN C stated the only thing she did to Resident #1's right leg was to ensure the ace bandage was secured. RN C stated she did not notice any s/sx of infections. During an interview on 09/07/24 at 1:45 p.m., the ADON stated Resident #1 was sent to the local hospital on 09/06/24 for x-rays that the wound care NP ordered on 09/05/24. The ADON stated the treatment nurse did not have to do a wound assessment on 08/23/24 when she removed the bandage and assessed the wound. The ADON stated when a task such as wound care was completed by the treatment nurse she should have documented in PCC under WAR as completed. The ADON stated if the task was not checked off on the WAR that meant the wound care was not completed. During an interview on 09/07/24 at 2:05 p.m., the Administrator stated she expected orders to be placed in PCC the day the order was given. The Administrator stated she expected documentation to be completed when an assessment or wound care was completed. The Administrator stated the DON was responsible for overseeing wound care/treatments. The Administrator stated these failures put Resident #1 at risk for an infection. During an interview on 09/09/24 at 9:36 a.m., the wound care NP stated he received a text message from the treatment nurse on 08/23/24 regarding Resident #1's laceration to her right leg. The wound care NP stated he replied with treatment orders that he expected her to start on 08/23/24. The wound care NP stated the outcome of the treatment not implemented was cellulitis. During an interview on 09/09/24 at 9:50 a.m., the DON stated she was unaware the treatment nurse received an order on 08/23/24 from the wound care NP and the order not been placed in PCC after the wound care NP visit on 08/29/24 until the state surveyor intervention. The DON stated the treatment nurse was responsible for ensuring wound care orders were implemented including not limited to wound treatments, antibiotics, etc. during rounds with the wound care NP or receiving the order on 08/23/24 via text message from the wound care NP. The DON stated the treatment nurse should have documented her assessment in PCC on 08/23/24 when she removed the dressing. The DON stated when the wound care was completed the treatment nurse should have documented in PCC under WAR as completed. The DON stated if the task was not checked off on the WAR that meant the wound care was not completed. When asked when an incident with a wound occurred did, she (DON) validate to ensure orders were in process, she stated, every morning I check the clinical dashboard for clinical alerts by reviewing the risk management and order listing report for residents with any skin related issues. The DON stated because the orders from 08/23/24 and 08/29/24 were not put in PCC the day the treatment nurse received them, there was no way her or the ADON could go in and validate the orders. The DON stated these failures could put Resident #1 at risk for infection and possible death. Record review of the facility policy titled, Skin Integrity Management, revised 10/05/16, indicated, 1. If wound is noted, performed an assessment, and initiate a treatment plan as soon as possible. Document in resident's chart, area of change, who you notified, and treatment applied . 3. Wound care should be performed as ordered by the physician . Record review of the facility's undated policy titled, Medication Orders,, indicated, 2. Documentation of the medication order . a. Each medication order is documented in the resident's medical record with the date, time and signature of the person receiving the order .The order is recorded on the physician order sheet, or the telephone order sheets (if it is a verbal order) and the MAR . b. the following steps are initiated to compete documentation: clarify the order, enter the orders on the medication order and receipt record, and transcribe newly prescribed medications on the MAR or treatment record . This was determined to be an Immediate Jeopardy (IJ) on 09/09/24 at 12:02 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 09/09/24 at 12:05 p.m. The following plan of removal submitted by the facility was accepted on 09/09/24 at 2:28 p.m. and included the following: On 9/9/24 during an abbreviated survey a surveyor Identified an Immediate Jeopardy situation for F684. On 9/9/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. F684 Quality of Care The facility failed to transcribe resident #1's physician orders for wound care and assess, document, and monitor resident #1's right shin wound from 8/23/24-8/31/24. Interventions: As of 9/9/2024 Resident #1 has returned to the facility and all wound treatment orders initiated. Treatment nurse completed wound care per physicians' orders on 9/9/2024. All residents in the facility received a skin assessment by the ADON/Tx Nurse/Regional compliance nurse/MDS nurse as of 9/9/2024. No new skin issues identified. Wound treatment records audited to verify that all residents with skin conditions orders are in place and match current wound care physician orders. Completed by ADON and Treatment nurse as of 9/9/2024. A 1:1 in-service was completed by the Regional Compliance Nurse with the DON/ADON/Tx Nurse on 9/9/9/2024 on entering orders for treatments in EMR, completing all ordered treatments and documenting in EMR, and Assessing and reporting new or worsened wounds to the physician and family and documenting notification in EMR. The Medical Director was notified of the immediate jeopardy situation on 9/9/2024. An ADHOC QAPI meeting was conducted on 9/9/2024 to include the IDT Team to discuss the immediate jeopardy and subsequent plan of removal. DON or designee will monitor clinical alerts daily for any new skin issues and follow up to assure all skin conditions proper orders, assessments, and notifications in place in EMR. Implemented on 9/9/2024. Skin integrity Management policy reviewed on 9/9/2024 and no changes made to current policy. Identification: All residents residing in the facility received a skin assessment by the DON/ADON and treatment nurse. No new skin issues were identified as of 9/9/24. Wound treatment records audited to assure all residents with skin conditions have orders in place and that orders match current Wound care physician recommended treatment orders. completed as of 9/9/2024. In-services: All charge nurses were in-serviced on the following topics below as of 9/9/2024 by the DON ADON and Treatment Nurse. All staff not present for in-servicing will not be allowed to resume their scheduled assignment until in-serviced. All new hired staff will be in-serviced during facility orientation. All agency staff will be in-serviced prior to start of their shift. Verification of comprehension will be made through a post test for topics in-serviced on. o Entering new physicians' orders in EMR without delay. o Completing all orders treatments and documenting treatments in EMR. o New or worsened wound should be assessed, and the physician and family notified and documented in EMR. On 09/09/24 the survey team confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: 1. During a telephone interview on 09/09/24 at 2:08 p.m., the Medical Director stated he was notified of the immediate jeopardy situation and attended a QAPI meeting via phone over the immediate jeopardy and subsequent plan of removal on 9/9/2024. 2. During an observation on 09/09/24 at 2:30 p.m., Resident #1 was observed in the dining room with a bandage noted to her right shin dated 09/09/24. 3. Record review of the skin assessments, were initiated on 09/07/24 and completed by 09/09/24, revealed all residents were reassessed for skin issues. No additional concerns were identified. 4. Record review of the wound treatment audit, were initiated on 09/07/24 and completed by 09/09/24, revealed all residents with skin conditions orders in place and match current wound care physician orders. 5. Record review of the ADHOC QAPI meeting, dated 09/09/24, revealed the meeting was conducted with Administrator, DON, Regional Nurse Consultant, and Medical Director. 6. Record review of the in-service form dated 09/09/24 revealed the DON/ADON/Treatment Nurse had received 1:1 in-service training with the Regional Compliance Nurse on entering orders for treatments in EMR, completing all ordered treatments and documenting in EMR, and Assessing and reporting new or worsened wounds to the physician and family and documenting notification in EMR. 7. Record review of the in-service forms and posttest dated 09/09/24, revealed RN D, LVN E, LVN F, LVN G, LVN H, LVN K, LVN L from all shifts were provided in-service education on entering new physicians' orders in EMR without delay, completing all orders treatments and documenting treatments in EMR, and new or worsened wound should be assessed, and the physician and family notified and documented in EMR. 8. Record review of the clinical alert monitoring tool for any new skin issues and follow up to assure all skin conditions proper orders, assessments, and notifications in place in EMR was implemented on 09/09/24. 9. Record review of the Skin Integrity Management policy was reviewed on 09/09/24, no changes were made. 10. During interviews conducted on 09/09/24 between 2:35 p.m. and 3:25 p.m., revealed RN D, LVN E, LVN F, LVN G, LVN H, LVN K, LVN L from all shifts were in-service on and could verbalize understanding of inservices of entering new physicians' orders in EMR without delay, completing all orders treatments, documenting treatments in EMR, assessed new or worsened wounds, notify the physician/family and document in EMR. The Administrator was informed the IJ was removed on 09/09/24 at 3:35 p.m. The facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview, observation and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 4 (Resident #1) residents reviewed for medication errors. The facility failed to administer the correct dosage of Potassium after the order was transcribed incorrectly resulting in Resident #1 having a critical high potassium level of 6.52 (the normal potassium lab value range 3.7 - 5.2) and being hospitalized . An Immediate Jeopardy (IJ) was identified on 03/31/2023. The IJ template was provided to the facility on [DATE] at 6:18 p.m. While the IJ was removed on 04/02/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on 5 rights of medication administration, obtaining, verifying, and transcribing orders, reporting medication errors, and reviewing admission/readmission orders prior to initiating orders. The failure could place other residents at risk of being over-medicated resulting in harm or death. Findings Included: During a record review on 03/31/2023 of the face sheet dated 03/30/2023 indicated Resident #1 was a [AGE] year old female admitted to the facility on [DATE] with a diagnoses including Congestive Heart Failure (the heart works less efficiently) Hyponatremia (a low concentration in sodium in the blood), Hypertension (high blood pressure), Atrial Fibrillation (abnormal heart rhythm characterized by rapid and irregular heart beat causing poor blood flow), and Kidney Failure (kidneys stop working). Physician Orders: Potassium 40 mEq by mouth one time a day for supplement every day starting 03/17/2023. During a record review on 03/31/2023 of the discharge paperwork from the hospital dated 03/17/2023 indicating an order for potassium chloride 20 mEq tablet by mouth every other day. Record review of the Medication Administration Record indicated Resident #1 received the Potassium 40 mEq by mouth one time a day for supplement every day starting 03/17/2023 through 03/29/2023 with no missed doses. During record review of the lab dated 03/29/2023, indicated Resident #1 had a critical high potassium level of 6.52. During a record review of the care plan dated 03/19/2023 indicated Resident #1 has Congestive Heart Failure (the heart works less efficiently). The care plan indicated interventions of monitor breath sounds, give cardiac medications as ordered, monitor labs as ordered and report to physician any results out of normal parameters, and monitor, document and report dependent edema of legs and feet, SOB (shortness of breath), cool skin, increased heart rate. During a record review of the comprehensive MDS dated [DATE] indicated Resident #1 had a BIMS of 11 (moderately impaired cognitive status). The MDS indicated Resident #1 required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. During a record review on 03/31/2023 am of the provider investigation report dated 03/30/2023 indicated Resident #1 was transported to the hospital on 03/29/2023 due to a critical high potassium value of 6.52 (the normal potassium lab value range 3.7 - 5.2). During a record review of SBAR progress note dated 03/29/2023 wrote by LVN B indicated new orders received from physician to stop potassium 40 mEq and send to ER. During a record review of hospital admission records to the emergency department dated 03/29/2023 indicated Resident #1 had a repeat blood draw for potassium of 6.52. During a Record Review on 03/31/2023 of the facilities Medication Orders Policy dated 2003 indicated, .WRITTEN TRANSFER ORDERS (SENT WITH A RESIDENT BY A HOSPITAL OR OTHER HEALTH CARE FACILITY). Implement a transfer order without further validation if it is signed and dated by the resident's current attending physician, unless the order is unclear or incomplete or the dated signed is different from the date of admission. If the order is unsigned or signed by another prescriber or the date is other than the date of admission, the receiving nurse verifies the order with the current attending physician before medications are administered. The nurse documents verification on the admission order record by entering the time, date, and signature During an interview and observation at the hospital on 03/31/2023 at 12:30 pm with Resident #1. located at the hospital. Resident #1 appeared alert, oriented and said she is feeling fine. Resident #1 She denied any complaints of chest pain or irregular heart rate. During an interview on 03/31/2023 at 12:56 pm with hospital RN. The hospital RN said Resident #1 was ordered Kayexalate (medication used to remove potassium from the body) 15 g BID until she has a bowel movement. The hospital RN confirmed resident had bowel movements. The hospital RN indicated potassium lab value 4.8 on 03/31/2023. The hospital RN said Resident #1 would not be discharged today. The hospital RN said preparations were being made for Resident #1 to return to her home with home health services per the daughter in law. During an interview on 03/31/2023 at 02:44 pm with LVN A. LVN A said the medications for Resident #1 are no longer in the medication cart. She stated the medications were sent out when Resident #1 left the facility to go to the hospital. During an interview on 03/31/2023 at 04:20 pm with the DON and Corporate Compliance RN. The Corporate Compliance RN stated the medication orders would have been received from the discharge paperwork from the hospital upon admission to the facility. The Corporate Compliance RN stated the charge nurse should transcribe the discharge orders upon admission to the nursing facility and verify with the attending physician prior to administering medications to the resident. The Corporate Compliance RN stated the policy had not been followed properly resulting in a facility error. The DON and Corporate Compliance RN said they were not aware of the error with the potassium until now. During an interview on 03/31/2023 at 04:40 pm with the DON. The DON stated the order had been transcribed incorrectly by LVN A at the time of admission. The DON said he was not aware of how the error occurred. He stated that LVN A did not follow the policy and it was an error. During an interview on 03/31/2023 at 05:00 PM with Corporate Compliance RN. She stated it is a transcribing error. She stated orders are received from the discharging facility, or a physician. She stated the resident's pill bottles from home are not utilized. She stated the orders were not verified with the attending physician prior to the medications being administered to the resident. The Corporate Compliance RN stated this was an error made by the facility. During a telephone interview on 03/31/2023 at 5:14 pm with attending physician. The attending physician said he did not think that was his order to give Potassium Oral Tablet Give 40 mEq by mouth one time a day for supplement because giving that large of a dose one time daily would be harmful to the gastric lining of the stomach. The attending physician further stated that the facility sends over the orders in bundles that he signs, and he expects the facility to get the orders correct. He said that he would not have ordered Potassium 20 mEq (milliequivalents) every other day either because of the resident's potassium lab value of 5.2 on 03/16/2023 at the time of discharge from the hospital. The attending physician stated the facility did not call him to verify transfer orders upon admission of Resident #1 to the facility. During an interview with LVN A on 03/31/2023 at 05:20 and record review of Inservice Attendance Regarding Medication Error dated 03/31/2023, LVN A said she does not know where she got the incorrect dosage/order from. LVN A said she did not use the resident's pill bottles to transcribe the medications upon admission. She stated she did not call the facility's attending physician to confirm the transfer orders upon the admission of Resident #1. Record Review of https://my.clevelandclinic.org/health/diseases/15184-hyperkalemia-high-blood-potassium which specifically says Hyperkalemia (High Potassium) People with hyperkalemia have high potassium levels in their blood. Signs like fatigue and muscle weakness are easy to dismiss. A low-potassium diet and medication changes often bring potassium numbers to a safe level. An extremely high potassium level can cause a heart attack and requires immediate medical care.What are the complications of hyperkalemia (high potassium)? Severe hyperkalemia can come on suddenly. It can cause life-threatening heart rhythm changes (arrhythmia) that cause a heart attack. Even mild hyperkalemia can damage your heart over time. The Corporate Compliance RN was notified on 03/31/2023 at 06:15 p.m. that an immediate jeopardy situation was identified due to the above failures. The facility's plan of removal was accepted on: 04/01/2023 at 04:24 pm and included: In the event of Resident #1's return to facility. Charge Nurse will call Medical Director and review hospital discharge prior to transcribing orders and noting any changes made by the Medical Director that deviate from hospital discharge instructions. DON or designee will audit transcribed orders vs hospital discharge instructions vs Medical Director recommendations to assure accuracy. When medications arrive from pharmacy the cards will be verified to assure the cards match current EMR dosing and instructions. Reviewed Medication order policy and Medication administration process on 3/31/2023. No changes made to current policies. DON or designee will monitor orders daily to assure policies and procedures are being followed. Interventions: o 100% audit completed on all Potassium orders to ensure resident is receiving the Physician ordered dose completed on 3/31/2023 by DON, ADON and Regional Compliance Nurse: o All resident cards verified that they match the ordered dose on 3/31/2023 by DON, ADON and Regional Compliance Nurse. o All resident potassium orders match current physician orders o 1 Resident card, whose order changed on 3/28/23, was found during med cart verification of cards. Medication was not being given in error. A dose change sticker was placed on card to alert staff of dose change and new card ordered from pharmacy. o Audit of all new admissions from 3/17/2023 to current initiated reviewing for correct medications and medication cards. Completed by DON ADON and Regional compliance on 3/31/2023. o Review initiated on 3/31/2023 with planned completion of 3/31/2023 any errors found will be handled following medication error process utilizing medication error form. Completed 3/31/2023 by DON ADON and Regional Compliance Nurse o On 4/1/2023 the Medical Director initiated a review of all resident orders including medications and treatment plans. All changes ordered by the Medical Director will be implemented by the DON on 4/1/2023. Completion date will be 4/1/2023. o On 4/1/2023 all residents Medication cards will be verified against orders for accuracy by DON and Regional Compliance Nurse. Completion date will be 4/1/2023. o Medication error completed on 3/31/2023 at 1830 by DON utilizing medication error form. A 1:1 in-service was completed with charge nurse on the 5 rights of medication administration, obtaining, verifying, and transcribing order, reporting medication errors, and calling practitioner to review all admission/readmission orders prior to initiating orders. o Pharmacy Consultant notified 3/31/2023 at 1808 by DON. o DON and ADON in-serviced by Regional Compliance Nurse on 3/31/2023 on checking to ensure there are no transcription errors with each new medication during the morning clinical meeting including review of all new admissions/readmissions. o The following in-services were initiated by DON, ADON and Regional Nurse on 3/31/23: Any staff member not present or in-serviced will not be allowed to assume their duties until in-serviced. A total of 10 licensed nurses will be required in servicing. As of 4/1/2023 5 licensed nurses have received in-services. A total of 5 CMA staff require in servicing. As of 4/1/2023 2 CMAs have been in serviced. In-services are being completed by DON ADON and Regional Compliance Nurse. o Licensed Nurses will be in-serviced on: ? 5 Rights of Medication administration ? Obtaining, verifying, and transcribing orders ? Reporting Medication error that has occurred or found immediately to Physician and DON ? Notify practitioner to review all new admission/readmission orders prior to initiating orders. ? Certified Medication Aides will be in-serviced on: ? 5 Rights of Medication Administration ? Reporting Medication error that has occurred or found immediately to charge nurse and DON. o The medical director was notified of the immediate jeopardy situation on 3/31/2023 at 1817. Monitoring o The DON / designee will monitor Order listing report daily to ensure all meds were transcribed as ordered. New admission/readmission orders will be reviewed to assure discharge orders match orders entered in EMR. Monitoring will occur daily x 5 days a week for a minimum of 6 weeks. o The QA committee will review the findings and make changes as needed. On 04/02/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of completed Preventing Significant Medication Errors Licensed Nurse and Medication Error Report Inservice's and trainings dated 3/31/2023 on LVN A. Record review of completed Preventing Significant Medication Errors Licensed Nurse and Medication Error Report Inservice's and trainings dated 4/01/2023 on LVN B. Record review on 04/01/2023 of completed Preventing Significant Medication Errors Licensed Nurse and Medication Aide Inservice's and trainings dated 03/31/2023. Record review of completed Reviewing new admission/readmissions and daily order checks by DON and ADON dated 03/31/2023. Record review of completed Audit of all medication carts to orders by Regional Compliance RN and DON dated 04/01/2023. Record review of completed current residents' medication reconciliation with the medical director dated 04/01/2023. Interviews held on 04/01/2023 indicated the following staff completed the required in-service trainings: DON ADON RN - E LVN A, LVN B, LVN C, LVN D MA F, MA G, MA H On 04/02/23 at 3:17 p.m., the Corporate Compliance RN was informed the IJ was removed, however the facility remained out of compliance at no actual harm with a scope of isolated with the potential for more than minimal harm 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 failed to ensure each resident received adequate supervision, and assistance to prevent accidents for 1 of 5 residents sampled for accidents. (Resident #1) Resident #1 had contractures and required two people for bed mobility and dressing. She was provided care on 9/14/22 and 9/15 by CNA D and sustained a fractured femur (thigh bone) and a spiral fracture to her knee requiring surgery. This facility failure could cause residents injuries and harm. Findings included: Record review of Resident #1's face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses were convulsions (sudden irregular movement of the limbs of the body), anorexia (eating disorder), unspecified disorder of psychological development (mental behavioral and developmental disorders), contracture (permanent shortening of muscle or joint), muscle wasting, age related [CONDITION(S)] without current pathological fracture (5/18/21) restlessness and agitation, pain, and [CONDITION(S)] ( brain development- the brain stops growing after birth). Record Review of Resident #1's Quarterly MDS dated [DATE] her cognitive status was severely impaired. Her activities of daily living required extensive assist of two people for bed mobility, transfer, dressing, toilet use, and bathing. The MDS indicated no impairment on functional limitation in range of motion. A quarterly MDS dated [DATE] indicated the same things except lowered extremity impairment on both sides. Record review of Resident # 1 care plan with an initial date of 5/19/21 indicated she had a communication problem related to [CONDITION(S)]. She does not talk and made vocalizations but no words. She is rarely understood and rarely understood others. Resident #1 had a problem of potential uncontrolled pain dur to [CONDITION(S)], contractures to bilateral knees. One of the interventions was to evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, and impact on functional ability and impact on cognition. The care plan revised on 4/13/22 indicated a problem of ADL self-care performance deficit. The resident is totally dependent for ADL care, for bathing and bed mobility she required 1 to 2 staff for assistance. The resident is totally dependent on staff for repositioning and turning in the bed. She required 1 to 2 staff to dress. The resident required mechanical aid Hoyer lift for transfers. Record review of Resident #1's weights indicated 10/08/21 the resident weighed 63.3 pounds. Her weight on 9/5/22 was 58.2 pounds. Record review of Resident #1's computerized physician ordered indicated she had an order for Acetaminophen 650 mg by mouth two times daily for pain, ibuprofen 600 mg by mouth as needed for pain every 6 hours. It was discontinued on 9/17/22. Children's ibuprofen suppression 30 ml every 6 hours for pain. Record Review of Resident #1's nursing note dated 9/15/22 at 7:29 a.m. indicated the charge nurse was summoned to Resident #1's room by CNA A. NA B was already in the room. They pointed out what appeared to be new bruising (to them) to the left elbow, and bottom of the left forearm. Left forearm bruising was dark blue in color and measured 1x 3 cm, she also had blue green bruising all over the left elbow, (there were some bruising for hospital IV bruising noted). The aides pointed out her right thigh and knee was more swollen than the left leg, and her leg no longer felt stiff like her normal. The nurse assessed the resident's leg, and the right thigh and knee was visibly more swollen than the left. The resident was normally contracted in both lower extremities and had a hard time with range of motion. The nurse noted that when maneuvering the resident's right leg there was no resistance and the leg felt like a noodle. The Resident had facial grimacing and yelling out when the leg was touched. The nurse stabilized the right leg with a pillow and instructed the aides to leave the resident in bed. The physician was notified of the findings. Written by LVN C. Record review of a nursing note dated 9/15/22 at 1:13 p.m. indicated the x-ray result with impression of acute displaced distal femoral fracture with orthopedist recommendation. The resident was already at the hospital . Written by LVN C. Record review of Hospital Emergency Department, Hospital Medicine, and History and Physical (all one title) dated 9/15/22 at 4:08 p.m. indicated the nursing home stated her leg is normally contracted but was very flaccid and swollen. They stated they took x rays, and it showed a break in the femur. The patient had a history of [CONDITION(S)] presented to the emergency room . The history per EMS was the nursing staff found the patient this morning to have right femur deformity. ER spoke with one of the staff who stated they had been reviewing video and did not see any trauma, they lifted the patient with a lift and the patient had no falls. Apparently, this morning a deformity in the right thigh was noted, and x ray was ordered and showed some type of femur fracture. Unknown when and how the patient had a right femur fracture. The patient is nonverbal and history otherwise unobtainable. The patient will have surgery today. Record review of the x-ray report dated 9/15/22 indicated the clinical indication was a fall, four views of the right femur (thigh bone). The impression was bilateral (both sides) superior dislocation of the femurs from the femoral acetabular joints hip dislocation (the head of the thigh bone is forced out of its socket). Disk packed angulated distal metaphyseal right femur fracture. The clinical indication of knee trauma, internal derange suspected, x ray done. The impression was a spiral fracture (bone broken with a twisting motion) of the right distal femoral meta diaphysis with anterior displacement and foreshortening of the distal fragment as described. Chronic bilateral congenital hip [CONDITION(S)]. (Chronic pain in hip.) Record review of a provider investigation report date 9/15/22 indicated CNA A and CNA B went into Resident #1's room to provide morning care and dress the resident. The staff noticed one leg was straight and was usually bent. While putting on pants the resident was exhibiting paradoxical movements. A stat x-ray was ordered, and the leg was broken. There were three statements in the report. One statement dated 9/15/22 from the previous shift CNA D that basically said she was working with CNA E and they put Resident #1 to bed. The resident was hollering, and they thought she wanted to lay down. When they put her to bed, she continued to holler until she went to sleep. There were statements form CNA A and CNA B, they both said what LVN C wrote in her notes. Record Review of nursing note dated 9/21/22 at 10:00 a.m. stated Resident #1 was screaming out, assessed the resident and noted her thrashing from side to side with hands clinched in fist, with facial grimacing noted. Per orders she received [MEDICATION(S)] 25 mg and was able to get her to drink 9 ounces of cold water. Record review of Resident #1's ADL sheet indicated from 9/09/22 through 9/15/22 indicated there were 23 opportunities to provide care. Seven of those opportunities did not have any documentation of care provided. Four of those opportunities 2 people aided with bed mobility and dressing. Seven of those opportunities indicated nothing occurred. The ADL sheet showed the resident was in the hospital on 9/15/22 until 9/17/22 During an interview on 9/17/22 at 10:44 a.m. LVN F said Resident #1 was total care, dependent, and could not voice her needs. Her legs were contracted up in a bent position, and she had never rolled out of bed, she said Resident #1 was like a baby. She did not move much and usually when she was upset, she would tense up more. She was not the nurse on duty on 9/14/22 or 9/15/22. During an interview on 9/17/22 at 11:07 a.m. the DON said charge nurse LVN C called him on 9/15/22 at 7:30 a.m. to say something was wrong with Resident #1's leg. She described the right leg as a limp noddle, orderedx-ray in house, and determined Resident #1 had a fracture. The DON said they were investigating the incident and they called the police. He said Resident #1 had never fallen out of bed. There were no reports that she fell out of bed that night. She did not transfer herself because she could not stand up or walk. He said Resident #1 had [CONDITION(S)] which meant small brain, she appears to be childlike. She was crying the day before which is basically the only way she can communicate. He said the staff that put her to bed that night said she was hollering. CNA D and CNA E do not normally work with her. He said the staff put her to bed with a Hoyer lift, provided incontinent care, and put on sleeping clothes. She was fine the day before other than the crying which she did from time to time. She was up in her wheelchair with no abnormalities noted on 9/14/22. He said Resident #1 was contracted and her legs are permanently bent at the knees, and she could not straighten them out. He said she had a diagnosis of [CONDITION(S)], and they asked the hospital to perform a scan to complete a bone density. During an interview on 9/17/22 at 11:58 a.m. CNA D who said she mostly worked in medical records and central supply but is also an aide. She said she arrived at work on 9/14/22 at 7:00 p.m. and Resident #1 was already hollering sitting in her wheelchair. She said Resident #1 hollered every day and that day was no different. She did not notice anything different about her leg. CNA D said she and CNA E put Resident #1 to bed around 8:00 p.m. and they used a Hoyer lift. Resident #1 had on pants and shirt, she took them off, and put her on gown. She said when she left the room Resident #1 was still hollering and hollered all night. She said she went to check on her once and she was dry. She fell asleep sometime during the night. She went back a second time about 4:00 a.m. and she changed her by herself. When she changed Resident #1 she woke up and she started hollering again. When she left the room, she did not holler long, she stopped, and went back to sleep. CNA D said she did not usually work with Resident #1 and did not know the different in the position of her legs. She said she did not notice if both legs were bent or not. CNA D played with her phone the entire interview. During an interview on 9/17/22 at 1:10 p.m. the Administrator said Resident #1 was upset on 9/14/22 and hollering. She had her in her office for about 2 hours watching the [NAME] channel. She calmed down during that time and was quiet. She did not notice anything usually about her legs. She said sometimes when Resident #1 is on her menstrual cycle she is agitated. The Administrator said they had called it in as an injury of unknow origin. She had some bruising, but she had been to the hospital the week before. The Administrator said the break was probably diagnosis of [CONDITION(S)] and a spontaneous break. They request the hospital complete bone density test. During an interview on 9/17/22 at 1:57 p.m. CNA G said she worked at the facility for a couple of weeks. Resident #1 was a Hoyer lift transfer. CNA G said she worked on 9/14/22 and Resident #1 seemed a little agitated that day. Resident #1 was not assigned to her. Resident #1 spent most of the afternoon in the Administrator's office. She did not appear to be in distress at that time. During a telephone interview on 9/17/22 at 4:20 p.m. LVN C said on 9/15/22 CNA A and CNA B called her to Resident #1's room around 7:00 a.m. She said CNA A showed her the bruising to her arm. Resident #1 did have some areas from the IV due to her recent hospital visit but those were different. She said when they started to put her pants on, her right leg was not contracted. The aides showed her, and she could see the right leg was swollen, lying flat, without resistant. LVN C said the right leg was like a Spaghetti Noodle. LVN C said she contacted the doctor and got x-rays immediately. She said the last time she worked with her was on 9/12/22 and she was on her menstrual cycle, and she generally had a lot of pain when on her cycle. LVN C said Resident #1 had been crying out a lot more lately. Last week she was sick on the 9/09/22 and went to the hospital she needed fluids. Normally Resident #1 was good at drinking fluids, but lately her appetite had decreased, and she refused anything by mouth. During a telephone interview on 9/17/22 at 4:31 p.m. CNA E said she worked at the facility for about 2 weeks but had only worked about 5 or 6 nights altogether. She had not worked with Resident #1 before 9/14/22. She said since she worked at the facility Resident #1 was quite only one night. She said when she arrived at work on 9/14/22 Resident #1 was sitting in her chair hollering. It did not appear to her she was hollering like she was in pain. CNA E said she and CNA D transferred Resident #1 with a Hoyer lift. She did not pay much attention to her legs. She said they put her in bed with Hoyer sling, and nothing happened during the transfer. They turned her over removed the sling. She said CNA D said she could finish taking care of Resident #1, so she left the room. CNA D undressed and changed Resident #1. CNA E said she did not see Resident #1 anymore that night. During an interview on 9/22/22 at 11:31 a.m. CNA D said CNA E helped her undress Resident #1. She said CNA E pulled off her shirt and she pulled off her pants. Then CNA E left the room. CNA D said she provided incontinent care and put on Resident #1's gown. She checked on her during the night, the first time she checked she was not wet. The second time around 4:00 a.m. she was wet, and she changed her by herself. The resident woke up and hollered some more. Resident #1 did not holler long and went back to sleep. CNA D did not say she did anything else except leave the room after she completed care. During an interview and record review on 9/22/22 at 12:31 p.m. LVN/MDS Nurse H and LVN/MDS Nurse I said Resident #1 was coded two people assist with dressing because they go by the 7 days look back period to determine how the staff had provided care to her. If they listed two people three days that is what they used to make their determination for documentation in the MDS according to the MDS guidelines. Review of Resident #1's ADL sheet from 9/09/22 through 9/15/22 indicated she required two people with bed mobility and dressing for 3 or more days. The LVNs said the resident was contracted and the no limitations on the range of motion for the Quarterly MDS dated [DATE] was incorrect. They also said they were going to change her care plan to reflect the documentation of the MDS. They were changing the care plan to say Resident #1 required two people for bed mobility and dressing, not 1 or 2. During an observation on 9/22/22 at 12:56 a.m. of Resident #1 with CNA G. Resident #1's left leg was bent at the knee, and the right leg was bandaged from ankle to thigh. The resident was none verbal and only made grunting sounds. She did smile on one occasion but was fussy when moved. CNA G said the left leg did have a little movement but when Resident #1 is agitated she tightens up and her leg was hard to move. During an interview on 9/22/22 at 1:54 p.m. the DON said they do not know what happened to cause the fracture, law enforcement said they do not feel that any abuse or force occurred. The DON said given Resident #1's medical history she is a small person, has a lot of muscle wasting and does not bear weight it could have been a spontaneous break. He could not explain the spiral fracture. The hospital did not complete the bone density test as requested. During a telephone interview on 9/22/22 at 2:05 p.m. Resident #1's physician said Resident #1's biggest problem was her nutrition. He said he could not address the question about Resident #1's broken leg at this time. He said he did not know if the break was [CONDITION(S)], a spontaneous break, or what happened. His concern currently was Resident #1 was not eating. During an interview on 9/23/22 at 11:36 a.m. LVN F said Resident #1's pain was controlled first couple of days, when she had [MEDICATION(S)]. Her family member did not want her to have the [MEDICATION(S)] and it was discontinued. The resident is only on regular Tylenol and Ibuprofen PRN. Resident #1 appears to be a little more fussy or just not comfortable now.

Based on observation, interview, and record review the facility failed to ensure residents were free from sexual abuse and neglect for 5 of 7 residents reviewed (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) for abuse. The facility failed to determine if Resident #'s 1, 2, 3, 4, and 5 had the capacity to engage in sexual acts. The facility failed to perform sexual assessments on any residents. The facility failed to develop care plans with interventions that targeted the resident needs. The facility failed to protect residents who did not have the mental capacity to determine the consequences of their actions. The facility failed to notify the physician of residents sexually inappropriate behaviors. The facility failed to educate the staff with interventions other than redirect the resident and keep them separated. The facility failed to follow their abuse policy by identifying abuse and protecting residents at risk. The facility failed to ensue resident behaviors were documented and staff were not fearful of consequences of reporting inappropriate behaviors. The facility failed to identify and intervene when two sexually aggressive females-initiated sexual behaviors for several months. The facility failed to protect Resident #5 (male resident who remained on the unit) from sexual overtures of the aggressive females. An Immediate Jeopardy (IJ) situation was identified on 5/18/22/22 at 5:20 p.m. While the IJ was removed on 5/19/22 at 5:14 p.m., the facility remained out of compliance at a scope of a pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for sexual abuse. Findings include: 1. Record review of Resident #1's Admission Record/Information Sheet indicated she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's MDS, dated [DATE], indicated a BIMS score of 2 (which indicates severely impaired cognition). Her behaviors were wandering that occurred daily. The resident moved from seated to standing position, walking around, and turning around were not steady, but she was able to stabilize without staff assistance. Record review of Resident #1's care plan indicated a Focus area of being at risk for wandering, dated 7/28/20. Some of the interventions were the resident wanders in other resident rooms and gets in bed with the residents. She resided on the secure unit. A care plan Focus area, dated 7/28/20, indicated Resident #1 had impaired cognitive function dementia without behavioral disturbances or impaired thought processes with a BIMS of 2. Some of the interventions were to use segmentation to support short term memory deficits. A Focus area, dated 2/8/22, indicated the resident showed signs of affection and removed clothing in front of other residents. The goal was Resident #1 would have no episodes of sexual inappropriate behavior in the next 90 days. The interventions were evaluating the residents' ability to understand behaviors, and the consequences of that behavior. Explain to the resident the acceptable expressions of sexuality based on the cognitive evaluation. Resident #1 had another Focus area, dated 3/16/2021, which indicated the resident had behavior problems related to her taking off her shirt in public, getting in other residents' beds, and sitting close to other residents on the couch in the common area. The intervention was anticipated and meet the residents needs if possible and caregivers to provide opportunity for positive interaction stop and talk with the resident when passing by. Record review of a facility provider investigation report, dated 3/16/22, indicated Resident #1 and Resident #4 were both on the memory care unit. Resident #4 was observed rubbing Resident #1's breast. The residents were on the memory care unit and were separated. The residents were monitored and an in-service was conducted on abuse and neglect, and on inappropriate sexual behaviors. The report contained statements from staff members. A written statement from MA N stated: On 3/16/22 at 11:57 a.m. inappropriate behavior was observed. The residents in bed with each other, separated the residents and staff in-serviced. Another statement from CNA O stated: On 3/16 at 12:08 p.m. inappropriate behavior observed resident kissing each other separated resident staff member in service. Record review of Resident #1 Behavioral Health Diagnostic Assessment, dated 3/28/22, indicated Resident #1 was assessed due to an incident that occurred which involved intimate affections. There was contact with a male resident. The recommendation regarding sexually appropriate behavior: immediate redirection, the patient lacked the cognitive skills to meaningfully listen to instruction, integrate information, apply to situations requiring judgment and decision making. Therapy will not be offered due to the same reasons. The treatment plan was no therapy was recommended to target symptoms sexually acting out. Record review of Behavior Nursing notes, dated 3/30/22 at 11:46 a.m., indicated Resident #1 continued to sit by men, take them by the hands, rub them, and follow men around. Record review of a Behavioral Nursing Note, dated 3/30/22 at 7:46 p.m., indicated Resident #1 continued to sit next to men, rub them in inappropriate areas, and attempted to follow them in into their rooms. Record review of Resident #1's nursing notes from January to April revealed no concerns. Record review of Resident #1's nursing notes, dated 4/19/22 at 10:00 p.m., indicated the nurse was informed the resident had sexual advances from another resident. A head-to-toe assessment was done. There were no apparent injuries and no noted emotional distress. Signed by LVN K. Record review of a facility Provider Investigation Report, dated 4/20/22, at 10:00 p.m., indicated the incident occurred on 4/19/22 at 9:30 a.m. The report indicated both residents were ambulatory, and none interview able. The description of the allegation was Resident #3 was witnessed by an aide to have Resident #1 in an empty room attempting inappropriate behaviors with Resident #1. Resident#1 was uncomfortable with the encounter. The report indicated the charge nurse was made aware of the incident on 4/19/22 but did not report the incident. The on-coming nurse noted the information and did the assessments and notifications. The DON was not made aware of the incident until almost 12 hours later. Resident #3 was placed on 15-minute monitoring and alternate placement was found. The LVN received disciplinary actions. Resident #1 was assessed and both residents were referred for psychological services. The staff were in serviced on abuse and neglect. Record review of statements that accompanied the facility provider investigation report indicated a note signed by LVN B, dated 4/20/22 at 2:20 p.m., which stated CNA A told LVN B Resident #3 touched Resident #1 inappropriately. When LVN B arrived on the unit both residents were separated. LVN B said she charted in the progress note and wrote in the 24-hour report but said there was too much going on and she forgot to mention the incident to administrative staff. LVN B said the situation was ongoing between the residents on the unit. LVN B stated Resident #1 could also be the aggressor toward male residents. LVN B said Resident #1 targeted male, Resident #3, Resident #4, and Resident #5. In the statement LVN B also said Resident #2 made sexual advances towards all males on the unit. Record review of another note which accompanied the facility investigation report, written by CNA A, indicated he reported Resident #3's sexually aggressive behaviors towards Resident #1 to his charge nurse. He also stated while working in the unit monitoring residents in the living area, he observed Resident #3 leading Resident #1 down the hallway. They went into his room. Resident #1 appeared to be going with Resident #3 willingly. When CNA A walked into Resident #3's room. The Residents were both leaned into each other and against the wall. Neither of them appeared to be in distress but they were in close contact with one another. The aide redirected residents and they separated, and CNA A left to do some charting. About 10 minutes later the CNA noted both residents had walked into an empty room. The incident occurred he separated them again, but this time noted Resident #1 appeared to be upset by the interactions with Resident #3. He notified the charge nurse. CNA A said in general any interactions Resident #1 had with other resident appeared to be consensual and she had been observed smiling related to behaviors like this. 2. Record review of Resident #2's Admission Record/Resident Information Sheet indicated Resident #2 was an [AGE] year-old female admitted to the facility on [DATE]. She had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's physicians orders, dated 1/4/22, indicated to admit to the security unit due to a history of elopement with active exit seeking behaviors. Record review of Resident #2's MDS, dated [DATE], indicated Resident #2 had a BIMS score of 4 (which indicated severely impaired cognition). Resident #2 's behaviors included wandering, and that type of behavior occurred daily. The MDS indicated Resident #2 required supervision with moving from seated to standing, walking and turning around and she used a wheelchair. Record review of Resident #2's care plan, dated 8/23/21, indicated she had a focus area of being at risk for wandering. Some of the interventions were to distract the resident from wandering by offering pleasant diversion, structural activities, food, conversation, television or a book. Resident #2 had a focus area, dated 2/8/22, of behaviors of showing affections towards other residents. The goal was the resident would have no episodes of sexually inappropriate behavior in the next 90 days. Some of the interventions were to evaluate the residents ability to understand behavior and the consequences of their behavior. Explained to the resident the acceptable expressions of sexually based on the cognitive evaluation. Reinforcement to staff that clear firm limits and were healthy and required when the resident made inappropriate gestures or statements. Report inappropriate sexual behaviors to charge nurse. If CNAs were involved immediately intervene and protect the safety of all residents involved. Another intervention was staff would be trained to respond but not react to residents' behaviors. Record review of Resident #2's nursing notes, dated 2/8/22 at 9:10 a.m., indicated the ADON was notified last night around 1:30 a.m. that resident was engaging in an episode of intimate affection with another resident in the memory care unit. Charge nurse stated that residents had been separated and were in their rooms at this time this charge nurse instructed the nurse to monitor 1 on 1. Signed by ADON. Record review of a nursing note, dated 2/25/22 at 11:00 a.m., indicated the resident had a male resident in her bed patting him on the buttocks and rubbing his abdomen and chest he was removed from the room. Signed by LVN B. 3. Record review of Resident #3's Admission Record/Information Sheet indicated he was a [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's MDS, dated [DATE], indicated his BIMS was a 4 (which indicated severely impaired cognition). He had behaviors of wandering that occurred daily. His balance during transition and walking the resident was able to move from seated to standing positions, walking and turn around with supervision only and the resident did not utilize any mobility devices. Record review of a Psychiatric Services note, dated 10/26/21, indicated Resident #3's concentration and attention span were impaired. Record review of Resident #3's nurses notes, dated 3/19/22, indicated Resident #3 wandered up and down the halls all night going into women's rooms. The resident was not easily redirected, brought him back to the front to watch television but he would go back down the hall into the rooms again resident did not sleep at all. Record review of a nursing note dated 4/19/22 at 10:32 a.m., indicated the nurse was called to the unit by an aide. The aide separated the resident from a female he was trying to put his hand on her inappropriately. Keep them separated through the day. Signed by LVN B. Record review of a Psychiatric Services note, dated 4/22/22, indicated a nurse reported sexually inappropriate behaviors. Resident #3 shoved a female resident against the wall yesterday and put his hands in her pants. This was reported to the state no injuries to the resident, he was delusional believed the females on the unit were his wife the duration of the encounter 5 minutes. Record review of Resident #3 care plan with a focus area, dated 7/28/21, indicated the resident had impaired cognitive function with dementia without behavior disturbances of impaired thought processes in Alzheimer's disease with the BIM of 4. Some of the interventions were to engage residents simple structured activities that avoid overly demanding tasks. Keep the residents' routine consistent and try to provide consistent caregivers as much as possible, monitor, document, report to MD any changes in cognitive function specifically changes in decision making ability memory recall. A focus area, dated 2/23/22, indicated the resident had the potential to demonstrate abusive behaviors with staff. Some of the interventions were intervene before agitation escalated. Remove the resident away from source of distress, engage calmly in conversation. A focus area, dated 4/20/22, sexually inappropriate as evidenced by the resident was placed on one to one for 8 hours some of the focused areas where the residents ability to understand behavior and consequences of the behavior and explain to the resident the expressions of sexuality based on cognitive evaluation. Record review of a Discharge Summary, dated 4/22/22, indicated a brief history was the resident had Alzheimer's disease and wandered. He was on the memory care unit, he was in good condition at discharge and he was discharged with his medications and personal belongings. 4. Record review of Resident #4's Admission Record/Information Sheet indicated he was a [AGE] year-old male admitted to the facility on [DATE]. He had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of an elopement risk assessment, dated 12/27/21, indicated Resident #4 was able ambulate independently and he was on the secure unit. Record review of Resident #4's physicians orders, dated 1/4/22, indicated to admit to the secure unit due to a history of elopement with active exit seeking. Record review of Resident #4's MDS, dated [DATE], indicated Resident #4 had a BIMS score of 2 (which indicated severely impaired cognition). He had behaviors of wandering that occurred daily. The residents balance during transition and walking was not steady but able to stabilize without staff assistance when moving from seated to standing, walking, turn around moving on and off surfaces. Record review of Resident #4's care plan indicated a focus area, dated 12/28/21, of cognitive function unspecified dementia without behavioral disturbances or impaired thought processes with a BIMS of 2. Some of the interventions were engage the resident in simple structured activities that avoided overly demanding tasks. To monitor, document, and report to the MD any changes in cognitive function. Specifically changes in decision making ability, memory, recall and general awareness difficulty expressing self-difficulty and understanding others the level of consciousness and mental status. A Focus area, dated 2/8/22, with a behavior of showing affection towards other residents. Some of the interventions were evaluate the residents' ability to understand behavior and consequences of the behavior. Explain to the resident the acceptable expressions of sexuality based on the cognitive evaluation. Reinforce with staff that clear firm limits were healthy and required when residents made inappropriate gestures or statements. The resident continued to sit close to other female residents on the couch. Staff were in-serviced on behavioral approach designed to effectively manage and acceptable sexual advances and avoid self-disclosing personal information. Record review of a behavioral health diagnostic assessment, dated 3/24/22, indicated Resident #4 was assessed and the symptoms supported a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The patient kept looking around the room as if searching for something but unable to clarify. The only valid screening was for cognitive cognition as patient clearly had significant impairment regarding sexual inappropriateness correction. He needed immediate redirection. The patient lacked the cognitive skills and meaning to listen to instruction, integrate information, and apply to situations requiring judgment decision making. Therapy was not started for those same reasons. The treatment plan was no therapies recommended, target symptoms for treatment sexual acting out. Record review a Resident # 4's nursing notes, dated 2/8/22 at 2:13 p.m., indicated the CNA called the nurses station approximately 1:30 p.m. regarding an issue with two residents. Upon entering memory unit noted Resident #4 was occupied in another Resident's room. He was laying in big bed having inappropriate sexual behavior. Resident #4 undressed only wearing orange T shirt and adult boxer briefs. The female resident was fully dressed in pants, shirt and shoes. Resident #4 was engaged in kissing the female resident's right side of the neck, stroking the residents' legs, when the nurse entered the room. The nurse interrupted activity while informing both residents that it was inappropriate behavior. Both needed to be in their room the nurse escorted Resident #4 to his room. A CNA was put on one on one by the door. Called the DON and spoke with ADON regarding this issue will continue to monitor. Signed by an Agency nurse. Record review of nursing notes, dated 2/8/22, indicated the ADON followed up with the agency nurse and educated her on the difference between inappropriate sexual behavior and intimate affection. The nurse verbalized understanding. Written by ADON. Record review of a nursing note dated 3/16/22 at 12:41 a.m., indicated the aide called nurse to the unit. When the nurse arrived Resident #4 was touching Resident #1's breast. They were immediately separated and educated CNA to keep the two away from each other as much as possible the nurse to educate resident not to touch her breasts no physical harm occurred to female resident. Signed by Agency nurse. Record review of a nurses note, dated 5/1/22 at 12:54 a.m., indicated Resident #4 wandered throughout the unit going from room to room. He was in another resident's room but refused to get out of the bed. Staff were able to coach him out by telling him his boots were down the hall in another room. He would try to swing at staff. Continued to assist with toilet related to the resident was unable to find the bathroom and wandered into females' rooms with ladies in the bathroom. Signed by LVN B. Record review of a progress note, dated 5/3/22 at 10:18 a.m., indicated Resident #4's responsible party called and notified her of behaviors last night. The SW asked that she seek a male secured unit placement she asked for suggestions. Signed by SW 5. Record review of Resident #5 MDS indicated he was a [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated he had a BIMS score was a 2 (which indicated a severely impaired cognition). Resident #5 had behaviors of wandering that occurred daily. His balance during transition and walking indicated he required assistance with moving from seated to standing. He was not steady with walking and turning but stabilized without staff assistance. Record review of Resident #5's care plan indicated he had a focus area of at risk for wandering, dated 10/7/21. One of the interventions was the resident would reside in the secure unit. Resident #5 had a focus area of impaired cognition function due to senile degeneration of the brain and impaired thought processes. One of the interventions was to encourage the resident in simple structured activities that avoided overly demanding tasks. Record review of Resident #5 physician order, dated 1/4/22, indicated he had to be admitted to the secure unit due to a history of elopement and exit seeking behaviors. During an interview on 5/16/22 at 11:05 a.m., a family member said a family member was at the facility for 7 months and was harassed by an overly sexual female resident the entire time. The resident was enticed and teased by the female resident. The family member said she had pictures of her hugged up with the resident. The family member said she was not seen doing any inappropriate touching but she was seen sitting on Resident #3's lap. The family member stated it was the female resident who was the aggressor, however, the family member was the one who was discharged due to inappropriate behaviors. The family member said in a later interview, the female resident's behaviors were so bad and her constant touching, and kissing was just too much. The family could not visit without her interference. When the family member visited, they had to take the resident off the unit. The family member said staff were always on the unit but acted like the female resident behaviors were an everyday occurrence. They never intervened when she was all over the family member. The family member said they told the nurse to try and keep her away from his family member because it would be an issue sooner or later. During an interview on 5/16/22 at 1:19 p.m., NA A said he worked at the facility for about 5 months. He worked on the secure unit sometimes. Resident #1 was very sexual in her behaviors. She raised up her blouse or opened her blouse. Then she would try and put men's hands on her breast. She would try to hug men, so their face was in her naked chest. The NA said he saw her rub on Resident #5's leg and he would tell her to leave him alone. It was not just a friendly rub on the leg, it was in an inappropriate way. He had seen her be inappropriate with Resident #4 by placing his hand on her breast. The NA said he had never seen her be inappropriate with Resident #3. On the date of the incident, 4/19/22, Resident #1 and Resident #3 were holding hands and walked down the hallway. He caught them in a room once that day. At that time Resident #3 was behind Resident #1 with his arms around her body and she was leaned into him. On the next occasion he found them in a room. Resident #3 had Resident #1 pushed up against the wall. He was behind her with his hand in her pants. He had one of her arms pinned to the wall. At this time Resident #1 appeared afraid, she had tears in her eyes and seemed even more confused. He said at lunch time he had a hard time getting her to eat. However, after lunch all was forgotten and she was back to her normal self. The NA said he was trained on behaviors and he was trained to get the nurse. That was what he did on 4/19/22. During an interview on 5/16/22 at 1:53 p.m., LVN B said Resident #1 was too friendly with the men, any man. Resident #1 would open her blouse and take a man's head and put their face in her breast area. LVN B said she had seen her touch men in their private parts. Resident #1 would take men by the hand and lead them into rooms and climb into the bed with them. The men did not have the mental capacity to say no. They only had five residents on the locked unit and Resident #5 was the only male. Resident #5 would tell Resident #1 to take her hands off him and go sit down somewhere. She said Resident #3 did fine for a long time. Then about three days prior to his discharge he started to have sexual behaviors. LVN B said she could not say if any of the residents had engaged in actual intercourse or not. She had heard Resident #2 and Resident #4 had, but she had not witnessed it. LVN B said Resident #2 would take a man's hands and put them on her as well. Resident #2 would touch men on their private parts, when she would try and redirect her, Resident #2 would say it made them feel good. She said she charted some of the behaviors and all management would say was keep them apart. She said she saw Resident #4 and Resident #2 in the bed one day. Resident #4 was down to his boxers. She said Resident #4 had Resident #2 and Resident #1 after him. Resident #2's focus was Resident #4. She thought he was her husband. Resident #2 was not as bad as Resident #1, however, since all the men were gone except Resident #5. Resident #5 was now both of their focus, and they were trying to touch, rub and hug on him. So far, he was resistant to their actions. LVN B said she was not worried her old dependable staff were working. They had quite a few new staff or agency staff and they were not always dependable to keep the residents separated. During an interview on 5/16/22 at 2:16 p.m., NA C said she worked on the unit for about 2 weeks. She saw Resident #2 touching and feeling on men, Resident #4 in particular. She would lead him to a room. She was going to try and kiss him one day, but she was moved. Resident #4 was discharged to another facility. During an interview on 5/16/22 at 2:19 p.m., CNA D said she had worked at the facility for about a year. She said Resident #3 would rub on arms and try to rub towards female breast area. He would stop if redirected. She said Resident #2 was very inappropriate, touching, kissing, rubbing, hugging when Resident #4 was still at the facility. CNA D said if she tried to redirect Resident #2 or separate her from Resident #4. Resident #2 would become aggressive. During an interview on 5/16/22 at 3:02 p.m., the Administrator said the facility discharged Resident #3 for sexual misconduct on the secure unit. Resident #3 stuck his hands down a female residents' pants. Resident #4 was discharged because of the same behavior. The Administrator said there was no distress with the female patient involved with Resident #4. He said there was some distress with the female resident involved with Resident #3. He said from what the staff told him. He said the SW would have the details she took care of Resident #4's discharge. During an interview on 5/16/22 at 3:50 p.m., the SW said she had written the note on 5/3/22 because Resident #4 and a female on the secure unit were kissing and holding hands. There was no hot zone touching that staff were aware of. He was redirected. Resident #4 was married, and his wife was very realistic and reasonable. The wife said Resident #4 had always been highly sexual. There was nothing sexual going on between Resident #4 and Resident #2 just some petting is what she was told. The SW said she was not aware of any residents on the secure unit having intercourse. During an interview on 5/16/22 at 4:24 p.m., CNA F said she worked at the facility for two years. She said Resident #1 was a follower, and Resident #2 got Resident #1 started on the inappropriate behaviors. Resident #2 was a hands-on type person. She would try to put a man's hand under her shirt. Resident #2 would try to go in men's rooms. She started a few of months ago. CNA F said Resident #2 had sexual intercourse with Resident #4. She said she did not witness it. The aide started to cry, she said she did not want to be fired. She did not know the State Surveyor did not know. CNA F said she heard from some aides on the night shift but would not say who. She was visibly upset. During an interview on 5/16/22 at 4:52 p.m., the ADON said Resident #1 was care planned that she exposed herself to residents. The ADON said she never saw her do anything inappropriate and as far as she was aware, she did not have any sexually inappropriate behaviors. She had never seen Resident #2 do anything inappropriate, she thought the men were her husband. Resident #2 did have a husband. The ADON said no one on the unit had intercourse. Resident #3 was the only one that exhibited inappropriate behaviors, and he was transferred. Resident #3 touched Resident #1 inappropriately. On the next day he was sent out because he exposed himself to a staff member. The ADON said she was not sure why Resident #4 was sent to another facility; she was on vacation. He may have been seen in a resident's room stroking a resident leg. She said she was not for sure. During an interview on 5/17/22 at 2:15 p.m., CNA E said Resident #4 was touchy feely (liked to hold hands and rub on arms and legs), and they had to keep him from touching inappropriately. Resident #5 would not touch, he just wanted to be left alone. Resident #1 would rub on men's legs, try to take men to a room. Resident #4 touched on women, rubbed on legs and held hands. Resident #4's behaviors were toward all the women, not just Resident #2. Resident #3 would touch and try to kiss on women. Things like that have been going on the secure unit for some time. The residents exhibited sexually inappropriate behaviors, and everyone knew about those behaviors. She said they were told to stop the behaviors and report it to the nurse. During an interview on 5/17/22 at 2:25 p.m., LVN B stated the female residents had targeted Resident #5 since he was the only man left. Resident #1 sought him out and appeared to have set her sights on him. The LVN said she thought if a women had short hair like a man Resident #1 would target her as well. LVN B said the residents on the secure unit were not able to make decisions about what was right or wrong. The LVN said they had dementia, and were in a closed environment. She said Resident #1 and Resident #2 were the aggressors. They would go up to a man, if the staff tell them do not put their hands on them. Then Resident #1 and Resident #2 would say well we will make them feel good. LVN B said they had meetings in January and February 2022 and were told staff needed to split these people up before something happened. Since then, the facility had c [TRUNCATED]

Based on observation, record review, and interview, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for 1 of 7 residents (Resident #1) reviewed for pain management. The facility did not accurately assess Resident #1 for pain when he refused care, despite the knowledge Resident #1 had persistently reported pain during care (incontinent care and repositioning) since 2/16/22. Resident #1 suffered pain since his fall on 2/16/22. He was sent to the hospital on 3/1/22 and was found to have a fractured right hip. This failure could place residents at risk for unnecessary pain, discomfort and decreased quality of life. Findings included: Record review of the physician order summary report dated 3/2/22 indicated Resident #1 was [AGE] years old readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the physician order with a start date of 8/2/21 indicated Resident #1 was to be assessed for pain every shift (every 12 hours). This order was discontinued on 3/1/22 . Record review of the active physician order with a start date of 1/7/22 indicated Resident #1 was to be administered Acetaminophen 325 mg 2 tablets (650mg) every 6 hours as needed for pain. Record review of the active physician order with a start date of 1/7/22 indicated Resident #1 was to be administered [MEDICATION(S)] [MEDICATION(S)] 1mg/ml, 1 ml sublingually every hour as needed for pain. Record review of the MDS dated [DATE] indicated Resident #1 understood others and made himself understood. The MDS indicated Resident #1 had moderate cognitive impairment (BIMS of 8). The MDS indicated Resident #1 rejected care 1-3 days during the 7-day look back period. The MDS indicated he required supervision only with eating. The MDS indicted he required extensive assistance with bed mobility, dressing, and toilet use. The MDS indicated transfers only occurred once or twice during the seven day look back period and required the assistance of at least two staff. The MDS indicated Resident #1 was totally dependent on staff for locomotion in his wheelchair and personal hygiene. The MDS indicated Resident #1's bathing activity was not performed by staff during the 7-day look back period. The MDS indicated Resident #1 was always incontinent of bowel and bladder. The MDS indicated Resident #1 had not received a scheduled pain management regimen; had not received or been offered PRN (as needed) pain medication; and had not received a non-medication intervention for pain; during the 5-day look back period. The MDS indicated Resident #1 was asked Have you had pain or hurting at any time in the last 5 days?- and indicated his response was 'no'. Record review of Resident #1's care plan , reviewed on 1/30/22, indicated Resident #1 was on pain medication therapy. The care plan interventions included administer medication as ordered, monitor for respiratory depression, monitor for altered mental status. The care plan included no additional interventions regarding pain management. Record review of the nursing note on 2/16/22 at 3:55 a.m., indicated Resident #1's family member called the facility to inform them Resident #1 had fallen out of the bed. The note indicated Resident #1 was found on his right side with his arm behind him. The nursing note indicated Resident #1 complained of pain to his right arm and hip. The nursing note indicated Resident #1 was sent to a local hospital for evaluation. This note was completed by LVN F. Record review of Resident #1's TAR (treatment administration record) for 2/16/22 indicated his pain level was 2 on the 0-10 pain scale on the 6am-6pm shift. Record review of the nursing note dated 2/16/22 at 2:00 p.m., indicated Resident #1 had returned from the local hospital and was administered 650 mg of Tylenol for pain he rated at a 4 on 0-10 scale (0 being no pain at all). Record review of Resident #1's nursing note on 2/16/22 at 7:27 p.m., indicated he denied pain. This note was completed by LVN F. Record review of Resident #1's TAR for 2/16/22 indicated his pain level was a 2 on the 0-10 pain scale on the 6pm-6am shift. Record review of Resident #1's TAR for 2/17/22 indicated his pain level was a 0 on the 0-10 pain scale on the 6am-6pm shift. Record review of the Nursing note on 2/17/22 at 10:28 pm indicated Resident #1 had no signs or symptoms of pain. This note was written by LVN K. Record review of Resident #1's TAR for 2/17/22 indicated his pain level was 0 on the 0-10 pain scale on the 6am-6pm shift. Record review of the pain assessment on 2/18/22 at 7:11 a.m., indicated Resident #1 reported pain of 0 on 0-10 scale. Record review of Resident #1's nursing note on 2/18/22 at 1:15 p.m., indicated a CNA had reported to the charge nurse Resident #1 refused incontinent care and stated he had just got comfortable. The nursing note did not indicate the Resident was assessed for pain. This note was written by LVN K. Record review of the pain assessment on 2/18/22 at 8:55 p.m. indicated Resident #1 reported pain of 0 on the 0-10 pain scale. Record review of the pain assessment log indicated there were no pain assessments between 7:11 a.m. and 8:55 p.m. on 2/18/22. Record review of Resident #1's TAR for 2/19/22 indicated his pain level was a 2 on the 0-10 pain scale on the 6am-6pm shift. Record review of Resident #1's TAR for 2/19/22 indicated his pain level was 2 on the 0-10 pain scale on the 6am-6pm shift Record review of Resident #1's TAR for 2/20/22 indicated his pain level was a 2 on the 0-10 pain scale on the 6am-6pm shift. Record review of Resident #1's TAR for 2/20/22 indicated his pain level was 2 on the 0-10 pain scale on the 6am-6pm shift. Record review of Resident #1's TAR for 2/21/22 indicated his pain level was a 1 on the 0-10 pain scale on the 6am-6pm shift. Record review of Resident #1's TAR for 2/21/22 indicated his pain level was 2 on the 0-10 pain scale on the 6am-6pm shift. Record review of the pain assessment on 2/22/22 at 11:00 a.m., indicated Resident #1 reported pain of 0 on the 0-10 pain scale. Record review of the nursing note dated 2/22/22 at 1:06 p.m., indicated Resident #1 refused incontinent care. This note was written by LVN F. The nursing note did not indicate Resident #1 was assessed for pain. Record review of the nursing note dated 2/22/22 at 5:11 p.m., indicated Resident #1 was still refusing incontinent care. This note was written by LVN F. The nursing note did not indicate Resident #1 was assessed for pain. Record review of the pain assessment log indicated there were no additional pain assessments on 2/22/22. Record review of the TAR for Resident #1 from 2/22/22 to 2/24/22 indicated he rated his pain (on a 0-10 scale) as followed: *2/22/22 on the 6pm to 6am shift- 0 *2/23/22 on the 6am to 6pm shift- 0 *2/23/22 on the 6pm to 6am shift- 0 *2/24/22 on the 6am to 6pm shift- 0 *2/24/22 on the 6pm to 6am shift- 2 Record review of the nursing note dated 2/24/22 at 10:52 a.m., indicated Resident #1 refused to be repositioned in the bed. The nursing note did not indicate Resident #1 was assessed for pain. This note was written by LVN L. Record review of the TAR for Resident #1 2/25/22 to 2/28/22 indicated Resident #1's was rated (on a 0-10 scale) as followed: *2/25/22 on the 6am to 6pm shift- 0 *2/25/22 on the 6pm to 6am shift- 0 *2/26/22 on the 6am to 6pm shift- 0 *2/26/22 on the 6pm to 6am shift- 0 *2/27/22 on the 6am to 6pm shift- 0 *2/27/22 on the 6pm to 6am shift- 0 *2/28/22 on the 6am to 6pm shift- 0 *2/28/22 on the 6pm to 6am shift- 0 Record review of Resident #1's MAR for February 2022, indicated Resident #1 was not administered [MEDICATION(S)] during the month of February 2022. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 2/28/22 at 12:37 p.m., Resident #1 was sitting in his bed eating lunch. Resident #1 indicated he was supposed to get an x-ray on his right hip. Resident #1 said his hip had been hurting since he fell out of the bed a few weeks ago. Resident #1 indicated the pain was bad when staff tried to move him in the bed. During an observation on 2/28/22 at 1:34 p.m., CNA B provided incontinent care for Resident #1. During the incontinent care CNA B rolled Resident #1 onto his right side. While on his right-side Resident #1 said OH, your breaking my hip! Oh my hip. CNA B said hold on we are almost done. CNA B completed the incontinent care. During an interview on 2/28/22 at 1:45 p.m., LVN A said she regularly took care of Resident #1 on the 6am-6pm shift. LVN A said Resident #1 had fallen out of his bed a few weeks ago. LVN A said his family had called to report he had fallen out of the bed because they have cameras in the room. LVN A said he was sent to the hospital after the fall and returned after the hospital evaluated him. LVN A said Resident #1's family called yesterday (2/27/22) and asked if an x-ray could be obtained of the right hip. She said the family requested the x-ray because since his fall, they (the family) observed on camera that every time staff gave incontinent care or moved him in the bed, Resident #1 would complain of pain to the right hip. LVN A said the CNAs had not reported to her Resident #1 was having pain during incontinent care to his right hip. LVN A said if she knew he was having pain with incontinent care she would have offered him pain medication. LVN A said she could not say what CNAs she worked with since Resident #1 had his fall a few weeks ago. LVN A said CNA B had not reported to her that Resident #1 had pain during incontinent care. LVN A said she had not told the CNAs that Resident #1's family reported he was having pain during incontinent care. LVN A said she was not sure if the CNAs knew about Resident #1's fall a few weeks ago. LVN A said she did not tell the CNAs about the fall because there had just been too much going on and she forgot. During an interview on 2/28/22 at 1:54 p.m., CNA B said she was with a staffing agency. CNA B said she had been working at the facility for approximately 2 weeks. CNA B said Resident #1 had complained of pain to his right hip several days over the past few weeks while being repositioned or receiving incontinent care. CNA B said she had reported these complaints of pain to the charge nurse. CNA B said she could not say who (which nurse) she reported to each time, but knew she had reported Resident #1's complaints of pain to LVN A within the past 2 weeks. CNA B said she was not aware Resident #1 had fallen out of the bed a few weeks ago. CNA B said she had did not know if LVN A had offered pain medication when she reported to her (LVN A) that Resident #1 complained of pain. CNA B said if LVN A had given medication with the plan to try the care again later it was not communicated to her. During an interview on 3/1/22 at 10:00 a.m., RN C said she took care of Resident #1 regularly on the 6am-6pm shift. RN C said Resident #1 routinely refused incontinent care. RN C said when the CNAs reported to her Resident #1 refused care she can usually talk him into it. RN C said Resident #1 has reported pain with incontinent care to the right hip in the past but would usually permit her to complete care. RN C said she had provided Tylenol for his complaints of pain in the past. She stated Resident #1 had a x-ray yesterday (2/28/22). Record review of the mobile x-ray report for Resident #1's right hip dated 2/28/22 stated Ostopenia (reduced bone mass) and [CONDITION(S)] disease no acute pathology. During an interview on 3/1/22 at 10:24 a.m., CNA D said Resident #1 often refused care. CNA D said he had reported right hip pain in past few weeks and she notified the charge nurse each time. CNA D said some nurses are better than others about checking on the residents when CNAs report issues. During an interview on 3/1/22 at 10:24 a.m., CNA E said Resident #1 had refused care as long as she could remember. CNA E said in the last week he complained about the hip consistently. She clarified, every single time care was provided (incontinent care) Resident #1 complained his hip was broke. CNA E said an x-ray of the hip was completed and the hip was not broke. CNA E said Resident #1 would sometimes refuse to have incontinent care or be repositioned in the bed, but said most of the time he could be convinced to allow the care. During an observation on 3/1/22 11:03 a.m., RN C and CNA E attempted to provide incontinent care to Resident #1. When RN C told Resident #1 they were going to provide incontinent care he indicated he did not want the care provided until after lunch. RN C asked if she could check his brief, CNA E attempted to reposition Resident #1 so RN C could check his brief. With the movement Resident #1 cried out you're going to break my legs. RN C persisted to attempt to convince Resident #1 to allow the care. She contacted the RP (resident representative) to inform them of Resident #1's refusal. Resident #1 said he was hurting and maybe after lunch. RN C told Resident #1 she could give him some medication and they could try to do the care later. Resident #1 agreed to this. Record review of Resident #1's MAR for March 2022 indicated Resident #1 was administered 650 mg of Tylenol by mouth on 3/1/22 at 11:20 a.m. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's MAR for March 2022 on 3/1/22 indicated Resident #1 reported his pain at a 9 on scale of 0-10 at 12:16 p.m. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the nursing note for Resident #1 on 3/1/22 at 12:47 p.m., indicated he was transferred to a local hospital emergency room for evaluation due to uncontrolled pain. During an interview on 3/1/22 at 5:05 p.m., Resident #1's family member said she called and reported to the facility on [DATE] that Resident #1 was complaining of pain to his right hip every time he was provided care (incontinent care or repositioning) since his fall on 2/16/22. Resident #1's family member said they knew Resident #1 was complaining of pain with each attempt of care because there were cameras in room and one of the cameras (directly pointed at the resident) recorded continuously. During an interview on 3/1/22 at 11:00 p.m., LVN F said she regularly took care of Resident #1 on the 6pm-6am shift. LVN F said CNAs had not really reported to her that Resident #1 was having pain during incontinent care. LVN F clarified, since Resident #1's fall on 2/16/22 she had been notified Resident #1 had aches and pains with care (incontinent care). LVN F said that was to be expected after a fall having occurred. LVN F said she had not given any pain medications to Resident #1 since his fall because he had not asked for medication . LVN F said she was told at least once a shift that Resident #1 refused incontinent care. LVN F said he refused care before the fall. During an interview on 3/1/22 at 11:30 p.m., CNA G said she regularly took care of Resident #1 on the 6pm-6am shift. CNA G said Resident #1 routinely refused incontinent care and would always say things like your breaking my back when care was attempted. CNA G said Resident #1 saying such things was not a new occurrence. She indicated while Resident #1 complained of pain within the last 2 weeks, Resident #1 had voiced these types of complaints long before 2/16/22. CNA G said she would let the nurse know (usually LVN F) when Resident #1 refused care and/or complained of pain. CNA G said LVN F's response was usually he does that. CNA G said she had did not know if LVN F had offered Resident #1 any pain medication after she reported he had refused care/reported pain. Record review of the hospital emergency room Medicine- History and Physical (H&P) dated 3/1/22 indicated Resident #1 reported to the emergency room physician he had a fall and had been hurting since the fall. The H&P indicated Resident #1 reported the pain was in his right hip. The hospital Medical Surgical Unit, Hospital Medicine -History and Physical dated 3/1/22 stated .Principal Problem: closed right hip fracture .HPI: (history of present illness) .Evaluation in the ER (emergency room ) with CT (computed tomography scan is a medical imaging technique used in radiology to obtain detailed internal images ) scan demonstrated possible right hip fracture, evaluated by orthopedic surgery who plan to take him to the OR (operating room) tomorrow (3/2/22) for a percutaneous (any medical procedure or method where access to inner organs or other tissue is done via needle-puncture of the skin, rather than by using an open approach ) procedure such as pinning . During an interview on 3/2/22 at 12:11 p.m., ADON H said the facility had been without a DON for a while. The ADON said the interim corporate DON was on vacation and not available for interview. ADON H said pain assessment should be performed at least every shift (every 12 hours). ADON H said if a nurse was informed by a CNA a resident complained of pain during care, the nurse should assess the resident at that time and offer pain medication. ADON H said if pain medication was administered the nurse should follow up and ensure the medication was effective. She said if the medication was ineffective, or a pattern of pain was recognized the nurse should notify the physician. ADON H indicated nurses not following up on CNAs reports that residents had pain could result in unmanaged pain for residents and residents suffering discomfort. ADON H said the morning stand up meeting was the system in place to ensure resident pain needs were addressed. ADON H said these meetings was a system of ensuring residents received appropriate care/services for pain management were dependent on the nurses' assessments of the residents. ADON H said there was no system in place to ensure CNA's reported pain to nurses; and ensure nurses assessed pain when CNA's reported resident complaints of pain. During an interview on 3/2/22 at 12:27 p.m., ADON J said pain assessment should be performed at least every shift (every 12 hours). ADON J said if a nurse was informed by a CNA a Resident complained of pain during care, the nurse should assess the resident at that time and offer pain medication. The ADON said if pain medication was administered the nurse should follow up and ensure the medication was effective. She said if the medication was ineffective, or a pattern of pain was recognized the nurse should notify the physician. ADON J said she did not thing know Resident #1's refusals of care had anything to do with pain. ADON J indicated nurses not following up on CNAs reports that residents had pain could result in unmanaged pain for residents and residents suffering discomfort. ADON J said there was no system in place to ensure nurses assessed Resident pain beyond the required once a shift. The Administrator was not available for interview 3/2/22. Record review of the facility policy and procedure titled, Pain Management revised 5/25/16 stated, Pain is a subjective sensation of discomfort derived from multiple sensory nerve interactions generated by physical, chemical, or psychological stimuli. Complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility .Procedure (1) Assess resident's physical symptoms of pain, physical complaints, and daily activities .

Based on observation, interview, and record review the facility failed to ensure the resident's environment remained as free of accident hazards as is possible for 1 of 9 residents reviewed for transfers (Resident #8). The facility failed to ensure NA D, NA F, and NA G were properly trained on gait belt transfers. The facility failed to ensure NA F and NA G did not cause a skin tear to Resident #8. These failures could place residents who required assistance with transfers at risk for discomfort, pain, and injury. Findings included: Record review of the consolidated physician orders dated 1/21/22 revealed Resident #8 was [AGE] years old, female and admitted on [DATE] with diagnoses including senile degeneration of brain (decline in cognitive and physical health), contracture (fixed tightening of muscle, tendons, ligaments, or skin) to right and left ankle, [CONDITION(S)] (brain disease that alters brain function or structure), chronic obstructive pulmonary disease ([MEDICATION(S)] of the airways), dementia, heart failure (heart does not pump enough blood), and difficulty in walking. Record review of the MDS dated [DATE] revealed Resident #8 was understood and usually understood others. The MDS revealed Resident #8 had severe cognitive impairment with a BIMS of 3 and required limited assistance for dressing, supervision for eating, extensive assistance for personal hygiene, and total dependence for bathing. The MDS revealed Resident #8 was limited assistance for bed mobility and transfer and total dependence for locomotion on and off the unit. The MDS revealed Resident #8 had minimal difficulty hearing with the use of hearing aids, clear speech, and impaired vision with use of corrective lenses. The MDS revealed Resident #8 was not steady, only able to stabilize with staff assistance for moving from seated to standing, moving on and off toilet, and surface -to-surface transfer. The MDS revealed Resident #8 had impairment on one side of the upper extremities and impairment on one side of the lower extremities. The MDS revealed Resident #8 used a wheelchair for mobility. Record review of the care plan dated 1/3/22 revealed Resident #8 had impaired cognitive function/senile degeneration of brain or impaired thought process. The care plan revealed Resident #8 was a fall risk/actual fall due to dementia with the unawareness of safety, muscle weakness and lack of coordination. Interventions included ensure resident is wearing appropriate footwear and staff assistance x 1 with transfers. The care plan revealed Resident #8 had potential/actual skin integrity related to fragile skin to left and right lower legs. Intervention included use caution during transfer and bed mobility to prevent striking arms, legs, and hands against sharp and hard surfaces. The care plan revealed Resident #8 had electronic monitoring device in room. The care plan revealed Resident #8 had ADL self-care deficit. Interventions included assist with personal hygiene as required, bed mobility required staff x 1 assistance, resident requires a lift for all transfers, resident uses a wheelchair, the resident is total dependence for toilet use, resident requires 1-2 staff with transfers, and resident requires mechanical aid with use of transfer pivot disc. The care plan revealed Resident #8 had a terminal prognosis and/or received hospice services initiated on 2/26/20. Record review of a nurse's note written by the ADON dated 1/14/22 at 10:40 p.m., revealed CNAs reported to the ADON while transferring Resident #8, her right leg rubbed against the bed and tore her skin. The ADON assessed Resident #8 and found a 5.1 cm skin tear noted. She cleaned the skin tear with normal saline and left it open to air. No documentation of pain assessment after incident. Record review of a nurse's note written by LVN E dated 1/15/22 at 12:41 p.m., revealed LVN E notified the hospice nurse that Resident #8 received a skin tear to right lower extremities on the 6p-6am shift during transfer from wheelchair to bed. During an observation on 1/20/22 at 1:32 p.m. of date stamped 1/9/22 at 1:57 p.m. ring video with audio and visual revealed Resident #8 sitting in her wheelchair with NA D in front of her. NA D is visualized and heard on the ring video. NA D partially lifted Resident #8 out of her wheelchair using the back of her pants and gait belt. Resident #8 's wheelchair is was seen moving when Resident #8 was partially lifted by NA D. NA D stated, that did not work, oh the gait belt is big as I don't know what! NA D is visualized attempting to rotate Resident #8 to her recliner but gets caught on something and starts to slide in her slippers and placed her back in the moving wheelchair. During an observation on 1/20/22 at 7:35 p.m. of date stamped 1/14/22 at 9:34 p.m. ring video with audio and visual revealed Resident #8 sitting in her wheelchair with NA F and NA G in the room. Resident #8 is facing her bed at an angle with NA G in front of her with Resident #8's arms around her neck. NA F is was on the left side of Resident #8. NA G lifted Resident #8 partially out of the wheelchair with no gait belt visualized. Resident #8 beginnings began to slide with her legs underneath the bed frame. NA G struggled to rotate Resident #8 and the wheelchair tipped back. NA G continued to struggle with Resident #8 and NA F stated, her legs. NA G placed Resident #8 on the edge of the wheelchair. NA F gets got behind the wheelchair and puts placed both arms underneath Resident #8 arm and pulled her fully back in the wheelchair. NA F turned Resident #8's wheelchair sideways next to the bed. NA G get got in front of Resident #8, instructed her to hold on tight and lifted her again with no gait belt visualized. NA G rotates Resident #8 towards her bed and NA F holds helps guide her from the back. Resident #8 upper body was placed on bed, on her side and NA G swings her lower legs on the bed. NA F moved the wheelchair next to the recliner. NA F returned back to the bed and looked at Resident #8's legs. NA F stated, oh, oh, that is not good! Resident #8 had a skin tear on her right shin with blood running down her leg. NA G sat on the foot of Resident #8's bed and looked at her legs. NA F grabbed something and wipes Resident #8's right leg. Resident #8 spoke but it was unable to understand what she said was not able to be understood. NA G removed Resident #8's socks. NA F left the room. During an interview on 1/21/22 at 10:11 a.m., LVN B said Resident #8 needed a gait belt for transfers. She said Resident #8 should be assisted x 2 people. LVN B said she did not know about her recent injury. LVN B said before transferring, CNAs should ensure the wheelchair is was locked, gait belt secured, and proper alignment. Improper transfers put residents at risk for bumps, bruise, and skin tears. During an interview and observation on 1/21/22 at 11:27 a.m., ADON H said staff should use a gait belt every time they transfer a resident no matter the required number staff needed. She said transferring without a gait belt placed residents at risk for injury because its unsafe. ADON H said all staff were trained on proper transfer. ADON H reviewed the ring video footage stamped 1/9/22 at 1:57 p.m., she said NA D was in the video and not using the gait belt properly. ADON H then reviewed ring video footage stamped 1/14/22 at 9:34 p.m., she said NA F and NA G were in the video. She said neither NA used a gait belt or the pivotal floor device Resident #8's family member purchased for transfers. ADON H said NA F pulled Resident #8 back in the wheelchair underneath her arms which was not correct. During an interview on 1/21/22 at 11:53 a.m., CNA C said a gait belt should be used for most residents, but we do not use one for Resident #8. CNA C said she knew it was important to use a gait belt to prevent injury. During an interview and observation on 1/21/22 at 12:27 p.m., NA D confirmed she was in the video footage stamped 1/9/22 at 1:57 p.m. She said she transferred Resident #8 with a loose gait belt. NA D said improper transfer could cause injuries like broken bones. During an interview on 1/21/22 at 1:26 p.m., LVN E said staff should use a gait belt and pivotal transfer disc (disc facilitates body rotation with minimal amount of physical exertion) to transfer Resident #8. She said she has seen CNAs transfer Resident #8 without a gait belt. LVN E said when she sees staff not using a gait belt for transfers, she instructions them to use one. She said improper transfers could cause skin tears and fractures. During an interview and observation on 1/21/22 at 2:31 p.m., NA F said Resident #8 was a two-person assisted. She said she has seen staff members grab Resident #8's pants to transfer her. NA F said she learned by watching other CNAs and NAs. She said she learned from watching NA A transfer Resident #8 by her pants with no gait belt. NA F said she has not had proper training on transferring with gait belt. NA F confirmed herself and NA G were in the video footage stamped 1/14/22 at 9:34 p.m. in Resident #8's room. NA F said NA G tried to transfer Resident #8 with one-person assistance and she had socks on which caused her legs to slip under the bed. She said Resident #8 got the skin tear on her leg from the transfer. NA F said we put Resident #8 back in her wheelchair and transferred her with two people but still no gait belt. She said she notified LVN B of the incident, and she said it looked like an old wound that the scab came off. NA F said we wear gait belts but do not know how to use them. She said not using gait belts for transfers or not knowing how to use a gait belt could get someone hurt. During an interview on 1/21/22 at 2:53 p.m., NA A said she had worked at the facility on and off for 4 years. She said she had not received training after she came back the last time. NA A said we should use a gait belt for one-person transfers and make sure the wheelchair is was locked before moving the residents. She said she had transferred residents without a gait belt and grab the back of their pants. NA A said improper transfer could hurt the residents and herself. She said she broke a resident's rib doing an improper transfer. NA A said she got training on the proper way to use a sliding board for transfer but not a gait belt. During an interview on 1/21/22 at 3:25 p.m., the ADON said staff members should use a gait belt and lock the wheelchair brakes with all transfers. She said improper transfers could cause a resident to get hurt. The ADON said everyone was responsible for ensuring CNAs were doing safe transfers. During an interview on 1/21/22 at 4:36 p.m., the Admin said he expected all residents to be transferred safely. He said improper transfers could cause falls, broken bones, or skin tears. The Admin said improper transfers could hurt the CNAs too. During an interview on 1/21/22 at 4:48 p.m., the ADON said NA F and NA G were both newly hired the end of December and beginning of January and had not done the non-certified nurse aide competencies. She said ADON H was primarily responsible for training nurses aides. Record review of weekly skin assessment dated [DATE] revealed Resident #8 had a 5.1 cm right front shin-healing skin tear with steri-strips intact on lower right shin. The skin assessment on 1/20/22 was observed by this surveyor. Resident #8 could not recall how did obtained the skin tear on shin. Record review of a facility moving a resident policy dated 2003 revealed, .to provide for safe transferring of the resident .if transferring the resident to a wheelchair .be sure the wheels are locked .position a gait belt around the resident's waist and clasp it .make sure it is tight enough that only a slight hand movement will guide the patient .if resident requires, two persons (one on each side) should grasp the gait belt and gently stand and turn the resident and sit him or her in the chair .if moving a resident from chair to bed .place the chair so it touches the side of the bed and faces the foot of the bed .

Based on observation, interview, and record review, the facility failed to maintain an effective infection control program to help prevent the development and transmission of communicable diseases and infections 4 of 68 residents reviewed for infection control (Resident #s 10, 50, 53, and 48) and The facility did not ensure the staff used proper personal protective equipment (masks, gloves, gowns, and masks) donning and doffing (putting on and taking off) while moving a COVID positive resident to a hot zone (area of isolation for COVID positive residents) The facility did not ensure a resident with known COVID-19 exposure was isolated from residents with no known COVID-19 exposure. The facility did not ensure a resident with no known COVID-19 exposure was not exposed to COVID-19 This failure resulted in an identification of an Immediate Jeopardy (IJ) on 1/3/22. While the IJ was removed on 1/5/22, the facility remained out of compliance at No Actual Harm with Potential for More Than Minimal Harm that is not Immediate Jeopardy with a scope identified as patterned due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. CNA D failed to follow proper procedure or appropriate hand hygiene while providing incontinent care to Resident #53. This failure could place residents at risk for infections, pain, and or hospitalization . Findings included: 1. Record review of facility policy Infection Prevention and Control dated 6/3/21 indicated, .14 days is recommended for those who have had a potential exposure to someone with confirmed COVID-19 or a new readmission to the facility .Residents with known or probable COVID-19 do not need to be placed into an airborne infection isolation room but should be placed in a private room .Any roommates should be moved and monitored for fever and symptoms-warm zone .Quarantine residents with prolonged close exposure, or symptoms, regardless of vaccination status .Quarantine resident with Potential or Confirmed Exposure . Record review of an undated facility policy PPE (personal protective equipment) Use When Positive COVID Residents are in the Facility indicated, .COVID Positive or Suspected Positive .Staff working in this area must wear Gown, Gloves-when providing direct care to residents, N95 mask if available, if not surgical mask, and Face Shield or eye protection when working with COVID positive/suspected patient .If you care for COVID positive patients and suspected COVID positive patients .You must change gown, gloves, and eye protection before moving from COVID positive patients to suspected positive patients. Record review of an undated PPE Use in Healthcare Settings: How to Safely DON, USE, and Remove PPE from the CDC (Centers for Disease Control indicated, .Key points about PPE .DON before contact with the patient, generally before entering the area, Use carefully-don't spread contamination. Remove and discard carefully, prior to leaving the area. Immediately perform hand hygiene . 2. Record review of the consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE] indicated Resident #10 usually understood others and usually made himself understood. The MDS indicated Resident #10 had a BIMS score of 08 indicating mild cognitive impairment. The MDS indicated Resident #10 the residents had wandering behavior daily. The MDS indicated Resident #10 required limited assistance for walking and personal hygiene. The MDS indicated Resident #10 required extensive assistance with bed mobility, transfer, dressing, and toilet use. Record review of the care plan revised on 1/5/22 indicated Resident #10 was at risk for wandering. The care plan indicated Resident #10 had an acute care plan for COVID-19 and required care and isolation precautions related to COVID-19. The care plan indicated interventions included encourage resident to cover his mouth and nose when coughing or sneezing, ensure good infection control measures and personal protective equipment was used when interacting with the resident. The care plan indicated Resident #10 did not maintain social distancing for COVID-19 precautions and was noncompliant with wearing a mask. The care plan indicated interventions included encourage resident to maintain safe social distance for COVID-19 precautions and reinforce use of mask. Record review of Resident #10's lab report for BinaxNOW COVID-19 Ag Card dated 1/3/22 indicated Resident #10 tested positive for COVID-19. Record review of Resident #10's Immunization Report dated 1/3/22 indicated Resident #10 refused the COVID-19 vaccination. 3. Record review of the consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE] indicated Resident #50 usually understood others and usually made himself understood. The MDS indicated Resident #50 had a BIMS score of 08 indicating mild cognitive impairment. The MDS indicated Resident #10 required extensive with bed mobility, transfer, personal hygiene, dressing, and toilet use. Record review of the care plan revised on 10/21/21 indicated Resident #50 was at risk for wandering. The care plan indicated Resident #50 was at risk for signs/symptoms of COVID-19. The care plan indicated interventions included observe for signs/symptoms of COVID-19-document promptly and report signs/symptoms: fever, coughing, sneezing, sore throat, respiratory issues. Record review of Resident #50's lab report for BinaxNOW COVID-19 Ag Card dated 1/6/22 indicated Resident #50 tested negative for COVID-19. Record review of Resident #50's Immunization Report dated 1/3/22 indicated Resident #50 had received 2 doses of the COVID-19 vaccination. The Immunization Report indicated Resident #50 had his first dose of the COVID-19 vaccination on 1/12/21 and his second dose on 2/12/21. 4. Record review of the consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE] indicated Resident #48 usually understood others and usually made himself understood. The MDS indicated Resident #48 had a BIMS score of 04 indicating severe cognitive impairment. The MDS indicated Resident #10 required extensive with bed mobility, transfer, personal hygiene, dressing, and toilet use. Record review of the care plan revised on 1/3/22 indicated Resident #48 was at risk for wandering. The care plan indicated Resident #48 did not maintain social distancing for COVID-19 precautions. The care plan indicated interventions included reinforce use of mask, encourage resident to maintain safe social distance for COVID-19 precautions, and teach and reinforce hand washing. The care plan indicated Resident #48 was at risk for signs/symptoms of COVID-19. The care plan indicated interventions included observe for signs/symptoms of COVID-19-document promptly and report signs/symptoms: fever, coughing, sneezing, sore throat, respiratory issues. Record review of Resident #48's lab report for BinaxNOW COVID-19 Ag Card dated 1/6/22 indicated Resident #48 tested negative for COVID-19. Record review of Resident #48's Immunization Report dated 1/3/22 indicated Resident #48 refused the COVID-19 vaccination. During an observation and interview on 01/03/22 at 11:00 a.m. LVN Q said she was testing Resident #10 for COVID-19 due to being symptomatic. During an interview on 01/03/22 at 11:12 a.m. LVN Q said Resident #10 had tested positive for COVID. During an observation on 1/3/22 at 11:12 a.m. Resident #10 was in his room with the door shut. Resident #50, the roommate of Resident #10, was sitting out in the day area. During an interview on 1/3/22 at 11:38 a.m. the DON said the facility was increasing the hot zone (area in the facility designated for COVID positive residents) on the secured unit by 2 rooms. The DON said Resident #10 would be moved to hot zone. The DON said to extend the hot zone Resident #48 would be moved in with Resident #10's roommate after the room was deep cleaned. The DON said Resident #10 would be moved to the room Resident #48 had been residing in. During an observation on 1/3/22 at 12:10 p.m. the Housekeeping/Laundry Supervisor entered Resident #10's room and exited, pulled down mask to speak to a visitor, and walked up and down the hall without removing his PPE. During an observation on 1/3/22 at 12:23 p.m. the Maintenance Supervisor entered Resident #10's room with furniture [NAME] to move Resident #10's personal belongings to the hot zone. The Maintenance supervisor wore a mask and gloves and did not don the rest of the appropriate PPE. The Maintenance Supervisor loaded Resident #10's recliner, exited room with recliner and [NAME], and delivered it to Resident #10's room on the hot zone. The Maintenance Supervisor continued to have a mask and gloves as his PPE. During an interview and observation on 1/3/22 at 12:24 p.m. the Maintenance Supervisor discarded his gloves and did not perform hand hygiene. The Maintenance Supervisor said when entering a COVID-19 positive area (hot zone) or COVID-19 positive resident's room staff should wear gown, gloves, face shield, and mask. The Maintenance Supervisor said it was important to wear proper PPE to keep from catching or spreading COVID-19. The Maintenance Supervisor said he had entered Resident #10's room without PPE because he was not aware the resident was positive for COVID-19. The Maintenance Supervisor said he would have worn the appropriate PPE had he been aware of Resident #10's positive status. During an observation on 1/3/22 at 12:27 p.m. the Maintenance Supervisor exited the secured unit into the rest of the building without performing hand hygiene. During an observation on 1/3/22 at 12:32 p.m. the Housekeeping/Laundry Supervisor and Laundry R moved Resident #10's personal belongings to his room on the hot zone wearing proper PPE. The Housekeeping/Laundry Supervisor and Laundry R did not doff their PPE before handling Resident #48's personal belongings to move them into his temporary room. During an observation on 1/3/22 12:32 p.m. The room Resident #10 was residing when he tested positive for COVID-19 was not deep cleaned prior to Resident #48's belongings being moved into the room. During an interview on 1/3/22 at 3:09 p.m. the Housekeeping/Laundry Supervisor said when entering a hot zone or the room of a resident that had tested positive for COVID-19 staff should wear full PPE. The Housekeeping/Laundry Supervisor said full PPE consisted of gown, gloves, mask (N95), and eye protection (face shield). The Housekeeping/Laundry Supervisor said PPE should be changed upon leaving the room. The Housekeeping/Laundry Supervisor said PPE should be changed after handling a positive resident's belongings and before handling a negative resident's belongings. The Housekeeping/Laundry Supervisor said he should have changed his PPE after handling Resident #10's belongings and before handling Resident #48's belongings. The Housekeeping/Laundry Supervisor said PPE was worn to prevent the spread of COVID-19. During an interview on 1/3/22 at 3:22 p.m. the DON said the facility was performing outbreak testing and started at 7am this morning. The DON said residents are being tested twice a week. The DON said the roommate of a COVID-19 positive resident was considered a confirmed exposure. The DON said the resident with confirmed exposure should be isolated and considered warm. The DON said full PPE should be worn when moving a positive resident's belongings. The DON said staff should change PPE after handling a positive resident's belongings and prior to handling a negative resident's belongings. The DON said she could not answer as to whether she would move a negative resident in with a warm/exposed resident. The DON said she needed to look at the policy. The DON said she did not who told the Maintenance Supervisor to move furniture or belongings of Resident #10 and Resident #48. During the interview on 1/3/22 at 3:25 p.m. the Maintenance Supervisor said Resident #10 and Resident #50 were roommates. The Maintenance Supervisor said the DON had notified him a resident testing positive for COVID-19 on the secured memory unit and asked him to move Resident #10's belongings into another room. The Maintenance Supervisor said the DON did not tell him if Resident #10 or Resident #50 had tested positive for COVID-19. The Maintenance Supervisor said before he entered their room and was unaware of which resident was COVID-19 positive. The Maintenance Supervisor said a resident who was positive for COVID-19 was isolated, placed in a private room, and had a sign posted with the required PPE needed before entry into the room. During an interview on 1/3/22 at 4:00 p.m. the Administrator said residents were being tested for COVID-19 twice a week. The Administrator said when resident tests positive for COVID-19 their roommate was considered exposed. The Administrator said if a resident was exposed to COVID-19 they would be moved to a warm zone. The Administrator said the facility would not put a cold resident (resident without known exposure to COVID-19) in with a warm resident (resident with known or suspected COVID-19 exposure). The Administrator said staff should change or discard their PPE after handling a COVID-19 positive resident's belonging. The Administrator said wearing proper PPE prevents spread of COVID. During an interview on 1/3/22 at 4:08 p.m. the Medical Director said the facility should isolate the roommate of a COVID-19 positive resident due to known exposure. The Medical Director said the facility should not put a negative resident in to reside with an exposed resident. The Medical Director said not isolating an exposed resident puts the facility at greater risk for COVID outbreak. During an interview on 1/3/22 at 4:21 p.m. LVN Q said the only 2 residents in the secured unit that have been tested for COVID-19. LVN Q said one of the residents had tested negative and was a female hospice patient. LVN Q said the other resident was Resident #10 and had tested positive. During an interview on 1/3/22 at 4:57 p.m. the Housekeeping/Laundry Supervisor said he should have waited for Resident #10's room to be deep cleaned before moving Resident #48 into the room. The Housekeeping/Laundry Supervisor said thing had been hectic and they were trying to hurry to get the room changes made. The Housekeeping/Laundry Supervisor said deep cleaning should have been done to prevent the spread of COVID-19. 4. Record review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the most recent Care Plan dated 12/13/21 revealed Resident#53 had bladder and bowl incontinence. Resident#52 had an impaired thought process. Resident#53's BIMS (brief interview for mental status) score was 5 indicating he was severely impaired cognition. Record review of the most recent MDS (minimum data sheet) dated 12/08/21 revealed Resident #53 was always incontinent of bowel and urine. Observation on 01/04/22 at 11:05 a.m. of incontinent care provided to Resident #53 revealed that CNA D wiped the Resident#53 rectal area from front to back using a new cleaning cloth each time. CNA D then applied barrier cream to Resident#53's buttock area without preforming hand hygiene. CNA D changed gloves but did not perform hand hygiene. Resident#53 was turned over and CNA D changed gloves and proceeded to wipe his groin and genitals from front to back with cleaning wipes. CNA D changed gloves following this care but did not perform hand hygiene. CNA D placed clean brief and clothes on Resident #53, removed her gloves and departed the room without performing hand hygiene. Interview on 01/04/22 at 11:20 a.m. CNA D said she failed to perform hand hygiene after removing dirty gloves and putting on clean gloves. CNA D said she should have performed hand hygiene prior to putting barrier lotion and new brief and clean clothes on Resident #53. CNA D said she was nervous being watched. CNA D said it was important to sanitize hands between going from dirty to clean care to prevent cross contamination. CNA D said she had received training on incontinent care during SNF (Skilled Nursing Facility) training last year. Interview on 01/07/22 at 09:44 a.m. CNA J said when doing incontinent care, CNA J should sanitize hands before and after procedure, and several times in-between. CNA J said performing hand sanitation was important to prevent cross contamination. CNA J said she had been in-serviced on hand hygiene yesterday, 1/6/22. Interview on 01/07/22 at 10:22 a.m. with CNA N said when doing incontinent care, hands should be sanitized every time the nurse assistant comes out of the room. CNA N said sanitizing hands was important to prevent transfer of germs to other residents. CNA N said she received training on when to sanitize hands during an in-service on 1/06/22 and during SNF (Skilled Nursing Facility) training. CNA N said she received training on incontinent care during orientation, and annual refresher training. Interview on 01/07/22 at 4:35 p.m. with the DON said the proper procedure for hand hygiene for incontinent care was to wash hands prior to contact with residents. The DON said once a glove is contaminated, hand hygiene should be performed before performing clean care. The DON said performing hand hygiene is important for infection control. The DON said the ADON and Infection Control Preventionist perform audits to ensure CNA's are properly performing hand hygiene when providing incontinent care to residents. The DON said does check off when a new CNA starts and also does refresher check offs. The DON said CNA's should perform hand hygiene before care, any whenever gloves become contaminated, and after completion of care Interview on 01/07/22 at 4:51 p.m. with the Administrator said he expects hand hygiene to be done properly before and after incontinent care. Record review of the facility's Infection Control Policy and Procedure Manual dated 2019 reflected the it is the policy of this facility to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. The facility will implement hand hygiene (hand washing) practices consistent with accepted standards of practice. Record review of the facility's Nursing Policy and Procedure Manual Perineal Care Male dated 12/08/2009 reflected that it is the policy of the facility for staff to wash hands prior to perineal care to male residents prior to beginning the care. If heavy soiling is present to wear gloves. Wash hands and put on clean gloves prior to perineal care. If at any time your gloves become contaminated with feces, change gloves. Gloves are to be changed when completing perineal care. Rectal area is to be cleaned and to change gloves. Rectal are is to be cleaned and gloves are to be removed. New gloves are put on and barrier lotion is applied. Soiled gloves are removed, and hands are washed. The administrator was notified on 1/3/22 at 5:17 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The administrator was provided the Immediate Jeopardy template on 1/3/22 at 5:23 p.m. The facility's Plan of Removal was accepted on 1/4/22 at 5:22 p.m. and included: Facility quarantined residents exposed to positive cases of COVID-19 on 1/3/2022 Facility staff were instructed to use all required PPE per updated guidance from CMS and CDC dated 12/23/21 while caring for residents COVID-19 positive and residents potentially exposed to COVID-19 The following in-services were initiated by the DON, ADON and regional nurse on 1/3/2022: Any staff member not present or in-serviced on 1/3/2022, will not be allowed to assume their duties until in-serviced. Staff will be Inservice on the following: o DON will be in serviced on Infection Control, Proper PPE Use on Residents Covid-19 positive and residents potentially exposed to COVID-19, and proper Donning /Doffing PPE by Corporate Compliance Nurse 1/4/22 o Inservice staff on Infection Control Overview 1/4/22 o Inservice staff on proper PPE use on residents COVID-19 positive and residents potentially exposed to COVID-19 1/4/22 o In-service staff on proper Donning / Doffing PPE 1/4/22 All Residents are screened daily by charge nurse for signs and symptoms indicative of COVID-19 utilizing the Respiratory screening assessment in the Electronic medical records. DON or designee will monitor daily for compliance 1/4/22 The medical director was notified of the immediate jeopardy situation on January 3, 2022 at 6:02PM Monitoring The DON / designee will observe PPE use by randomly selecting 10 staff members weekly on various shifts x 6 weeks and review monthly in QA The QA committee will review findings and makes changes as needed x 3 month On 1/4/22 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Interviews of staff (5-nurses on the 6:00 a.m.-6:00 p.m. shift; 2-nurses on the 6:00 p.m.-6:00 a.m. shift; 2-Dietary Staff, the Business Office Manager, 2-CMA's on the 6:00 a.m.-2:00 p.m. shift, 1-CNA on the 6:00 a.m.-2:00 p.m. shift, 2-Activities Personnel, 2-Housekeeping Staff, 2-CNA's on the 2:00 p.m-10:00 p.m. shift, the DON, the ADON, 1-CMA on the 2:00 p.m.-10;00 p.m. shift, 2-CNA's on the 10:00 p.m.-6:00 a.m. shift, and the Marketer) were performed. During these interviews' staff stated correctly the appropriate PPE to be worn in COVID-19 positive areas and rooms of COVID-19 positive residents. Staff were able to correctly verbalized proper donning and doffing off PPE. The staff were able to correctly state when residents should be isolated. Record review of the facility in-service log titled Infection Control-COIVD-19 PPE dated 1/4/22 indicated the DON had been in-serviced over appropriate PPE to be worn with suspected and conformed cases of COVID-19, as well as appropriate donning and doffing techniques. Record review of the facility in-service log titled Infection Control-COIVD-19 PPE dated 1/4/22 indicated 25 staff members had been in-serviced over appropriate PPE to be worn with suspected and conformed cases of COVID-19. Record review of the facility in-service log titled PPE-donning/doffing dated 1/4/22 indicated 25 staff members had been in-serviced over appropriate donning and doffing techniques of PPE. Record review of the facility in-service log titled Infection Control Overview dated 1/4/22 indicated 25 staff members had been in-serviced over infection control practices. Record review of the sampled residents EMR for 1/4/22 indicated daily COVID-19 screenings were performed by the charge nurses. Record review of the facility document titled Screening log dated 1/4/22 indicated the DON had initiated review of the residents daily COVID-19 screenings. During observations on 1/4/22 from 8:00 a.m.- 12:00 p.m., 7 staff members were observed donning and doffing correctly when caring for warm and hot residents. Record review of the facility document titled PPE observations dated 1/4/22 indicated the DON had initiated random PPE observations to ensure staff were donning and doffing PPE correctly. On 1/5/22 at 12:40 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to ensure the resident environment remained free of accident and hazards for 2 of 25 residents (Resident #s 17 and 25) reviewed for accident hazards. The facility failed to ensure coffee temperatures were a safe temperature before Resident #17 was served to her coffee. Coffee was spilt spilled on Resident #17 which resulted in a severe burn to her lower abdomen/2nd degree. The facility failed to ensure coffee temperatures were safe before coffee was made available to all residents in the dining area. These failures could place residents at risk of severe injuries. Findings included: 1. Record review of the order summary report dated 1/7/2022, indicated Resident #17 was [AGE] years old, admitted on [DATE] with diagnoses including [CONDITION(S)] (a build-up of fluid in the cavities of the brain), cognitive communication deficit, limitation of activities due to disability, lack of coordination, cerebral infarction (stroke), and convulsions (a sudden, violent, irregular movement of a limb or of the body). Record review of the most recent MDS dated [DATE], indicated Resident #17 usually made herself understood and usually understood others. The MDS indicated Resident #17 required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. The MDS indicated Resident #17 was totally dependent for locomotion on and off the unit. The MDS indicated resident #17 had a BIMS (brief interview for mental status) score of 10 (moderate cognitive impairment). Record review of the care plan dated 4/8/2021, indicated Resident #17 had little or no activity involvement related to physical limitation and resident wished to not participate. The care plan indicated Resident #17 had a stroke related to [CONDITION(S)]. The care plan indicated staff should monitor Resident #17's abilities for activities of daily living and assist resident as needed. Record review of the care plan dated 8/1/2021 indicated Resident #17 had [CONDITION(S)] due to hot liquids with interventions implemented to assist resident with hot liquids, apply [MEDICATION(S)] cream per orders, and to add ice, water or milk to coffee to cool down before drinking. Record review of an incident report dated 8/1/2021, indicated Resident #17 had breakfast coffee and spilled it onto herself. The incident report indicated the physician was notified and orders were received to apply [MEDICATION(S)] cream to the area on the abdomen and right finger. Record review of a weekly skin assessment dated [DATE], indicated Resident #17 had a coffee spill burn to the right lower abdomen, a line of blisters across right abdomen to side measuring 23cm x 4 cm. Record review of a hot liquid assessment dated [DATE] indicated Resident #17 had contractures to the fingers/hands/wrists/elbows and shoulders. Record review of a weekly skin assessment dated [DATE], indicated right lower abdomen burn was healing well, blisters open and much smaller. Measured 23 cm x 4 cm wide of clustered blisters, no signs of infection noted. Record review of a weekly skin assessment dated [DATE], indicated Resident #17 had a right abdomen healing 2nd degree burn with pink epithelial tissue present, dry, and no drainage. The assessment indicated the burn was resolved. During an interview on 1/5/2022 at 11:31 a.m., CMA B said she assisted with serving coffee to residents. CMA B said the coffee served to residents came from the kitchen with breakfast trays. CMA B said if the coffee was steaming it was kept on the cart and cooled with ice prior to serving to the residents. CMA B was unable to recall if she had served coffee to Resident #17 in the past. The CMA B said aides did not temp. coffee. During an interview on 1/5/2021 at 12:00 p.m., CNA C said she served coffee to residents. She said the coffee came from the kitchen with the breakfast trays. CNA C said if the coffee was steaming it was kept on the tray cart and cooled with ice prior to being served to residents. CNA C said aides did not temp coffee prior to serving to residents. During an interview on 12/5/2021 at 2:50 p.m., CNA D said she never re-heated coffee for residents. CNA D said prior to serving coffee she tried to ensure the coffee was not steaming. CNA D said if the coffee was steaming, she would allow it to cool before serving to the residents. During an interview on 1/5/2021 at 2:50 p.m., CNA E said aides did not temp coffee. CNA E said if the coffee was steaming, she would tell the resident to allow the coffee to cool before drinking it. During an observation and interview on 1/5/2021 at 2:45 p.m., Resident #17 said she was burned at the facility several months ago after being served coffee in her bed at breakfast. Resident #17 said the coffee cup toppled over and burned the right side of her lower abdomen. Resident #17 said she did not feel safe pouring her own coffee due to her stroke. Resident #17 said the staff always poured the coffee for her. Resident #17 said sometimes the coffee served at the facility was cold and sometimes the coffee was very, very hot. Resident #17 said some of the aides would re-heat the coffee. Resident #17 said the burn to her lower abdomen was red, raw and open. Resident #17 had two raised scarred areas to the lower right abdomen. Resident #17 said these scars were from the burn she received when the coffee spilled. 2. A face sheet dated 01/07/22 indicated Resident #25 was a [AGE] year-old female admitted on [DATE] with diagnoses of [CONDITION(S)] disorder ([CONDITION(S)] type), lack of coordination, cortical age-related cataract (bilateral), unsteadiness on feet, drug induced subacute dyskinesia (involuntary and erratic movements of the arms and legs) and right shoulder arthritis. An MDS dated [DATE] indicated Resident #25 made herself understood, understood others, and was cognitively intact. Resident #25 was independent with eating and mobility and required limited assistance with bed mobility, transfers, and bathing. Resident #25 used a wheelchair for mobility. A care plan dated 01/04/19 and revised on 03/09/19 indicated Resident #25 required [CONDITION(S)] medications [MEDICATION(S)], and [MEDICATION(S)] for [CONDITION(S)] disorder. The care plan interventions included to administer medications as ordered by the physician and to monitor, record and report to the MD as need side effects and adverse reactions of psychoactive medications: unsteady gait, tardive dyskinesia (uncontrollable, abnormal, and repetitive movements of the face, torso, and/or other body parts), extrapyramidal symptoms (shuffling gait, rigid muscles, shaking). Resident #25 had an alteration in neurological status related to tardive dyskinesia. The care plan interventions included to assess for effects of [CONDITION(S)] meds; [CONDITION(S)] (movement disorder in which your muscles contract involuntarily, causing repetitive or twisting movements), akathisia (movement disorder that makes it hard for you to stay still), akinesia (loss or impairment of the power of voluntary movement), rigidity and tremors. Resident #25 had limited physical mobility. The care plan intervention included wheelchair for locomotion. Resident #25's care plan did not address handling hot liquids. A record review on 01/07/22 revealed there was no documentation of a hot liquid assessment for Resident #25 in her file at this time. During a kitchen observation on 01/05/22 at 10:39 a.m., DA FF and DM brewed a fresh pot of coffee directly into the coffee dispenser. After the coffee was finished brewing the DM poured a cup of coffee and checked the temperature with the kitchen's digital thermometer. The coffee temperature was 166.8 degrees Fahrenheit. During an interview on 01/05/22 at 10:43 a.m., the DM said she has worked in the facility's kitchen for 2 years and took over as the dietary manager 5 weeks ago. The DM said the safe serving temp for coffee was between 175-190 degrees Fahrenheit. The DM said the dietary staff checked the coffee temperature when the coffee was finished brewing then placed out into the dining room for the residents. The DM said she did not document and keep coffee temperature logs and asked the surveyor if she should. The DM said about 2 or 3 months ago, before she became the dietary manager, coffee temperatures were checked and documented but they have not been documented since. The DM said several months ago Resident #17 suffered a burn after she spilled coffee on herself. The DM said she was working in the kitchen when Resident #17 burned herself. The DM said she checked the coffee temperature and the temperature was 140 degrees Fahrenheit before it was served to Resident #17. The DM said she heard from other staff members a CNA (unknown) heated Resident #17's coffee up in the microwave before she spilled it and burned herself. The DM said she could not remember if she had documented the temperature of the coffee and did not have the coffee temperature log for the day Resident #17 burned herself. During an interview on 01/05/22 at 10:49 a.m., DA FF said she worked the 5:30 a.m.- 2:00 p.m. and made fresh coffee in the morning for the residents and to be served to them for breakfast. DA FF said before breakfast was served, she brewed a fresh pot of coffee directly into the coffee dispenser and took it out to the dining room after it was finished brewing. DA FF said did not check the temperature of the coffee because the residents were not in the dining room and that gave the coffee time to cool down before breakfast service. DA FF said residents had access to the coffee dispenser and they could get their own cup of coffee before breakfast service if they were in the dining room. DA FF said she had not seen residents in the dining room before breakfast getting coffee. DA FF said normally a CNA would bring residents coffee before they served breakfast. During an interview on 01/05/22 at 12:05 p.m., DA FF said a burn occurred when the temperature reaches 190 degrees Fahrenheit. During an interview on 01/05/22 at 12:09 p.m., the DM said a burn occurred when the temperature reaches 200 degrees Fahrenheit. During a dining room observation on 01/05/22 at 12:52 p.m., there was a coffee dispenser at the back of the dining room sitting on a countertop. There were coffee cups turned upside down and sitting on a tray to the left side of the coffee dispenser. During a dining room observation on 01/06/22 at 06:11 a.m., Resident #25 was sitting in her wheelchair going towards the back of the dining room without assistance. Resident #25 was holding an empty coffee cup in her right hand directly above her legs. Resident #25's right hand was shaking, and the top rim of her coffee cup was tilting back and forth continuously from left to right. Resident #25 stopped in front of the coffee dispenser and placed her coffee cup under the spout. Resident #25 poured her own coffee into her cup and filled it with coffee approximately 1/2 inches from the top rim of her cup. Resident #25 held her coffee cup with both hands directly above her legs and started to leave the dining room in her wheelchair without assistance. There were coffee cups turned upside down and sitting on a tray to the left side of the coffee dispenser. During an observation and interview on 01/06/22 at 06:14 a.m., Resident #25 said she drinks coffee in the morning before breakfast and gets it herself when she is up. Resident #25 said she had not spilled coffee on herself and was going back to her room. Resident #25 used her legs and held her coffee cup directly above her legs with both of her hands when she left the dining rom. Resident #25 left the dining room without assistance. During a dining room observation on 01/06/22 at 06:18 a.m., DA GG was in the dining room and grabbed a coffee cup next to the coffee dispenser. DA GG placed the cup under the coffee dispensers spout and poured coffee into the cup. DA GG placed a digital thermometer from the kitchen into the cup and checked coffee temperature. There was steam rising from the cup of coffee. The coffee temperature was 161.0 degrees Fahrenheit. During an interview on 01/06/22 at 06:19 a.m., DA GG said she worked the 5:30 a.m.-2:00 p.m. shift. DA GG said either her or the DC on shift will make coffee in morning before breakfast then place it out in the dining room for the residents. DA GG said there were clean cups next to the coffee dispenser for the residents to serve themselves. DA GG said she did not make the coffee or check the temperature of it this morning before it was taken to the dining room. DA GG said DC HH made it before she started her shift. DA GG said she did not know if DC HH checked temperature of the coffee after she made it. DA GG said the coffee temperature this morning was not documented. DA GG said she did not document coffee temperatures and was never told she needed to do so. DA GG said she did not know if the coffee in the dining room was at a safe serving temperature for the residents. DA GG did not know at what temperature a burn can occur. During an interview on 01/06/22 at 06:25 a.m., the DC HH said she had worked in the facility's kitchen for 2 years and was a cook. DC HH said either her or the DA on shift will make coffee in morning before breakfast then place it out in the dining room for the residents. DC HH said there were clean cups next to the coffee dispenser for the residents to serve themselves. DC HH said she arrived to work at 5:00 a.m. this morning and the first thing she did was make the coffee. DC HH said she checked the coffees temperature this morning after it finished brewing and the temperature was 160.0 degrees Fahrenheit. DC HH said she put the coffee she made in the dining room at 5:10 a.m. this morning then started to prepare breakfast in the kitchen. DC HH said she did not document the coffee temperature before she took to the dining room. DC HH said they did check and document coffee temperatures several months ago but were no longer doing it and did not know why. DC HH said she did not know if the coffee in the dining room was at a safe serving temperature for the residents. DC HH did not know at what temperature a burn can occur. During a dining room observation on 01/06/22 at 07:06 a.m., there were coffee cups turned upside down and sitting on a tray to the left side of the coffee dispenser. Resident #25 was sitting in her wheelchair in front of the coffee dispenser holding an empty coffee cup in her left hand and placed it under the spout. Resident #25 poured coffee into her cup. There was steam rising from Resident #25's coffee cup. Resident #25 was holding her coffee cup with both hands directly above her legs and left the dining room in her wheelchair without assistance. During a dining room observation on 01/06/22 at 07:10 a.m., the surveyor was in the dining room and grabbed a coffee cup next to the coffee dispenser. The surveyor placed the cup under the coffee dispensers spout and poured coffee into the cup. There was steam rising from the cup of coffee. The surveyor placed his digital thermometer into the cup and checked the temperature of the coffee. There was steam rising from the cup. The coffee temperature was 161.2 degrees Fahrenheit. During an interview on 1/6/2022 at 10:25 a.m., the Administrator said there was no policy on Hot Liquids. The Administrator said they had several complaints about the coffee being too cold when they turned the coffee down to 140 degrees Fahrenheit. The Administrator said there were no recent logs for temping coffee and told staff to start keeping temperature logs on 01/5/2022. The Administrator said Resident #17 did have a coffee burn and he conducted an in-service regarding coffee temperature at that time. The Administrator said he did not know when a Hot Liquid assessment should be done. During an interview on 01/6/2022 at 10:25 a.m., the Area Director of Operations said there was no policy on Hot Liquids. She said they had several complaints about the coffee being too cold when they turned the coffee down to 140 degrees Fahrenheit. She said there were no recent logs for temping coffee, and she said told staff to start keeping temperature logs on 01/5/2022. She said he did not know when a Hot Liquid assessment should be done. During a medication pass observation and interview on 01/06/22 at 11:59 a.m., CMA B was in the hallway in front of Resident #25's room with her medication cart. Resident #25 was in her room sitting in her wheelchair and came to the doorway. There was a pitcher of ice water and a stack of plastic cups sitting on the top of the medication cart. CMA B grabbed a plastic cup and the pitcher of water from the medication cart. CMA B filled the cup half full of water and gave Resident #25 the cup of water. Resident #25 reached out with her left hand and grabbed the cup of water from CMA B. Resident #25 brought the cup of water back towards her body and held it directly above her legs with her left hand. Resident #25's left hand started to shake. Resident #25's cup moved vigorously back and forth in her hand and the water from her cup spilled onto her lap. Resident #25 took her medications with the remaining water in her cup. Resident #25 said her hand started shaking and she ended up spilling water onto her lap. Resident #25 said it was the first time she could remember that had happened. Resident #25 said she when her hands start shaking, she was unable to make them stop. During an interview on 01/06/22 at 01/06/22 at 2:01 p.m., CMA B said she worked the 6:00 a.m.-2:00 p.m. shift and administered medications to Resident #25. CMA B said Resident #25 spilled water on herself when she took her medications earlier today. CMA B said she has seen Resident #25 spill water on herself before. CMA B said Resident #25's hands were shaky and unsteady, and she has seen Resident #25 spill water on herself before when administering her medications. A Hot Liquid/Food Spills policy dated 2003 indicated, Residents are at risk of having any hot liquid/food spilled on their person. Examples of hot liquids/food are coffee, tea, hot soup, oatmeal, or any other dietary substance that could cause injury .4. An incident report and investigation will then be completed and determine if the resident needs further interventions to prevent future occurrences. An American Burn Association Scald Injury Prevention Educator's Guide undated indicated, .Although scald [CONDITION(S)] can happen to anyone, young children, older adults and people with disabilities are the most likely to incur such injuries. Most scald burn injuries happen in the home, in connection with the preparation or serving of hot food or beverages . Both behavioral and environmental measures may be needed to protect those vulnerable to scalds because of age or disability . When the temperature of a hot liquid is increased to 140o F/60o C it takes only five seconds or less for a serious burn to occur 1. Coffee, tea, hot chocolate and other hot beverages are usually served at 160 to 180o F /71-82o C, resulting in almost instantaneous [CONDITION(S)] that will require surgery . Older adults, like young children, have thinner skin so hot liquids cause deeper [CONDITION(S)] with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults.2 Older adults may also have conditions that make them more prone to falls in the bathtub or shower or while carrying hot liquids . 1 [NAME], AR, Herriques, FC Jr. Studies of thermal injuries: II The relative importance of time and surface temperature in the causation of cutaneous [CONDITION(S)]. Am J Pathol 1947; 23:695-720. 2 Stone, M, [NAME] J, [NAME] J. The continuing risk of domestic hot water scalds to the elderly. [CONDITION(S)] 2000; 26:347-350.

Based on observation, interview and record review, the facility failed to ensure treatment and care consistent with professional standards of practice was provided in accordance with the plan of care for 1 of 12 residents reviewed for arterial wounds. (Resident #16) The facility did not reposition Resident #16 every two hours and did not float the resident's heels while in bed as care planned. The facility did not place heel protectors on Resident #16 as ordered. The facility did not implement dietary recommendations promptly. Resident #16 developed deep tissue injuries to the right heal, right 5th toe, right medial and ankle within 8 days of re-admission to the facility. These failures could place residents at risk for new development or worsening of existing wounds, infection, pain, and decreased quality of life. Findings included: Record review of consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The face sheet indicated Resident #16 was originally admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . stent is a small, metal mesh tube that keeps the artery open), [CONDITION(S)], and diabetes. The most recent MDS dated [DATE] indicated Resident #16 was readmitted to the facility on [DATE] from a hospital. Resident #16 usually made himself understood, usually understand others, and had severe cognitive impairment. The assessment indicated Resident #16 did not reject evaluation of care. He required extensive assistance with bed mobility, dressing, eating and personal hygiene. He also required total dependence with toileting and bathing. The MDS indicated the activity of transferring of Resident #16 occurred only once or twice. Resident #16 was always incontinent of bowel and bladder. The assessment indicated Resident #16 was at risk of developing pressure injuries and had four unstageable pressure injuries that were not present on admission. The care plan updated on 12/7/20 indicated Resident #16 had a potential for pressure ulcer development. The care plan addressed the pressure injuries identified the right heel, right 5th toe, and right ankle. The care plan was revised on 2/1/21 to reflect a deep tissue injury to left heel, left medial heel and right medial heel identified on 1/30/21. The care plan interventions included; use of a low-air mattress, weekly skin assessment; turn/reposition every two hours; and ensure heels are floated with pillows. The care plan indicated Resident #16 has [CONDITION(S)] (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) related to diabetes. The care plan interventions included monitor/document/report to MD PRN any signs and symptoms of skin problems related to [CONDITION(S)]. The care plan interventions also included that the charge nurse should be notified for any injury/wound, new/increased swelling or change in skin color. The care plan does not address that the wounds are unavoidable. A Braden scale for predicting pressure injury risk dated 11/27/20 indicated Resident #16 was at high risk for developing pressure injuries. An initial skin assessment dated [DATE] at 5:14 p.m., completed by LVN D indicated Resident #16 had a rash to his buttocks. A skin assessment on 12/4/20 indicated Resident #16 had an unstageable DTIs to the right heal, right 5th toe, and right medial ankle. A weekly ulcer assessment dated [DATE] completed by LVN T indicated Resident #16 had: * an unstageable pressure injury to the right heel that measured 2 centimeters in length, 2 centimeters in width and an undetermined depth. * a deep tissue pressure injury to the right 5th outer toe that measured 1.5 centimeters in length, 1.5 centimeters in width and an undetermined depth. * a deep tissue pressure ulcer to the right medial ankle that measured 3 centimeters in length, 1.5 centimeters in width and an undetermined depth. An order summary report dated 2/5/21 indicated a wound care consult and a low air loss mattress were ordered on 12/9/20 for Resident #16's wounds. A wound evaluation and management summary dated 12/10/20, completed by the wound care provider indicated Resident #16 had: *an unstageable deep tissue injury to the right heel measured 0.6 centimeters in length, 0.6 centimeters in width and 0.1 cm centimeters in depth. A wound evaluation and management summary dated 12/16/20 completed by the wound care provider indicated Resident #16 had: *an unstageable deep tissue injury to right heel measured 0.4 centimeters in length, 0.3 centimeters in width and 0.1 centimeters in depth. *an unstageable deep tissue injury to right medial ankle measured 3.5 centimeters in length, 3 centimeters in width and 0.1 centimeters in depth. *an unstageable deep tissue injury to right distal lateral foot measured 1.1 centimeters in length, 0.8 centimeters in width and unable to determine depth. A wound evaluation and management summary dated 12/24/20 completed by the wound care provider indicated Resident #16 had: *an unstageable deep tissue injury to right medial ankle measured 2.5 centimeters in length, 2.5 centimeters in width and 0.1 centimeters I depth. *unstageable deep tissue injury to right distal lateral foot measured 1.5 centimeters in length, 1.0 centimeters in width and unable to determine depth. The wound evaluation indicated the unstageable deep tissue injury to right heel was resolved. A dietary note dated 12/30/20 at 3:08 p.m. written by the dietitian recommended Resident #16 take the following supplements to aid with wound healing; a multivitamin; vitamin C 500 mg (milligrams) twice a day; [MEDICATION(S)] 220 mg daily; and liquid protein 30 ml (milliliters) twice a day. A wound evaluation and management summary dated 12/31/20 completed by the wound care provider indicated Resident #16 had a: *an unstageable deep tissue injury to right medial ankle that measured 2.5 centimeters in length, 2.5 centimeters in width and 0.1 centimeters in depth. *an unstageable deep tissue injury to right distal lateral foot that measured 1.2 centimeters in length, 0.9 centimeters in width and an undetermined depth. A wound evaluation and management summary dated 1/7/21 completed by the wound care provider indicated Resident #16 had: *an unstageable deep tissue injury to right medial ankle measured 2.5 centimeters in length, 2.5 centimeters in width and 0.1 centimeters in depth. *an unstageable deep tissue injury to right distal lateral foot measured 1.3 centimeters in length, 1 centimeter in width and an undetermined depth. *an unstageable deep tissue injury to right heel measured 0.5 centimeters in length, 0.5 centimeters in width and unable to determine depth. A wound evaluation and management summary dated 1/14/21 completed by the wound care provider indicated Resident #16 had: *an unstageable deep tissue injury to right medial ankle measured 2.5 centimeters in length, 2.5 centimeters in width and 0.1 centimeters in depth *an unstageable deep tissue injury to right distal lateral foot measured 1 centimeters in length, 1 centimeters in width and unable to determine depth. *unstageable deep tissue injury to right heel measured 1 centimeters in length, 1 centimeters in width and unable to determine depth. *a wound to the right medial foot measured 0.2 centimeters in length, 0.8 centimeters in width and 0.1 centimeters in depth. A wound evaluation and management summary dated 1/21/21 completed by the wound care doctor indicated Resident #16 had: *an unstageable deep tissue injury to the right medial ankle that measured 2 centimeters in length, 2.5 centimeters in width and 0.1 centimeters in depth. *an unstageable deep tissue injury to the right distal lateral foot that measured 1.5 centimeters in length, 1.2 centimeters in width and an undetermined depth. *an unstageable deep tissue injury to right heel that measured 0.7 centimeters in length, 1 centimeters in width and undetermined depth. * wound to the right medial foot measured 0.7 centimeters in length, 0.3 centimeters in width and 0.1 centimeters sin depth A wound evaluation and management summary dated 1/28/21 completed by the wound care doctor indicated Resident #16 had: *an unstageable deep tissue injury to right medial ankle measured 2 centimeters in length, 2.5 centimeters in width and 0.1 centimeters in depth. *an unstageable deep tissue injury to right distal lateral foot measured 1 centimeters in length, 1 centimeters in width and unable to determine depth. *an unstageable deep tissue injury to the right heel measured 0.7 centimeters in length, 1 centimeters in width and unable to determine depth. *a wound to the right medial foot that measured 0.7 centimeters in length, 0.3 centimeters in width and 0.1 centimeters in depth. *an unstageable deep tissue injury to left heel that measured 3 centimeters in length 4 centimeters in width and 0.1 centimeters in depth. *a wound to the left medial ankle that measured 1.4 centimeters in length, 2 centimeters in width and unable to determine depth. During an observation on 2/1/21 at 10:03 a.m., Resident #16 was lying in bed asleep. His back was on the bed and his right heel was lying on the on the low air mattress. Resident #16's heel protector laid on the side of the bed. Resident #16's right heel was not floated with a pillow. During an observation on 2/1/21 at 1:42 p.m., Resident #16 was lying in bed awake. Resident #16 was on his back with his right heel laying on the on the low air mattress. Resident #16's heel protector was laid on the side of the bed. Resident #16's right heel was not floated with a pillow. During an observation on 2/2/21 at 8:59 a.m., Resident #16 was lying in bed asleep. Resident #16 was on his back with both heels lying on the low air mattress. Resident #16's heel protectors laid in the chair next to the bed. Resident #16's heels were not floated with a pillow. During an observation on 2/2/21 at 12:20 p.m , Resident #16 was lying in bed awake. He was on his back. His heels were lying on the low air loss mattress. Resident #16's heel protectors laid in the chair next to the bed. Resident #16's heels were not floated with a pillow. During an observation on 2/2/21 at 2:17 p.m., Resident #16 was lying in bed. His back and heels were laying on the low air loss mattress. Resident #16's heel protectors laid on the chair next to the resident's bed. Resident #16's heels were not floated with a pillow. During an observation on 2/3/21 at 11:00 a.m., LVN T measured the arterial wounds to Resident #16's right medial ankle at 1.5 centimeters in length, 2 centimeters in width. The wound care nurse did not give a depth measurement. The wound had a scabbed area over the wound bed. The area of skin surrounding the wound bed was light pink in color. The wound had no odor. There was no dressing noted to area. During an observation on 2/3/21 at 11:00 a.m., LVN T measured the arterial wounds to Resident #16's left heel at 3 centimeters in length, 4 centimeters in width and 0.3 centimeters in depth. The wound bed of the left heel arterial wounds as pink on the edges and white in the center. The area of skin surrounding the wound bed was light pink in color. The wound had no odor. When LVN T removed the dressing from the wound there was a moderate amount of brown drainage to the dressing. There was no visible adipose tissue, muscle, tendon, ligament, cartilage or bone in the wound. During an observation on 2/3/21 at 11:00 a.m., LVN T measured the arterial wounds to Resident 16's left medial ankle at 1.5 centimeters in length, 1.5 centimeters in width and 0.3 centimeters in depth. The wound had a scabbed covering over the wound bed. The area of skin surrounding the wound bed was light pink in color. The wound had no odor. There was no dressing noted to area. During an observation on 2/3/21 at 11:00 a.m., LVN T measured the arterial wounds to Resident 16's right 5th toe at 1 centimeters in length, 0.9 centimeters in width. LVN T did not give a depth measurement. The wound had a scab over the wound bed. The area of skin surrounding the wound bed was light pink in color. The wound had no odor. During an observation on 2/3/21 at 11:00 a.m., LVN T measured the arterial wounds to Resident 16's left lateral ankle at 1.5 centimeters in length, 1.2 centimeters in width. LVN T did not give a depth measurement. The wound bed of the arterial wounds was white. The area of skin surrounding the wound bed was red in color. The wound had no odor. When the wound care nurse removed the dressing from the wound there was a small amount of serous drainage to the dressing. There was no visible adipose tissue, muscle, tendon, ligament, cartilage or bone in the wound. During an interview on 2/3/21 at 2:30 p.m., CNA E said she turned Resident #16 as much as she could. CNA E said because she often worked the hall by herself, she did not have time to reposition Resident #16 every two hours. CNA E said Resident #16 heels are supposed to be floated all day. She said there have been times Resident #16's heel protectors were in the chair and not on his heels. During an interview on 2/3/21 at 2:41 p.m., LVN H said residents are supposed to be turned and repositioned every two hours. She said Resident #16 should have his heel protectors on at all times. During an interview on 2/4/21 at 9:30 a.m. Resident #16 said staff does not turn or repositioned him every two hours. During an interview on 2/4/21 at 10:23 a.m., ADON F said she received a signed dietitian recommendation order dated 1/31/21 on 2/3/21 for Resident #16. She said she was not aware of the dietician's recommendations on 12/30/20. During an interview on 2/4/21 at 10:30 a.m., ADON G said she was not aware of the dietician's recommendations on 12/30/20. During an interview on 2/4/21 at 10:53 a.m., LVN T said that Resident #16 should wear heel protectors at all times. She said he should be turned and repositioned every two hours. She said the dietary recommendations on 12/31/20 could have promoted wound healing. During an interview on 2/4/21 at 1:46 p.m., CNA J said residents should be turned and repositioned every two hours but sometimes it is impossible due to staffing. During an interview on 2/5/21 at 10:00 a.m., CNA K said residents should be turned and repositioned every two hours. She said Resident #16 should have his heel protectors on at all times. CNA K said she thought staffing was an issue and did not think resident's needs were met. During an observation on 2/5/21 at 10:26 a.m., Resident #16's heel protectors laid on the side of the bed and were not on his heels. Resident #16's right heel was not floated with a pillow. During an interview on 2/4/21 at 3:16 p.m., the wound care provider said turning/repositioning Resident #16 every two hours and the dietician recommendation that was ordered on 12/30/20 would have helped promote wound healing. The wound care provider said he will order a test today to measure the amount of blood flow through Resident #16's arteries and veins. A progress note written by the wound care provider, dated 2/4/21 stated Based on Resident #16's clinical condition-including decreased circulation to the bilateral lower extremities, combined with his reluctance to recommended care, his wounds are at risk for further deterioration and would be considered clinically unavoidable. During an interview on 2/5/21 at 4:22 p.m., the DON said she expected residents who had wounds or who were at risk to have their heels offloaded while in bed. The DON said she expected Resident #16's heels to be floated at all times. The DON said she expected Resident #16 to be turned/repositioned every two hours. The DON said the dietary recommendations given on 12/30/20 should have been implemented promptly. During an interview on 2/5/21 at 4:43 p.m. the administrator said Resident #16 should be turned/repositioned every two hours. The administrator said Resident #16's heels should be floated at all times. The Administrator said all orders should be followed and he expected the dietary recommendations from 12/30/20 to be implemented when it was ordered. A nursing note dated 2/5/21, written by the DON, stated DON spoke with Wound Care provider APRN upon completion of wound rounds and asked about the bedside doppler results. He stated that the right foot pulse was absent, and that there was highly diminished blood flow to the back part of the right leg behind the knee joint, left foot and the back part of the right leg behind the knee joint pulses. He did state that he has ordered a test that measures the amount of blood flow through Resident #16 arteries and veins. A review of the wound care provider's wound evaluation and management summaries dated 2/4/21-2/17/21 indicated the wounds to Resident #16's right medial ankle; right distal lateral foot; right medial foot, and left medial ankle were arterial wounds. During an interview on 2/23/21 at 6:10 p.m., the wound care provider said the wounds to Resident #16's lower extremities were arterial wounds and not pressure injuries. The wound care provider said if the facility would have ensured the dietary recommendations and care plan interventions (ensuring repositioning 1-2 hours/heel protectors applied) were implemented it was unlikely the interventions would have prevented the development of the pressure injuries or the arterial wounds. He said this was because Resident #16's medical conditions cause a significant circulation issue. He said perfusion is imperative for wound healing. He said it was unlikely the arterial wounds or the pressure wounds would heal. The wound care provider said Resident #16 has also refused recommended treatment to his pressure injuries. He said Resident #16 had refused debridement and circulation studies multiple times in the past. The wound care provider said Resident #16 eventually allowed him to perform a doppler study. The wound care provider said the study indicated Resident #16 had poor circulation to his lower extremities. He said the right pedal pulse was undetectable. He said based on the results of the doppler study he ordered an arterial study. He said the arterial study was not completed because it was refused by the family. During an interview on 2/24/20 at 12:20 p.m., CNA N said she had taken care of Resident #16 in the past. CNA N said Resident #16 often kicked off his heel protectors. CNA N said Resident #16 should be repositioned every 2 hours. CNA N said she could not confidentially say she was able to regularly reposition Resident #16 every 2 hours when she cared for him because of staffing. CNA N said there just was not enough CNAs to ensure everything was done. During an interview on 2/24/20 at 12:30 p.m., CNA W said Resident #16 often refused repositioning and the application of his heel protectors. CNA W said Resident #16 would refuse by yelling at staff to leave him alone or would scream obscenities at them. CNA W said on the occasions she managed to talk him into allowing her to apply the heel protectors, he would often kick them off. CNA W said the facility has been short staffed. CNA W said she has many residents that do not refuse care. CNA W said due to staffing shortages she sometimes had to prioritize resident care. CNA W said when she had to prioritize care, she would place tasks that Resident #16 refused on the bottom of the list. CNA W said if the facility was not short staffed, she would attempt to reposition and apply Resident #16's heel protectors at least every 2 hours. She said even though Resident #16 would likely refuse the interventions, she knew he needed to have them performed and occasionally he would allow the interventions. During an interview on 2/24/20 at 12:43 p.m., ADON F said she often works the floor and provides care for Resident #16. ADON F said Resident #16 will refuse care. ADON F said Resident #16 often kicked off his heel protectors or rolled to his back after being repositioned. A facility policy titled Skin Integrity Management, revised 10/5/2016 indicated: *Correction of the resident's underlying medical, surgical, and/or nutritional problems must be accomplished if proper healing of pressure sores is to occur. Notify dietician of a resident at risk, or who has known skin breakdown. *Reposition residents at risk for pressure sore or with pressure sores at least every two hours, if unable to turn themselves. *Use pillows of foam wedges to keep bony prominences for direct contact. *The Treatment Nurse/designee and the DON should add a written plan for the use of positioning devices and schedules to the care plan. *The presence of a pressure reducing device/specialty bed does not negate the need to turn/reposition the resident at least every two hours in order to prevent pulmonary and renal complications as well as pressure sores. *Any individual assessed to be at high risk for developing pressure ulcers should be placed when lying in bed on a pressure reducing device. *Additional heel protection may be needed even if a resident is on a pressure reducing/relieving device. Use pillows to off-pressure heel. *Care planning in response to risk prediction must be completed. Care planning in response to the presence of pressure sores must be completed. The DON or designee does this. *All residents should have a skin assessment on a weekly basis completed in PCC.

Based on interview and record review, the facility failed to ensure necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new pressure injuries from developing was provided for 1 of 12 residents reviewed for pressure injuries. (Resident #16) The facility did not reposition Resident #16 every two hours while in bed as care planned. The facility did not implement dietary recommendations promptly. Resident #16 developed deep tissue injuries to the sacrum and buttock within 8 days of re-admission to the facility. These failures could place residents at risk for new development or worsening of existing pressure injuries, infection, pain, and decreased quality of life. Findings included: Record review of consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The face sheet indicated Resident #16 was originally admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . stent is a small, metal mesh tube that keeps the artery open), [CONDITION(S)], and diabetes. The most recent MDS dated [DATE] indicated Resident #16 was readmitted to the facility on [DATE] from a hospital. Resident #16 usually made himself understood, usually understand others, and had severe cognitive impairment. The assessment indicated Resident #16 did not reject evaluation of care. He required extensive assistance with bed mobility, dressing, eating and personal hygiene. He also required total dependence with toileting and bathing. The MDS indicated the activity of transferring of Resident #16 occurred only once or twice. Resident #16 was always incontinent of bowel and bladder. The assessment indicated Resident #16 was at risk of developing pressure injuries and had four unstageable pressure injuries that were not present on admission. The care plan updated on 12/7/20 indicated Resident #16 had a potential for pressure ulcer development. The care plan addressed the pressure injuries identified on the resident's sacrum and sacral. The care plan interventions included; use of a low-air mattress, weekly skin assessment; and turn/reposition every two hours. The care plan interventions also included that the charge nurse should be notified for any injury/wound, new/increased swelling or change in skin color. The care plan does not address that the wounds are unavoidable. A Braden scale for predicting pressure injury risk dated 11/27/20 indicated Resident #16 was at high risk for developing pressure injuries. An initial skin assessment dated [DATE] at 5:14 p.m., completed by LVN D indicated Resident #16 had a rash to his buttocks. A skin assessment on 12/4/20 indicated Resident #16 had an unstageable DTIs to the sacrum. A weekly ulcer assessment dated [DATE] completed by LVN T indicated Resident #16 had: * a deep tissue injury to the sacrum that measured 5 centimeters in length, 2 centimeters in width and an undetermined depth. An order summary report dated 2/5/21 indicated a wound care consult and a low air loss mattress were ordered on 12/9/20 for Resident #16's pressure injuries. A wound evaluation and management summary dated 12/10/20, completed by the wound care provider indicated Resident #16 had: *A Stage 4 pressure injury to the sacrum that measured 2 centimeters in length, 1 centimeter in width and 0.1 cm centimeter in depth. *A Stage 3 pressure injury to the left buttock that measured 5 centimeters in length, 7 centimeters in width and 0.1 centimeters in depth. The wound evaluation and management summary also indicated the Stage 4 pressure injury was debrided on 12/10/20. A wound evaluation and management summary dated 12/16/20 completed by the wound care provider indicated Resident #16 had: *A Stage 4 pressure injury to the sacrum that measured 4 centimeters in length, 3 centimeters in width and 0.1 centimeters in depth. *A Stage 3 pressure injury to left buttocks that measured 6.5 centimeters in length, 1.5 centimeters in width and 0.1 centimeters in width. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The new treatment order is to apply collagen powder three times per week for 24 days; Apply hypochlorite gel (anasept) three times per week for 24 days and alginate calcium three times per week for 30 days. A wound evaluation and management summary dated 12/24/20 completed by the wound care provider indicated Resident #16 had: *A Stage 4 pressure injury to the sacrum measured 3 centimeters in length, 2.5 centimeters in width and 0.1 centimeters in depth. *A Stage 3 pressure injury to the left buttock measured 3 centimeters in length, 1 centimeters in width and 0.1 centimeters in depth. A dietary note dated 12/30/20 at 3:08 p.m. written by the dietitian recommended Resident #16 take the following supplements to aid with wound healing; a multivitamin; vitamin C 500 mg (milligrams) twice a day; [MEDICATION(S)] 220 mg daily; and liquid protein 30 ml (milliliters) twice a day. A wound evaluation and management summary dated 12/31/20 completed by the wound care provider indicated Resident #16 had a: *A Stage 4 pressure injury to the sacrum that measured 3.5 centimeters in length, 1.5 centimeters in width and 0.1 centimeters in depth. *A Stage 3 pressure injury to left buttock that measured 3 centimeters in length, 3.5 centimeters in width and 0.1 centimeters in depth. A wound evaluation and management summary dated 1/7/21 completed by the wound care provider indicated Resident #16 had: *A Stage 4 pressure injury to the sacrum that measured 3 centimeters in length, 1.2 centimeters in width and 0.4 centimeters in depth. *Stage 3 pressure injury to the left buttock measured 3 centimeters in length, 1.2 centimeters in width and 0.1 centimeters in depth. A wound evaluation and management summary dated 1/14/21 completed by the wound care provider indicated Resident #16 had: *A Stage 4 pressure injury to the sacrum that measured 2.5 centimeters in length, 2 centimeters in width and 0.4 centimeters in depth. *Stage 3 pressure injury to the left buttock that measured 2.5 centimeters in length, 2.5 centimeters in width and 0.1 centimeters in depth. A wound evaluation and management summary dated 1/21/21 completed by the wound care doctor indicated Resident #16 had: *A Stage 4 pressure injury to the sacrum measured 2 centimeters in length, 1 centimeters in width and 0.4 centimeters in depth. The wound evaluation indicated the Stage 3 pressure injury to left buttock resolved. A wound evaluation and management summary dated 1/28/21 completed by the wound care doctor indicated Resident #16 had: *A Stage 4 pressure injury the to sacrum that measured 2 centimeters in length, 1 centimeters in width and 0.4 centimeters in depth. During an observation on 2/1/21 at 10:03 a.m., Resident #16 was lying in bed asleep. His back was on the bed and his right heel was lying on the on the low air mattress. Resident #16's heel protector laid on the side of the bed. Resident #16's right heel was not floated with a pillow. During an observation on 2/1/21 at 1:42 p.m., Resident #16 was lying in bed awake. Resident #16 was on his back with his right heel laying on the on the low air mattress. Resident #16's heel protector was laid on the side of the bed. Resident #16's right heel was not floated with a pillow. During an observation on 2/2/21 at 8:59 a.m., Resident #16 was lying in bed asleep. Resident #16 was on his back with both heels lying on the low air mattress. Resident #16's heel protectors laid in the chair next to the bed. Resident #16's heels were not floated with a pillow. During an observation on 2/2/21 at 12:20 p.m , Resident #16 was lying in bed awake. He was on his back. His heels were lying on the low air loss mattress. Resident #16's heel protectors laid in the chair next to the bed. Resident #16's heels were not floated with a pillow. During an observation on 2/2/21 at 2:17 p.m., Resident #16 was lying in bed. His back and heels were laying on the low air loss mattress. Resident #16's heel protectors laid on the chair next to the resident's bed. Resident #16's heels were not floated with a pillow. During an observation on 2/3/21 at 11:00 a.m., LVN T measured the pressure injury to Resident #16's sacrum at 1.5 centimeters in length, 1 centimeters in width and 0.2 centimeters in depth. The wound bed of the Stage 4 pressure injury was white. The area of skin surrounding the wound bed was light pink in color. The wound had no odor. The Stage 4 pressure injury had no signs or symptoms of infection. There was no visible adipose tissue (fat), muscle, tendon, ligament, cartilage or bone in the wound. During an interview on 2/3/21 at 2:30 p.m., CNA E said she turned Resident #16 as much as she could. CNA E said because she often worked the hall by herself, she did not have time to reposition Resident #16 every two hours. CNA E said Resident #16 heels are supposed to be floated all day. She said there have been times Resident #16's heel protectors were in the chair and not on his heels. During an interview on 2/3/21 at 2:41 p.m., LVN H said residents are supposed to be turned and repositioned every two hours. She said Resident #16 should have his heel protectors on at all times. During an interview on 2/4/21 at 9:30 a.m. Resident #16 said staff does not turn or repositioned him every two hours. During an interview on 2/4/21 at 10:23 a.m., ADON F said she received a signed dietitian recommendation order dated 1/31/21 on 2/3/21 for Resident #16. She said she was not aware of the dietician's recommendations on 12/30/20. During an interview on 2/4/21 at 10:30 a.m., ADON G said she was not aware of the dietician's recommendations on 12/30/20. During an interview on 2/4/21 at 10:53 a.m., LVN T said that Resident #16 should be turned and repositioned every two hours. She said the dietary recommendations on 12/31/20 could have promoted wound healing. During an interview on 2/4/21 at 1:46 p.m., CNA J said residents should be turned and repositioned every two hours but sometimes it is impossible due to staffing. During an interview on 2/5/21 at 10:00 a.m., CNA K said residents should be turned and repositioned every two hours. She said Resident #16 should have his heel protectors on at all times. CNA K said she thought staffing was an issue and did not think resident's needs were met. During an interview on 2/4/21 at 3:16 p.m., the wound care provider said turning/repositioning Resident #16 every two hours and the dietician recommendation that was ordered on 12/30/20 would have helped promote wound healing. During an interview on 2/5/21 at 4:22 p.m., the DON said she expected Resident #16 to be turned/repositioned every two hours. The DON said the dietary recommendations given on 12/30/20 should have been implemented promptly. During an interview on 2/5/21 at 4:43 p.m. the administrator said Resident #16 should be turned/repositioned every two hours. The administrator said Resident #16's heels should be floated at all times. The Administrator said all orders should be followed and he expected the dietary recommendations from 12/30/20 to be implemented when it was ordered. A review of the wound care provider's wound evaluation and management summaries dated 2/4/21-2/17/21 indicated the measurements for Resident #16's Stage 4 pressure injury to his sacrum were as followed; *on 2/4/21- 2 centimeters x 2 centimeters x 0.4 centimeters; *on 2/11/21- 2 centimeters x 2 centimeters x 0.4 centimeters; and *on 2/17/21- 2 centimeters x 2 centimeters x 0.4 centimeters. During an interview on 2/24/20 at 12:20 p.m., CNA N said she had taken care of Resident #16 in the past. CNA N said Resident #16 often kicked off his heel protectors. CNA N said Resident #16 should be repositioned every 2 hours. CNA N said she could not confidentially say she was able to regularly reposition Resident #16 every 2 hours when she cared for him because of staffing. CNA N said there just was not enough CNAs to ensure everything was done. A facility policy titled Pressure Injury, revised 8/12/16: prevention, assessment and treatment indicated: residents should be turned every two hours or more if necessary . maintain body alignment with support for body parts; pillows, cradles, pads, heel/elbow protectors, and mattresses can be used to help relieve pressure. Maintain adequate nutrition. A facility policy titled Skin Integrity Management, revised 10/5/2016 indicated: *Correction of the resident's underlying medical, surgical, and/or nutritional problems must be accomplished if proper healing of pressure sores is to occur. Notify dietician of a resident at risk, or who has known skin breakdown. *Reposition residents at risk for pressure sore or with pressure sores at least every two hours, if unable to turn themselves. *Use pillows of foam wedges to keep bony prominences for direct contact. *The Treatment Nurse/designee and the DON should add a written plan for the use of positioning devices and schedules to the care plan. *The presence of a pressure reducing device/specialty bed does not negate the need to turn/reposition the resident at least every two hours in order to prevent pulmonary and renal complications as well as pressure sores. *Any individual assessed to be at high risk for developing pressure ulcers should be placed when lying in bed on a pressure reducing device. *Additional heel protection may be needed even if a resident is on a pressure reducing/relieving device. Use pillows to off-pressure heel. *Care planning in response to risk prediction must be completed. Care planning in response to the presence of pressure sores must be completed. The DON or designee does this. *All residents should have a skin assessment on a weekly basis completed in PCC. The website http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ accessed 2/25/21 indicated the following . Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [CONDITION(S)] of intact skin Intact skin with a localized area of non-blanchable [CONDITION(S)], which may appear differently in darkly pigmented skin. Presence of blanchable [CONDITION(S)] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [CONDITION(S)] (IAD), intertriginous [CONDITION(S)] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, [CONDITION(S)], abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epiboly (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions .

Based on observation, interview and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections were maintained for the facility related to COVID-19 (a new respiratory disease which can cause mild to severe illness with most severe illness in adults [AGE] years and older) for 2 of 2 wings and 1 of 6 residents reviewed for infection control. (Resident #1) The facility did not ensure staff who worked the COVID-19 positive unit were screened prior to their shifts. The facility did not ensure staff work masks while within close proximity to Resident #1 including while she was on the COVID-19 positive unit. The facility did not ensure all visitors were screened prior to entering the facility. The facility did not dedicate staff to only work on the COVID-19 positive unit. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 12/18/20. While the IJ was removed on 12/19/20 the facility remained out of compliance at a potential for more than minimal harm with a scope identified as pattern due to the facility's need to complete in-service trainings and evaluate the effectiveness of the corrective actions. These failures could place residents at risk for exposure to COVID-19, health complications, and death. Findings included: During an observation on 12/16/20 the facility did not screen (obtain temperature, ask questions regarding signs and symptoms or determine potential COVID-19 exposure) the surveyor prior to her entering the facility. Record review of the CDC website at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html> accessed 12/18/20 indicated, .Implement Source Control Measures. HCP should wear a facemask at all times while they are in the facility .Screen visitors for fever (T?100.0oF), symptoms consistent with COVID-19, or known exposure to someone with COVID-19. Restrict anyone with fever, symptoms, or known exposure from entering the facility. Ask visitors to inform the facility if they develop fever or symptoms consistent with COVID-19 within 14 days of visiting the facility .Screen all HCP at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature* and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. *Fever is either measured temperature >100.0'F or subjective fever. Note that fever may be intermittent or may not be present in some individuals, such as those who are elderly, immunosuppressed, or taking certain medications (e.g., NSAIDs). Clinical judgement should be used to guide testing of individuals in such situations. HCP who work in multiple locations may pose higher risk and should be encouraged to tell facilities if they have had exposure to other facilities with recognized COVID-19 cases .Identify space in the facility that could be dedicated to care for residents with confirmed COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19. Identify HCP who will be assigned to work only on the COVID-19 care unit when it is in use .Residents with known or suspected COVID-19 should be cared for using all recommended PPE, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown .Because of the higher risk of unrecognized infection among residents, universal use of all recommended PPE for the care of all residents on the affected unit (or facility-wide depending on the situation) is recommended when even a single case among residents or HCP is newly identified in the facility; this could also be considered when there is sustained transmission in the community. The health department can assist with decisions about testing of asymptomatic residents .Source Control: Use of a cloth face covering or facemask to cover a person's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing .Respirator: A respirator is a personal protective device that is worn on the face, covers at least the nose and mouth, and is used to reduce the wearer's risk of inhaling hazardous airborne particles (including dust particles and infectious agents), gases, or vapors. Respirators are certified by the CDC/NIOSH, including those intended for use in healthcare . Record review of the facility's COVID-19 plan policy updated 11/3/20 indicated, .Vendors/Surveyors/Ombudsman/Other medical personnel/parcel delivery services - will need to be screened prior to entry .For residents with known or suspected COVID-19: staff wear gloves, isolation gown, eye protection and an N95 or higher-level respirator if available. When COVID-19 is identified in the facility, staff wear all recommended PPE for the care of all residents, regardless of symptoms .As a measure to limit HCP exposure and conserve PPE, this facility will consider designating an entire unit within the facility if available, with dedicated HCP if possible, to care for known or suspected COVID-19 patients. Dedicated means that HCP are assigned to care only for these patients during their shift . Record review of the facility's Screening for COVID-19, Respiratory Illnesses, and other Communicable Diseases - Nursing Home Healthcare Personnel and Visitors dated 11/18/20 indicated, .100% screening of all who enter the facility is used to identify potentially contagious individuals during an infectious disease disaster . Record review of a resident list provided by the DON updated on 12/17/20 indicated there were 20 residents positive for COVID-19. Record review of a staff list provided by the DON updated on 12/19/20 indicated there were 9 staff members positive for COVID-19. Record review of consolidated physician orders [REDACTED].#1 was [AGE] years old, re-admitted on [DATE] with [DIAGNOSES REDACTED]. The orders indicated Resident #1 was diagnosed with [REDACTED]. Record review of the most recent MDS dated [DATE] indicated Resident #1 made herself understood, usually understood others, and had severe cognitive impairment. The MDS indicated Resident #1 required extensive assistance with bed mobility, transferring, dressing, eating, toileting, and personal hygiene; and total assistance with bathing. The MDS indicated Resident #1 had an active [DIAGNOSES REDACTED]. Record review of the care plan updated on 12/9/20 indicated Resident #1 required care and isolation precautions specifically related to active COVID-19 infection. The care plan indicated Resident #1 required assistance with all ADLs related to an ADL self-care performance deficit. The care plan indicated an intervention in Resident #1's care plan was to follow facility protocols for COVID-19 screening/precautions. Review on 12/17/20 of date and time stamped pictures and/or videos indicated on 11/22/20 at 7:09 a.m. and 12:36 p.m. (two different unidentified staff members); 11/26/20 at 2:56 a.m.; 11/28/20 at 10:31 p.m. and 12:50 a.m.; 12/1/20 at 2:10 a.m. (LVN F); and 12/4/20 at 4:30 a.m. (a housekeeper) were not wearing a mask within close proximity to Resident #1. During an interview on 12/17/20 at 3:15 p.m., CNA K said she worked on the COVID-19 positive unit and the negative halls on separate shifts/days. CNA K said she was not screened prior to her shift when she worked on the COVID-19 hall. During an interview on 12/17/20 at 3:28 p.m., LVN E said she worked on the COVID-19 hall and was not screened prior to her shift. LVN E said she had not ever been screened prior to her shift on the COVID-19 unit. LVN E said there were no logs or book for screening staff on the COVID-19 unit. During an interview on 12/17/20 at 4:27 p.m., CNA H said she usually worked the COVID-19 unit but sometimes worked on the cold halls. CNA H said she was not screened prior to her shift when she worked on the COVID-19 unit. During an interview on 12/17/20 at 4:59 p.m., the DON viewed the date and time stamped pictures and confirmed Resident #1 was the resident in the pictures. The DON confirmed LVN F was the staff member in the pictures not wearing her N95 mask appropriately. The DON said the pictures of LVN F and Resident #1 were while Resident #1 was on the COVID-19 unit. The DON said LVN F should have had her mask on at all times. During an interview on 12/18/20 at 8:10 a.m., the DON said LVN F confirmed she had removed her mask to speak to Resident #1 while she was on the COVID-19 unit because Resident #1 was very hard of hearing. During an interview on 12/18/20 at 8:15 a.m., the administrator said there was no excuse for LVN F to have her mask down and improper use of PPE was not tolerated. During an observation and interview on 12/18/20 at 9:10 a.m., CNA D was working on the COVID-19 unit. CNA D said he worked on the COVID-19 unit and was not screened prior to his shift on any shift he worked on the COVID-19 unit. CNA D said there were no logs or book for screening staff on the COVID-19 unit. During an observation and interview on 12/18/20 at 9:13 a.m., MA B was working on the COVID-19 unit. MA B said she worked the COVID-19 and the negative halls on different shifts/days. MA B said she was not screened when she worked on the COVID-19 unit. During an observation and interview on 12/18/20 at 9:24 a.m., HSK J was working on the COVID-19 unit. HSK J said she worked on the COVID-19 unit and was not screened prior to her shift on the COVID-19 unit. During an interview on 12/18/20 at 9:30 a.m., LVN C said all staff were supposed to be screened before their shifts including the staff who worked on the COVID-19 unit. LVN C said there were logs for screening and she was not sure where the logs were at this time. During an interview on 12/18/20 at 9:45 a.m., the DON said staff who worked on the COVID-19 unit should be screened prior to their shifts. The DON said she had not monitored if the staff were screened prior to their shifts on the COVID-19 unit. During an interview on 12/18/20 at 9:50 a.m., the administrator said all staff should be screened prior to entering the facility. During an interview on 12/18/20 at 11:24 a.m., the DON said staff were dedicated to the COVID-19 unit during a shift. The DON said staff could work the COVID-19 unit then go home and shower and come back to work the negative halls. The administrator was notified on 12/18/20 at 12:25 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The administrator was provided the Immediate Jeopardy template on 12/18/20 at 12:39 p.m. The facility's Plan of Removal was accepted on 12/19/20 at 11:47 a.m. and included: Interventions: *The following in-services were initiated by the DON, ADON and regional nurse on 12/18/20: Any staff member not present or in-serviced on 12/18/20, will not be allowed to assume their duties until in-serviced. *Staff will be Inservice on the following in-services with a completion date of 12/18/20 and as needed thereafter Inservice staff on Infection Control Overview Inservice staff on proper PPE use in the facility Inservice staff on Screening staff, all persons, upon entry into facility, Covid unit and building Facility will follow Covid plan for emergency staffing Place dedicated staff in the Covid unit Dedicated door screener will be educated on process of screening and to remain at door at all times Off-going staff in Covid unit will screen on-coming staff *The medical director was notified of the immediate jeopardy situation on 12/18/20 at 12:40pm Monitoring *The DON / designee will observe PPE use by randomly selecting 10 staff members weekly on various shifts x 4 weeks *The DON/designee will observe screening for Covid unit/building by randomly on various shifts x 4 weeks *Covid nurse will randomly observe the screening log for compliance *Covid nurse will randomly observe the covid staff for PPE compliance *The QA committee will review findings and infection control policies and makes changes as needed on 12/18/20 and as needed thereafter. On 12/19/20 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Eight LVNs, eleven CNAs, two MAs and one RN (on all shifts - 6 a.m. to 6 p.m.; 6 p.m. to 6 a.m.; 2 p.m. to 10 p.m.; and 10 p.m. to 6 a.m.); three housekeepers; two dietary staff; the activity director; two door screeners; one ADON; and one Physical therapy assistant said they were in-serviced on proper PPE use in the facility; infection control measures; screening staff -all persons, upon entry into facility, COVID unit and building; dedicated staff on the COVID-19 unit; dedicated door screening; and who was responsible for screening on-coming staff on the COVID-19 unit. They said all staff had to be screened prior to entering the facility and if they worked on the COVID-19 unit that was where they would be scheduled. On 12/19/20 at 1:17 p.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure adequate assistance was provided to prevent accidents for 1 of 6 residents reviewed for accidents. (Resident #1) The facility did not provide adequate assistance to prevent Resident #1 from sustaining a fractured left hip during incontinent care. The facility did not change the bed linen for Resident #1 (who was capable of getting out of bed with assistance) properly while he was in the bed. CNA A pulled the bed linen under the resident causing him to roll out of the bed. The resident sustained [REDACTED]. Seventeen days after the fracture the resident remains in pain. This failure could place other residents who require staff assistance with incontinent care at risk for falls or severe injury. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, was readmitted to the facility 12/6/19, and had [DIAGNOSES REDACTED]. Physicians orders dated 1/6/19 indicated Resident #1 was to receive [MEDICATION NAME] (a medication used to control pain) 50 mg routine twice a day and 50 mg every 6 hours as needed. A physician order [REDACTED].#1 was to receive [MEDICATION NAME] (a medication used for moderately severe pain) 10 mg tablets 4 times a day for 7 days. The most recent MDS dated [DATE] indicated Resident #1's cognition was moderately impaired, and he required extensive assistance of 1 staff with bed mobility, transfers, and toileting and had an impairment on 1 side of his body involving his arm and leg. The MDS indicated the resident did not have any behavior and did not resist care and was always continent of bowel and bladder. The MDS indicated Resident #1 did not have any pain in the 5 days prior to this assessment. A care plan initiated 1/6/19 indicated Resident #1 required 1 staff member for assistance with bed mobility and toileting. The care plan indicated the resident was to be provided incontinent care at least every 2 hours. A care plan initiated 3/20/19 and revised on 4/19/19 indicated Resident #1 had limited physical mobility related to his [MEDICAL CONDITION]. An incident report dated 12/2/19 at 3:45 a.m. indicated a CNA called LVN B to Resident #1's room. Resident #1 was lying on the floor between the bed and wall. Resident #1 stated I fell out of bed. An X-ray report dated 12/2/19 indicated Resident #1 had an acute left subcapital (a fracture at the head and neck junction of the femur) [MEDICAL CONDITION]. During an interview on 12/19/19 at 11:00 a.m., Resident #1 said on 12/2/19, he put on his call light and they responded to his room. He said he did not know if 1 or 2 staff responded to his room. Resident #1 said he wanted to be changed and was told his sheets were wet. Resident #1 said they pulled his bed away from the wall and pulled the sheets really hard out from beneath him. He said this caused him to roll out of bed. He said he did not attempt to turn himself. Resident #1 said he should have been gotten up and put in his wheelchair while his sheets were being changed. He said his wheelchair was nearby at the foot of his bed. Resident #1 said it felt like his hip was cracked at first and he did not want to go to the hospital. Resident #1 said his hip started hurting worse later that day. He said his hip was X-rayed and it showed a fractured left hip. During an interview on 12/19/19 at 4:49 p.m., Resident #1 said his left hip still hurts pretty much all the time. He said he got a pain pill for his pain once in a while, but it did not take his pain away completely. During a telephone interview on 12/19/19 at 2:45 p.m., Resident #1's daughter said she received a call from LVN B on 12/2/19 at 5:25 a.m. notifying her Resident #1 had fallen. She said LVN B told her Resident #1 had pushed his hand against the wall, the bed moved, and the resident fell and was found between the wall and the bed. Resident #1's daughter said Resident #1 was paralyzed on his left side, and his bed was against the wall on Resident #1's left side. She said Resident #1 could not turn onto his left side and would not be able to push the wall. Resident #1's daughter said she was told Resident #1 did not have any injuries. She said she received another call from LVN B on 12/2/19 at 8:20 p.m., saying Resident #1 had been complaining his left hip was hurting, an x-ray had been completed and it was discovered Resident #1 had a left [MEDICAL CONDITION]. The daughter said she was informed Resident #1's physician wanted him evaluated at the emergency room . She said the resident's hip must have really been hurting for him to complain of pain since he had a high tolerance for pain and his left side was paralyzed. Resident #1's daughter said she asked Resident #1 what happened when she got to the hospital and Resident #1's story did not match with what she had been told by LVN B. Resident #1's daughter said Resident #1 was sane and his brain worked fine. She said Resident #1 told her he pushed his call light on 12/2/19 at 2:20 a.m. because his bedsheet was wet. He told her a lady came in and was changing his sheets while he was in the bed and she pulled his bed 4 feet from the wall and dumped him out in the floor. Resident #1 told his daughter he hit his head, twisted his leg, and broke his hip. A nursing note dated 12/2/19 at 3:45 a.m. written by LVN B indicated a CNA called LVN B to Resident #1's room because the resident was on the floor between the bed and wall. The note indicated LVN B asked Resident #1 what happened, to which Resident #1 stated oh, I don't know, my head hurts and so does my leg. The note indicated the resident was assessed, responded appropriately to all questions, had a small skin tear to his left elbow and red areas to his left hip. The note indicated Resident #1 was able to move all of his extremities and was assisted to back to bed by 3 staff members. During an interview on 12/19/19 at 5:25 p.m., LVN B said on 12/2/19 around 3:45 a.m., CNA A came to her and told her Resident #1 was in the floor. LVN B said she asked CNA A what happened, and CNA A told her she did not know. She said CNA A said she just found the resident in the floor. LVN B said Resident #1 was between the bed and the wall, lying on his left side. LVN B said she assessed Resident #1 and he said he was sore but did not say his leg hurt. LVN B said she asked Resident #1 what happened, and he said, I don't know, I just fell . LVN B said Resident #1 had no open areas and was not bleeding. She said she and CNA A assisted Resident #1 back into the bed. She said she started neurological checks on Resident #1 and notified the DON, the physician and the resident's daughter of the fall. She and she informed the oncoming nurse of Resident #1's fall. LVN B said 1 staff could provide incontinent care for Resident #1, but if his linens needed changed, it would be safer for 2 staff to change his linens. LVN B said 1 staff member should hold the resident, while the other staff member pulled the old linens out from beneath the resident and put the new linens on. During a telephone interview on 12/19/19 at 6:29 p.m., CNA A said on 12/2/19, she had to move Resident #1's bed away from the wall in order to change his linens because his entire bed was saturated with urine. CNA A said she was standing on the right side of Resident #1's bed and she pulled the sheet from beneath him. CNA A said Resident #1 was facing the wall on the left side of his bed, and when she pulled the sheet, he put his right foot over his left foot, and that was what threw him out of the left side of his bed. CNA A said she tried to catch Resident #1, but he just went over. CNA A said she went to get LVN B. She said she told LVN B Resident #1 slid out of bed while she was changing him. She said Resident #1 told LVN B he slid out of bed when she (CNA A) pulled the sheet from beneath him. CNA A said Resident #1 did not complain of any pain. She said herself, another CNA and LVN B got the resident back into bed using a sheet. CNA A said she knew it was wrong for her to change Resident #1's linens by herself while he was in the bed, but LVN B was busy and the 2 other aides in the facility were providing care for other residents. CNA A said she did not ask anyone for assistance. CNA A said she was usually able to provide incontinent care for Resident #1 by herself, and she had changed Resident #1's linens by herself while he was in bed in the past. A nursing note dated 12/2/19 at 3:45 a.m. indicated Resident #1 stated my head hurts and so does my leg. The resident was offered pain medication, but declined. A nursing note dated 12/2/19 at 4:43 a.m. indicated the DON and Resident #1's physician were notified of Resident #1's fall. A nursing note dated 12/2/19 at 5:28 a.m. indicated Resident #1's daughter was notified of Resident #1's fall. A nursing note dated 12/2/19 at 5:38 a.m. indicated Resident #1 was resting quietly, did not want any medications, repositioning and incontinent care was provided, the resident remained alert, and neuros (neurological checks) remained within normal limits. A nursing note dated 12/2/19 at 2:25 p.m. indicated Resident #1 was alert and oriented and no swelling was noted. The note indicated the resident complained of left hip and leg pain and had been resting in bed all morning. The note indicated PRN (as needed) [MEDICATION NAME] every 6 hours was administered and Resident #1's physician was notified of his continued pain. The note indicated Resident #1's physician ordered an X-ray of his left hip. A nursing note dated 12/2/19 at 7:22 p.m., indicated the DON spoke with Resident #1 and asked him how the fall happened. The note indicated Resident #1 said he was soiled, the CNA helped change his soiled linen and he rolled off the bed. The note said Resident #1 was aware of his [MEDICAL CONDITION] and order to go to the hospital. A nursing note dated 12/2/19 at 9:00 p.m. indicated the ambulance took Resident #1 to the hospital. A nursing note dated 12/6/19 at 6:24 p.m. indicated Resident #1 was readmitted from the hospital with some discomfort and had a surgical dressing to his left hip which was intact. The note indicated the resident complained of discomfort and pain rated as a 6 out of 10 and routine [MEDICATION NAME] was administered. A nursing note dated 12/9/19 at 9:21 a.m. indicated Resident #1 voiced moderate pain to his left lower extremity and [MEDICATION NAME] was administered for pain. A nursing note dated 12/10/19 at 9:41 p.m. indicated Resident #1 was wet with urine but refused incontinent care and stated, I hurt too bad right now. The resident refused pain medication and stated he wanted to go to sleep. A nursing note dated 12/11/19 at 11:59 a.m. indicated Resident #1 refused incontinent care and stated it hurt his left knee and left hip when they turned him and told the CNA's Don't touch me!. A nursing note dated 12/11/19 at 12:44 p.m., indicated Resident #1 was to receive [MEDICATION NAME] 10 mg tablets 4 times a day for 7 days for additional pain management. A nursing note dated 12/16/19 at 9:53 a.m. indicated Resident #1 complained of occasional left hip pain which was treated with [MEDICATION NAME]. A nursing note dated 12/18/19 at 10:22 a.m. indicated Resident #1 complained of pain to his left lower extremity with [MEDICATION NAME] given as ordered. During an interview on 12/19/19 at 12:42 p.m., LVN C said she worked from 6 a.m. to 2 p.m. on 12/2/19. She said when she came to work at 6 a.m. on 12/2/19, LVN B told her CNA A reported Resident #1 pushed the bed away from the wall and fell . She said LVN B told her the resident had a small scratch to his left hip and he complained of pain but refused any pain medicine. LVN C said around breakfast time a CNA reported Resident #1 was complaining of pain. LVN C said she went and assessed Resident #1 and he had a small skin tear to his left elbow in addition to the superficial scratch on his left hip. LVN C said Resident #1 told her he wanted to lay back down and did not want to get back up. LVN C said she asked Resident #1 about the fall and he said they had been changing him and he fell . LVN C said Resident #1 required 1 or 2 staff to provide incontinent care for him. She said sometimes Resident #1 could help roll himself over in the bed during incontinent care. She said Resident #1 was weak on his left side and it would not be safe for 1 staff to change the linens while he was in bed. LVN C said to change Resident #1's linens his bed would need to be moved away from the wall. LVN C said it would put Resident #1 at risk for falling if no one was on the side of the bed near the wall when his linens were changed. During an interview on 12/19/19 at 12:53 p.m., CNA D said she worked with Resident #1 the morning of 12/2/19 during the 6 a.m. to 2 p.m. shift. CNA D said she was not told anything regarding Resident #1's fall. She said she and CNA [NAME] got Resident #1 up that morning and Resident #1 was complaining he was sore on his left side. CNA D said Resident #1 said the girl who worked the night before was mean to him and flipped him out of the bed. CNA D said Resident #1 told her the aide told him the fall was his fault. CNA D said she asked LVN C about it and was informed Resident #1 had fallen during the night. CNA D said she reported Resident #1's pain to LVN C. CNA D said Resident #1 had to be put back to bed for the remainder of the shift because of his pain. CNA D said Resident #1 was paralyzed on his left side and could not turn himself at all using his left side. CNA D said prior to this incident, she could safely provide incontinent care to Resident #1 by herself. CNA D said Resident #1 could turn to his right side, and she could use the lift pad to turn him back over. CNA D said Resident #1 was dead weight on his left side. She said if Resident #1's sheets were changed when he was in bed, a second aide would be needed to get on the left side of the bed to prevent him from falling. During an interview on 12/19/19 at 1:12 p.m., CNA [NAME] said on 12/2/19 around 6 or 7 a.m., she assisted CNA D to get Resident #1 out of bed. She said Resident #1 said my leg is hurting and I fell last night. She said the resident said he fell between the bed and the wall. CNA [NAME] said she was putting Resident #1's pants on him and he said, ouch, ouch that hurts and reached for his left leg. CNA [NAME] said that was unusual for him and she reported his pain to LVN C. CNA [NAME] said Resident #1 told LVN C he fell the night before while he was being changed and the girl jerked him over and he fell out of bed by the wall. CNA [NAME] said if Resident #1's linens needed to be changed while he was in the bed it would take 2 aides to do it safely. She said Resident #1 would push back and try to turn himself back over to lie on his back because he was scared to fall out of bed. CNA [NAME] said Resident #1 did not have any memory problems. During an interview on 12/19/19 at 6:13 p.m., the DON said although Resident #1's left side was flaccid (limp) and he was able to help when turning in the bed. The DON said she had changed Resident #1's linens by herself while Resident #1 was in bed. She said she pulled the bed away from the wall and used her body to prevent Resident #1 from falling. She said she rolled Resident #1 towards her while she pulled the sheets beneath one side of him, she rolled him onto his back, and then went to the other side and again rolled the resident towards her while she removed the rest of the linens. The DON said it would not be appropriate for the CNA to change Resident #1's linens without being on the side he was rolled towards, but it was possible because Resident #1 helps. During an interview with the DON and administrator on 12/19/19 at 10:40 a.m., the administrator said Resident #1 was usually assisted by 1 staff during incontinent care. The administrator said Resident #1 usually assisted with the incontinent care process and would roll over and put his hands against the wall. He said on 12/2/19, when CNA A went in to provide incontinent care for Resident #1, she noticed his sheets were saturated beneath him and needed to be changed. The administrator said CNA A said she pulled the bed away from the wall, and when the resident turned himself as he usually did, he went to put his hands against the wall but because the bed was moved out, the resident rolled out of bed. The administrator said Resident #1 was cognitive and agreed this is what happened. The administrator and DON said Resident #1 complained of pain some time later, and an x-ray was completed. It was discovered the resident had a fractured left hip. The DON and administrator said there were no concerns in how CNA A performed incontinent care and repositioned the resident. A Urinary Incontinence policy revised 2/1/2007 and a Linens policy dated (YEAR) did not specify anything regarding the procedure for changing a resident's linens while they were in bed. The website https://hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/licensing-credentialing-regulation/nurse-aide/cna.pdf accessed on 1/2/2020 indicated the following: . Procedural Guideline #12 - Making The occupied Bed . 1. lock wheels of bed, put head of bed as flat as tolerated and assist resident to roll on side .5. Loosen bottom linen and roll or fanfold linen .to center of bed .7. Apply clean bottom linen .roll the clean bottom linen to the center of the bed .8. Raise side rail, assist resident to roll over linen toward you, and assure that resident is comfortable and safe .9. Raise side rail, then go to opposite side of bed and lower side rail .10. Remove soiled linen from the bed .13. Assist resident to roll back to the center of the bed .

Based on observation, interview, and record review, the facility failed to implement their written policies to prohibit and prevent neglect for 1 of 22 residents reviewed for neglect. (Resident #6) The facility did not prevent Resident #23 from continued harassment of Resident #6. Resident #6 was crying, secluded herself in her room and did not want to leave, was scared at night and was sent to a behavioral hospital for defending herself. This failure could place 78 residents at risk for a decreased quality of life. Findings included: The facility policy to prohibit the mistreatment, neglect, and abuse of residents updated August 1, 2015 indicated each resident has the right to be free from abuse and residents will not be subjected to abuse by anyone, including, but not limited to facility staff and other residents. It also indicated the facility's identification of residents whose personal histories render them at risk for abusing other residents required development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis. A face sheet dated 5/9/17 indicated Resident #6 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #6 could usually understand others, usually made herself understood, and had moderately impaired cognition. She was independent with transfers and locomotion and required supervision with bathing. Her assessment indicated depression and no behaviors. A face sheet dated 5/9/17 indicated Resident #23 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #23 could usually understand others, usually made himself understood, and had impaired cognition. He wandered one to three days a week. He was mobile per wheelchair. A written concern form dated 1/5/17 indicated Resident #6 complained Resident #23 was coming into her room at night. The intervention signed off by the administrator was to redirect Resident #23. A written statement dated 3/20/17 by CNA F indicated Resident #23 rolled up to Resident #6 in the dining room and said something to her. CNA F then witnessed Resident #6 holler if you don't go away, I am going to throw this pitcher of water on you, and then she did. An event report dated 3/20/17 indicated resident to resident inappropriate/unwanted behavior between Resident #6 and Resident #23. A nursing note dated 3/20/17 at 7:00 p.m. indicated Resident #6 was crying in her room because she threw water on Resident #23 in the dining room. She stated he made an inappropriate comment to her, and this occurred multiple times and she reported Resident #23 came to her room in the night and frightened her. She said she talked to several staff members about Resident #23 approaching her and felt no one took her seriously. A nursing note dated 3/26/17 at 6:30 p.m. by LVN G indicated Resident #6's daughter called and told the nurse that Resident #6 said that man threatened her in the dining room. Resident #6 told LVN G that man was going to hurt her and nobody believed her. A nursing note dated 4/29/17 at 8:40 p.m. by RN H indicated Resident #6 was upset because Resident #23 came into her room again. She said she went to the administrator and he was not doing anything. A nursing note dated 5/4/17 at 5:50 p.m. by LVN C indicated Resident #6 was in the dining room when Resident #23 approached her where she was seated at her table, and she told him to not to come closer, but he continued to approach her, and she threw iced tea on him. She accused Resident #23 of stalking her, saying he came to her room at night, and was always trying to get next to her. She said she had to protect herself since no one else would. During an interview on 5/7/17 at 2:30 p.m., Resident #6 said Resident #23 bothered her by singling her out, stalking her, coming into her room at night and said it he scared her. She said she reported it a number of times to the administrator but nothing was done. During an interview on 5/7/17 at 3:15 p.m., Resident #21 said Resident #23 came in her room on several occasions and thought it was his room. She said she told the charge nurse and administrator, but it still happened. During an observation on 5/7/17 at 4:55 p.m., Resident #6 ate her meal in her room. She said she did not want to eat in the dining room because Resident #23 bothered her in there. During an interview on 5/8/17 at 11:54 a.m., the DON said she was aware of on-going issues between Resident #6 and Resident #23, but did not think there was willful intent to hurt one another. She said she did not know why Resident #23 was fixated on Resident #6 and told staff to keep an eye on them. During the group meeting on 5/8/17 at 1:50 p.m., three residents said Resident #23 intentionally picked at Resident #6. They said he came up behind her and tried to push her wheelchair. All three residents thought it was inappropriate and distracting. They said the administrator was aware of the issue between Resident #23 and Resident #6, and tried to keep him away from her during the week, but on weekends he was always bothering her. Another female resident in the group said Resident #23 was always coming into her room. During an interview on 5/8/17 at 2:07 p.m., CNA I said Resident #23 wandered in and out of rooms and had to be redirected. During an interview on 5/8/17 at 2:10 p.m., CNA J said Resident #23 was redirected out of rooms on the east hall when he wandered in them. During an observation and interview on 5/9/17 at 8:27 a.m., Resident #6 was upset, tearful and said she and her daughter met with the administrator yesterday and he told her he would intervene into the situation with Resident #23. She said she was told this morning that she was being transferred to a behavioral hospital. She said she felt she was being sent to a hospital because she complained about Resident #23 said she felt like she was going to jail. She said she could tell the administrator was mad yesterday and said he was just getting even. During an interview on 5/9/17 at 8:39 a.m., LVN C said Resident #6 was referred to behavioral hospital because she threw water on another resident a month ago, and then did it again a week ago. She said she completed the incident report and the DON and administrator reviewed the incident report. She said she separated Resident #6 and Resident #23 and requested Resident #6 to recluse herself from the dining room. She said Resident #23 wandered in and out of rooms and was redirected. She said Resident #23 was moved to West Hall, but still wandered to East Hall. During an interview on 5/9/17 at 9:00 a.m., the administrator said he had known of the issues between Resident #6 and Resident #23 for one to two months and told staff to keep them separated. He said he had not met or contacted Resident #23's family or attended a care plan meeting for him. During an interview on 5/9/17 at 9:09 a.m., the DON said she knew Resident #6 was fixated on Resident #23, stalking her since January. She said she told the staff to redirect the two residents, but said no other interventions were initiated. An undated grievance policy indicated this facility will make prompt efforts to resolve the grievance, including those with respect to the behavior of other residents. The CMS 672 dated 5/7/17 indicated the facility had a census of 78 residents.

Based on interview and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 of 10 residents reviewed for accidents. (Resident #9) The facility did not use a Hoyer lift while transferring Resident #9 to and from the commode from her wheelchair. She fell and sustained a left leg (femur) fracture. This failure could place 25 residents who were transferred with a Hoyer lift at risk of discomfort or injury. Findings included: Physician orders [REDACTED].#9 was [AGE] years old, admitted [DATE], and had [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #9's cognition was moderately impaired and she required extensive assistance of one staff member for transfers. An ADL care plan initiated 4/7/17 indicated Resident #9 required total assistance of two staff using a Hoyer lift for transfers. An incident report dated 3/10/17 indicated Resident #9 was assisted to the restroom, lost her stance, and was assisted to the floor. A Fall Scene Investigation Report dated 3/10/17 indicated Resident #9 was assisted with the gait belt during the transfer. Resident #9 was noted with increased weakness and was changed to requiring a Hoyer lift transfer at that time. An in-service dated 3/10/17 indicated the staff were informed of Resident #9 now requiring a two person transfer with the Hoyer lift due to risk for falls. A nurses note dated 4/23/17 indicated CNA A reported to the charge nurse while transferring Resident #9 from the toilet to the wheelchair after resident completed her toileting task, Resident #9 told CNA A her legs were giving away. CNA A slowly eased Resident #9 to the floor and then called for assistance. Resident #9 requested pain medication for knee pain after she was assisted back to bed. A nurses note dated 4/25/17 indicated the facility obtained an x-ray for Resident #9's left knee due to pain and swelling. The x-ray returned and confirmed a left femur fracture. During an interview on 5/8/17 at 9:46 a.m., Resident #9 said when she fell in the bathroom, CNA A transferred her by herself to and from the toilet. Resident #9 said CNA A had a gait belt around Resident #9 and stood the resident up from the toilet. Resident #9 said she told CNA A her legs were getting weak and she was going down. Resident #9 said her legs started hurting before she slid down to the floor. She said CNA A was unable to get her off the floor herself, so another aide assisted. Resident #9 said before that transfer, two staff were transferring her with a lift. Resident #9 said she was in occasional pain from the broken leg, but it was treated successfully with pain medication. During an interview on 5/8/17 at 8:25 a.m., CNA A said she was the CNA involved with the transfer for Resident #9 in the bathroom on 4/23/17. She said Resident #9 was supposed to be lifted with a Hoyer lift by two staff members. She said Resident #9 was able to bear weight. She said when she transferred Resident #9 from the wheelchair to the toilet, the resident was able to pivot and turn with no problems. She said when she stood Resident #9 up off the toilet, the resident complained her legs were getting weak. She said Resident #9 could not pivot to sit in her wheelchair or back on the toilet. She said she set Resident #9 on the floor and then went to get another CNA to assist her with getting the resident off the floor. She said she did not tell the charge nurse until the resident was off the floor. CNA A said transferring Resident #9 without a Hoyer lift was bad judgment. During an interview on 5/9/17 at11:38 a.m., the DON said Resident #9 was bearing some weight prior to her fall. She said Resident #9 was asking numerous aides to not transfer her with the Hoyer lift, but the DON told the staff to wait until therapy evaluated and approved for Resident #9 to be transferred by another method. She said Resident #9 told her she did not want to be lifted with a Hoyer lift. She said CNA A told the DON that Resident #9 begged to be put on the toilet and was really adamant about needing to go to the bathroom and wanted to be transferred right then without the lift. The DON said Resident #9 should have been transferred with the Hoyer lift. During an interview on 5/9/17 at 2:37 p.m., Resident #9 said she had no clue whether she asked CNA A to transfer her without the Hoyer lift. During an interview on 5/9/17 at 11:40 a.m., the physical therapist said prior to Resident #9's fall, the resident was seen by physical therapy only 5 times. She said Resident #9 was not considered safe for a manual transfer and should have been transferred with the Hoyer lift. A policy on Safe Lifting and Movement of Residents revised December 2013 indicated in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. The policy indicated Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. A list provided by the DON on 5/10/17 indicated there were 25 residents who were transferred with a Hoyer lift.

Based on observation, interview, and record review, the facility failed to ensure residents were free from chemical restraints which were not required to treat medical symptoms but used for staff convenience for 1 of 6 residents reviewed for chemical restraints. (Resident #1) The facility did not accurately assess and document the need for increasing Resident #1's [MEDICATION NAME] to 1.0 milligrams (mg) three times daily. The facility did not implement non-pharmacological interventions or diversions prior to increasing medication. The facility administered [MEDICATION NAME] to Resident #1 without medical justification, resulting in intentional oversedation. This failure could place 24 residents on antianxiety medication at risk of over-sedation and other side effects of medication, decreased quality of life and psychological harm. Findings included: An electronic face sheet with print date 7/18/16 indicated Resident #1 was [AGE] years old. She was admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. A physician order [REDACTED].#1 [MEDICATION NAME] 0.5 mg twice a day as needed. The most recent MDS dated [DATE] indicated Resident #1 had clear speech, was understood and understood others. The MDS indicated Resident #1 had moderate cognitive impairment and no behaviors. The MDS indicated Resident #1 required moderate assistance from staff for all ADLs. A PRN (as needed) Medication Administration History for 5/1/16 to 5/31/16 indicated Resident #1 received [MEDICATION NAME] 0.5 mg twice in May 2016. She received the medication on 5/9/16 at 3:32 a.m. for nervousness and on 5/13/16 at 3:00 p.m. for anxiety. There were no nurse notes reflecting behaviors for May 2016. A nursing note dated 6/13/16 at 4:58 a.m. indicated Resident #1 was constantly trying to get out of bed and continued to be anxious. No other behaviors were documented in the nurse notes from 6/1/16 to 6/30/16. A physician order [REDACTED].#1 [MEDICATION NAME] 0.5 mg twice a day routinely, not as needed. A Behavior History dated 6/1/16 to 6/30/16 indicated Resident #1 had no behaviors documented for the month of June. The nursing notes from 7/1/16 - 7/6/16 did not indicate if Resident #1 exhibited any behaviors. A nursing note dated 7/7/16 at 8:49 a.m. indicated Resident #1 was nauseous and anxious. A physician order [REDACTED].#1's [MEDICATION NAME] 0.5 mg from twice a day to three times a day routinely. A nursing note dated 7/8/16 at 10:54 a.m. indicated Resident #1 continued to holler at times. The nursing notes from 7/9/16 - 7/13/16 did not indicate if Resident #1 exhibited any behaviors. A nursing note dated 7/14/16 at 8:05 a.m. indicated Resident #1 had increased agitation. A physician order [REDACTED].#1's [MEDICATION NAME] from 0.5 mg to 1 mg three times a day. A Behavior History for Resident #1 dated 7/1/16 to 7/17/16 indicated she had no behaviors. The MAR indicated [REDACTED]. at 9 p.m. The most recent care plan revised on 7/15/16 indicated Resident #1 had a [DIAGNOSES REDACTED]. During an observation on 7/17/16 at 3:22 p.m. Resident #1 was sitting in her recliner asleep. During an observation on 7/18/16 at 7:50 a.m. Resident #1 was sitting in her wheelchair at the dining room table on Hall 300, leaning forward resting her forehead on the table. She appeared to be sleeping. She ate 25 % of her breakfast. During an interview on 7/18/16 at 10:40 a.m. Resident #1's daughter-in-law said the nurse told Resident #1 was being sedated so she would not get out of bed. She said the staff told her the use of a bed alarm was against the law. She said she visited daily and that the time varied when she visited. She said that Resident #1 was usually asleep when she visited. During an observation on 7/18/16 at 11:00 a.m. Resident #1 was lying in her bed and appeared to be asleep. During an interview on 7/18/16 at 12:00 p.m. LVN E said Resident #1 received [MEDICATION NAME] 1 mg three times a day because she kept trying to get out of bed and was hollering. She said they had not tried anything prior to increasing the [MEDICATION NAME]. She said that Resident #1 was more sedated. During an observation on 7/18/16 at 2:00 p.m. Resident #1 was in her recliner and appeared to be asleep. During an observation on 7/19/16 at 7:38 a.m. Resident #1 was still in bed and appeared to be drowsy but she answered questions appropriately. During an observation on 7/19/16 at 9:15 a.m. Resident #1 was in bed asleep. During an observation on 7/19/16 at 10:50 a.m. Resident #1 was in bed asleep. During interviews on 7/19/16 at 11:45 a.m. and 11:50 a.m., CNA J said that she had noticed Resident #1 sleeping more. She said they had never been told to try any new interventions when Resident #1 became agitated. She said mainly Resident #1 just wanted to get out of bed and would become upset when she could not. During an interview on 7/19/16 at 10:07 a.m. the physician said the nurses were not documenting like they should be. He said that the [MEDICATION NAME] should not have been increased just for agitation or hollering. During an interview on 7/19/16 at 3:15 p.m. ADON U said the staff were not documenting on Resident #1 as they should. She said Resident #1 hollers a lot and becomes very anxious because she wants to get out of bed. During an interview on 7/20/16 at 8:25 a.m. the pharmacy consultant said he felt the facility was using [MEDICATION NAME] as a chemical restraint to keep Resident #1 in bed. During an interview on 7/20/16 at 10:00 a.m. the DON said the facility did not have a policy and procedure on chemical restraints. The CMS 672 dated 7/17/16 indicated 24 residents received antianxiety medications.

Based on observation, interview, and record review, the facility failed to ensure the drug regimen was free from unnecessary medications for 2 of 7 residents reviewed for psychoactive medications. (Resident #1, #9) -The facility did not attempt non-pharmacological interventions or diversions. The facility did not accurately assess and document the need for increasing Resident #1's [MEDICATION NAME]. The facility increased Resident #1's [MEDICATION NAME] dose without medical justification, resulting in intended increased sedation. -The facility did not have an appropriate [DIAGNOSES REDACTED]. This failure could place 36 residents who received antipsychotic medications and 24 residents who receive antianxiety medications at risk for over sedation and adverse reactions. Findings included: 1. An electronic face sheet with print date 7/18/16 indicated Resident #1 was [AGE] years old. She admitted date 4/28/14 and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED].#1 had an order for [REDACTED].#1 ' s [MEDICATION NAME] on: -6/17/16 it was the order for [MEDICATION NAME] 0.5 mg was changed from as needed to twice a day routinely. -7/7/16 the [MEDICATION NAME] 0.5 mg increased from twice a day to three times a day routinely. -7/14/16 the [MEDICATION NAME] was increased from 0.5 mg to 1 mg three times a day. The most recent MDS dated [DATE] indicated Resident #1 had clear speech, was understood and understood others. The MDS indicated Resident #1 had moderate cognitive impairment and no behaviors. The MDS indicated Resident #1 required moderate assistance from staff for all ADLs. A PRN (as needed) Medication Administration History for 5/1/16 to 5/31/16 indicated Resident #1 received [MEDICATION NAME] 0.5 mg twice in May 2016. She received the medication on 5/9/16 at 3:32 a.m. for nervousness and on 5/13/16 at 3:00 p.m. for anxiety. A nurse ' s note dated 6/13/16 at 4:58 a.m. indicated Resident #1 was constantly trying to get out of bed and continued to be anxious. No other behaviors were documented in the nurses' notes from 6/1/16 to 6/30/16. During an observation on 7/18/16 at 2:00 p.m. Resident #1 was in her recliner and appeared to be asleep. During an observation on 7/19/16 at 7:38 a.m. Resident #1 was still in bed and appeared to be drowsy but responded appropriately to questions. During an observation on 719/16 at 9:15 a.m. Resident #1 was in bed asleep. During an observation on 7/19/16 at 10:50 a.m. Resident #1 was in bed asleep. During an interview on 7/18/16 at 10:40 a.m. Resident #1's daughter-in-law said the nurse told Resident #1 was being sedated so she would not get out of bed. She said the staff told her the use of a bed alarm was against the law. She said she visited daily and that the time varied when she visited. She said that Resident #1 was usually asleep when she visited. During an interview on 7/18/16 at 12:00 p.m. LVN E said Resident #1 received [MEDICATION NAME] 1 mg three times a day because she kept trying to get out of bed and was hollering. She said they had not tried anything prior to increasing the [MEDICATION NAME]. She said that Resident #1 was more sedated. During interviews on 7/19/16 at 11:45 a.m. and 11:50 a.m., CNA J said that she had noticed Resident #1 sleeping more. She said they had never been told to try any new interventions when Resident #1 became agitated. She said mainly Resident #1 just wanted to get out of bed and would become upset when she could not. During an interview on 7/19/16 at 10:07 a.m. the physician said the nurses were not documenting like they should be. He said that the [MEDICATION NAME] should not have been increased just for agitation or hollering. During an interview on 7/19/16 at 3:15 p.m. ADON U said the staff were not documenting on Resident #1 like they should be. She said Resident #1 hollers a lot and becomes very anxious because she wants to get out of bed. During an interview on 7/20/16 at 8:25 a.m. the pharmacy consultant said he felt the facility was using the [MEDICATION NAME] as a chemical restraint to keep Resident #1 in bed. 2. A Resident Face sheet electronically generated on 7/19/16 indicated Resident #9 was [AGE] years old, admitted ,[DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED].#9 received [MEDICATION NAME] 25 milligram (mg) by mouth once a day and [MEDICATION NAME] 12.5 mg by mouth once a day. The most recent MDS assessment dated [DATE] indicated Resident #9 usually understood others and was usually understood. The MDS indicated Resident #9 did not have hallucinations, delusions, physical, or verbal behaviors. The MDS indicated Resident #9 did not refuse care and her behavior had not changed compared to the prior assessment. Resident #9 required extensive assistance of 2 persons with transfers and extensive assistance of one person with dressing, eating, toileting, and hygiene. The most recent care plan electronically generated on 7/19/16 indicated Resident #9 received [MEDICAL CONDITION] drug therapy. The care plan indicated .attempt a gradual dose reduction quarterly and PRN .monitor resident ' s behavior and response to medication .monitor resident ' s functional status .quantitatively and objectively document the resident ' s behavior .review for continued need at least quarterly . During observations on 7/17/16 at 4:09 p.m., Resident #9 was lying in bed watching television. No disruptive behavior was noted During observations of Resident #9 on 7/18/16 at 8:35 a.m., 9:14 a.m., 10:36 a.m., 11:24 a.m., and 3:48 p.m. no disruptive behaviors were noted. During observations of Resident #9 on 7/19/16 at 8:21 a.m and 9:32 a.m. no disruptive behaviors were noted. During an interview on 7/18/16 at 3:40 p.m., MA R said Resident #9 was cooperative with care. She said Resident #9 did not have any physical or verbal behaviors towards staff. During an interview on 7/18/16 at 3:46 p.m., CNA Q said Resident #9 had never resisted care. She said she was pleasant and cooperative. CNA Q said Resident #9 did not have negative behaviors. She said she had never seen her act out physically or verbally. During an interview on 7/18/16 at 4:16 p.m., LVN A said Resident #9 refused to get out of bed occasionally. She said Resident #9 did not refuse care or act out aggressively. She said she had never seen Resident #9 exhibit verbal or physical behaviors. LVN A said Resident #9 was given [MEDICATION NAME] for paranoia because she was sometimes fearful staff would drop her during transfers. LVN A said behaviors should be charted on the computer under behavior monitoring. During an interview on 7/19/16 at 9:35 a.m., the Pharmacist said he requested the appropriate [DIAGNOSES REDACTED]. He said he could not find a recommendation for a gradual dose reduction of the [MEDICATION NAME]. He said the [MEDICATION NAME] had been increased from 25 mg once a day to 12.5 mg once daily at 9:00 a.m. and 25 mg once daily at 8:00 p.m. He said he did not know why the [MEDICATION NAME] was increased. During an interview on 7/19/16 at 2:20 p.m., the Activity Director (AD) said Resident #9 was pleasant. She said she enjoyed doing independent activities and enjoyed croqueting the most. The AD said she had never seen Resident #9 have physical or verbal behaviors. During an interview on 7/20/16 at 9:18 a.m., the Don said she was not sure why Resident #9 was on [MEDICATION NAME]. She said she expected staff to document resident behaviors daily. She said the ADON ' s were responsible for following up with the pharmacy recommendations. Nursing notes dated 3/19/16 to 7/19/16 for Resident #9 did not contain any references to hallucinations, delusions, physical, verbal, or any negative behaviors. The Behavior History sheet dated 4/19/16 to 7/19/16 indicated Resident #9 did not have negative behaviors. An undated Monitoring of Antipsychotics policy indicated .residents receive antipsychotic medications only when medically necessary .CMS approved indications for use of antipsychotic medications: [REDACTED].specific behavior must be documented quantitatively(number of episodes) and described objectively. If there is no response as indicated by quantitative and objective measures, a gradual dose reduction will be attempted with the goal of complete withdrawal of the medication .the continued need for and the effectiveness of the antipsychotic medication is reassessed by the responsible physician. If continuation of the medication is d necessary , the physician indicates in the residents medical record. Non pharmacological behavior modification activities and their effects, as well as the effect of pharmacological behavior modifiers are addressed in nursing notes and in resident care planning .Dose reductions must be tried twice yearly .the nursing staff must do monitoring of targeted behaviors. http://www.fda.gov/Safety/MedWatch/SafetyInformation/Safety-RelatedDrugLabelingChanges/ucm 9.htm accessed on 7/21/16 indicated the following for Quetiapine .BOXED WARNING WARNING: Increased Mortality in Elderly Patients with Dementia-Related [MEDICAL CONDITION] - Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotic drugs are at an increased risk of death. Analyses of seventeen placebo-controlled trials (modal duration of 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. [MEDICATION NAME] is not approved for the treatment of [REDACTED]. The CMS 672 dated 7/17/16 indicated 68 residents took psychoactive medications.

Based on observation, interview, and record review, the facility failed to provide necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 18 residents reviewed for assessments (Resident #14) LVNs R and S did not accurately assess, and provide treatment for [REDACTED]. Although she could receive anti-diarrhea medicine prn (as necessary), she received only one dose. Resident #1 had loose stools for 15 days and received a blood transfusion on 8/4/15. LVN S did not assess Resident #14 following a family report the resident fell on [DATE], that resulted in a lumbar dislocation, until 8/3/15 (8 days). These failures could have contributed to Resident #14's decline requiring a blood transfusion, and lack of medical intervention for a lumbar dislocation. These failures could place 20 residents who resided on Hall 200 West at risk for a delay in needed medical intervention. Findings included: Physician orders [REDACTED].#14, was [AGE] years old admitted [DATE] with [DIAGNOSES REDACTED]. An order dated 3/6/15 instructed [MEDICATION NAME] (anti-diarrheal) 2 milligram (mg) / 2 tablets, to be given after the first loose stool once a day as needed, then [MEDICATION NAME] 2 mg/1 tablet, after each additional loose stool every 6 hours as needed. Resident #14 had laboratory orders for the 3rd Wednesday in July 2015 for a complete blood count (CBC) and a complete metabolic panel (CMP). An order dated 8/8/14 indicated to give [MEDICATION NAME] 7.5mg-325 mg one tablet every 4 hours PRN pain. The most recent MDS assessment dated [DATE] indicated Resident #14 had memory problems and impaired ability to make decisions. There was no documentation of recent or history of falls in this assessment. Nursing notes dated 7/23/15 at 9:11 a.m., indicated Resident #14 had loose stools for 3 days, complained of urinary urgency, was pale and had no energy. Nursing notes dated 7/23/15 at 10:40 p.m., indicated a critical lab of PT 42.5 and INR of 4.03. MD notified and order received to hold [MEDICATION NAME] and redraw PT/INR on 7/27/15. Nursing notes dated 7/28/15 at 4:21 p.m., indicated PT/INR of 2.02. Start [MEDICATION NAME] 2 mg every day. Recheck PT/INR 8/3/15 Nursing notes dated 7/30/15 at 1:57 a.m., indicated Resident #14 continued to have loose stools. A comprehensive care plan with a problem start date of 8/8/14 indicated Resident #14 had 3 problem areas related to falls. She was at risk for falls due to dizziness. She had a history of [REDACTED]. The comprehensive care plan dated 8/4/15 indicated a new problem of Resident #14 being diagnosed with [REDACTED]. There was no documentation of Resident #14 having frequent bloody diarrhea. There was no documentation of Resident #14's fall. Nursing notes dated 8/4/15 at 12:11 a.m. indicated to hold [MEDICATION NAME] per protocol. Medication administration history notes dated 7/5/15 to 8/4/15 for all three shifts, indicated Resident #14 received only one dose of [MEDICATION NAME] 2 mg, one tablet for diarrhea on 7/27/15 at 2:55 p.m. Nursing notes dated 8/2/15 at 11:36 a.m., indicated Resident #14 complained of loose stools. A culture for [MEDICAL CONDITION] was negative and the nurse received physician orders [REDACTED]. Nursing notes dated 8/2/15 at 9:41 p.m. indicated the abdominal x-ray was negative. Nursing notes dated 8/3/15 at 4:53 p.m., indicated Resident #14's daughter had reported she fell around 7/26/15. The family felt Resident #14 had increased confusion today and was not able to be interviewed about the fall because of confusion. The nurse's note did not indicate Resident #14 was assessed for injuries. There was no incident report completed for Resident #14's fall reported on 7/26 or 27/15. During an interview on 8/4/15 at 10:25 a.m., LVN R said she normally cared for Resident #14 and the resident began looking pale on 7/30/15. She said she was aware Resident #14 had loose stools off and on for the past 2 weeks. LVN R said Resident #14 had orders for [MEDICATION NAME] to be given as needed for loose stools, but she had not administered any anti-diarrheal medication. LVN R said she did not administer the [MEDICATION NAME], because Resident #14 had a history of [REDACTED].>During an interview on 8/4/15 at 3:55 pm, Resident #14's daughters said their mother fell on [DATE]. They reported the fall to LVN S on 7/26/15. The daughters said Resident #14 complained of rib and back pain since she fell on [DATE], and experienced a decline in cognitive status and generalized weakness. They said they questioned LVN S about treatment provided to Resident #14 as the result of the fall, and was told she had forgotten to document the fall in Resident #14's chart. The medication history for July and August 2015 indicated LVN R administered Resident #14, [MEDICATION NAME] 7.5 mg-325 mg, one tablet, for complaint of back pain, pain level of 8, on 7/30/15 at 12:16 p.m. During an interview on 8/4/15 at 4:25 p.m., LVN S said Resident #14's family had reported that Resident #14 fell on [DATE]. LVN S said she looked at the resident, but did not see any noticeable injuries. She said she did not believe Resident #14 really fell . LVN S said she did not document the fall in Resident #14's chart or on an incident form. She said Resident #14's daughter asked her how she followed up on Resident #14's fall, and she admitted to them she did not report or document the fall until 8/3/15. She said the physician ordered a spine and rib x-ray which indicated a lumbar dislocation. LVN S said Resident #14 was to be referred to an orthopedic doctor. Nursing notes dated 8/3/15 at 10:43 p.m., indicated Resident #14 tested positive for salmonella in her stool. Contact isolation was initiated. Nursing notes dated 8/4/15 at 2:35 a.m., indicated Resident #14 had blood in her stool and weakness. No further assessment was performed on the night shift. Nursing notes dated 8/3/15 at 7:31 p.m., indicated Resident #14 had pain in her ribs, and the MD was notified of a possible fall. New orders were obtained for x-ray of spine and ribs and complete blood count and comprehensive metabolic panel. The physician was not informed the resident said she had fallen around 7/26/15. Nursing notes dated 8/4/15 at 9:17 a.m. indicated the x-ray of Resident #14's spine indicated a lumbar dislocation and an order for [REDACTED]. A laboratory result dated 8/4/15 for Resident #14 indicated a critical hemoglobin (HGB) result of 7.4 (normal range for women-12.0 to 15.5 grams) was called to LVN S on 8/4/15 at 1:03 p.m. These results were not documented in the nursing notes until 3:29 p.m. at which time an order was received to send to the emergency room . Nursing notes dated 8/4/15 at 9:17 a.m., indicated Resident #14 had a lumbar dislocation and an orthopedic referral was to be made. No assessment of resident condition made or documented. During an observation and interview on 8/4/15 at 10:00 a.m., Resident #14 was sitting up in a wheelchair with her son at her side. Resident #14 said she felt very tired and had diarrhea that morning, but could not recall other times due to forgetfulness. Resident #14's son said he was very worried as his mother was very sick, weak and pale. He said she had diarrhea almost daily for 2 weeks and bloody stools several times. Resident #14's son said the resident had been very pale and very weak the past 3-4 days. He said he or his sisters were with Resident #14 most of the time, because she needed more help and they wanted to keep an eye on her. He said he did not feel staff were concerned and did not check on Resident #14 as they should. He said he had to ask staff to check on Resident #14 and call the doctor on 8/2/15, because he felt his mom was worsening. Resident #1's son said an x-ray of her abdomen was clear, and staff told him they were giving her medicine to stop the loose stools. He said he found out later she had only received one dose of anti-diarrheal medicine in the past 2 weeks, and he was upset they would allow her to continue to have diarrhea. Resident #14's son said he was worried about his mom because she was more pale and becoming weaker. During an interview on 8/4/15 at 10:25 a.m., LVN R said Resident #14's vital signs were normal and she did not notice the resident looking any worse that morning (8/4/15) when she made rounds. LVN R re-checked Resident #14's vital signs after surveyor intervention and family request. LVN R said in her opinion Resident #14 did not look any different from that morning. She said she was not alarmed by the paleness and her vital signs were good. During an interview on 8/4/15 at 10:30 a.m., MA U said she had not given Resident #14 any anti-diarrhea medication in the past few weeks. She said she was aware Resident #14 had loose stools, but did not know about bloody stools. Nursing notes dated 8/4/15 at 3:05 p.m., indicated Resident #14 continued to complain of loose stool and the nurse would continue to monitor. Nursing notes dated 8/4/15 at 3:29 p.m., indicated Resident #14 had a critical hemoglobin result of 7.4 and an order was received to send to the emergency room . No assessment of Resident #14's status was documented and no vital signs were taken. Nursing notes dated 8/4/15 at 3:55 p.m., indicated Resident #14 transferred to a local hospital. There was no documentation of an assessment of Resident #14's condition when leaving the facility or how she was transported. There were no assessments documented in the nurses' notes regarding Resident #14's pale skin, vital signs, diarrhea, or decline in condition on 7/30/15 when LVN R said Resident #14 began to be pale. LVN R took Resident #14's vital signs on 8/4/15 at 10:25 a.m., but did not document any values or assessment of Resident #14's appearance in the nurses' notes. During an interview on 8/5/15 at 11:30 a.m., the DON said Resident #14 had [MEDICATION NAME] orders and should have received the medication with each episode of loose stools. She said Resident #14 had a laboratory test ordered for CBC and CMP the 3rd Wednesday of July 2015, (7/15/15), that were not done. She said she did not know why the laboratory test was missed. The DON said she was not aware Resident #14 fell . She said she expected her staff to document any falls with or without obvious injury in resident nurses' notes and on incident reports. The DON said she was not aware Resident #14 had declined prior to 8/4/15. She said she expected her nurses to perform full assessments and notify the physician with any decline or change of condition, then document the assessments and notifications in the medical record. The census list dated 8/3/15 indicated 20 residents resided on Hall 200 West.

Based on interview, and record review, the facility failed to ensure 1 of 1 nurse (LVN A) assessed and provided care and services that met the professional standards of quality of care for 1 of 7 residents reviewed for assessment. (Resident #6) Resident #6 was readmitted from the hospital on [DATE] at 3:09 p.m. with [DIAGNOSES REDACTED]. Upon re-admission the resident did not receive a respiratory assessment and oxygen was not provided although the hospital notes indicated she would get confused when she was not on oxygen. Resident #6 fell at 4:00 p.m. and had a change of condition. A neurological assessment was documented as completed every 15 minutes until 10:00 p.m. The assessment indicated the resident was stable although the resident was not stable. The physician was not notified of the fall or change of condition. At 7:00 p.m. LVN A indicated Resident #6 was gasping for breath and was pronounced dead after her respirations stopped for 2 minutes. This failure contributed to Resident #6's compromised respiratory status. An Immediate Jeopardy was identified that existed on [DATE]. The facility identified a failure in care and services and implemented corrective action to remove the immediacy on [DATE] prior to the survey. The facility remained out of compliance at isolated actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. However, the facility remained out of compliance with quality of care based on a [DATE] re-certification survey related to F309. This failure could place the census of 82 residents at risk of not receiving needed medical services. Findings included: The Nurse Practice Act indicated: (2) Standards Specific to Vocational Nurses. The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician's assistant, physician, podiatrist, or dentist. Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity. The licensed vocational nurse shall assist in the determination of predictable healthcare needs of clients within healthcare settings and: (A) Shall utilize a systematic approach to provide individualized, goal-directed nursing care by: (i) collecting data and performing focused nursing assessments; (ii) participating in the planning of nursing care needs for clients; (iii) participating in the development and modification of the comprehensive nursing care plan for assigned clients; (iv) implementing appropriate aspects of care within the LVN's scope of practice; and (v) assisting in the evaluation of the client's responses to nursing interventions and the identification of client needs; (B) Shall assign specific tasks, activities and functions to unlicensed personnel commensurate with the educational preparation, experience, knowledge, and physical and emotional ability of the person to whom the assignments are made and shall maintain appropriate supervision of unlicensed personnel. (C) May perform other acts that require education and training as prescribed by board rules and policies, commensurate with the licensed vocational nurse's experience, continuing education, and demonstrated licensed vocational nurse competencies. 15.2 The Role of the Licensed Vocational Nurse in the Pronouncement of Death LVNs do not have the authority to legally determine death, diagnose death, or otherwise pronounce death in the State of Texas... Facility consolidated physician orders [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident # 6 required limited to extensive assistance with ADLs and had a history of [REDACTED]. A care plan with a review date of [DATE] indicated Resident #6 was at risk for complications due to a [DIAGNOSES REDACTED]. A nursing care plan dated [DATE] indicated Resident #6 had chest pain and to administer oxygen as needed. Nursing notes dated [DATE] at 1:00 p.m. indicated Resident #6 was transferred to the hospital with chest pain. A hospital physician progress notes [REDACTED]. The hospital history and physical dated [DATE] indicated Resident #6 was admitted to the hospital with [REDACTED]. Hospital discharge instructions printed [DATE] at 1:34 p.m. indicated the resident was to be monitored for worsening of [MEDICAL CONDITION] and contact doctor and return to emergency room if symptoms worsen. Nursing notes for Resident #6 dated [DATE] completed by LVN A indicated: *at 4:00 p.m., Resident #6 was up and down the halls several times and had gotten up on her own and fell . Vital signs and an incident report were completed with no complaints of pain. (No documentation physician or family notified of call per facility protocol) *at 4:30 p.m., [MEDICATION NAME] was administered and the resident was placed in bed but requested to get back up and was assisted to the wheelchair. *7:00 p.m., CNA B reported to LVN A she needed to check on the resident and when she arrived to the resident's room, she said the resident was having "air hunger" (gasping for breaths). LVN A documented she notified the family and stayed with the resident until her respirations had stopped for two minutes. She pronounced the resident and notified the funeral home. There was no documentation in the nursing notes that LVN A assessed Resident #6's cardiac or respiratory status upon return from the hospital with [DIAGNOSES REDACTED]. During an interview on [DATE] at 2:05 p.m., CNA B said when Resident #6 was readmitted to the facility she was "frigidity" and not breathing normally. The only time she saw LVN A enter Resident #6's room was when she called LVN A to the resident's room because she found Resident #6 breathing loud and heavy. A Witness Statement dated [DATE] at 1:56 p.m., documented CNA B said when Resident #6 came back from the hospital on [DATE], she was very confused and her complexion was pale. CNA B said the resident would get out of breath very quickly. She said the resident was yelling "help me, help me." CNA B said she never saw LVN A check Resident #6's respiratory status. She said the resident was getting in and out of bed all evening and was confused. CNA B said she heard someone breathing loud and heavy, and upon checking on Resident #6, she got help from another CNA and LVN A. A Witness Statement from CNA C dated [DATE] at 2:37 p.m. indicated the CNA observed Resident #6 to be "different" when she returned from the hospital, on [DATE], from what she normally was. CNA C said Resident #6 seemed scared and confused. She would ask to go to bed but before the CNA could leave the room she would start screaming, "Help" and she assisted the resident in and out of bed about 7 times between 4:00 - 7:00 on [DATE]. A Witness Statement dated [DATE], documented that on [DATE] LVN A said she was leaving the dining room at about 6:30 p.m., when a CNA summoned her to Resident #6's room. She said she did not assess the resident's oxygen saturation levels and did not apply oxygen. LVN A said Resident #6 was blue from head to toe, and she did not think oxygen would help. A Neurological assessment dated [DATE] completed by LVN A indicated Resident #6 was assessed for neurological changes every 15 minutes from 4:00 p.m. following a fall until 10:00 p.m. Documentation of orientation, pupillary response and vital signs did not change from 4:00 p.m. through 10:00 p.m. although LVN A documented the resident's respiration stopped at 7:00 p.m. Entries on the assessment form indicated the resident's pupils were equal and reactive, the resident was alert and oriented and vital signs were consistently the same through 10:00 p.m. During an interview on [DATE] at 11:40 a.m. the ADON said she felt the neurological check values were "made up." A Provider Investigation Report dated [DATE] indicated on [DATE] Resident #6 was readmitted at approximately 3:09 p.m. The resident returned from the hospital with [DIAGNOSES REDACTED]. The facility investigation determined that LVN A failed to confirm physician orders [REDACTED]. The facility said LVN A failed to follow good nursing practices and Resident #6 expired with signs and symptoms of [MEDICAL CONDITION] unrelated to her fall. On [DATE] the surveyor attempted to contact LVN A but the nurse was not able to be reached for an interview. During an interview on [DATE] at 3:15 p.m., the ADON said Resident #6 should have had an acute care plan completed upon re-admission for her new [DIAGNOSES REDACTED]. She said when a resident had a change in condition regarding respiratory diagnoses, nurses were to assess lung sounds, obtain oxygen saturation and apply oxygen as needed. When a resident had a fall and the nurse was not sure if they hit their head or not, neurological checks were to be performed per the facility protocol, and assessed for pain or change in cognitive status. The ADON said there was an oxygen concentrator in Resident # 6's room due to her [DIAGNOSES REDACTED].#6. During an interview on [DATE] at 4:40 p.m. the administrator, the corporate nurse and the ADON said LVN A did not perform respiratory assessments for Resident #6, did not notify the physician when the resident fell or when she demonstrated a change of condition in respiratory status. The administrator was notified at this time that an Immediate Jeopardy situation related to quality of care had existed on [DATE] due to the above failures. During an interview on [DATE] at 11:20 a.m., the ADON and administrator said the following corrective actions had been implemented on [DATE] prior to the survey: *The physician was notified on [DATE] of Resident #6's death. *LVN A was suspended pending the investigation and then terminated. *All nurses were in serviced by the corporate nurse on nursing assessment, following readmission orders [REDACTED]. *An emergency quality assurance meeting was held on [DATE] with the medical director to discuss assessments, change of condition, notification and the LVN role. The committee agreed with the corrective actions and made no further recommendations. An In-service Training Report dated [DATE] indicated the licensed nurse received training in death pronouncement policy and procedure, the chain of command and who and when to call, change of condition, even when do not resuscitate, requirements for nursing assessment and re-admission orders [REDACTED] On [DATE] four nurses were interviewed and appropriately responded to questions regarding assessment of residents readmitted to the facility with a respiratory diagnosis. These nurses also knew to contact the physician with any fall or change of condition. The immediacy was removed by the facility on [DATE] based on the above; however, the facility remained out of compliance from a [DATE] re-certification survey with quality of care F309. The CMS-672 dated [DATE] indicated a census of 82.

Based on interview and record review, the facility failed to provide care and services according to the comprehensive assessment and plan of care for 1 of 7 residents reviewed for assessment. (Resident #6) Resident #6 was readmitted from the hospital on [DATE] at 3:09 p.m. with [DIAGNOSES REDACTED]. Upon re-admission the resident did not receive a respiratory assessment and oxygen was not provided although the hospital notes indicated she would get confused when she was not on oxygen. Resident #6 fell at 4:00 p.m. and had a change of condition. A neurological assessment was documented as completed every 15 minutes until 10:00 p.m. The assessment indicated the resident was stable although the resident was not stable. The physician was not notified of the fall or change of condition. At 7:00 p.m. LVN A indicated Resident #6 was gasping for breath and was pronounced dead after her respirations stopped for 2 minutes. This failure contributed to Resident #6's compromised respiratory status. An Immediate Jeopardy was identified that existed on [DATE]. The facility identified a failure in care and services and implemented corrective action to remove the immediacy on [DATE] prior to the survey. The facility remained out of compliance at isolated actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. However, the facility remained out of compliance with quality of care based on a [DATE] recertification survey related to F309. This failure could place the census of 82 residents at risk of not receiving needed medical services. Findings included: Facility consolidated physician orders [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident # 6 required limited to extensive assistance with ADLs and had a history of [REDACTED]. A care plan with a review date of [DATE] indicated Resident #6 was at risk for complications due to a [DIAGNOSES REDACTED]. A nursing care plan dated [DATE] indicated Resident #6 had chest pain and to administer oxygen as needed. Nursing notes dated [DATE] at 1:00 p.m. indicated Resident #6 was transferred to the hospital with chest pain. A hospital physician progress notes [REDACTED]. The hospital history and physical dated [DATE] indicated Resident #6 was admitted to the hospital with [REDACTED]. Hospital discharge instructions printed [DATE] at 1:34 p.m. indicated the resident was to be monitored for worsening of [MEDICAL CONDITION] and contact doctor and return to emergency room if symptoms worsen. Nursing notes for Resident #6 dated [DATE] completed by LVN A indicated: *at 4:00 p.m., Resident #6 was up and down the halls several times and had gotten up on her own and fell . Vital signs and an incident report were completed with no complaints of pain. (No documentation physician or family notified of call per facility protocol) *at 4:30 p.m., [MEDICATION NAME] was administered and the resident was placed in bed but requested to get back up and was assisted to the wheelchair. *7:00 p.m., CNA B reported to LVN A she needed to check on the resident and when she arrived to the resident's room, she said the resident was having "air hunger" (gasping for breaths). LVN A documented she notified the family and stayed with the resident until her respirations had stopped for two minutes. She pronounced the resident and notified the funeral home. There was no documentation in the nursing notes that LVN A assessed Resident #6's cardiac or respiratory status upon return from the hospital with [DIAGNOSES REDACTED]. During an interview on [DATE] at 2:05 p.m., CNA B said when Resident #6 was readmitted to the facility she was "frigidity" and not breathing normally. The only time she saw LVN A enter Resident #6's room was when she called LVN A to the resident's room because she found Resident #6 breathing loud and heavy. A Witness Statement dated [DATE] at 1:56 p.m., documented CNA B said when Resident #6 came back from the hospital on [DATE], she was very confused and her complexion was pale. CNA B said the resident would get out of breath very quickly. She said the resident was yelling "help me, help me." CNA B said she never saw LVN A check Resident #6's respiratory status. She said the resident was getting in and out of bed all evening and was confused. CNA B said she heard someone breathing loud and heavy, and upon checking on Resident #6, she got help from another CNA and LVN A. A Witness Statement from CNA C dated [DATE] at 2:37 p.m. indicated the CNA observed Resident #6 to be "different" when she returned from the hospital, on [DATE], from what she normally was. CNA C said Resident #6 seemed scared and confused. She would ask to go to bed but before the CNA could leave the room she would start screaming, "Help" and she assisted the resident in and out of bed about 7 times between 4:00 - 7:00 on [DATE]. A Witness Statement dated [DATE], documented that on [DATE] LVN A said she was leaving the dining room at about 6:30 p.m., when a CNA summoned her to Resident #6's room. She said she did not assess the resident's oxygen saturation levels and did not apply oxygen. LVN A said Resident #6 was blue from head to toe, and she did not think oxygen would help. A Neurological assessment dated [DATE] completed by LVN A indicated Resident #6 was assessed for neurological changes every 15 minutes from 4:00 p.m. following a fall until 10:00 p.m. Documentation of orientation, pupillary response and vital signs did not change from 4:00 p.m. through 10:00 p.m. although LVN A documented the resident's respiration stopped at 7:00 p.m. Entries on the assessment form indicated the resident's pupils were equal and reactive, the resident was alert and oriented and vital signs were consistently the same through 10:00 p.m. During an interview on [DATE] at 11:40 a.m. the ADON said she felt the neurological check values were "made up." A Provider Investigation Report dated [DATE] indicated on [DATE] Resident #6 was readmitted at approximately 3:09 p.m. The resident returned from the hospital with [DIAGNOSES REDACTED]. The facility investigation determined that LVN A failed to confirm physician orders [REDACTED]. The facility said LVN A failed to follow good nursing practices and Resident #6 expired with signs and symptoms of [MEDICAL CONDITION] unrelated to her fall. On [DATE] the surveyor attempted to contact LVN A but the nurse was not able to be reached for an interview. During an interview on [DATE] at 3:15 p.m., the ADON said Resident #6 should have had an acute care plan completed upon re-admission for her new [DIAGNOSES REDACTED]. She said when a resident had a change in condition regarding respiratory diagnoses, nurses were to assess lung sounds, obtain oxygen saturation and apply oxygen as needed. When a resident had a fall and the nurse was not sure if they hit their head or not, neurological checks were to be performed per the facility protocol, and assessed for pain or change in cognitive status. The ADON said there was an oxygen concentrator in Resident # 6's room due to her [DIAGNOSES REDACTED].#6. During an interview on [DATE] at 4:40 p.m. the administrator, the corporate nurse and the ADON said LVN A did not perform respiratory assessments for Resident #6, did not notify the physician when the resident fell or when she demonstrated a change of condition in respiratory status. The administrator was notified at this time that an Immediate Jeopardy situation related to quality of care had existed on [DATE] due to the above failures. During an interview on [DATE] at 11:20 a.m., the ADON and administrator said the following corrective actions had been implemented on [DATE] prior to the survey: *The physician was notified on [DATE] of Resident #6's death. *LVN A was suspended pending the investigation and then terminated. *All nurses were in serviced by the corporate nurse on nursing assessment, following readmission orders [REDACTED]. *An emergency quality assurance meeting was held on [DATE] with the medical director to discuss assessments, change of condition, notification and the LVN role. The committee agreed with the corrective actions and made no further recommendations. An In-service Training Report dated [DATE] indicated the licensed nurse received training in death pronouncement policy and procedure, the chain of command and who and when to call, change of condition, even when do not resuscitate, requirements for nursing assessment and re-admission orders [REDACTED] On [DATE] four nurses were interviewed and appropriately responded to questions regarding assessment of residents readmitted to the facility with a respiratory diagnosis. These nurses also knew to contact the physician with any fall or change of condition. The immediacy was removed by the facility on [DATE] based on the above; however, the facility remained out of compliance from a [DATE] re-certification survey with quality of care F309. The CMS-672 dated [DATE] indicated a census of 82.

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with the comprehensive assessment for 1 of 27 residents reviewed for pain. (Resident # 18) Resident #18 experienced pain during meals due to a broken tooth/bone spur on her upper gums. The resident was assessed for pain but she did not receive any interventions to relieve her pain. This failure contributed to Resident #18's unrelieved pain during meals, and had the potential to place 35 residents on a pain management program at risk of not having effective pain management . Findings included: Consolidated physician orders [REDACTED]. A dental history report dated 12/7/11-7/10/12 indicated Resident #18 had multiple teeth extractions and debridements. An annual MDS assessment dated [DATE] indicated Resident #18 had no difficulties with her mouth, teeth or gums. An MDS assessment dated [DATE] indicated Resident #18 was usually able to express wants and needs but had some short term memory problems, required extensive assistance with ADLs including brushing her teeth and could feed herself with supervision. She was assessed as having no pain, nor any broken teeth, mouth pain, or chewing discomfort. A care plan updated 9/7/12 indicated Resident #18 was at risk for pain related to arthritis and recent dental work. Interventions included ensuring: the appropriate pain management flow sheet was used to determine intensity of pain/comfort, a weekly pain assessment was completed and family and physician were aware of any changes that indicated pain. During an observation and interview on 9/17/12 at 1:00 p.m., Resident #18 had a full plate of food after most everyone had eaten. When asked if the food was not good the resident said she could not eat because of her teeth. She said she had difficulty eating her meal. She said her food was chopped because of her "teeth." She pointed to the roof of her mouth and said it " hurts so badly" when she chewed anything firm or hard. During an observation and interview on 9/17/12 at 4:00 p.m., Resident #18 complained of having pain in her mouth. LVN C assessed the resident's mouth after surveyor intervention. She touched the resident's upper left gumline and Resident #18 said, "Oh, Oh, that hurts." LVN C said it looked like an ulcerated area on her gumline and her lower gums were swollen, red, and food was packed in her teeth at the gumline. LVN C said Resident #18 had not complained of pain to her. LVN C did not document this assessment or that the resident had mouth pain. During an interview on 9/18/12 at 8:45 a.m., LVN B said he was not made aware of Resident #18 having mouth pain. He said he knew the resident had dental surgery in the past; he said he would check on the resident. During an interview on 9/18/12 at 3:30 p.m., LVN B said he did not assess Resident #18 for pain in her mouth. He said he was going to tell the 2 p.m. to 10 p.m. charge nurse. During an observation and interview on 9/18/12 at 3:35 p.m., LVN K assessed Resident #18's mouth after surveyor intervention. LVN K touched the resident's left upper gum line; Resident #18 jumped and said "Oh, it ' s my tooth coming through my gums." Her upper gum was red and swollen. LVN K said the resident had a broken tooth. During an interview on 9/18/12 at 3:45 p.m., the SW said no one had notified her of Resident #18 having any mouth/tooth pain. Nursing notes dated 9/18/12 at 3:45 p.m., documented Resident #18's mouth was assessed at this time. The note indicated that " bone spurs were noted on back of gum line." Resident #18 did not complain of current pain, but stated it was an "8" on a pain scale of 1-10 (1= little pain and 10= excruciating pain), when she chewed food. Nursing encouraged her to ask for pain medication when she was in pain. The September 2012 MAR and TAR indicated Resident #18 did not receive any as needed [MEDICATION NAME] 50 mg for pain during the month. The September 2012 Pain Management Flowsheet for Resident #18 did not document any episodes of pain or interventions for pain management. During an interview on 9/19/12 at 1:15 p.m. LVN B said pain assessments were documented on the Pain Management Flowsheet. LVN B said Resident #18 did not have a documented pain assessment for September 2012. During an interview on 9/19/12 at 1:23 p.m., a family member said Resident # 18 had been complaining of her mouth hurting for weeks. He said the facility called him yesterday wanting to increase her pain medication and he refused. He said he wanted the resident to get her teeth fixed not just get pain medication. He agreed the resident should get something for pain and he thought the [MEDICATION NAME] would be helpful. The facility's undated Pain assessment policy stated, "To assess the resident's frequency, intensity and signs/symptoms of pain. To identify indicators of pain to target the site of pain. To serve to monitor resident's response to pain management interventions, maximize comfort, enhance quality of life and improve quality of care." The CMS dated 9/17/12 indicated 35 residents were on a pain management program.

Based on interview and record review, the facility failed to consult with the physician after a change of condition for 1 of 8 residents reviewed for change in condition. (Resident #4) Resident #4 was diabetic, did not eat breakfast or lunch and was unresponsive the entire day shift. The nurse did not consult with the physician until 1:50 p.m., almost 8 hours after the shift began. Resident #4 was admitted to the hospital where and her blood sugar was too low to register on the glucometer. This failure contributed to Resident #4's low oxygen saturation, severe low blood sugar and subsequent hospitalization and could place the census of 89 residents at risk for serious health complications. Findings included: Physician orders [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #4 was cognitively impaired and totally dependent on staff for ADLs. A nurse note dated 12/9/11 indicated Resident #4 was alert and communicating with staff. The nursing notes dated 12/12/11 at 1:50 p.m. indicated Resident #4 slept the entire shift (6 a.m. - 2 p.m.), was unresponsive with care and did not eat breakfast or lunch. Her oxygen saturation was 89% and her blood sugar was "low". The note indicated the physician was consulted regarding Resident #4's change of condition at this time. During an interview on 12/16/11 at 1:20 p.m. the DON said Resident #4 was usually alert and able to communicate with staff. She said "low" meant Resident #4's blood sugar was too low to register on the glucometer. The DON said RN A should have assessed Resident #4 and checked her blood sugar when she first identified Resident #4 was not responding as she usual. A hospital history and physical dated 12/12/11 indicated Resident #4 was lethargic and would not respond to painful stimulation. Her oxygen saturation was in the 80s and her blood sugar was initially "unrecordable". The history and physical indicated Resident #4's blood sugar was 11 mg/dL (normal range 70-100) when obtained by the laboratory. During an interview on 12/16/11 at 3:20 p.m., Resident #4's primary physician said RN A notified his office at 1:50 p.m. of Resident #4 unresponsiveness, low blood sugar and oxygen saturation. He said he instructed the RN to give the resident glucose and oxygen and send her to the emergency room . He said the RN should have notified him when she first observed the change of condition. During an interview on 12/16/11 at 1:50 p.m., the DON said staff should consult a resident's physician when a change of condition was observed. She said she had not in-serviced the staff about physician notification because she felt like it was an isolated incident. During an interview on 12/16/11 at 3:40 p.m., the DON said the facility did not have a policy on physician notification or resident change of condition. The CMS 672 dated 12/16/11 indicated the census was 89.

Based on observation, interview, and record review, the facility failed to provide care and services to ensure accurate assessment and timely and effective interventions for 1 of 8 residents reviewed for change of condition. (Resident #4) Resident #4 was diabetic, did not eat breakfast or lunch and was unresponsive the entire day shift. The nurse did not consult with the physician until 1:50 p.m., almost 8 hours after the shift began. Resident #4 was admitted to the hospital where her blood sugar was too low for the glucometer to register. This failure contributed to Resident #4's low oxygen saturation and severe low blood sugar and subsequent hospitalization and could place the census of 89 residents at risk for serious health complications. Findings included: Physician orders [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #4 was cognitively impaired and totally dependent on staff for ADLs. A nurse note dated 12/9/11 indicated Resident #4 was alert and communicating with staff. The nursing notes dated 12/12/11 at 1:50 p.m. indicated Resident #4 slept the entire shift (6 a.m. - 2 p.m.), was unresponsive with care and did not eat breakfast or lunch. Her oxygen saturation was 89% and her blood sugar was "low". The note indicated the physician was consulted regarding Resident #4's change of condition at this time. During an interview on 12/16/11 at 1:20 p.m. the DON said Resident #4 was usually alert and able to communicate with staff. She said "low" meant Resident #4's blood sugar was too low to register on the glucometer. The DON said RN A should have assessed Resident #4 and checked her blood sugar when she first identified Resident #4 was not responding as she usual. During an interview on 12/16/11 at 3:20 p.m., Resident #4's primary physician said RN A notified his office at 1:50 p.m. of Resident #4 unresponsiveness, low blood sugar and oxygen saturation. He said he instructed the RN to give the resident glucose and oxygen and send her to the emergency room . He said the RN should have already given Resident #4 the glucose and put the resident on oxygen. He said after his call with RN A he was concerned for the residents immediate welfare and called the facility administrator to request she send someone to assist RN A with Resident #4's care. He said Resident #4's condition was unusual for her and RN A should have notified him when she first observed the change of condition. A hospital history and physical dated 12/12/11 indicated Resident #4 was lethargic and would not respond to painful stimulation. Her oxygen saturation was in the 80s and her blood sugar was initially "unrecordable". The history and physical indicated Resident #4's blood sugar was 11 mg/dL (normal range 70-100) when obtained by the laboratory. Resident #4's care plan dated 11/10/11 did not address her diabetes or the need to monitor her for signs and symptoms of low blood sugar. The website www.nlm.nih.gov/medlineplus.htm, viewed 11/20/11, indicated blood sugar below 70 mg/dL is considered low and a blood sugar at or below this level was harmful. The most common causes of low blood sugar in people with diabetes was not eating enough during meals or snacks after taking diabetes medicine and skipping meals. The Drug Information Handbook for Nursing, 12th edition, page 673, 674 indicated [MEDICATION NAME] was a medication used to lower the blood sugar in diabetic patients. The book indicated low blood sugar was more likely to occur when caloric intake was deficient and in elderly patients. Patients with a decreased caloric intake may need doses held to avoid low blood sugar. The Lippincott Manual of Nursing Practice, 7th Edition, page 849 indicated low blood sugar could occur as a result of an imbalance of food and oral anti-diabetic agents. Page 854 indicated signs and symptoms of low blood sugar included depression of the central nervous system (feeling sleepy, slurred speech, slowed reflexes and breathing) as as blood sugar levels progressively fall and low blood sugar should be treated promptly with fast-acting carbohydrates such as 4 ounces of juice, glucose, etc. During an interview on 12/16/11 at 1:50 p.m.., the DON said staff should consult a resident's physician when a change of condition was observed. She said she had not in-serviced the staff about physician notification because she felt like it was an isolated incident. During an interview on 12/16/11 at 3:40 p.m., the DON said the facility did not have a policy on assessment of resident change of condition. The CMS 672 dated 12/16/11 indicated the census was 89.

Based on observation, interview and record review the facility failed to provide care and services to ensure: *pain control interventions were initiated timely for 3 of 7 residents sampled for pain (Resident #s 3, 16 and 20), and *indwelling urinary (Foley) catheter tubing was secured for 1 of 3 residents sampled with Foley catheters. (Resident #9) Pain Control Resident #20 was crying out in pain and 3 staff failed to intervene or reposition her as indicated on her care plan. Resident #3's complaints of pain were not addressed by staff and orders for pain medication had not been obtained. Resident #16 was not premedicated prior to a treatment. His complaints of pain were not addressed timely and orders for pain medication had not been obtained. Catheter tubing Resident #9's Foley catheter tubing was not secured to prevent pulling and tension. These failures could place 58 residents with [DIAGNOSES REDACTED]. Findings included: 1.) Physician orders [REDACTED]. Pain medications included Tylenol and [MEDICATION NAME] as needed. The MDS dated [DATE] indicated Resident #20 had clear speech and could express her needs. The MDS indicated she received prn pain medication and non medication interventions for pain. She required extensive assistance with transfers and mobility. A care plan dated 07/21/11 indicated Resident #20 needed to be repositioned due to back pain. Nurses were to monitor for signs and symptoms of increased pain/discomfort, assess resident for possible causes, give medication and relaxation modalities for relief. During an observation on 10/05/11 at 8:20 a.m. Resident #20 was sitting in a wheelchair close to the nursing station crying. An unidentified CNA stopped to talk to her and told LVN I who was at the nursing station Resident #20 was hurting and wanted to go to bed. LVN I told the resident the CNA would put her to bed. Resident #20 was not repositioned for 5 minutes. According to the October 2011 MAR, Resident #20 was last administered pain medication 10/03/11 on the 2-10 shift. During an observation and interview on 10/05/11 at 8:25 a.m., CNA H assisted Resident #20 to her room and began to exit the room with the resident still in the wheelchair crying. The surveyor asked the CNA if she was going to assist the resident to bed. CNA H said the resident was going to get a shower. Resident #20 said, "No, I'm hurting and need to go to bed." The resident was transferred to bed where she curled up on her right side and said, "I hurt so bad." The resident was no longer crying. During an observation on 10/5/11 at 8:40 a.m., LVN I administered Resident #20 [MEDICATION NAME]. During an observation on 10/5/11 at 9:00 a.m., Resident #20 was asleep. During an interview on 10/05/11 at 6:45 p.m. the AD said Resident #20 would come to activities and stay 10 to 25 minutes then say her back hurt and she needed to go to bed. 2.) Physician orders [REDACTED]. There were no orders for pain medication. A hospital progress note dated 9/20/11 indicated Resident #3 had a left [MEDICAL CONDITION], a left partial hip replacement and had been on [MEDICATION NAME] for pain control. An admission nursing assessment dated [DATE] indicated Resident #3 was alert and had a 15 inch surgical incision with staples intact. He was to keep a wedge pillow between his legs for positioning and was on hip precautions. A care plan dated 7/19/11 indicated Resident #3 was to be assessed for pain and "treated per order." During an observation and interview on 10/3/11 at 10:15 a.m., Resident #3 was in bed on his back with a wedge pillow between his legs. Resident #3 said his leg was hurting. RN P, present at the time of the observation, said the resident was admitted from the hospital 9/29/11 where he had surgery for [REDACTED]." During an observation on 10/4/11 at 7:40 a.m., RN P and LVN I repositioned Resident #3 by log rolling him to his side. The resident complained of pain but neither nurse acknowledged his complaint. During an observation on 10/4/11 at 8:45 a.m., CNAs M and S provided Resident #3 with incontinent care. CNA S reached across the resident and grasped the resident's incision site with one hand and the back of his knee with her other hand and attempted to roll him over causing his knee to bend. The resident yelled out in pain. After surveyor intervention, CNA S reported the resident's complaint of pain to the nurse. CNAs S and M continued with care and again attempted to roll the resident over. The resident pleaded to not be turned. He said he could not take it, "just let me kill myself". The surveyor stopped the care at that point. During an interview on 10/4/11 at 9:15 a.m., RN P said Resident #3 had no pain medication ordered. She said she had notified the physician. During an observation and interview on 10/4/11 at 9:30 a.m., CNAs M, S and an unidentified CNA provided incontinent care for Resident #3. The resident continued to complain of pain. LVN I, present at the time of the observation, said she had received orders for pain medication and administered it to him at that time. A nursing note dated 10/4/11 at 9:00 a.m. indicated an order for [REDACTED]. 3.) Physician orders [REDACTED]. A care plan dated 9/1/11 indicated Resident #16 was to be assessed for pain and treated per orders. The care plan required Resident #16 to be premedicated prior to dressing changes as needed. A skin condition report dated 9/7/11 indicated Resident #16 had a pressure on her right heel. During an observation and interview on 10/5/11 at 9:55 a.m., LVN I performed a treatment on Resident #16's pressure sore on her right heel. The resident told the LVN, "stop, that hurts." LVN I told the resident, "You told me last night it hurt to touch it." LVN I said she was sorry and she would get her something for pain when she got through. Resident #16 continued to complain of pain while LVN I completed her treatment. LVN I said Resident #16 did not have pain medication ordered and she would notify the physician for orders. 4.) Physician orders [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #9 required extensive assist with ADLs and had a Foley catheter. A nursing care plan dated 10/11/10 did not address securing Resident #9's catheter tubing. During an observation and interview with ADON W on 10/03/11 at 10:25 a.m., Resident #9 was in bed without her catheter tubing secured. ADON W said the catheter should be secured and the resident had a history of [REDACTED]. During an observation and interview with CNA D on 10/03/11 at 1:30 p.m., Resident #9 was in bed without her catheter tubing secured. CNA D said she was not aware of residents' catheters being secured. During an interview on 10/3/11 at 1:45 p.m., Resident #9 said her catheter tubing had not been "taped down" with anything for about 4 or 5 months. She said the staff pulled the catheter during transfers causing discomfort. During an interview on 10/3/11 at 2:00 p.m., LVN E said catheters should be secured but she was unaware of any straps in the facility. The undated catheter policy indicated: Secure urinary drainage bad below the level of the bladder and keep off the floor at all times coil the extra tubing and secure. According to the website at Lippincott's Nursing Center.com reviewed on 10/06/11, www.nursingcenter.com/prodev, Reasons to secure a catheter: To prevent urethral trauma or erosion, as well as inadvertent catheter removal Types of securement devices. - A number of catheter securement devices for short- and long-term indwelling catheters are available, and they can be divided into three categories: * improvised devices that make use of adhesive tape, safety pins, or sutures * manufactured devices with an adhesive backing and a mechanism for attaching the catheter * nonadhesive devices that incorporate Velcro and straps to secure the catheter to the upper thigh. The CMS-672 dated 10/03/11 indicated 3 residents had urinary catheters. The resident list dated 10/05/11 indicated there were 58 residents with [DIAGNOSES REDACTED].

Based on observation, interview and record review, the facility failed to implement interventions to prevent development and worsening of pressure sores for 2 of 5 residents sampled for pressure sores. (Resident #s 3 and 16) Resident #16 had a deep tissue injury on her right heel that worsened to two unstageable pressure sores. The facility did not perform skin assessments for a 3 week period or provide necessary pressure relief. Resident #3 developed a new unidentified Stage III pressure sore on his coccyx and inner buttock and a deep tissue injury on his left inner buttock after being readmitted . Resident #3 was not turned and repositioned in accordance with his plan of care. He stayed on his back and was not provided necessary pressure relief. These failures contributed to the development of new pressure sores and the worsening of the existing pressure sores for Resident #s 3 and 16 and could place 4 other residents with pressure sores at risk for developing new pressure sores and worsening of existing pressure sores. Findings included: 1.) Physician orders [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #16 required extensive assistance with bed mobility, was incontinent and did not have pressure sores. The MDS indicated her cognitive status was severely impaired. A Braden scale assessment dated [DATE] indicated Resident #16 was at mild risk for skin breakdown. The care plan dated 9/1/11 indicated staff were to provide pressure relief, perform weekly skin assessments, and assist Resident #16 with turning and repositioning every two hours and as needed. A skin assessment sheet dated 9/7/11 indicated Resident #16 had a 3.5 x 4.5 cm deep tissue injury on her right heel. Resident #16 was to be on a pressure relieving mattress and her heels were to be offloaded. A physician order [REDACTED]. A physician order [REDACTED]. A dietary assessment dated [DATE] indicated Resident #16 did not have pressure sores. A wound care clinic note dated 9/22/11 indicated Resident #16's right heel pressure sore was cultured on 9/13/11. The note indicated the culture [MEDICAL CONDITION]. A physician order [REDACTED]. During an observation on 10/3/11 at 10:40 a.m., Resident #16 was in bed with her heel resting on the bed. Her heel protectors were on the night stand. During an observation on 10/5/11 at 9:40 a.m., Resident #16 was in bed with her right heel resting on a pillow. Her heel protectors were on the night stand. During an observation on 10/5/11 at 9:55 a.m. with LVN I, Resident #16 had the following pressure sores on her right heel: *2.2 x 1.8 cm with a black necrotic wound bed and *3.0 x 2.3 cm, with yellow slough in the wound bed and black necrosis around the outer edges of the pressure sore. During an interview on 10/5/11 at 11:00 a.m., LVN I said she could not find a skin assessment since 9/7/11 when Resident #16 was assessed to have a deep tissue injury to her right heel. She said she did not know when the area went from a deep tissue injury to an unstageable pressure sore. During an interview on 10/5/11 at 11:15 a.m., the DON said she did not know when the deep tissue injury on Resident #16's right heel opened and became an unstageable pressure sore. She said Resident #16 went to the wound clinic for care of her pressure sore. During an interview on 10/5/11 at 4:45 p.m., the DON said she was not aware Resident #16 [MEDICAL CONDITION] in her pressure sore. 2.) Physician orders [REDACTED]. The admission nursing assessment dated [DATE] indicated Resident #3 was alert and non-weight bearing. The assessment indicated he was on bed rest and had an abduction pillow between his legs. The admission skin assessment sheet dated 9/29/11 indicated Resident #3 was admitted with a 2 x 1.5 cm open area with a 1 x 1 cm necrotic center on his left great toe; and a 1.5 x 0.5 cm necrotic area on his left outer foot. A Braden scale assessment dated [DATE] indicated Resident #3 was at high risk for skin breakdown. A pressure sore care plan dated 7/19/11 indicated staff were to provide Resident #3 with pressure relief and assist him to turn and reposition every two hours and as needed. During an observation and interview on 10/3/11 at 10:15 a.m., Resident #3 was in bed on a mattress resting on his back with an abduction pillow between his legs. No pressure reduction devices, pads or pillows were being utilized to protect Resident #3's bony prominences. RN P said he was readmitted on [DATE] from the hospital following hip surgery. She said he was on hip precautions and was to be repositioned using a technique referred to as log roll. During an observation and interview on 10/3/11 at 4:00 p.m., Resident #3 was on his back. He said he could not turn over and "it sure got old lying" on his back. Resident #3 did not have pressure reduction devices, pads or pillows utilized to protect his bony prominences. During an observation on 10/4/11 at 7:40 a.m., RN P and LVN I identified a new Stage III pressure sore on Resident #3's coccyx. Resident #3 had a large bowel movement that had dried around the pressure sore. The RN and LVN said the CNAs would provide incontinent care and then they would measure the pressure sore. RN P said she did not feel like Resident #3 needed a speciality mattress when he was admitted because he did not have any pressure sores. The RN and LVN left the room without cleaning the stool from Resident #3's pressure sore. During an observation and interview on 10/4/11 at 8:45 a.m., CNAs M and S entered Resident #3's room to perform incontinent care. CNAs M and S said they began their shift at 6 a.m. but did not start their first round until 8:30 - 9:00 a.m. They said they did not usually get to Resident #3 until around 10:00 a.m., but the nurse had told them to check on Resident #3 first. During an observation with LVN I on 10/4/11 at 9:30 a.m., Resident #3 had the following pressure sores: *coccyx - 3.5 x 5.25 cm Stage III *left inner buttock - 9.25 x 2.5 cm deep tissue injury *right inner buttock - 2.25 x 5.0 cm deep tissue injury *left middle toe - 0.3 x 0.3 cm unstageable *left great toe - 1.3 x 1.0 cm Stage II *left second toe -0.2 x 0.6 cm unstageable *outer left foot - 0.8 x 1.2 cm deep tissue injury *scrotum - Stage I During an interview on 10/4/11 at 10:20 a.m., LVN I said she assisted with Resident #3's admission on 9/29/11 and he did not have "all those new places." She said nurses were to perform weekly skin assessments. She said the CNAs were to report any new skin issues to the charge nurse. A physician order [REDACTED]. *pressure relieving mattress on bed, check every shift and *[MEDICATION NAME] cream and light dressing to his left foot every day. The undated facility pressure ulcer care and prevention protocol indicated the following: *use pressure reducing devices to relieve pressure, *position with pads or pillows to protect bony prominence, *off load heels if resident unable to move lower extremities, and *preventative measures as per orders. The National Pressure Ulcer Advisory Panel at <http://www.npuap.org/pr2.htm>, accessed 10/06/11, noted the following pressure ulcer definitions: "A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Pressure Ulcer StagesSuspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Further description:Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.Further description:The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate "at risk" persons (a heralding sign of risk)Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Further description:Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal [MEDICAL CONDITION], maceration or excoriation. *Bruising indicates suspected deep tissue injuryStage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Further description: The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.Further description: The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] possible. Exposed bone/tendon is visible or directly palpable.Unstageable:Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.Further description:Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as "the body's natural (biological) cover and should not be removed." The CMS 672 dated 10/3/11 indicated 6 residents had pressure sores.