Every finding on record at Hollymead

Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 3 residents (Resident #1) reviewed for care plans. The facility failed to develop a care plan to address Resident #1's transfer assistance. This failure could place residents at risk of not having the sufficient number of staff needed for safe transfer. Findings included:Record review of Resident #1's Comprehensive MDS Assessment, dated 08/17/2026, revealed a [AGE] year-old female admitted to the facility on [DATE] with a BIMS score of 14 (cognitively intact with little to no impairment) and active diagnosis of hypertension (occurs when the force of blood pushing against your artery walls is consistently too high). Mobility devices used wheelchair or walker. Section GG (Self Care)revealed Resident #1 was independent for toileting hygiene. Section GG (Mobility) revealed Resident #1 required substantial/maximal assistance for toilet transfer (the ability to get on and off a toilet or commode). Record review of Resident #1's Care Plan, dated 08/11/2026, revealed a Focus: Resident #1 was dependent on staff with transfer to/from bed chair, wheelchair, standing position with intervention including transfers - required assistance of two staff members using a gait belt for transfers. Further review revealed Focus: Resident had an ADL self-care performance deficit r/t recent hospitalization for Laminectomy (a surgical procedure that removes part or all of the lamina (the bony arch of a vertebra) to ease pressure on the spinal cord or nerves), with the goal listed as Resident #1 would demonstrate the appropriate use of adaptive device to increase mobility. Interventions included transfer: Resident #1 required assistance x1 or x2 staff to move between surfaces. During an observation and interview on 08/19/2026 at 1:00 PM, Resident #1 was lying in bed under the covers with the lights off. She stated that she fell in the restroom about an hour ago and her pain level was 6. She stated the nurse gave her medication for pain and she was currently comfortable. She stated that there was one staff member that assisted with the transfer. During an interview on 08/19/2026 at 1:02PM, family member of Resident #1 stated she was able to monitor Resident #1's room for safety and observed CNA A transfer Resident #1 from her bed to the wheelchair then to the in-room restroom about an hour ago and; during that transfer Resident #1 fell. During an interview on 08/19/2026 at 2:16PM, CNA A stated she responded to Resident #1's call light for assistance with transfer to the toilet. She stated she transferred Resident #1 from the bed to the wheelchair, then from the wheelchair to the toilet. She stated she remained on standby until the resident was ready to transfer from the toilet to the wheelchair. CNA A stated during the transfer, Resident #1's legs gave out. CNA A stated Resident #1 was in a squat position but did not fall to the floor. She stated Resident #1 was holding the grab bar. CNA A stated Resident #1 was placed back in the wheelchair. CNA A stated she alerted the nurse on duty of the incident. She stated that she understood Resident #1 was a one-person transfer. During an interview on 08/19/2026 at 4:37 PM, the DON stated the purpose of a resident centered care plan was for the staff to know how to care for the residents. The DON stated the negative risk of (what) was resident safety. The DON stated the interventions for residents were discussed with the IDT team and that information was then given to direct care staff. The DON stated it was understood that Resident #1 was a one person transfer. During an interview on 08/19/2026 at 4:41PM, the Administrator revealed the purpose for resident care plans was to assure Resident #1 received the proper level of care from the staff. He stated resident care plans were reviewed upon admission, quarterly or change of conditions. He stated the MDS Coordinator and IDT team members were responsible for entering the care plans. He stated care plans were reviewed during morning meeting for accuracy. Review of facility policy titled, Comprehensive Care Plans, revision 2025 revealed, The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on interview and record review, the facility failed to appropriately discharge for 1 (Resident #1) of 7 residents reviewed for transfer/discharge. The facility failed to ensure Resident #1 was not discharged home without Home Health services to assist with ongoing care needs. This failure could place residents at risk of being discharged inappropriately causing a disruption in their care and services and potential decline in health. Findings included:Record review of Resident #1's face sheet, dated 06/12/26, reflected that Resident #1 was an [AGE] year-old male resident who was admitted to the facility on [DATE] and discharged on 06/10/2026 with the diagnoses of Hepatic Encephalopathy (a nervous system disorder caused by severe liver disease), Hypertensive Heart Disease with Heart Failure (condition where chronic high blood pressure forces the heart to work too hard over time), Alcoholic Polyneuropathy (nerve damage caused by heavy alcohol consumption), and Alcoholic Cirrhosis of Liver without Ascites (destruction of normal liver tissue). Record review of Resident #1's MDS, dated [DATE], reflected that Resident#1 had a BIMS score of 10, which indicates Resident #1 had moderate cognitive impairment. MDS indicated Resident #1 was admitted for Inpatient Rehabilitation Facility. MDS indicated in Section Q Participation in Assessment and Goal Planning:Is active discharge planning already occurring for the resident to return to the community? 1. YesHas a referral been made to the Local Contact Agency (LCA)? 0.NoIndicate Reason why referral to LCA was not made. 4. discharge date 3 or fewer months away Record review of Resident #1's care plan, not dated, reflected the following: FocusRisk for Wandering/Elopement Identified, resident exit seeks.GoalThe Resident's safety will be maintained.Interventions1 to 1 supervision, Engage Resident is purposeful activity, identify if there is a pattern and purpose if wandering, Provide clear, simple instructions. FocusThe resident has risk for impaired cognitive function/impaired thought processes diagnoses hepatic encephalopathy.GoalThe resident will improve current level of cognitive function through the review date.InterventionAdminister medications as ordered. Monitor and document for side effects and effectiveness, Ask yes/no questions to determine the resident's needs, Monitor/document/report PRN any changes in cognitive function, specifically changes in decision making, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Care Plan did not indicate information regarding discharge planning. Record review of a text message that was sent to Family Member from the SW number on 06/08/26 reflected Hi this is SW at [Facility]. Resident #1 is going to need to discharge today. The Administrator is asking for a family member to come get him. Please contact me at your earliest convenience. He is still a danger for exit seeking. We provided a sitter through the weekend. The Administrator is no longer willing to cover the cost. Record review of a letter from Resident #1's external doctor dated 06/10/26, reflected To whom it concerns: As you know Resident #1 suffers from chronic alcoholism that has led to cirrhosis, hepatic encephalopathy, neuropathy causing balance disorder, anemia and cognitive impairment. It is my medical opinion that he not live unsupervised or be allowed to drive due to his cognitive impairment. Family Member is currently in the process of trying to find a permanent living facility. Please allow him to continue to stay at your rehabilitation facility a bit longer so Family Member can find a permanent facility. During a phone call on 06/15/26 at 12:55 PM, the Family Member stated when Resident #1 was at the hospital the doctor informed her that they did not recommend Resident #1 to go home. Family Member stated when she went to the facility on [DATE] they were supposed to have a care plan meeting, but the care plan meeting turned into a discharge meeting. The Family Member stated she told the [Facility] it would be an unsafe discharge due to Resident #1 living alone and he had cognitive issues. The Family Member stated the [facility] told her Resident #1 did not have any cognitive issues. The Family Member stated when she told the administrator that if they discharged Resident #1 it would be unsafe the administrator told her, They were just going to get the DON and the physician to clear Resident #1 so they could move forward with the discharge. The Family Member stated that she requested the facility to notify her the day that Resident #1 was going to see the Physician because she wanted to be present due to having some questions, but she was never notified. The Family Member stated that is when she reached out to the doctor from the [Hospital] to get a letter to give to the [facility] letting them know that the [Hospital] did not recommend letting Resident #1 discharge, but she stated by the time she received the letter from the hospital they were already letting Resident #1 discharge. The Family Member stated she was never notified that he was being discharged the day Resident #1 left the [Facility] and she did not even know how he had gotten home. Family Member stated she was going to send the POA paperwork, but surveyor never received it. During a phone call on 06/15/26 at 1:40 PM, the SW stated Resident #1 was discharged due to continuously requesting to be discharged . The SW stated Resident #1 was confused when he first admitted to the facility and she stated that he thought he was in an Anonymous Alcohol center. The SW stated that Resident #1 knew he was in a treatment center and he just did not know it was skilled nursing facility. The SW stated Resident #1 became increasingly agitated about wanting to go home. The SW stated Resident #1 did not remember signing any kind of POA paperwork. SW stated the family member was the POA, but she did not submit the POA paperwork to them until the day before the Resident was being discharged on 06/09/26. The SW stated the family member did not understand resident right's when she was told the resident was going to be discharged due to wanting to go home. The SW stated that Resident #1 stated he did not want to go to a group home. The SW stated that the family member was unhappy about the discharge and stated if they discharged Resident #1 it would be an unsafe discharge because he lived alone. The SW stated the family member became very mad about the discharge and cussed her out. The SW stated she made a report to APS to go and inspect Resident #1's home to determine if his home was a safe environment due to Resident #1 living home alone. SW stated when APS reported back to her that Resident #1's home was a safe environment and there were no hazards. When asking the SW who did she speak with from APS and if she had their contact number she stated that she was unsure of the person's name and she did not have that information in front of her at that moment. SW stated she then made the referral on 06/08/26 for home health care services to go out to the Resident #1's home after he was discharged . The SW stated she then attempted to notify the family member that Resident #1 would be discharged but she stated the Family Member did not answer the phone. The SW stated they discharged Resident #1 and then arranged an Uber ride for Resident #1 to be transported home on [DATE]. The SW stated she followed up with home health care to find out if they went to Resident#1's home, but she stated that she was told they were still in the process of verification and she stated she was unsure who she spoke with. The SW stated she was unsure of the dates that she reached out to home healthcare. The SW stated she made no other follow-ups with home health care to see if they went to the Resident's home She stated she was unsure about what else was discussed due to the incident being so long ago and she stated she was not in front of her computer to look at her notes. The SW stated the risk of discharging a resident inappropriately was that the resident could be put at risk to be sent back to the hospital, or the resident could be injured if no one was checking on him. During an interview on 06/15/26 at 2:34 PM, the DOR stated Resident #1 could walk and on the first day they had trouble finding him in the facility. The DOR stated Resident #1 could walk 500 feet with stand-by assistance. The DOR stated Resident #1 was in his room at first and the next minute they could not find him. The DOR stated Resident #1 needed supervision because of his cognitive impairments and confusion. The DOR stated when Resident #1 was admitted he had some confusion and he was a little better by the time he discharged but he was still slightly confused. The DOR stated during the time Resident #1 was in the facility he had to be redirected quite a few times and she had to educate him that he was confused and it was unsafe for a confused person to leave the facility. The DOR stated that Resident #1 tried to go out of one of the side exit doors, but a staff member was able to redirect him as soon as he opened the door on 06/03/26. The DOR stated when they redirected Resident#1 it only lasted about 15 minutes sporadically and then he would be in the hallway again just looking around trying to see where he was going. The DOR stated Resident #1's was not oriented to the task at times. The DOR stated that Resident #1 would sit in the dining room and he would look around in confusion as if he was lost in his thoughts. The DOR stated in in Resident #1's case he was diagnosed with alcoholic cirrhosis of the liver without ascites, and he also had Hepatic encephalopathy which caused his confusion and the reason he needed supervision. The DOR stated she believed Resident #1 would be safe if he lived with someone at home, but if he lived by himself-there was a chance he could open the door and walk out because that was what he had been trying to do during his time at the facility. The DOR stated she did have some concerns about Resident #1 being discharged due to his cognitive decline and she asked the ADON why he was being discharged and she had told her that it was due to Resident #1 persistently wanting to go home. The DOR stated the risk of inappropriately discharging Resident #1 was that he could make some unsafe decisions that would compromise his health. During an interview on 06/15/26 at 2:58 PM, CNA A stated Resident #1 was a sweet person and from the moment he was admitted he would always say he wanted to go home. CNA stated Resident #1 thought that he was in an anonymous alcohol center. CNA A stated some days Resident #1 would be calm and other days he would say he wanted to go home and he would try to leave the facility. CNA A stated the family member would go to the facility and attempted to convince Resident #1 to stay in the facility but then other times he would feel like the family member was not listening to him and he would become aggressive. CNA A stated Resident #1 would then pack up his belongings and then say that he was leaving. CNA A stated Resident #1 was cognitive enough because he was able to tell her how to get to his home. CNA A stated that Resident #1 told her that he ordered his own groceries. CNA A stated when Resident #1 found out he was in FM he had told her that he did not live too far from the facility and he could walk home. CNA A stated the only time Resident #1 was confused was during the first night he was admitted when they could not find him in his room and then found him sitting in the chapel. CNA A stated Resident #1 was not confused any other time, and he took care of himself, so he had been trying to go home. CNA A stated the risk of discharging a resident inappropriately is that the Resident could be harmed and they should not discharge any residents who they feel would not be suitable for discharge. During a phone call on 06/15/26 at 3:30 PM, Admissions at [Home Health Care] stated they just received the referral for Resident #1 around 3:00 PM on 06/15/26. During an interview on 06/15/26 at 3:37 PM, LVN B stated Resident #1 was in his hall and from the first time he saw him he was always packing his belongings. LVN B stated Resident #1 was always confused and he always had to redirect him. LVN B stated Resident #1 did not understand he was in a nursing facility and thought he was in a hotel. LVN B stated that Resident #1 was not aware of what he was doing due to his acute condition that caused him to be confused. LVN B stated that Resident #1 would think that his truck was parked outside and he could just go and drive it out of the parking lot. LVN B stated he thought that the receptionist had his keys, and he would go to the front and ask for his keys. LVN B stated he did not work with Resident #1 too often he just took his vital signs; made sure he was stable and he would give Resident #1 his medication. LVN B stated Resident #1 would not be safe to discharge himself and he did not give him the impression that he could take care of himself. LVN B stated a risk of a resident being inappropriately discharged was that they could harm themselves. During an interview on 06/15/26 at 3:49 PM, the Physician stated the last time she saw Resident #1 was on 06/08/26 and he appeared very anxious and he wanted to go home. The Physician stated Resident #1 kept telling her someone was going to pick him up. The physician stated during the day she visited Resident #1 the facility still had him under supervision 1 to 1. The Physician stated the facility was worried about an elopement and he kept asking to go home. The physician stated she couldn't remember the day that the SW called her, but she stated she received a call and the SW told her Resident #1 was cleared from therapy and that he seemed to be oriented and that he physically did not need to be in the facility any longer and he could go home. The physician stated that Resident #1 told them he had a friend that could check on him often and so the SW set up his home healthcare services. The Physician stated Resident #1 was admitted with Hepatic Encephalopathy and that's why they did not discharge him immediately. During an interview on 06/15/26 at 4:00 PM, the ADON stated Resident #1 was admitted from the hospital due to him suffering from alcohol abuse. The ADON stated when Resident #1 was admitted he did not agree to be at the facility. The ADON stated Resident #1's Family Member put him at the facility, and the resident wanted to go home. The ADON stated on 06/02/26 when the resident was admitted , they realized Resident #1 was not in his room. The ADON stated the resident was found in the front of the building by the library area, and she called the Administrator. The ADON stated since they did not know the resident too well, they agreed to place him on one in one monitoring to make sure he did not try to leave. The ADON stated the resident did not have exit seeking behavior, but they looked at him as an elopement risk. The ADON stated on 06/03/26 the resident kept saying he wanted to leave, and he did not want to be at the facility. The ADON stated the family member went to the facility and spoke with her directly. The ADON stated she informed the family member that if Resident #1 kept saying he wanted to leave they would need to discharge him and they could not keep him there because they did not have a locked unit. The ADON stated he remained on one-to-one supervision until 06/09/26 when he packed his bags and put them in his wheelchair and said he was leaving. The ADON stated she called the family member to notify of the Resident #1's behavior, and the family member responded, What do you want me to do? The ADON stated the family member said to let Resident #1 go outside and once Resident #1 realized he could not go anywhere he would go back into the facility. The ADON stated she then informed the Family Member they could not do that. The ADON stated on 06/09/26 they had a care plan meeting with Resident #1 and the family member. During the meeting, the Family Member was asked where Resident #1 lived. The ADON stated the family member reported that the resident lived alone and that if he were discharged it would be an unsafe discharge. The ADON stated Resident #1 then stated in the care plan meeting that he wanted to go home again. The ADON stated that the family member cussed out the SW and told the administrator that she did not want to hear anything else from him because she was upset that they were going to discharge Resident #1. The ADON stated the SW then setup a discharge date and made an APS report so they could go and view Resident#1's home to see if the home environment was safe. The ADON stated APS reported back and said the home would be safe and that it would not be an unsafe discharge. The ADON stated they did not plan on discharging Resident #1 but once he said he wanted to leave he was able to go after therapy cleared him and the physician said he could go. The ADON stated that once he was discharged on 06/10/26 he went home and called from a neighbor's phone and let the facility know he had made it home, he was doing well, and that his neighbor said he would check on him. The ADON stated she had set up home health care to visit to go to Resident #1's home. The ADON stated the risk of discharging a resident inappropriately could be catastrophic and a resident could fall, be disoriented, or go back to the hospital and not be able to take care of themselves. During a phone call on 06/15/26 at 4:45 PM, the Physician stated she did not know if the surveyor was still at the facility, but she had just left and she wanted to call to clarify. The Physician stated she spoke with the DOR, and she was unaware that therapy had concerns regarding Resident #1 being able to discharge. The Physician stated she questioned therapy about not notifying her of their concerns. The Physician stated when the SW called her and told her that Resident #1 was cleared from therapy and that APS went out to Resident #1's home and confirmed his environment would be safe she stated she told her okay he could discharge. The physician stated she typically just trusts them when they say a resident is cleared to go home. The physician stated at the time when she spoke with the SW about the discharge, she was also unaware that the Family Member felt the discharged would have been unsafe. The Physician stated had she would have known that the Family Member had concerns about the discharge she would have told them to have a meeting with the Family Member to discuss the concerns. The Physician stated the risk of a resident being discharged inappropriately was that the resident would not get the care they needed. During an interview on 06/16/26 at 9:45 AM, the Administrator stated he and the Regional Director went to visit Resident #1 at his home. The Administrator stated the resident appeared to be fine. During an interview on 06/16/26 at 10:20 AM, the Speech Therapist stated he only worked with Resident#1 for two sessions of therapy and from the times he worked with him his cognitive status was pretty low. The Speech Therapist stated his problem-solving abilities were severe, and it only improved to moderate by the time he left. The Speech Therapist stated he was not sure about the discharge process, and they only told him when a resident was being discharged . The Speech Therapist stated his day-to-day recall was not all the way there. He stated Resident #1 was able to tell him about something that happened a couple of months ago, but he could not remember the details. The Speech Therapist stated on another occasion Resident #1 asked him if the facility was an anonymous alcohol center, and he told him that it was a skilled nursing and facility. He stated the next day the resident did not remember that conversation and asked him if the facility was an anonymous alcohol center again. The Speech Therapist stated that he did not know much about the discharge, so he would not know what the risk of discharging a resident inappropriately would be. During a phone call on 06/16/26 at 3:35 PM, Resident #1 gave the surveyor consent to go to his house to check on him. During a phone call on 06/16/26 at 3:40 PM, Family Member stated she received a call from the RD on 06/15/26 and he told her that they were going to go to Resident #1's house to check on him and she stated she told him not to go to Resident #1's house. The Family member stated The Administrator and the RD still went to Resident #1's home and she said Resident #1 said that he was scared because he said, he did not know who they were and he thought they were trying to take him back to the [Facility]. Family member stated she would meet surveyor at Resident #1 house because she did not want him to be scared when the surveyor went to visit him. During an interview with Resident #1 and the family member on 06/17/26 at 4:15 PM, when trying to ask Resident #1 about the [Facility] he stated, which one is [Facility] is that the one in [NAME]? The family member informed Resident #1 that he was never in a facility in A. When trying to ask Resident #1 questions about what happened when he discharged from [Facility], Resident #1 then stated, where is [Facility] again. Resident #1 stated so I was never in [NAME], and the family member answered, no. Resident #1 stated it is clearly something wrong with my memory. When attempting a third time to ask the residents questions about [Facility] he stated, that's not the one in [NAME]. The family member then told Resident #1 it's the one you think that is in [NAME]. The family member stated the [Facility] is the one where the two guys came to visit with you yesterday. Resident #1 stated oh that's who came to the house yesterday, he stated there were two guys and one stood back and the other one stood at the door and he stated they did not have on any professional clothes. Resident #1 stated they scared him and he started not to open his door. Resident #1 then stated all he remembered was that the driver that brought him home was nice and he stated he did not remember who the transport was, but it could have possibly been transportation that the facility uses all the time. Resident #1 stated he had his walker when he left the facility and remembered falling 5 times. Resident #1 had no visible injuries during the visit on 06/16/26. Resident #1 stated that he did not remember if the [Facility] told him why he was at the facility.Resident #1 stated you have to remember it has been 8 weeks of being in two different facilities. The family member then informed Resident #1 that it had not been 8 weeks at all and that he was only at the [Hospital] and the [Facility] within a span of 3 weeks. Resident #1 then asked the surveyor what today's date was. Surveyor then stepped outside to take a phone call and went back into the Resident's house and the family member stated she put a chair in the Resident's doorway because he wanted to get in his bed due to him saying he was in pain. Resident #1 then stated he could not remember if he told the facility that he wanted to go home or not. Resident #1 said that he probably did say that he wanted to go home but that did not mean he needed to go home. Resident #1 stated who would want to be in a place like that, but he stated he knew that he needed to be there to get the care he needed. Resident #1 then stated when he was being discharged the [Facility] told him, Alright get your stuff and leave, and they opened the door. Resident #1 stated he felt that they could have discharged him professionally. Resident #1 could not elaborate on what he meant by that. Resident #1 stated he did not know which medication to take, and he stated that they never told him when he was supposed to take his medication. The Family Member stated that she was the POA, and the [facility] never asked for the POA paperwork until the last couple of days he was at the facility. Resident #1 asked what POA was, the Surveyor told Resident #1 that POA is Power of Attorney, the family member continued the conversation and then Resident #1 then asked what POA was about 30 seconds later. During an interview on 06/16/26 at 4:30 PM, Family Member, stated Resident #1 did not start taking his medications until 06/15/26 around 7:00 PM when she organized them in a pill box. Family Member stated she had to dig his medications out of his bag because he did not know where they were. Family Member stated that she explained to Resident #1 which medication he needed to take from his pill organizer, but she noticed he took two morning pills and a nighttime pill extra than what he was supposed to take. Family Member was unsure of which specific medication Resident #1 took due his medication being in the pill organizer she did not know which pills they were. During an interview on 06/17/26 at 9:49 AM, LVN C stated on 06/10/26 he was informed that Resident #1 was being discharged and he went to Resident #1's room and went through his medications with him and educated him on when to take his medications, but he stated Resident #1 seemed to understand. LVN C stated by the time he finished educating Resident #1 on how he needed to take his medications Resident #1 verbalized that he understood how he was supposed to take his mediation. LVN C stated his duties were only to give the Resident #1 his medications and he ate breakfast. LVN C stated the facility then set up the uber ride which was the private transport. LVN C stated he only knew that Resident #1 was being discharged but he did not know why he was being discharged . LVN C stated Resident #1 expressed that he wanted to go home and watch the basketball finals on his big screen television at home. During an interview on 06/17/26 at 4:11 PM, the DON stated she was on vacation when Resident #1 was first admitted so she was unaware of his cognitive status at the beginning. The DON stated when she spoke with Resident #1, he stated he wanted to go home, and he thought he was in a different type of rehab. The DON stated when she assessed him on 06/08/26 and he was oriented to the time, and he could tell her how to get to his house, and he had given her his address. The DON stated she asked Resident #1 if he lived in a single-family home, she stated he replied yes. The DON stated she asked Resident #1 if he had a phone and he said he did not have a cellphone, but he had a house phone. The DON stated when she spoke with Resident #1, he also knew he had been in the hospital. The DON stated the last time she saw Resident #1 was on 06/09/26 and he appeared to be in good spirits and he was not argumentative. The DON stated Resident #1 was still on one to one monitoring when she assessed him. The DON stated once the SW spoke with APS and they reported his home would be a safe environment and therapy and the physician cleared him they felt that he was safe to go home. The DON stated from her understanding the SW sent the referral for home healthcare services on 06/08/26, but she was notified on 06/15/26 that home healthcare never received the referral. The DON stated when she asked the SW for the physical copy of the referral that was faxed the SW stated that she no longer had it. When asking the DON if Resident #1 is asking what the date is she would that be considered oriented, she stated no, if he us asking questions. The DON stated he was disoriented when she interviewed him on 06/08/26. The DON stated if Resident #1 had been disoriented when she assessed him, she would not have let him be discharged and she would have kept him the facility. The DON stated the risk of discharging a resident inappropriately was that the resident could be at risk of returning to the hospital, they could fall or even have some medication issues. During an interview on 06/17/26 at 4:13 PM, the Administrator stated when Resident #1 was first admitted he received a call Resident #1 was not in his room and he told staff to do a search of the building. The Administrator stated he guessed Resident #1 did not know he had to stay in his room. The Administrator stated they decided to move Resident # '1's room closer to the nurse's station because he was new and they did not know if he would try to leave the building. The Administrator stated at first they were going to put him one-to-one supervision for the first couple of days and then they decided to get a sitter for Resident #1 and continue one-on-one supervision. The Administrator stated on 06/09/26 the day before Resident #1 was discharged he packed all his stuff and said that he wanted to go home. The Administrator stated when they had the meeting with the family member to notify her that they were going to let Resident #1 discharge, and he stated the family member started using profanities toward him and he told her he was not going to continue to speak to her any longer due to her not having a civilized conversation. The Administrator stated the family member told them that it would be an unsafe discharge due to Resident #1 living by himself. The Administrator stated that is when the SW set up for APS to go visit Resident #1's home and then had Resident #1 assessed and the SW set up home health care services for Resident #1. He stated that he had heard that home health care did not receive the referral, and he asked the SW about it, but the SW said she set it up on 06/08/26 and that's all he could go off of. The Administrator stated the DON and the physician stated he was safe to discharge. The Administrator stated Resident #1 was alert and oriented when he was discharged . The Administrator stated Resident #1 knew his exact address and where he wanted to go. The Administrator stated the expectation of staff were to notify the physician, family, and set up appropriate post discharge services like home health care or hospice. The Administrator the risk of discharging a resident inappropriately was that the resident would not get the appropriate services or equipment needed for their health and they could possibly not get their medications. Record Review of facility policy titled Transfer and Discharge (including AMA), undated, reflected the following in part:Policy: It is the policy of this facility to permit each resident to remain in the facility and not transfer or discharge the resident from the facility, except in limited circumstances. This policy applies to all residents regardless of their payment source.Policy Explanation and Compliance Guidelines:The facility will evaluate and determine the level of care needed for the resident prior to admission to ensure the facility's ability to meet the resident's needs. Once admitted , the resident has the right to remain at the facility unless their transfer or discharge meets one of the following specified exemptions: The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility.The transfer or discharge is appropriate because the resident's health has improved sufficiently so that the resident no longer needs the services provided by the facility.The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident.The health of individuals in the facility would otherwise be endangered.Anticipated Discharge to the CommunityFacility will obtain a physician's order for transfer or discharge and instructions or precautions for ongoing care.A member of the interdisciplinary team will complete relevant sections of the Discharge Summary. The nurse caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes, but not limited to, the following:A recap of the resident's stay that includes diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultation results.A final summary of the resident's status.Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter).A post discharge plan of care that is developed with the participation of the resident, and the resident's representative(s) which will assist the resident to adjust to his or her new living environment. Orientation for transfer or discharge will be provided and d

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests in two halls (Hall 600 and Hall 700) of three halls reviewed for pests. The facility failed to ensure Hall 600 and Hall 700 were free of millipedes.This failure could place residents at risk of insect-born illness and not having a home free of pests in which to live. Findings included:Review of Resident #1's admission Record reflected Resident #1 was a [AGE] year old female resident admitted to the facility on [DATE], residing on the 700 Hall, with diagnoses in part including cerebral infarction (a type of stroke caused by blocked blood flow to the brain), essential hypertension (high blood pressure not due to another medical condition), heart failure (when the heart doesn't pump blood as well as it should), and diabetes mellitus (disease of inadequate control of blood sugar). Review of Resident #1's annual MDS dated [DATE] reflected Resident #1 had a BIMS score of nine, indicating moderate cognitive impairment and hallucinations or delusions. Review of Resident #2's admission Record reflected Resident #2 was a [AGE] year old female resident admitted to the facility on [DATE], residing on Hall 700, with diagnoses in part including transient cerebral ischemic attack (temporary blockage of blood flow to the brain), kidney failure (kidneys no longer work well), diabetes mellitus (disease of inadequate control of blood sugar), heart failure (when the heart doesn't pump blood as well as it should), and essential hypertension (high blood pressure not due to another medical condition). Review of Resident #2's Quarterly MDS dated [DATE] reflected Resident #2 did not have hallucinations or delusions, and she had a BIMS score of 13 which indicated she was cognitively intact Review of Resident #3's admission Record reflected Resident #3 was a [AGE] year old female resident admitted to the facility on [DATE], residing in Hall 600, with diagnoses in part including acute diastolic congestive heart failure (when the left chamber of the heart is stiff and cannot accept an adequate amount of blood to meet the body's need), chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs), hyperlipidemia (elevated levels of fat in the blood), and diabetes mellitus (disease of inadequate control of blood sugar). Review of Resident #3's Quarterly MDS dated [DATE] reflected Resident #3 did not have delusions or hallucinations, and she had a BIMS score of 13 which indicated she was cognitively intact. Review of Resident #4's admission Record reflected he was a [AGE] year old male resident admitted to the facility on [DATE], residing in Hall 600, with diagnoses in part including acute cholecystitis (inflammation of the gallbladder), diabetes mellitus (disease of inadequate control of blood sugar), essential hypertension (high blood pressure not due to another medical condition), and end stage renal disease (kidney failure that requires dialysis or kidney transplant).Review of Resident #4's admission MDS dated [DATE] reflected he did not hallucinate or have delusions, and his BIMS score was 13 which indicated he was cognitively intact.In an observation on 06/06/26 at 10:29 a.m., Resident #1 was observed receiving incontinent care when a two-inch brown millipede was seen crawling in the bed near her leg. CNA A saw the millipede and removed it from Resident #1's bed. Two millipedes were observed crawling up two different walls of Resident #1's bedroom. Two partially smashed, dead millipeds were observed smeared on Resident #1's wall and ten or more brown spots were noted on three of the bedroom walls. In an interview on 06/06/26 at 10:35 a.m., Resident #1 stated that the millipeds had been coming into her room from outdoors for the past month and she was told by the facility staff (unknown name) that it was due to the rain, and they had sprayed for millipedes but that her room had never been sprayed. She stated that the multiple brown spots on the walls were from staff using her cane to kill the millipedes but not cleaning them off afterwards. In an interview on 06/06/26 at 10:40 a.m., CNA A stated she had seen millipedes in residents' rooms on halls 600 and 700 for the past month. She stated that when staff saw pests they would put in a work order for maintenance, but that maintenance had already been made aware and had sprayed for them. She stated she had not seen them spray. In an interview and observation on 06/06/26 at 11:05 a.m., Resident #2 stated, The centipedes are terrible. She stated that they had been in her room for at least a month. She stated she had been told that facility had sprayed for them. She stated there had been some improvement in the number of millipedes she saw and that she typically saw them in her room every couple of days now. She stated, You worry about them falling in your hair. No millipedes or other pests were observed in her room at the time of the interview. In an interview and observation on 06/06/26 at 11:20 a.m., Resident #3 stated that, I don't like having the centipedes. They don't bite though. I just pick them up and flush them down the toilet. She stated that the centipedes had been in her room for, a couple of months. She stated she was told by facility staff (names unknown) that the millipedes were coming in from the mulch in the flower beds due to the rain. No millipedes were seen in her room at the time of the interview. In an interview and observation on 06/06/26 at 12:10 pm, Resident #4 stated, The millipedes are all over. He stated he had been at the facility for about a week, and the millipedes had been in his room during that time. He stated there was a dead one on his bathroom floor. He stated there had been a dead one in his bathroom sink today but he had washed it away. One millipede was observed crawling on the bathroom wall and one dead millipede was observed on the floor of the bathroom. Resident #4 stated, You wouldn't think this would happen at a medical facility. In an interview and record review on 06/06/26 at 12:10 pm, the Pest Control Personnel stated he was responsible for providing pest control for the facility. He stated he provided outdoor treatment for millipedes around the facility perimeter on 05/21/2026 and the invoice for this treatment was reviewed. He stated he had not provided any other treatments for millipedes and did not have any other invoices indicating millipede treatment. He stated he would return to provide another treatment when the ADM wanted it done. He then spoke to the ADM who confirmed another treatment should be done and the Pest Control Personnel stated he would be back to do it next week. In an interview on 06/06/26 at 3:08 p.m., the Maintenance Director stated that the millipedes were a seasonal problem and the facility had them for six to eight weeks each year. He stated they had not found a treatment to prevent them, and they just had to treat them and vacuum them up. He stated that the facility was about three weeks into having them. He stated that the pest control company typically started treating around February or March and would continue treating for them every other week until they were gone. He stated that the chemicals they used for ants were also used for the millipedes. Regarding the millipedes he stated, I can't figure out how to keep them out of the building and that they were coming in from outdoors. He stated he had previously thought the millipedes had come in with the mulch but that he had used a different brand of mulch this year. He stated that as the Maintenance Director he had asked staff to stop smashing the millipedes on the walls because the maintenance department would have to go around and repaint the walls. He stated that the smears on the walls went unaddressed until housekeeping realized it and tended to it. In an interview on 6/6/26 at 03:20 p.m., the Housekeeping Supervisor stated housekeeping staff were aware of the millipedes and had been informed to check the corners of rooms for the dead ones, wipe things down, and vacuum them up. She stated that by the time staff could get down the hall doing these things there were more millipedes in residents' rooms because they kept coming in. She stated that the rooms were cleaned once a day and then as needed when they were alerted to any concerns. She stated that it was most likely that nursing staff during the day were smashing the millipedes on the walls because her staff were aware not to do that because it left spots on the wall and maintenance had to repaint them. She stated that she herself as well as the Maintenance Director were responsible for monitoring the cleanliness of the environment.In an interview on 06/06/26 at 03:43 p.m., the ADM stated that the facility's pest control company was aware of the presence of millipedes and had treated for them several times. He stated that anytime millipedes were seen in residents' rooms he expected that staff had housekeeping clean them up. He stated that the pest control company evaluated and followed their treatment plan. He stated that the millipedes were in the soil and could not be stopped from coming indoors due to the rain. He stated that sometimes residents would request staff to kill the millipedes and staff would do that. He stated that resident rooms were checked each day and cleaned or painted as needed. He stated that all staff were responsible for monitoring the effectiveness of the pest control program and monitoring to ensure housekeeping is completed appropriately. Review of the facility policy titled, Pest Control Program revised 12/1/2025 was reviewed and reflected, It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents.

Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician accident involving the resident which results in injury and has the potential for requiring physician intervention, and/or a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 or 5 residents (Resident #1) reviewed for notification of physician of change of condition and falls. 1. The facility failed to ensure the physician was notified of Resident #1's fall on 04/02/2026. 2. The facility failed to ensure the physician was notified of Resident #1's pneumonia diagnosis when she was hospitalized on [DATE].3. The facility failed to ensure NP E was notified of the extent Resident #1's injuries from her fall on 04/02/2026. This failure could result in physicians not being able to provide thorough care and lead to negative or adverse outcomes to a resident's health. Findings included:Record review of Resident #1's face sheet revealed a [AGE] year-old woman admitted with a primary diagnosis of Huntington's Disease (neurodegenerative disorder characterized by chorea, which involves involuntary, dance-like movements, along with cognitive and psychiatric symptoms). Other pertinent diagnoses included bipolar disorder (mental health condition causing extreme mood swings), mild cognitive impairment (decline in memory or thinking skills, trouble with language), major depressive disorder (persistent low mood, profound sadness), abnormalities of gait and mobility (unusual patterns of walking or movement), and lack of coordination (difficulty in controlling voluntary movements). Record review of the video of Resident #1's fall on 04/02/2026 at 12:42 a.m. revealed Resident #1 was walking from her bathroom towards her bed (the long side of the bed was against the wall). Resident #1 turned her body, with her back facing the bed. Resident #1 leaned back with what appeared to be intentions of falling into bed, but Resident #1 did not make contact with the bed and fell backwards and landed on the floor. Resident #1 had a lounge chair in her room that made it unclear if she had hit her head on the floor or wall during the fall. Resident #1's body motion during the fall made it appear that she most likely hit her head. Resident #1 struggled to get up from the fall, but it was not seen when she got herself up from the fall. Record review of Resident #1's care plan, revised 04/03/2026, reflected: Initiated 05/17/2025: [Resident #1] is at risk for falls related to [sic] Hunington?s disease. [Resident #1] has documented history of falls and has been observed to independently rise after falling, subsequently reporting the incident to nursing staff. [Resident #1] refuses to use her walker related to spasticity.9/22/25: unwitnessed fall, with bruise10/2/25: unwitnessed fall, no injuries10/26/25 witnessed fall, no injuries1/15/2026: fall with major injury to right clavicle.1/19/26 unwitnessed, fall, no injury2/1/26. unwiseness fall, no injury3/30/26 unwitnessed fall, delayed bruises to bilateral [sic] eyes0 observed on 4/2/26Date Initiated: 05/17/2025Revision on: 04/03/2026Interventions included to anticipate and meet resident needs, to be sure call light was within reach and encourage resident to use it for assistance as needed, to keep door partially open to frequently check on resident, to educate resident/family/caregivers about safety reminders and what to do if fall occurred, to ensure resident wore proper footwear, to follow facility fall protocol, to frequently round, to increase nursing rounds with resident, to keep environment free of clutter, to review medication, to rearrange furniture in resident's room to accommodate with needs, and therapy to educate resident on walker safety. Initiated 03/31/2026: [Resident #1] requires hospice as evidenced by terminal illness: G10-Huntington's DiseaseInterventions included hospice assist with ADLs and provide comfort measures as needed, monitor for decreased appetite and pain, report decline in condition to hospice agency, weekly skin assessments, and feed resident if she was unable to feed self. Initiated 04/03/2026: The resident has PneumoniaMedications Amoxicillin-Pot ClavulanateInterventions included to give medications as ordered, listen to lung sounds for crackles and diminished bread sounds, encourage fluid intake, monitor vitals signs and notify MD for abnormalities, monitor/document/report to MD recurrent fever, monitor/document for mental changes. Record review of Resident #1's progress notes reflected: 3/23/2026: Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Abnormal vital signs (low/high BP, heart rate, respiratory rate, weight change) Altered mental status Functional decline (worsening function and/or mobility) Seems different than usual. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback:A. Recommendations:B. New Testing Orders:--C. New Intervention Orders: 04/02/2026, created by LVN C: Resident was observed with bruising noted upon assessment. Resident was asked if she experienced a fall; resident responded, I don't remember. Resident assess for further signs of injury. Vitals wnl. Emergency contact, [family member], was notified and made aware of situation. [family member] reviewed camera footage and confirmed that the resident did experience a fall. Resident was [able] [NAME] [sic] to get herself up and back in bed. Resident reports headache like pain. PRN pain medication administered. DON notified. [hospice] notified. Record review of Resident #1's Fall - Unwitnessed incident report, dated 4/2/2026 and timed 00:08 (12:08 a.m.), and completed by LVN C reflected: . Incident Description Nursing Description: Resident was observed with bruising noted upon assessment. Resident was asked if she experienced a fall; resident responded, I don't remember. Resident assessed for further signs of injury. Vitals wnl. Emergency contact, [family member], was notified and made aware of situation. [family member] reviewed camera footage and confirmed that the resident did experience a fall. Resident was able to get herself up and back in bed. Resident reports headache like pain. PRN pain medication administered.Immediate Action TakenDescription: First aid rendered, vital signs obtained, xray ordered, pain medication administered, Neuro intact, neuro checks initiated, ROM WNL.Injuries Observed at Time of Incident Injury Type Injury LocationAbrasion 5) Back of headBruise 4) FaceBruise 62) Right Upper ArmSkin Tear 4) Face . Agencies/People NotifiedAgency / Person Name DateDirector of Nursing/ Designee [DON] 4/2/2026 08:14 [a.m.]Physician/NP/PA [MD] 4/2/2026 09:08 [a.m.]Physician/NP/PA Hospice 4/2/2026 10:08 [a.m.]Family Member/Guardian [family member] 4/2/2026 08:07 [a.m.] . Record review of Resident #1's orders revealed an order was placed on 04/02/2026 at 9:13 a.m. for an x-ray of Resident #1's facial bones (the front part of the skull), which includes around the eyes, nose, and mouth. Record review of Resident #1's Radiology Results Report dated 04/02/2026 11:13 (a.m.) reflected: PROCEDURE: FACIAL BONES COMP MIN 3V (complete minimum 3 views; complete x-ray of face bones from 3 different angles). FINDINGS: Suboptimal views [images obtained not high quality] of the facial bone demonstrate no fracture [crack or break] or dislocation [bones out of normal position]. Intact nasal [nose] bones. The orbits [eyes] appear normal. The visualized paranasal sinuses [sinus cavity] are grossly [obviously] clear without opacification [cloudiness] or air-fluid [mucus] levels [in sinuses]. No bony sclerotic or lytic lesion [hardening or thickening of bone] identified. The soft tissues [i.e. body muscles or body fat] are unremarkable [normal] without focal [specific spot or location] soft tissue swelling.CONCLUSION: Suboptimal views of the facial bones suggest no acute [present] fracture or dislocation. CT may be considered for more optimal [effective, higher quality] evaluation based on degree of clinical suspicion [healthcare provider's assessment of how likely a specific disease is causing a patient's symptoms before tests confirm it].Record review of Resident #1's neurological checks dated 04/02/2026, revealed Resident #1 neurological checks did not show variation in results and remained intact. During an interview on 04/03/2026 at 10:10 a.m. the Hospice Nurse said Resident #1 was just admitted to hospice on 03/31/2026 and had fallen on 04/02/2026. The Hospice Nurse said Resident #1's Huntington's Disease process caused a lot of involuntary movements and at that time, Resident #1 was very agitated, and she could not even touch the resident. She said there was no bruising on Resident #1's face when she was admitted to hospice on 03/31/2026. During an observation and attempted interview on 04/03/2026 at 10:15 a.m. with Resident #1 revealed she had bruising around her eyes and a scab on her nose. She had what appeared to be involuntary movements. The state surveyor attempted to talk to her, but she was not able to communicate strongly but was able to indicate she wanted a nurse. The state surveyor went to request nursing staff and CNA A went to assist Resident #1.During an interview on 04/03/2026 at 10:19 a.m. with CNA A, she said she saw the bruises on Resident #1's face yesterday morning, 04/02/2026, around 5:30 a.m. and had reported it to LVN C. CNA A said she did not see any blood. She stated Resident #1 had involuntary movements and it was a part of the disease process. During an interview on 04/03/2026 at 10:32 a.m. with LVN C, she said Resident #1 had a lot of falls since she had come back from the hospital and she guessed a fall caused the bruises on her face because they were not there the day before (04/01/2026). She said Resident #1 could communicate when asked yes or no questions. LVN C said she saw the bruises when she came to pass medication. She said she took her vitals right before 8:00 a.m. and contacted Family Member #1. She then assessed the rest of the resident and gave her medication for pain and then reviewed Resident #1's chart to see if something happened the day before. LVN C said the injuries were on her eyes, her nose, and one side of her face was more swollen. LVN C said she did not notice the abrasion on the back of her head right away; she said she noticed an hour later when she did a thorough skin check. LVN C said the private caregiver did not notify her, but she notified the caregiver when she got to the facility. LVN C said the skin check was documented in the incident report. LVN C said if a resident fell, nurses were to initially not move the resident. She said nurses checked vitals, checked neuros, checked skin to make sure there were no injuries, assessed pain, and then helped the resident up and reeducated them to use the call light. She said she would notify the family, MD, and supervisor (DON).During an interview on 04/03/2026 at 11:13 a.m. Family Member #1 said the LVN C contacted her the morning of 04/02/2026 around 8:30 a.m. to notify her of the bruises to Resident #1's face. Family Member #1 said she reviewed the video and told them she saw Resident #1 fall backwards based on the video footage recording from 04/02/2026 at around 12:30 a.m. Family Member #1 said the facility did not know about the injury to the back of Resident #1's head. She said Resident #1's private caregiver noticed the injury to the back of her head when they were walking to lunch. She said the facility never notified her of the injury to the back of the head and did not think the nurse checked the back of her head. Family Member #1 said she sent the facility the video of Resident #1's fall after they called her. Family Member #1 had also said Resident #1 was recently hospitalized on [DATE] due to pneumonia and was there until 3/30/2026. During an interview on 04/03/2026 at 11:27 a.m. with Resident #1's Private Caregiver, she said the facility did not know about Resident #1's injury to the back of her head until she was walking with Resident #1 to lunch on 04/02/2026. She told LVN C and LVN C said Oh let me see. She said it was the first time LVN C saw that. The Private Caregiver was not sure if LVN C did a full body assessment. She said when she changed Resident #1's clothes, LVN C asked if the Private Caregiver saw any other injuries and the Private Caregiver told her she saw bruising on Resident #1's right arm and LVN C noted that. The Private Caregiver said it was later when LVN C saw the injury to the back of her head. During an interview on 04/03/2026 at 1:20 p.m. with NP D, she said she provided care for Resident #1. She said she or the primary care provider were notified by staff about Resident #1's falls. It was unclear if she had been notified about Resident #1's fall on 04/02/206, but she had been notified about previous falls. NP D said she had to provide care to another patient; she could not be interviewed further. During an interview on 04/03/2026 at 1:55 p.m. with the MD, he said he provided care for Resident #1 and knew she had multiple falls. He said he had not seen her in a few months. The MD said his NP (NP E) may know more about Resident #1. He said he was aware of her having falls, but indicated nobody notified him of the fall on 04/02/2026. The MD said the facility was typically supposed to notify him of falls, but sometimes they notified NP E, and they may have notified NP E. The MD said he did not know Resident #1 recently had pneumonia. The MD deferred to NP E again and said she may be a more appropriate contact. During a phone call interview on 04/03/2026 at 2:00 p.m. with NP E, she said she had known about the recent falls Resident #1 had. NP E said she knew about the fall on 04/02/2026 because someone sent her an x-ray of Resident #1's face but did not tell her directly that Resident #1 fell. She said she pieced it together, but no one had called her about it. NP E said there was no fracture on the x-ray and that was all that was communicated. NP E said she believed the falls were a part of the neurological disease process, and there had been interventions in place to reduce falls including increased rounding, scheduled toileting, and review of medications. She said the family did coordinate appointments with a specialist to see Resident #1 for Huntington's Disease management. NP E said she did not know that Resident #1 was recently hospitalized with pneumonia as well. She said [NP D, NP for specialized health care plan] was notified for things, but the facility was supposed to notify the primary care providers. NP E said she was not aware of the injury to the back of Resident #1's head and she would have sent Resident #1 to the hospital to get a CT scan to rule out bleeding. She said when it was a head injury, it was standard for her to request a CT scan and send a resident to a hospital to rule out a bleed. NP E said she was not aware Resident #1 had recently been placed on hospice. She said it would not make a difference in her providing care to Resident #1. NP E said she would still see residents even if they were on hospice; in a skilled setting, she would still see them while on hospice. NP E said it was important the facility contacted her about Resident #1 because she knew Resident #1 and it made sense to contact her about those situations. She said if the facility talked to a provider that did not know Resident #1, they would not really know how to direct care and know her baseline. She said it was better that they contact the providers that know Resident #1. Interview on 04/03/2026 at 2:23 p.m., NP E called the state surveyor. NP E said not that she was aware of the injury to the back of Resident #1's head, and she would need to call the nurse at the facility to see what was going on with Resident #1 and know her neuro status to determine next steps. She said the facility initiated neuro checks and if neuro condition changes, Resident #1 would need to go to the ER. NP E then said Resident #1 being on hospice care changed the situation on whether she would go to the hospital or not. NP E said if the family wanted her to go to the hospital, Resident #1 would have had to come off of hospice. During an observation and interview on 04/03/2026 at 3:00 p.m. Family Member #2 said she did not know who knew about Resident #1's fall first, but she did not think the facility had mentioned anything about the injury to the back of the head. She indicated the Private Caregiver noticed the injury and said something about it. Family Member #2 said Resident #1 had two brain bleeds in the past from falls; one was from when she had fallen in December 2025. She said she did not know if Resident #1 was susceptible to brain bleeds, but it may be part of the condition of the brain (due to Huntington's Disease). During the interview, Family Member #2 attempted to have Resident #1 show the state surveyor the back of her head. Resident #1 did not want to show the back of her head; there were no signs of blood on her sheets or in her hair. During an interview on 04/03/2026 at 3:44 p.m. with the ADM, he said when a resident fell, staff were to notify the attending physician, family, and DON. He said it was expected that staff included all details when notifying of falls. The ADM said he was notified of the bruises on Resident #1's face the morning of the fall on 04/02/2026, but he was not aware of the injury to the back of her head. The ADM said he expected staff to communicate. During an interview on 04/03/2026 at 4:15 p.m. with the DON, she said Resident #1 was not sent to the hospital after her fall because her neuros were intact and they had an order for a face x-ray. The DON said she talked to LVN C and LVN C told her she talked NP E when they got the x-rays. The DON said when she came in to work on 04/02/2026, she talked with LVN C and LVN C had said something about bruising on Resident #1's face. The DON said she went to see Resident #1 and asked if she was in pain, and she had said no. The DON said she told LVN C to make sure she called the physician and to conduct a facial assessment, and to make sure to call the family. The DON said she became aware of the injury to the back of Resident #1's head later on. She said LVN C did not see the abrasion at first, but then she saw it. She said she expected staff to notify the NP of the injury to the back of Resident #1's head, even though it was found later. The DON said it would not have necessarily made a difference whether Resident #1 would have gone to the hospital if NP E knew about the injury to the back of the head; she said even with Resident #1's history of falling previously and having a head injury where she needed stitches and had a brain bleed. The DON said her head injury from her fall in December 2025, she needed stitches because the bleeding was hard to control, so of course she got a CT scan. She said that was why it was circumstantial. She said they were not going to send every patient out that hit their head and that it was unrealistic. The DON said she could not say if NP E was notified of the injury to the back of the head. The DON said she had spoken to NP E and the MD and they started a HIPAA compliant group text (for communication to be on the same page). The DON said if a resident was being sent out of the facility, and staff notified the MD and the NP with the specialized healthcare plan, they did their job and followed their policy by letting them know. The DON said if an incident occurred, the facility may not talk to the MD or NP E, but it did not mean there was a lack of notifying the MD. She said nurses had been in-serviced on communicating with the MD. The DON said if they were getting orders for x-rays then they would be communicating. The DON said it was not abnormal for them to assess (residents) and then call the physician and say they want an order and the MD says yes. She said she trusted her nurses when they called the MD, when they say they did, and when they documented it. The DON said the risk of not notifying the MD of all injuries was residents may not receive proper follow up, if there was an injury, the MD would guide nurses with orders on what to do. During an interview on 04/02/2026 at 5:54 p.m. with LVN F, she said if a resident fell, the protocol was to notify the MD and everyone, and if the MD did not want the resident sent out, neuro checks were done. She said notifying family was the responsibility of the nurses. LVN F said after a resident fell, part of assessing residents included feeling the resident's s' head and neck to feel for any bumps. Record review of the facility's Change of Condition policy, dated 10/1/2025, reflected: Policy:To identify and evaluate a change in condition and notify the Physician and Responsible Party when indicated.A significant change in Resident's status is any sign or symptom that is: Acute or sudden onset A marked change (i.e., more severe) in relation to usual signs and symptoms New or worsening symptoms Examples include but are not limited to the following: cardiovascular, respiratory, behavioral, fall with major injury, infection, dehydration, altered mental status, pressure injury and any other condition based on professional judgment.Procedure:When a change in condition occurs, the Licensed Nurse will:1. Evaluate the signs and symptoms the Resident is experiencing and collect pertinent information to report to the Physician on the Resident's status.2. Notify the Physician of the change in condition and advanced directives.3. Document date, time Physician, Responsible Party was notified of findings from the evaluation and any new orders obtained.4. The Licensed Nurse will monitor and document the Resident's progress and response to orders given by Physician in the EMR.5. If it is determined that there is no improvement or resolution in the Resident's condition change, the nurse will notify the Physician for further guidance and document response in the EMR.6. If the Physician chooses to send the Resident to the hospital for further evaluation and treatment, the charge nurse will initiate the transfer process. Evaluation findings will be documented on the communication tool used to transition the Resident to the next level of care.7. The Resident's plan of care will be updated accordingly. Record review of the facility's Fall Prevention policy, dated 12/2/2025, reflected: Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy Explanation and Compliance Guidelines: .9. When any resident experiences a fall, the facility will:a. Assess the resident.b. Complete a post-fall assessment.c. Complete an incident report.d. Notify physician and family.e. Review the resident's care plan and update as indicated.f. Document all assessments and actions.g. Obtain witness statements in the case of injury.

Based on observation, interview, and record review, the facility failed to ensure food items were not cross contaminated for 1 of 5 (Resident #1) residents reviewed for infection control. The facility failed to ensure CNA A did not contaminate Resident #1's cookie when she picked up wrapped chocolate candies off the floor and put them on the plate with the unpackaged cookie.This failure could place residents at risk of consuming contaminated food items that could result in foodborne illness or foodborne intoxication. Findings included:Record review of Resident #1's face sheet revealed a [AGE] year-old woman admitted with a primary diagnosis of Huntington's Disease (neurodegenerative disorder characterized by chorea, which involves involuntary, dance-like movements, along with cognitive and psychiatric symptoms). Other pertinent diagnoses included bipolar disorder (mental health condition causing extreme mood swings), mild cognitive impairment (decline in memory or thinking skills, trouble with language), major depressive disorder (persistent low mood, profound sadness), abnormalities of gait and mobility (unusual patterns of walking or movement), and lack of coordination (difficulty in controlling voluntary movements). During an observation and attempted interview on 04/03/2026 at 10:15 a.m. with Resident #1, revealed she was not able to communicate strongly but was able to indicate she wanted a nurse. The state surveyor went to request nursing staff and CNA A went to assist Resident #1.During an observation on 04/03/2026 at 10:19 a.m., revealed CNA A was seen setting up a snack for Resident #1. CNA A had put an unpackaged cookie on a plate on Resident #1's bedside table. CNA A then picked up wrapped chocolate candies off Resident #1's floor and put them onto the plate with the unpackaged cookie. During an interview on 04/03/2026 at 10:21 a.m. with CNA A, she said it was a risk to place the wrapped chocolate candies from the floor onto the plate because it was contaminated. She then realized she had contaminated the cookie that was on the plate with the chocolate candies and said, I never do that; I am so sorry. CNA A said the risk was Resident #1 could get sick (from the contamination). During an interview on 04/03/2026 at 6:16 p.m. with CNA B, she said she would not pick up food off the floor to give to residents. She said the risk was a resident could choke if not sure what the item was, a chance of chemical residue on the floor, it could make residents sick resulting in diarrhea or convulsions but did not want to take a chance. CNA B indicated she had been in-serviced on infection control and proper protocols. During an interview on 04/03/2026 at 6:48 p.m. with the DON, she said she heard about the wrapped chocolate candies being transferred from the floor to the plate with the unpackage cookie. She said they had done an in-service on infection control. The DON said it was a problem because of infection control, and germs from the floor could transfer over. She said, The likelihood of anything happening is nothing. I get where you are going but in real world actuality, just like if [CNA A] wasn't in the room and [Resident #1] picked up chocolate off the floor and eats it, it transfers. Worst case scenario something could happen. Record review of the facility's Infection Prevention and Control Program, dated 12/1/2025, reflected: Policy:This facility has established and maintains 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 as per accepted national standards and guidelines.Policy Explanation and Compliance Guidelines:1. The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases.2. All staff are responsible for following all policies and procedures related to the program.3. Surveillance:a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards.b. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee.c. The RNs and LPNs participate in surveillance through assessment of residents and reporting changes in condition to the residents' physicians and management staff, per protocol for notification of changes and in-house reporting of communicable diseases and infections.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 6 of 16 residents (Residents #67, #71, #36, #97, #401, #66) reviewed for care plans. 1. The facility failed to develop a comprehensive person-centered care plan regarding Resident #71's attention deficit disorder diagnosis. 2. The facility failed to ensure Resident #36's comprehensive care plan included a plan of care for ADL dependence including fingernail care. 3. The facility failed to ensure Resident #97's comprehensive care plan included a plan of care for Diagnosis of diabetes and insulin dependence. 4. The facility failed to develop and implement a care plan that reflected Resident #401 need for fall interventions after his initial falls on 3/14/2025. 5. The facility failed to develop and implement a comprehensive care plan that reflected Resident #66's measurable objectives, interventions, and timeframes for how staff would meet Resident #66's needs . This deficient practice could place residents at risk of not receiving the necessary care or services. Findings included: 1-Resident #71 Record review of Resident #71's Quarterly MDS, dated [DATE], reflected he was a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of paraplegia (paralysis of legs), diabetes (high blood sugar), and a BIMS score of 15 (intact cognition). Record review of Resident #71's care plan reflected a focus area, dated initiated 01/31/25, that indicated he used anti-anxiety medication due to an anxiety disorder with the interventions of monitoring for side effects and effectiveness. Further review revealed a focus area of the resident had potential to be verbally aggressive and yelled at staff due to ineffective coping skills, dated initiated 03/23/25, with the interventions of assess resident's coping skills and support system and administer medications as ordered. Record review of Resident #71's psychological subsequent assessments, dated 02/14/25 revealed resident had the diagnoses included generalized anxiety disorder and attention deficit hyperactivity disorder. In an interview on 04/23/25 at 12:17 PM with Resident #71 revealed he had the diagnosis of attention deficit hyperactivity disorder since he was 6 years old and received psychological services at the facility. In an interview on 04/23/25 at 2:07 PM with the Social Services Director revealed Resident #71 had a diagnosis of attention deficit hyperactivity disorder and received psychological services at the facility. She reviewed Resident #71's care plan and stated he did not have attention deficit hyperactivity disorder care planned. She stated that nursing and the MDS nurse were responsible for care planning, and it was important to care plan resident diagnosis to ensure their needs are met. In an interview on 04/24/25 at 9:06 AM with LVN H revealed he was aware that Resident #71 had a diagnosis of attention deficit hyperactivity disorder and was not aware it was not care planned. He stated care plans were important because they guided the plan of care for residents. An interview on 04/24/25 at 11:47 AM with the MDS Coordinator revealed Resident #71's diagnosis of attention deficit hyperactive disorder was not care planned. She stated that it looks like the physician did not enter the diagnosis into their electronic system, so it did not trigger a care plan on the facility side and it was not caught during the MDS look back periods. She stated it was important to care plan Resident #71's diagnosis because it provided more information and insight into his needs. She stated the ADON, MDS, and DON were responsible for care planning resident needs . An interview on 04/24/25 at 12:29 PM with the DON she stated she was aware that Resident #71 had a diagnosis of attention deficit hyperactivity disorder and anxiety disorder and received psychological services. She stated the diagnosis of attention deficit hyperactivity disorder should have been care planned. She stated care plans were important to guide the care of the resident. 2-Resident #36 Record Review of Resident #36 Quarterly MDS, dated [DATE], reflected that Resident #36 was a [AGE] year-old male admitted to facility on 02/24/2023 with BIMS Score of 13 that indicates Resident #36 had intact cognition. Resident #36 had diagnoses of Heart failure, Anxiety, Renal insufficiency (condition in which kidneys lose the ability to remove waste and balance fluids), Limitation of activities due to disability. It also indicated Resident #36 was dependent on staff for personal hygiene. Record Review of Resident #36 Comprehensive care plan dated 4/24/25 revealed Resident #36 did not have a care plan for ADL assistance. In an interview and observation with Resident #36 revealed his fingernails on both his hand were at least 0.75 inch - 1 inch long. It also revealed Resident #36 had slight contracture on right middle finger. Resident #36 stated he would like staff to trim his fingernails since he cannot cut his own nails. He stated staff had not approached him lately to cut his nails. 3-Record Review of Resident #97 MDS dated reflected Resident #97 was a [AGE] year-old female admitted to facility on 04/02/2025 with BIMS Score of 3 that indicates Resident #97 had severe cognitive impairment. Resident # 97 had diagnoses of Hypertension (high blood pressure), Diabetes Mellitus (high blood glucose) , Hyperlipidemia (high blood lipids), Non-Alzheimer's Dementia, Acute Pancreatitis without necrosis (a condition where the pancreas becomes inflamed but without death of the pancreatic tissues). It also reflected Resident #97 had Insulin injections during the last 7 days or since admission. Record review of Resident #97 Physician order dated 4/21/25 reflected, Humalog Injection Solution 100 Unit/Milliliters; Inject as per sliding scale subcutaneously (applied under the skin) four times a day for [Diabetes]. Record review of Resident #97 Physician order dated 4/3/25 reflected, Insulin Glargine Solution 100 Unit/Milliliters; Inject 10 unit subcutaneously (applied under the skin) at bedtime for diabetes. Record Review of Resident #97 Comprehensive care plan dated 4/24/25 revealed Resident #97 did not have a care plan for Diagnosis of diabetes or insulin dependence. In an interview on 04/24/2510:11 AM with LVN D revealed Nurses, ADONs and DONs were responsible for care planning. He stated that care planning should be tailored to resident's specific needs, and it was important to care plan accurately so that residents care needs were met. He stated that Resident #36 liked to be independent, however he needed assistance with ADLs specifically with nailcare related to his disability. In an interview on 04/24/25 at 11:20 AM CNA J revealed Care plans were important since they provide information about Residents care needs and the dos and don't's. She stated that CNAs were not involved with care planning, however the risk of not care planning resident care needs may lead to failure to provide care for the resident. In an interview with the DON on 4/24/25 at 09:55 AM revealed Resident # 36 was dependent on staff for ADL and Resident #97 was dependent on insulin related to Diagnosis of Diabetes. The DON stated every resident should have a plan of care that is personalized for their care. She stated the MDS Coordinator, ADONS and DON were responsible for writing the care plans and risk of not care planning could lead to failure to provide personalized care to residents. In an interview on 04/24/25 at 02:09 PM with ADON G stated that Resident #36 should have ADL dependence on staff care planned. She also stated that Resident #97 had diagnosis of diabetes and was receiving insulin injections daily. She stated that MDS Nurses, ADONs and DONs were responsible for completing and updating care plans as needed. She stated the risk of not care planning was failure possibility of residents not getting care or assistance they need, and quality of life could be affected. 4-Resident #401 Review of Resident #401's admission Minimum Data Set (MDS) Assessment, dated 3/17/2025, reflected she was a [AGE] year-old male with an admission date of 3/13/2025. Resident #401 was moderately cognitively impaired, and his BIMS score was 9. He needed some help with self-care and required a walker. Resident had a history of falls with a fall in the last month resulting in injury. He had impairment to one side of his lower extremities. He had the following diagnosis: Hip fracture, other fracture and Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions). Review of Resident #401's care plan revised on 4/7/2025 revealed Risk for Injury: Fall occurred 3/14, Fall occurred 3/16/25, Fall Occurred 3/18/25, Fall occurred 3/25/25 Date Initiated: 03/19/2025 .o Alert provider Date Initiated: 03/19/2025 Revision on: 04/07/2025 Cancelled Date: 04/07/2025 04/07/2025 o CANCELLED: Assess Resident and identify any injuries from fall Review pain management regimen for resident Date Initiated: 03/19/2025 Revision on: 04/07/2025 Cancelled Date: 04/07/2025 o CANCELLED: Consult physical therapy per order Date Initiated: 03/19/2025 Revision on: 04/07/2025 Cancelled Date: 04/07/2025 o CANCELLED: Determine and address causative factors of the fall Low Bed Fall Matts Room close to nurse station Date Initiated: 03/26/2025 Revision on: 04/07/2025 Cancelled Date: 04/07/2025 o CANCELLED: Follow facility post-fall policy Date Initiated: 03/19/2025 Revision on: 04/07/2025 Cancelled Date: 04/07/2025o CANCELLED: Assist Resident with ambulation and transfers, utilizing therapy Recommendations Date Initiated: 03/17/2025 Revision on: 04/07/2025 Cancelled Date: 04/07/2025 RN LPN o CANCELLED: If Resident is a fall risk, initiate fall risk precautions Date Initiated: 03/17/2025 Revision on: 04/07/2025 Cancelled Date: 04/07/2025 . Review of facility Accident/Incident Report for March 2025 revealed Resident #401 had falls on the following dates: 3/14/2025, 3/14/2025, 3/16/2025, 3/18/2025 and 3/25/2025. Interview with LVN H on 4/24/25 at 9:48 am revealed when a resident was a fall risk at admission, the interventions would have been put on the initial care plan and updated after every fall . Interview with RN A on 4/24/25 at 10:44 am revealed residents who were at risk of falling had the fall risk listed on their care plan immediately. The risk of not having fall risk on their care plan would be not staff would know of the fall risk, thus putting the resident at risk to fall. Interview with ADON G on 4/24/25 at 10:07 am revealed after every resident fall, staff would update the care plan. If the resident was a fall risk at admission, they would put fall risk and interventions in the initial care plan. As they got more information on the residents, they would update the interventions and care plan as needed. Initial care plans or Circle of Excellence (COE) were done within 72 hours of admission with each resident. Interview with MDS on 4/24/25 at 12:18 pm revealed that at the Interdisciplinary Teams meetings all falls of resident from the day before or overnight were discussed and then the DON would delegate someone to update the Care Plan of each resident who fell. She was unsure if the care plan was updated after every fall or the time frame they had to update the care plan after a fall. Interview with DON on 4/24/25 at 1:35pm revealed that Resident #401 admitted to the facility with fall precautions. Their protocol was after each fall, they would talk about the fall as a team and discussed appropriate interventions. Resident #401 admitted with the following precautions: low bed, room close to nurses' station and listed as a fall risk by displaying a stamped leaf on the name plaque outside his room. The leaf on the plaque alerts all staff that he was at risk of falling. They added a scoop mattress after one fall, a fall mat at bedside after another fall and then had him in a chair in a common area during waking hours for maximum observation. The care plan for Resident #401 was not updated after every fall because some of the initial falls happened on the weekend when staff who update the care plan are off. His care plan was updated the following week when all staff returned to the facility. They tried to update Care Plans as quick as possible, but interventions discussed are implemented immediately. All staff were aware of the interventions and that Resident #401 was a fall risk because they had shift to shift conversations about Resident #401 after every fall and he had the leaf stamp on his door. There was no risk to the resident that his care plan was not updated timely because all staff knew . Interview with Administrator on 4/24/25 at 2:56pm revealed when a resident admitted into the facility as a fall precaution it would be on the careplan, and they would add other interventions in place that weren't already being used. Staff would put in new falls in the care plan by the next morning. 5-Resident #66 Record Review of Resident #66 MDS dated reflected Resident #66 was a [AGE] year-old male admitted to facility on 01/18/2025 with BIMS Score of 0 that indicates Resident #66 had severe cognitive impairment. Resident # 66 had diagnoses of Congestive heart failure, Diabetes Mellitus (high blood glucose), Atrial Fibrillation (an irregular heart rate), Bell's Palsy (sudden weakness in the muscles on one half of the face), and Hypertensive Heart Disease (high blood pressure damages the heart). Record review of the comprehensive care plan for Resident #66 indicated no comprehensive care plan was initiated. An interview on 4/24/25 at 4:30pm, the DON reviewed Resident #66's record and stated Resident #66 had no comprehensive care plan. Record Review of Facility policy titled, Care plans Comprehensive, dated September 2010, reflected: Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 4 residents (Resident #2, Resident #36, Resident #27, Resident #16) of 15 residents reviewed for ADLs. The facility failed to ensure: 1. Resident #2 had his nails cut and cleaned on 04/22/25. 2. Resident #36 had his nails trimmed on both hands on 04/22/25. 3. Resident #27 had her fingernails cleaned and trimmed on both hands on 4/22/25. 4. Resident #16 had her fingernails cleaned and trimmed on both hands on 4/22/25. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1- Resident #2 Record review of Resident #2's quarterly MDS assessment, dated 02/19/25, reflected a [AGE] year-old female with an admission date of 03/11/20. Resident #2 had BIMS score of 15 which indicated she was cognitively intact. She required substantial to maximum assistance for personal hygiene and had not refused care. She had functional limitation in range of motion both upper and lower extremities on one side. Diagnoses included diabetes, cerebral vascular accident (stroke) and hemiplegia (paralysis on one side of the body). She had not received occupational therapy (therapy that focus on regaining dexterity and strength in fine motor skills) or restorative nursing services in the 7 days look back period. Record review of Resident #2's care plan dated 04/23/25 reflected, Self-care Deficit-Extensive assistance required with bathing, hygiene, dressing, and grooming related to Resident #2's Document Survey report for April 2025 did not list personal hygiene as a task to be provided. In an observation and interview on 04/22/25 at 11:10 AM Resident # 2 was observed lying in bed. Her right hand had nails that were approximately ½ inches in length and had brown/black substance under all her nails. Her left hand was drawn up in a fist and resident was unable to open her left hand. Resident #2 stated she had a stroke and was not able to use her left hand. She stated her nails were long and needed cut and cleaned. She stated no one had offered to trim her nails or clean them. She stated she feeds herself and does not like how dirty her nails are. She stated her sister cut her nails the last time they were cut. In an interview and observation on 04/22/25 at 01:55 PM CNA B was observed in Resident #2's room heating up food the resident's family had brought for her. CNA B stated they were responsible for trimming residents' nails on shower days, or as needed. She stated the resident's shower days were on the 2:00 p.m. shift, but stated nails were to be cleaned and trimmed no matter what shift. She stated she had not noticed Resident #2's nails and stated the nails on her right hand were dirty. CNA B opened resident left hand gently revealing her nails to be 1 1/2 inches long and jagged. Inspection of her palm did not reveal any skin breakdown. CNA B stated they were very long and needed trimming. She stated the risk of not cleaning and keeping nails clean were infection. In an observation and interview on 04/22/25 at 02:01 PM RN A was observed at Resident #2's bedside to look at her nails. RN A stated the CNAs were to trim nails on shower days or as needed. She stated the Restorative Aide was also responsible for trimming nails. She observed Resident #2's nails and stated the nails on her left hand (contracted hand) need to be kept short to prevent skin breakdown. She stated the resident wanted her right-hand nails long, Resident #2 spoke up and stated she did not want them long. She stated when they got this long, she had trouble using her phone and they get dirty. RN A stated the risk of not keeping nails clean and trimmed were infection and skin breakdown with the contracted hand. 2- Resident #36 Record Review of Resident #36 Quarterly MDS dated [DATE] reflected that Resident #36 was a [AGE] year-old male admitted to facility on 02/24/2023 with BIMS Score of 13 that indicates Resident #36 had intact cognition. Resident #36 had diagnoses of Heart failure, Anxiety, Renal insufficiency (condition in which kidneys lose the ability to remove waste and balance fluids), Limitation of activities due to disability. It also indicated Resident #36 was dependent on staff for person hygiene. Record Review of Resident #36 Comprehensive care plan dated 4/24/25 revealed Resident #36 did not have a care plan for ADL assistance. In an Observation and Interview with Resident #36 revealed his fingernails on both his hand were at least 0.75 inch - 1 inch long and jagged. It also revealed Resident #36 had slight contracture on right middle finger. Resident #36 stated he would like staff to trim his fingernails since he cannot cut his own nails. He stated staff had not approached him lately to cut his nails. In an interview on 04/23/25 03:39 PM with CNA F stated that CNAs were responsible for trimming fingernails on shower days and as needed. He stated that the Staffing Coordinator, who is also a CNA, sometimes helps with trimming nails. She added Resident #36 sometimes refused clipping his fingernails, however she had not made the Charge Nurse or DON aware of it. She stated untrimmed and jagged fingernails could cause skin irritation or infection. In an interview on 04/24/25 10:11 AM with LVN D revealed Resident #36 was dependent on staff for ADL care including nail care. He stated that CNAs and restorative aides were responsible for nail care, unless if the resident was diabetic, then LVN should be trimming nails. He stated that Resident #36 did not have diagnosis of diabetes and added Resident #36 liked to be independent, however needed assistance with ADLs specifically with nailcare related to his disability with right hand. He stated risk of long, jagged nails was possibly of infection and loss of quality of life. 3- Resident # 27 Record review of Resident #27's Comprehensive MDS assessment dated [DATE] reflected Resident #27 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses included stroke (a loss of blood flow to part of the brain, which damaged brain tissue), and dementia (a group of thinking and social symptoms that interferes with daily functioning). Resident #27's BIMS score of 00, which indicated Resident #27's cognition was severely impaired. The MDS assessment indicated Resident #27 required maximal assistance with personal hygiene. Record review of Resident #27's Care Plan dated 03/19/25, reflected the following: Focus: [Resident has an ADL selfcare deficit . Goal: Resident will maintain current level of function . Interventions: . Check nail length and trim and clean . as necessary. Report any changes to the nurse . In an observation and attempted interview on 04/22/25 at 10:59 AM revealed Resident #27 was laying in her bed. The nails on both hands were approximately 0.4cm in length extending from the tip of her fingers. The nails were discolored tan on both hands. Resident #27's answers to questions did not make sense. In an interview on 04/22/25 at 11:09 AM, CNA K stated CNAs and nurses were responsible to clean and cut the residents' nails. CNA K stated did not notice Resident #27's nails. She stated she would do it right then. She stated the risk would be infection control and injury. 4- Resident #16 Record review of Resident #16's Quarterly MDS assessment dated [DATE] reflected Resident #16 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses included diabetes mellitus, and dementia (a group of thinking and social symptoms that interferes with daily functioning). Resident #16's BIMS score of 04, which indicated Resident #16's cognition was severely impaired. The MDS assessment indicated Resident #16 required moderate assistance with personal hygiene. Record review of Resident #16's Care Plan dated 04/24/24, reflected the following: Focus: [Resident #16]'s ADL function: 1 person assist with ADLs . Goal: . will maintain a sense of dignity by being clean, dry, odor free, and well groomed . Interventions: . Assist as needed . In an observation and interview on 04/22/25 at 11:45 AM revealed Resident #16 was sitting in her bed. The nails on both hands were approximately 0.6cm in length extending from the tip of her fingers. The nails were discolored tan and had yellow greenish colored residue underside and on the nails' bed on the right hand. Resident #16 stated she did not like her fingernails long and dirty. In an interview on 04/22/25 at 11:50 AM, LVN L stated CNAs were responsible for trimming the nails of residents who were not diabetic, and nurses were responsible for trimming nails of residents who were diabetic. LVN L stated did not notice Resident #16's nails. She stated she would do it. She stated the risk would be infection control and skin breakdown. In an interview with the DON on 04/24/25 at 09:06 a.m. she stated nails were to be trimmed and cleaned on shower days. She stated in addition the Restorative aide as well as the Staffing Coordinator were to check residents' nails to ensure they were trimmed and cleaned. She stated she was very disappointed that any resident was found with dirty long nails, since there were assigned individuals responsible for ensuring the nails were kept trimmed and clean. She stated the risk of not cleaning and trimming nails were infection and poor hygiene. In an interview with the Staffing Coordinator on 04/24/25 at 10:00 a.m. she stated she was assigned as back up for the CNAs to trim and clean fingernails for the long-term care residents. She stated she had not trimmed Resident #2's nails because when she had gone in her room in the past, she would be asleep or ask her to come back later. She stated she had not reported to anyone she had not trimmed her nails; she just assumed the CNAs would take care of it. Record review of Facility policy titled, Care of Fingernails/ Toenails revised October 2010, reflected Purpose: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections Nail care includes daily cleaning and regular trimming .

Based on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one of three (Resident #2) reviewed for range of motion. The facility failed to implement interventions to prevent further decline of Resident #2's contracture to her left hand on 04/22/25. This failure could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures. Findings included: Record review of Resident #2's quarterly MDS assessment, dated 02/19/25, reflected a [AGE] year-old female with an admission date of 03/11/20. Resident #2 had BIMS score of 15 which indicated she was cognitively intact. She required substantial to maximum assistance for personal hygiene and had not refused care. She had functional limitation in range of motion both upper and lower extremities on one side. Diagnoses included diabetes, cerebral vascular accident (stroke) and hemiplegia (paralysis on one side of the body). She had not received occupation therapy (therapy that focus on regaining dexterity and strength in fine motor skills) or restorative nursing services in the 7 days look back period. Record review of Resident #2's care plan with an initiation date 03/30/25 reflected, The Resident has a contracture to left hand. Upper/lower extremities, hand wrist foot and hip .Interventions .Use of supportive devices such as splints, braces, canes, crutches etc., as recommended by OT . Record review of Resident #2's revised care plan dated 04/23/2025, reflected, The resident has a contracture to left hand. She refuses the splint frequently .Intervention .Carrot splint(splint used to position fingers away from the palm of the hand) to be applied to left hand impairment every morning up to four hours on as tolerated .Educate resident on importance of applying splint .Monitor and repot to Nurse any change in skin integrity . Record review of Resident #2's of the CNAs task list dated 04/22/25 did not indicate splint placement or range of motion to be provided to Resident #2's left hand. Record review of Resident #2's Document Survey report for April 2025 reflected, Carrot splint to be applied to left hand impairment every morning up to four hours on as tolerated, with an effective date of 04/15/25 for the day shift. There was no documentation the splint was applied or refused from 04/15/25 through 04/22/25. On 04/23/25 the splint was applied, and the codes indicated the Resident participated and had tolerated it good. In an observation and interview on 04/22/25 at 11:10 AM Resident # 2 was observed lying in bed. Her left hand was drawn up in a fist and resident was unable to her open her left hand. Resident #2 stated she had a stroke and was not able to use her left hand. She stated she used to have a splint for her left hand but had not seen it in a while. A blue hand/forearm splint was observed on her bedside chest of drawers and a carrot splint was hanging on her closet door. Resident stated she would sometimes have the staff put a washcloth in her hand at night. In an interview and observation on 04/22/25 at 01:55 p.m. CNA B gently opened Resident #2's left hand revealing her nails to be 1 1/2 long and jagged. Inspection of her palm did not reveal any skin breakdown. CNA B stated the resident's nails were very long and needed trimming. She stated she thought the Carrot splint was for her right hand to use for exercise. She stated she had only seen the resident use the other splint one time since she had been working here. She stated she had not been instructed on any splint placement or the use of the carrot splint for the resident. She stated she was not sure if the resident was on restorative care or not. She stated it was not on their task list for them to apply any splint or any range of motion exercises. In an interview with the OTR on 04/22/25 at 2:10 p.m. she stated she does not usually work in this building and was just helping today. She stated Resident #2 was on OT services from 01/23/25 through 01/30/25 but stated it does not appear they worked with her left hand. She stated she could screen her today and determine if they needed to put her back on services. In an observation on 04/22/25 at 02:15 p.m. the OTR was observed assessing Resident #2's left hand. During the assessment Resident#2 told the OTR that when she manipulated her thumb it hurt on her inner arm. The OTR stated the tendon was tight. She stated she would complete a new evaluation on her and determine if the resting splint (The blue hand/forearm splint) would still work for her. Record Review of Resident #2's OT assessment completed by the OTR on 04/22/25 reflected, .Initial Assessment .Orthotics- Splint/Orthotic (supportive devices used to correct, support, or protect body parts) Recommendations: comfy wrist/hand/finger orthosis- ordered today. This splint does not stretch the thenar eminence (the fleshy mound at the base of the thumb, formed by three small muscles that control thumb movement) so will trial this splint first . In an interview with the MDS on 04/23/25 at 9:35 a.m. she stated she was the Skilled MDS nurse and was also covering for long-term care resident since the position had been open for a while. She stated they do not have a restorative program, but stated they do have an aide that does some restorative on residents. She stated there was no specific restorative care plan but stated it should be on the comprehensive care plan and on the CNAs task list. She stated therapy would provide them a plan of care when a resident was coming off therapy. She stated Resident #2 was not currently listed on the restorative list. In an interview with the Restorative Aide on 04/23/25 at 09:40 a.m. she stated Resident #2 was not on her list for restorative. She stated she does not get a restorative care plan; she just gets a list from the DON on who she was supposed to work with and what they needed done. She stated she had attempted to put the splint on Resident #2 in the past, but stated the resident told her it hurt, so she did not put it on her. She stated she had not documented anywhere because she did not have access to the new system they have had since February. She stated she just got access this week to the new system. She stated she had not told anyone about the splint hurting the resident. In an interview with the DOR on 04/23/25 at 12:40 p.m. who stated they do not have a contracture program, but stated they had a list of residents in the facility with contractures they screen quarterly. He stated the last time they had addressed Resident #2's left hand contracture was January 26, 2025, and they had provided her a carrot splint for her left hand because it was easier. He stated the facility had recently gone from one electronic record system to a different system in February 2025. He stated he could now add a restorative care plan. He stated Resident #2's care plan had been updated as of today (04/23/25) to reflect the placement of the carrot splint. He stated most of the communication prior was to the DON, ADON or Charge nurse and it was verbal. In an interview with the DON on 04/23/25 at 02:00 p.m. who stated they had all residents screened by therapy upon admission and any time there was a functional decline. She stated they do not have a restorative program, but Range of motion and splinting can be carried out by the nursing staff and the CNAs once therapy determines the need. She stated she had not been informed about Resident #2's refusing her splint or the change to the carrot splint. She stated therapy set ups the plan for what restorative needs the resident will require and communicates with the MDS nurse. She stated those needs would be placed on the task list for the CNAs to carry out. She stated anytime the resident was refusing any service the CNAs had to let the Charge Nurse and herself know. She stated the interventions needed to be care planned. She stated failing to implement interventions for residents with limited Range of motion could lead to worsening of a resident's contractures and decline in function. Review of the facility's policy titled, Restorative Nursing Services, dated July 2017, reflected, Residents will receive restorative nursing care as needed to help promote optimal safety and independence .Restorative nursing care consist of nursing interventions that may or may not be accompanied by formalized rehabilitative services .Resident may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. Restorative goals and objectives are individualized and resident-centered, and are outline in the resident's plan of care .

Based on observation, interview, and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 3 medication carts (med aid cart hall400/500) of 4 medication carts reviewed for pharmacy services in that: The facility failed to ensure: 1- LVN D responsible for Nurses Cart Hall 300, removed medications in unsecure containers from the Nurses Cart. 2- LVN L responsible for Nurses Cart Hall 100, removed medications in unsecure containers from the Nurses Cart. 3- RN A responsible for Nurses Cart Hall 200, removed medications in unsecure containers from the Nurses Cart. These failures placed residents at risk of not receiving full dosage of medication, and place residents at risk of not having the medication available due to possible drug diversion, and place residents at risk of not receiving medications as ordered. Findings Included: 1- Record review and observation on 04/22/25 at 12:15 PM of Nurses Cart Hall 300, with LVN D revealed the blister pack for Resident #83's tramadol 50 mg tablet (controlled medication used for pain) had 2 blister seals broken and the pills still inside the broken blister. Interview on 04/22/25 at 12:23 AM, LVN D stated the count was done at shift change and the count was correct. She stated she did not check the blister packs during the count. She stated she was unaware when the blister pack seals were broken, and she was not aware of who might have damaged the blisters. She stated the risk would be a potential for drug diversion. She stated the nurses were responsible to check the medication blister packs for broken seals during the count of narcotics during the change of the shift. She stated when a broken seal was observed, she would waist the pill with another nurse. 2- Record review and observation on 04/22/25 at 12:29 PM of Nurses Cart Hall 100, with LVN L revealed the blister pack for Resident #51's tramadol 50 mg tablet (controlled medication used for pain) had 1 blister seal broken and the pill still inside the broken blister and taped over. Interview on 04/22/25 at 12:32 AM, LVN L stated the count was done at shift change and the count was correct. She stated she did not see the damaged blister. She stated it was not allowed to tape over the damaged blister. She stated the risk would be a potential for drug diversion and infection control. She stated the nurses were responsible to check the medication blister packs for broken seals during the count of narcotics during the change of the shift. She stated when a broken seal was observed, she would waist the pill with another nurse. 3- Record review and observation on 04/22/25 at 12:45 PM of Nurses Cart Hall 200, with RN A revealed the blister pack for Resident #62's tramadol 50 mg tablet (controlled medication used for pain) had 1 blister seal broken and the pill still inside the broken blister. Interview on 04/22/25 at 12:50 AM, RN A stated the count was done at shift change and the count was correct. She stated she did not check the blister packs during the count. She stated she was unaware when the blister pack seal was broken. She stated the risk would be a potential for drug diversion. She stated the nurses were responsible to check the medication blister packs for broken seals during the count of narcotics during the change of the shift. She stated she would waist the pill with another nurse. Interview on 04/24/25 at 10:02 AM, the DON stated she expected if a blister pack medication seal was broken the pill should be discarded. The DON stated it would not be acceptable to keep a pill in a blister pack that was opened. The DON stated the risk would be potential for drug diversion. She stated nurses were responsible for checking the medication blister packs for broken seals during the count on the change of shifts. The DON stated the ADON, and the DON were supposed to check the carts weekly and the pharmacy consultant to do the audit once a month. Record review of the facility's policy titled Storage of Medications, revised April 2007, revealed in part .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner . 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. The facility failed to ensure food item in the facility walk-in freezer were covered. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: Observation on 04/22/25 at 09:54 AM of the facility walk-in freezer revealed a packet of Frozen pork and vegetable eggrolls loosely wrapped in a plastic bag which was kept in an open cardboard box. In an interview on 4/23/25 9:56 AM with Corporate Dietitian stated it was her expectation that all food items should be dated, labeled, and covered at all times. She stated the frozen egg rolls were thrown away on 4/22/25 since they were left open in the freezer. She stated if food items are not covered, the risk would be cross contamination of food with possible freezer burn and loss of quality. In an interview on 04/23/25 10:04 AM with the Dietary Manager stated everyone including cooks and herself were responsible for covering, dating, and labeling all food items in the kitchen. She stated her expectation was all food items in the kitchen should be appropriately covered and sealed. She stated the risk of not covering food items was cross could result in freezer burn, contamination resulting in food borne illness. In an interview on 4/24/25 at 11:24 AM with [NAME] E revealed she had been working in the facility for the last 10 months. She stated everyone in the kitchen including cooks, dietary aides, and the dietary manager were responsible for covering food items in the kitchen. She stated not covering food items appropriately could cause food to be spoiled and residents could get sick. Review of facility's policy titled Food Storage undated reflected, .16. Frozen foods . Foods should be covered, labeled, and dated . Review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on observation, interview, and record review, the facility failed to ensure that residents had physician's orders for the residents' immediate care for 2 (Resident #402 & Resident #67) of 16 residents observed for physician orders for oxygen. 1. The facility failed to provide physician orders for Resident #402 when admitted to the facility with a need for oxygen and while resident was on 4L of oxygen via nasal cannula on 11/8/24. 2. The facility failed to obtain orders for colostomy care for Resident #67 on 3/10/25 These failures could place the residents at risk of not receiving necessary physician ordered care that could result in worsening conditions or decline in health. Findings included: 1-Review of Resident #402's Face Sheet dated 4/23/25 reflected that resident was a [AGE] year-old female admitted on [DATE] and discharged to the hospital on [DATE]. Relevant diagnoses included morbid obesity, heart failure (a chronic condition in which the heart doesn't pump blood), acute and chronic respiratory failure with Hypoxia (a condition in which the body doesn't receive enough oxygen), shortness of breath, and Pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid). Review of Resident #402's MDS assessment dated [DATE] reflected that Resident #104 had moderate cognition with a BIMS score of 12. Resident admitted to the facility with intermittent oxygen therapy and oxygen treatment was performed while Resident #402 was at the facility. Review of Resident's #402's Baseline Care Plan dated 10/31/2024 reflected no documentation of Resident #402's oxygen therapy treatment . Review of Resident #402's physician orders dated on 4/23/2025 reflected no physician orders for continuous and/or as needed oxygen supplement. Review revealed no physician order for when to change the cannula and oxygen tubing. Review of Resident #402's Patient Medication Summary on 4/23/2025 reflected no physician orders to keep the oxygen cannula and tubing in a bag when not in use. Review revealed no physician orders for when to change the humidifier. Review of Resident #402's Patient Medication Summary on 4/23/2025 reflected no physician's order to wash filters from oxygen concentrator. Review revealed no physician order for what to assess, like redness to nares (openings of the nose where the prongs of the cannula are inserted). Review of Resident #402's progress note dated 11/8/24 at 12:23pm Resident was assessed per request of nurse as she stated SOB (shortness of breath) and wanted to go to the ER (emergency room). O2 (oxygen) was 91% on 4L (liters) NC (nasal cannula) with RR20(respiration rate 20), resi dent was breathing out of her mouth and stated her nose felt stuffy. Changed to mask and increased O2 to 6L (liters)and O2(oxygen) increased to 93-94%. Pulmonary Nurse Practitioner was contacted and had a telehealth visit with resident with new orders to increase O2 to 5-6L In an interview with LVN I on 4/24/25 at 9:33am revealed if a resident needed oxygen, they had to review the standing orders to determine how many liters to give, if there was no standing order for oxygen they would call the doctor for an order. If a resident came to the facility with oxygen, they would give oxygen based on the hospital discharge order and would enter it in the system. There should always be an order for oxygen if it is being given. The risk to a resident would be hyperoxygenation that can negatively impact their respiratory system. In an interview with LVN H on 4/24/25 at 9:48am revealed when a resident needed oxygen, they needed to make sure orders were in their chart. When a resident was admitted with oxygen, they also needed to make sure there was an order. There should always be an order for oxygen if the resident required it. The risk to the resident not having an order for oxygen and the resident receiving oxygen, it could cause the resident to have respiratory issues. In an interview with ADON G on 4/24/25 at 10:07am revealed when a resident was admitted with oxygen, they would review orders, would take vitals and complete head to toe assessment. They would get a concentrator and items necessary for the order. They would enter the order in the resident's chart, to include number of liters and route. They would administer oxygen according to physician's order. All residents who need oxygen should have an order in the system. Oxygen would usually be included on the care plan. In an interview with RN A on 4/24/25 at 10:44am revealed most residents should have had a standing order for oxygen, typically 2 to 3 liters for emergencies. If a resident came to the facility with oxygen the nurses would ensure that an order was on file. If a resident needs oxygen daily or intermittently there should have been an order in the file. Oxygen should have also been included in the Care Plan. The risk to the resident of not having had an order for oxygen and getting oxygen was that the resident can have severe respiratory issues. In an interview with LVN D on 4/24/25 at 11:02am revealed when a resident was admitted to the facility with oxygen, there must be an order in the system for oxygen. If there is not order, he would notify the doctor at admission that the resident has admitted and has a need for oxygen and would get an order for it. The need for Oxygen would have been in the Care Plan. During observation and interview with MDS on 4/24/25 at 12pm who revealed she was unsure if the need for oxygen should have been on a baseline care plan but the need for oxygen should be on a care plan. If the resident needs oxygen there should have been an order and she proceeded to look for an order for Resident #402 in both their electronic systems. She was unable to find an order for oxygen for Resident #402 . She stated the risk to the resident of not having oxygen on the care plan would be that the resident would not get the right care. The care informed staff on the resident's needs. In an interview with DON on 4/24/25 at 1:35pm revealed the Baseline Care Plan is completed within 24 hours of admission and would have oxygen listed if the resident admitted with oxygen. There should have always been an order for all residents who required oxygen. The risk to the residents of not having had the proper order on record could be Hypoxia. In an interview with Administrator on 4/24/25 at 2:56am revealed the only time oxygen should have been administered to a resident was if the patient was crashing and it was an emergency, otherwise there would have had to be on order on file to administer oxygen. Review of the Facility's Oxygen Administration policy revised October 2010 revealed The purpose of this procedure is to provide guidelines for safe oxygen administration .1. Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident . 2-Record review of Resident #67's 03/14/25 Quarterly MDS, reflected he was an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of heart failure, chronic kidney disease, acute respiratory failure (lung failure). He had intact cognition with a BIMS score of 14. Review of Section H- Bladder and Bowel reflected he was not noted to have an ostomy (a surgically created opening on the abdomen to allow waste to exit the body). Record review of Resident #67's 03/03/25 Discharge MDS reflected he had an ostomy appliance. Record review of Resident #67's care plan reflected a focus area of The resident has an alteration in gastrointestinal status r/t (due to) colostomy (a surgically created opening on the abdomen to allow waste to exit the body) with the interventions to give medications as ordered and monitor/document side effects and effectiveness, dated initiated 01/31/25. Record review of Resident #67's active order summary report, dated 04/24/25, reflected there were no orders regarding his colostomy care. Record review of Resident #67's Treatment Administration Record (TAR) for March 2025 revealed an order for colostomy care- change pouch/appliance one time a day with a start date of 02/26/25, discontinue date of 03/10/25 and marked as completed on 03/01/25 and 03/02/25 and not marked as provided on from 03/11/25-03/31/25. Further review revealed an order for Colostomy- Check placement and Empty Contents every shift to ensure it is secured. Empty Contents shift (every shift) and more often as necessary, with a start date of 02/04/25 and discontinue date of 03/10/25. In an interview and observation on 04/22/25 at 11:36 AM with Resident #67 revealed he had a colostomy pouch since around February of 2025 that staff changed daily and he was also able to change it himself. In an interview on 04/24/25 at 9:06 AM with LVN H revealed Resident #67 had a colostomy pouch that was changed by nurses daily and sometimes twice a day. LVN H reviewed Resident #67's orders and stated he did not see an order for Resident #67's colostomy pouch care and he must have missed that it was not in the TAR when Resident #67 readmitted to the facility in 3/10/25. He stated it was routine to change Resident #67's colostomy bag at least once a day and must not have noticed the order was not in the TAR. He stated that nurses were responsible to enter the resident orders when they are admitted to the facility. An interview on 04/24/25 at 4:08 PM with the DON revealed Resident #67 should have a physician order for colostomy care and should have been care planned. She stated she was not sure why it had been missed when Resident #67 readmitted on [DATE] and thought it was due to their electronic medical record's transfer from one system to a new system at the end of February 2025. She stated it was important to have physician orders for colostomy care to ensure a resident received the services they needed. Review of the facility's policy Physician's Orders revised January 2020. .Procedure: 1. All physicians' orders shall be recorded on the Patients Medical Record and must be signed electronically by the attending/prescribing physician .3. Physician orders include: a. All medications, b. Treatments, C. Diets, d. Restorative Measures (long-term and short term), e. Special medical procedures required for the safety and well being of the Patient, f. limitations of activities and g. Others as necessary and appropriate .5. Medications, diets, therapy or any treatment may not be administered to the Patient without a written order from the attending physician.

Based on interview, and record review the facility failed to ensure the MDS assessment accurately reflected the resident status for 2 (Resident #71 and Resident #67) of 8 residents whose records were reviewed for assessment accuracy. 1. Resident #67's colostomy status was not coded on his 03/14/25 Quarterly MDS after readmission on [DATE]. 2. Resident #71's attention deficit hyperactivity disorder diagnosis was not listed on his 03/05/25 Quarterly MDS. This failure to ensure comprehensive and accurate assessments could affect residents by placing them at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services. Findings included: 1-Record review of Resident #67's 03/14/25 Quarterly MDS, reflected he was an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of heart failure, chronic kidney disease, acute respiratory failure (lung failure). He had intact cognition with a BIMS score of 14. Review of Section H- Bladder and Bowel reflected he was not noted to have an ostomy (a surgically created opening on the abdomen to allow waste to exit the body). Record review of Resident #67's 03/03/25 Discharge MDS reflected he had an ostomy appliance. Record review of Resident #67's care plan reflected a focus area of The resident has an alteration in gastrointestinal status r/t (due to) colostomy (a surgically created opening on the abdomen to allow waste to exit the body) with the interventions to give medications as ordered and monitor/document side effects and effectiveness, dated initiated 01/31/25. In an interview on 04/22/25 at 11:36 AM with Resident #67 revealed he had a colostomy pouch since around February of 2025 that staff changed daily and he was also able to change it himself. An interview on 04/24/25 at 11:47 AM with the MDS Coordinator revealed Resident #67's ostomy status should have been selected on his 03/14/25 Quarterly MDS and was not sure why it was not selected. She stated Resident #67's 03/03/25 Discharge MDS indicated he had an ostomy appliance, and it must have been missed when he returned. She stated it was important for MDS assessments to be accurate to ensure a resident received the proper services they needed. 2-Record review of Resident #71's Quarterly MDS, dated [DATE], reflected he was a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of paraplegia (paralysis of legs), diabetes (high blood sugar), and a BIMS score of 15 (intact cognition). Record review of Resident #71's care plan reflected a focus area, dated initiated 01/31/25, that indicated he used anti-anxiety medication due to an anxiety disorder with the interventions of monitoring for side effects and effectiveness. Further review revealed a focus area of the resident had potential to be verbally aggressive and yelled at staff due to ineffective coping skills, dated initiated 03/23/25, with the interventions of assess resident's coping skills and support system and administer medications as ordered. Record review of Resident #71's psychological subsequent assessments, dated 02/14/25 revealed resident had the diagnoses included generalized anxiety disorder and attention deficit hyperactivity disorder. In an interview on 04/23/25 at 12:17 PM with Resident #71 revealed he had the diagnosis of attention deficit hyperactivity disorder since he was 6 years old and received psychological services at the facility. In an interview on 04/23/25 at 2:07 PM with the Social Services Director revealed Resident #71 had a diagnosis of attention deficit hyperactivity disorder and received psychological services at the facility. She stated that the physician should have added the diagnosis to the resident's electronic health record and was not sure why it was missed. She stated it was important to have residents' diagnoses in the MDS and electronic health record to ensure residents received any needed services. In an interview on 04/24/25 at 9:06 AM with LVN H revealed he was aware that Resident #71 had a diagnosis of attention deficit hyperactivity disorder and was not aware it was not listed as one of his diagnoses on his MDS or on his factsheet . An interview on 04/24/25 at 11:47 AM with the MDS Coordinator revealed Resident #71's diagnosis of attention deficit hyperactive disorder was not in his 03/05/25 Quarterly MDS. She stated that she was not sure why it was not added to the resident's diagnoses, and it was important to have all current diagnoses accurately noted in the resident's MDS because it guides the plan of care and provided insight into each resident's needs. An interview on 04/24/25 at 4:08 PM with the DON revealed Resident #67 should have a physician order for colostomy care and it was care planned. She stated she was not sure why Resident #67's ostomy status had been missed when he readmitted to the facility in March 2025. She stated it was important to have physician orders for colostomy care to ensure a resident received the services they needed. She stated she was aware that Resident #71 had a diagnosis of attention deficit hyperactivity disorder and anxiety disorder and received psychological services. She stated the diagnosis of attention deficit hyperactivity disorder should have been listed as a diagnosis to ensure he received the correct care and services. She stated that the facility had changed its electronic health record system to another documentation programan and may have been missed in the transfer. She stated it was the responsibility of nursing to ensure resident diagnoses were updated during readmission and admission. She stated it was the responsibility of the MDS Coordinator to ensure assessments were complete. Record review of facility's resident assessment policy, titled Resident Assessments, dated March 2022, reflected: A comprehensive assessment of every resident's needs is made at intervals designated by OBRA (Omnibus Budget Reconciliation Act) and PPS (Prospective Payment System) requirements .

Based on observation, interview, and record review the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents for one (Resident #5) of two residents observed during a transfer. The Facility failed to ensure CNA K used a gait belt when transferring Resident #5 from her bed to the wheelchair on 04/22/2025. This failure could affect the residents by placing the residents at risk for falls, discomfort, pain, and/or injury. Findings included: Record review of Resident #5's Quarterly MDS assessment, dated 03/13/25, reflected an admission date of 11/29/23. Resident #5' active diagnoses included weakness and other abnormalities of gait and mobility. Resident #5 had a BIMS score of 06, meaning her cognition was severely impaired. she required maximal assist with transfers from a bed to a wheelchair. Record review of Resident #5's care plan, dated 03/19/25, reflected Focus .The resident has potential risk for injury due to unsafe independent transfers . Goal: The resident will be free from injury . Interventions included .to be transferred with assist of one and use of gait belt . An observation on 04/22/25 at 10:29 AM revealed CNA K provided incontinent care to Resident #5. CNA K assisted Resident #5 onto the side of the bed. CNA K placed the wheelchair next to the bed facing toward the head of the bed and locked the wheels. CNA K placed her feet outside of the resident legs and lifted her by her clothes from the back. She lifted her from the bed toward the wheelchair. CNA K held Resident #5 by the arm pits, and she assisted her to sit on the wheelchair. Resident #5 hollered ouch. Resident stated it hurt under the breasts. In an interview on 04/22/25 at 11:45 AM, CNA K stated she was supposed to use a gait belt when transferring residents. She stated not using a gait belt could lead to a fall, or she could injure herself. She stated she had been in serviced on gait belt transfers when she was hired. In an interview on 04/24/25 at 10:02 AM, the DON stated it was the expectation for staff to use a gait belt when providing transfers to residents to prevent the risk of injury to the resident and the staff. She stated they had issued gait belts to all the CNAs, and she expected them to always have the belts with them to use it. She stated going forward she would do skills check monthly and she would do her rounds for monitoring. Record review of the facility's policy, Using a Transfer Belt revised July 2014, reflected, Belt should be used on any patient who requires any type or level of assistance with transfers or ambulation .

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of two residents (Resident #1) reviewed for catheter care. 1. The facility failed to ensure CNA B provided catheter care and appropriate perineal care for Resident #1 when she failed to separate the labia and wash downward, failed to clean under the resident's skin folds and failed to clean around the suprapubic catheter (catheter that is inserted through the abdominal wall into the bladder) on 04/23/25. 2. The facility failed to ensure RN A maintained a sterile procedure while re-inserting Resident #1's suprapubic catheter on 04/23/25. This failure could place residents at risk for the development and/or worsening of urinary tract infections and skin breakdown. Findings included: Record review of resident #1s quarterly MDS assessment, dated 02/28/25, reflected a [AGE] year-old female with an admission date of 08/01/24. She had a BIMS score of 15 which indicated she was cognitively intact. She was dependent for toileting care. She had a foley catheter and was frequently incontinent of bowel. Active diagnoses included multiple sclerosis (disease that causes breakdown of the protective covering of nerves) and neurogenic bladder (disruption in the nervous systems connection to the bladder). Record review of Resident #1's Physician Order Summary report dated 04/24/25, reflected, Indwelling catheter care every shift with a start date of 02/04/25 and Suprapubic Catheter 18 F 10 bulb {18 French 10 bulb is the size of the catheter} as needed for occlusion or leakage as needed, with a start date of 04/23/25. Record review of Resident #1's care plan, initiated on 01/09/25, reflected, The resident has indwelling Suprapubic catheter .Goal-the resident will show no signs and symptoms of urinary infection .Interventions .monitor for signs and symptoms of discomfort on urination and frequency . In an interview and observation on 04/23/25 at 9:50 a.m. Resident #1 was lying in bed with a strong urine odor. Resident #1 stated she thinks her catheter is leaking and stated she hated the smell. Staff were called to Resident's room. On 04/23/25 at 10:14 a.m. CNA B and Restorative aide entered Resident #1's room. Both staff washed their hands and put on gown and gloves. CNA B unfasted the resident's brief. Resident was noted to have redness extending out from under her belly folds. Resident had suprapubic catheter but unable to observe insertion site due to skin fold. CNA B wiped down each groin, revealing the Resident had a bowel movement that had pushed up between her legs. CNA B wiped to remove the bowel movement from the resident inner thighs, then wiped across the pubic mound but did not spread her labia and wipe down the middle. CNA B did not clean under the resident's skin folds or around the suprapubic catheter, which was leaking urine. Both staff rolled the resident onto her side, revealing the brief was saturated with urine and a large soft bowel movement. CNA B continued to clean from front to back until all bowel movement was removed. CNA B then removed her gloves, performed hand hygiene, and re-gloved before placing a clean brief under the resident. Restorative aide gathered the trash, removed her gloves and gowns, performed hand hygiene, and left the room. Observed RN A on 04/23/25 at 10:30 a.m. entered Resident #1's room with the catheter kit needed to change the suprapubic catheter. RN A washed her hands and put on utility gloves but did not put on a gown. RN A placed the catheter kit and foley catheter on the bed, put on utility gloves and deflated the balloon on the suprapubic catheter with a 10-cc syringe and then removed the catheter. Urine was noted running down the Residents side. CNA B opened a trash bag and RN A placed the old catheter and catheter bag, which was half full of urine, in the trash bag. RN A removed her gloves and washed her hands. CNA B asked if she was needed and RN A stated no. CNA B removed her gown and gloves, gathered the trash, performed hand hygiene, and left the room. RN A then opened the catheter kit and removed the packet containing sterile gloves. RN A then put on the sterile gloves without first sitting up her sterile field or opening the foley catheter. RN A placed the sterile drape on top of the resident legs and around the resident's lower abdomen. RN A reached into the catheter kit and opened the betadine swabs and lifted the residents belly fold to reveal the insertion site. RN A cleaned around the stoma site with the betadine swabs and then removed her sterile gloves. RN A washed her hands and put on utility gloves and opened the catheter package and opened a package of lubricant. She then picked up the catheter midway down, with approximately 3 inches of the catheter dangling and guided it into the packet of lubricant. RN A then proceeded to raise the resident belly fold and inserted the catheter approximately 3-4 inches until urine return. RN A then attached the syringe to the catheter port and inserted 10 cc of normal saline to inflate the [NAME]. The end of the catheter was left open to air and urine was noted draining onto the resident's side. RN A then connected the catheter to the urinary drainage bag. RN A then removed her gloves, disposed of the trash, and performed hygiene. She stated the aides would have to come back in and clean her up again since the urine had run down her side. In an interview with RN A on 04/23/25 at 10:45 a.m. she stated changing a catheter required sterile procedure to decrease the risk of infection. She stated she thought she had maintained a sterile procedure while changing Resident #1's catheter. In an interview with the DON on 04/23/25 at 02:00 p.m. she stated the CNAs were supposed to perform catheter care anytime they provided incontinence care to reduce the risk of infection. She stated they had to follow the proper procedure for incontinence care which included spreading the labia and wiping down the middle to ensure the residents were clean and help reduce infection risk. She stated RN A should have set up her sterile field up first to perform the catheter change. She stated once she removed her sterile gloves and put on utility gloves and then inserted the catheter with utility gloves, the procedure was no longer considered sterile. She stated she would re-educate her on catheter changes. Record Review of the Facility's policy titled, Suprapubic Catheter-Insertion Of, dated June 2006, reflected, .Equipment-Sterile catheter insertion set, Sterile indwelling catheter, Sterile water for inflation of bulb, Sterile gloves .Procedure .Wash your hands .Peel back wrapper of catheter insertion set. DO NOT CONTAMINATE CONTENTS. Place on working surface. Open catheter if in separate packaging. Open sterile wrap to provide sterile filed. Put on sterile gloves. Place protective pad below opening for catheter. Open lubricating jelly and squeeze onto catheter tip. Use a clean cotton ball/swab stick for each cleansing, clean edges and skin around opening to catheter with antiseptic solution. Begin at edges of opening and cleanse in concentric circles moving outward. Clean directly over opening with last cotton ball/swab stick and antiseptic solution, taking care not to let solution run into opening. Gently without force, insert lubricated catheter into opening about one to one-half inches. Place other end of catheter into specimen container .Inflate balloon to capacity as stated on catheter. Attach catheter to drainage bag .Leave the Patient clean, dry and in comfortable position . Record Review of the Facility's policy titled, Perineal Care, dated October 2010, reflected, The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition .Wash and dry your hands .put on gloves .For female resident .Wash perineal area, wiping from font to back .Separate labia and wash area downward from front to back. (Note: if resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches .). Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side, and using downward strokes .Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks .Remove gloves .Wash and dry your hands .

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 21 residents (Resident #1 and Resident #5) observed for infection control. 1. The facility failed to ensure RN A used the required PPE for Resident #1, who was on enhanced barrier precautions due to her indwelling urinary catheter, while changing the indwelling urinary catheter on 04/23/25. 2. The facility failed to ensure CNA K changed her gloves and performed hand hygiene while providing incontinence care to Resident #5 on 04/22/25. These failures could place the residents at risk of cross-contamination and development of infection. Findings included: 1. Record review of resident #1s quarterly MDS assessment, dated 02/28/25, reflected a [AGE] year-old female with an admission date of 08/01/24. She had a BIMS score of 15 which indicated she was cognitively intact. She was dependent for toileting care. She had a foley catheter and was frequently incontinent of bowel. Active diagnoses included multiple sclerosis (disease that causes breakdown of the protective covering of nerves) and neurogenic bladder (disruption in the nervous systems connection to the bladder). Record review of Resident #1's Physician Order Summary report dated 04/24/25, reflected, Enhanced Barrier precautions every shift Follow Facility Policy-**USE for patients with any of the following (when Contact Precautions do not otherwise apply) Wounds or indwelling medical devices regardless of MDRO (multiple drug resistant organism) colonization(the presence of microorganisms like bacteria where the organisms grow and multiply but do not cause visible disease) status infection or colonization with an MDRO**, with a start date of 01/09/25. Record review of Resident #1's care plan, initiated on 03/20/25, reflected, Enhanced Barrier Precautions implemented related to Urinary catheter .Goal-The spread of MDRO will be reduced over the next 90 days .Interventions .Implement Enhanced Barrier precautions .monitor for signs and symptoms of infection . In an interview and observation on 04/23/25 at 9:50 a.m. Resident #1 was lying in bed with a strong urine odor. Resident #1 stated she thought her catheter was leaking and stated she hated the smell. Signage was posted outside of the Resident's door indicating she was on Enhanced Barrier Precautions. Observed container inside Resident #1's room which contained gowns and gloves. In an observation on 04/23/25 at 10:30 a.m. RN A entered Resident #1's room with the catheter kit needed to change the suprapubic catheter (catheter that is inserted through the abdominal wall into the bladder). RN A washed her hands and put on utility gloves but did not put on a gown. RN A placed the catheter kit and foley catheter on the bed, put on utility gloves and removed the old catheter. RN A removed her gloves and washed her hands and proceeded with the replacement of the suprapubic catheter. RN A then removed her gloves, disposed of the trash, and performed hygiene. In an interview with RN A on 04/23/25 at 10:45 a.m. she stated Resident #1 was in Enhanced Barrier Precautions due to her indwelling urinary catheter. She stated she should have worn a gown and just overlooked it when she entered the room. She stated the risk of not following Enhanced Barrier Precautions was the spread of MDRO's. In an interview with the DON on 04/23/25 at 02:00 p.m. she stated any resident who had any type of indwelling medical device was placed on Enhanced Barrier precautions to help reduce the spread of MDRO's. She stated signage was posted outside to the door, which explained what PPE was to be worn and for what task the PPE was to be worn for. She stated any contact with a resident with a urinary catheter required the use of gown and gloves. She stated the staff had received numerous trainings on the use of Enhanced Barrier Precautions. Record review of the Facility's policy titled, Enhanced Barrier Precautions, dated August 2022, reflected, Enhanced Barrier Precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents .EBP employ targeted gown and glove use during high contact resident care activities when contact precautions no not otherwise apply .Examples of high-contact resident care activities requiring the use of gown and gloves for EBP's include .device care or use ( .urinary catheter .)EBPs remain in place for the duration of the residents stay or until resolution .or discontinuation of the indwelling medical device that places them at increased risk .Staff are trained prior to caring for resident on EBPs .Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required . 2. In an observation on 04/22/25 at 10:29 AM CNA K entered Resident #5's room to provide peri-care. She washed her hands and put on gloves. She uncovered resident and she unfastened the resident brief revealing wet brief. She cleaned the resident's front pubic area with several wipes. CNA K changed her gloves without hand hygiene. She rolled the resident on her side, removed the soiled brief, and wiped the anal area from front to back and then the buttocks, changing to a clean wipe with each swipe. CNA K then pushed the soiled sheet under the resident and with soiled gloves placed a clean brief under the resident. She then rolled the resident over, and she closed the resident brief. Without changing gloves, she assisted resident to sitting position and then to standing position and she transferred her from bed to wheelchair. She changed gloves without hand hygiene and assisted resident to put on clean T-shirt. She removed her gloves, washed her hands, and left the room. In an interview on 04/22/25 at 11:45 AM CNA K stated she was supposed to change her gloves and perform hand hygiene when she went from dirty to clean. CNA K stated she should have sanitized her hand between change of gloves. She stated failing to provide proper care exposed the resident to infections. CNA K stated she did not realize she had soiled gloves on when she put the clean brief under the resident. In an interview on 04/24/25 at 10:02 AM the DON stated they had trained at length on when staff were to change their gloves and sanitize their hands. She stated staff needed to change their gloves when they go from dirty to clean. She stated the risk was increased risk of infections. She stated she and the ADON would be re-training and observing care to ensure staff compliance. Record review of CNA K's competency check off for hand hygiene and infection control revealed she was proficient in care as of 02/28/25. Record Review of the Facility's policy titled, Perineal Care, dated October 2010, reflected, The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition .Wash and dry your hands .put on gloves .For female resident .Wash perineal area, wiping from font to back .Separate labia and wash area downward from front to back. Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side, and using downward strokes .Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks .Remove gloves .Wash and dry your hands . Record review of the facility's policy titled, Hand Washing, dated August 2012, reflected, .Hand washing is the single most important means of preventing the spread of infection .After Patient contact .Wash hands with soap and running water .May use Hand sanitizing gel in place of soap and water .

Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications for 1 (Resident #1) of 2 residents reviewed for enteral nutrition. The facility failed to ensure Resident #1's correct G-tube feeding was administered as ordered by the physician on 2/19/25. This deficient practice could affect residents who receive tube feedings by not receiving the appropriate nutrition and hydration. Findings included: Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed that Resident #1 was an [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included Stroke ( interrupted blood flow to the brain) , Hypertension (high blood pressure), Diabetes Mellitus (high blood glucose), Hyperlipidemia (high blood lipids), Anxiety Disorder, Depression, Malnutrition. Resident #1 had a G-tube. Resident #1 had BIMS score of 11 suggesting moderate cognitive impairment. Review of Resident #1's comprehensive care plan revised undated revealed, Focus: [Resident #1] requires Enhanced Barrier Isolation as evidenced by G-tube status. Goal: Will not have any psycho-social concerns and will no longer require isolation within the next 90 days. Intervention: Inform staff and visitors of isolation requirements. Provide protective equipment at entrance to room. Post isolation precautions on the door to the room. Review of Resident #1's Physician order dated 1/21/2025 reflected, Isosource 1.5 Cal Oral Liquid (Nutritional Supplements) Give 250 ml via G-Tube five times a day for supplement. Observation on 2/19/25 at 11:07 AM, revealed LVN A proceeded to feed Resident #1 via G-tube. LVN A performed hand hygiene, wore gloves, opened 1 can of enteral (Enteral nutrition is nutrition delivered into the intestine by a tube is used where nutrition cannot be taken normally by mouth) formula with name Fibersource HN 1.2 She then administered the enteral formula via bolus method (administering formula through a feeding tube in large, rapid doses over a short period) into Resident#1's G-tube. She threw away the empty enteral formula carton in the trash can next to the resident bedside. In an interview on 2/19/25 at 11:18 AM, LVN A revealed Resident#1 gets a formula starting by name Iso. She stated she will need to look through Resident #1's Physician orders to find out the exact name. She reviewed the physician orders in the EHR and stated that the G-tube formula's name was Isosource 1.5. She then added that Resident #1 had complained of heart burn with the Isosource 1.5 G-tube formula, and she was going to talk to the physician about changing it. She stated that all medications and supplements including enteral formula should be administered per physician order. She stated that G-tube formula Fibersource HN 1.2 that was administered to Resident #1 was not ordered by the physician. She stated that Isosource 1.5 was more calorically dense than Fibersource HN 1.2 and the risk of administering incorrect formula was resident receiving inadequate nutrition. In an interview and observation on 2/19/25 at 11:44 AM, ADON B revealed her expectation was that nurses should follow physician orders while administering medications and G-tube feeds. She picked up the empty feed carton from Resident #1's room and read the name as Fibersource HN 1.2 She stated that Resident #1 was NPO and dependent on G-tube feeding for all his nutrition needs. She stated Resident #1 was on Isosource 1.5 G-tube formula for nutrition. She stated that they had Isosource 1.5 in the med storage room. Observation of the med storage room revealed facility had 2 boxes (48 cartons) of Isosource 1.5 formula on stock. She stated that the risk of administering incorrect formula could be weight loss and decreased nutrition. She stated that she will educate the nurse regarding following physician orders all times. In an interview on 2/19/25 at 1:17 PM, the DON revealed her expectation was to follow physician orders each time. She also stated that Nurses should be cross checking the physician order for G-tube feeds against the formula and quantity to be administered to the resident. She stated that the two formulas were calorically different, with Isosource 1.5 being more calorically dense and the risk of not providing correct enteral formula was decreased nutrition and decreased quality of care. In an interview on 2/20/25 at 1:06 PM with Dietitian revealed that her expectation was tube feeding should be admisnitered per physician orders. She stated that failure to proivde the correct tube feeding formula can lead to tube feeding complications such as nausea, vomiting, and potential weight concerns. She stated that LVN A informed her yesterday about Resident #1 not tolerating Isosource 1.5 and she will be assessing Resident #1 after the interview. Record review of facility policy titled, Administration of formula via feeding tube Gravity, Bolus, Pump updated March 2019 reflected, To administer nutrients to Patients who are unable to eat normally, without complications; to assure proper absorption of nutrients by proper administration, without side effects . Bolus Method: Open formula and pour prescribed amount into a graduated container .

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 (Resident #1) of 2 residents observed for infection control. The facility failed to ensure LVN A donned the appropriate PPE (personal protective equipment) required for EBP (enhanced barrier precautions) during administering G-tube (external tube inserted in the stomach to provide nutrition and hydration) for Resident #1 who was on enhanced barriers precautions on 2/19/25. These failures could place residents at risk for infection and cross contamination of pathogens and illness. Findings included: Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed that Resident #1 was an [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included Stroke (interrupted blood flow to the brain), Hypertension (high blood pressure), Diabetes Mellitus (high blood glucose), Hyperlipidemia (high blood lipids), Anxiety Disorder, Depression, Malnutrition. Resident #1 had a G-tube while admitted as a resident in the facility. Resident #1 had BIMS score of 11 suggesting moderate cognitive impairment. Review of Resident #1's comprehensive care plan revised undated revealed, Focus: [Resident #1] requires Enhanced Barrier Isolation as evidenced by G-tube status. Goal: Will not have any psycho-social concerns and will no longer require isolation within the next 90 days. Intervention: Inform staff and visitors of isolation requirements. Provide protective equipment at entrance to room. Post isolation precautions on the door to the room. Record review of physician orders dated 2/20/25 revealed Resident #1 did not have orders for Enhanced Barrier precautions. Observation on 2/19/25 at 11:07 AM, revealed Resident #1 had EBP signage on the door. LVN A entered Resident #1's room, performed hand hygiene, donned gloves, she did not wear a gown or any other PPE that was indicated for EBP. LVN A checked G-tube residuals and administered the water flushes and feeding via G-tube. In an interview on 2/19/25 at 11:18 AM, LVN A revealed she had worked in the facility for about 6 months. She stated that EBP was required for all residents that had wounds or external devices such as catheters. She added PPE for EBP was gowns and gloves and any additional PPE per resident condition. She stated that she forgot to don a gown while administering G-tube feeding to Resident #1. She also stated that PPE for EBP was necessary to prevent infections and failure to do so can cause increase the spread of infection. In an Interview on 2/19/25 at 1:17 PM, the DON revealed her expectation was all direct care staff follow Enhance Barrier precautions (EBP) while providing high contact resident care to resident with who had central line, urinary catheter, or G-tube. She added that gowns and gloves were the minimum level of PPE required for EBP resident care activities. However, as part of Standard Precautions, additional PPE may be required depending on the resident. She stated that failure to follow EBP while providing care can put residents at greater risk for infection. The DON stated that all staff were trained on EBP precautions and PPE to be used. She added she will ensure that all direct care staff was retrained on EBP. Competency skill checks for LVN A for EBP was requested from the facility. The competency skillcheck list for LVN A for EBP was not provided by the date and time of exit. Record review of facility policy titled, Enhanced Barrier Precautions dated August 2020 reflected, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents .2.a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and wound care (any skin opening requiring a dressing)

Based on observation, interview, and record review 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 2 residents (Resident #1) reviewed for pain management. The facility failed to adequately assess and treat Resident #1's severe breakthrough pain. This failure could place residents at risk for unnecessary pain, discomfort and a decreased quality of life. Findings include: Record review of Resident #1's electronic face sheet, dated 12/31/24 reflected a [AGE] year-old female, who admitted to the facility on [DATE]. Resident #1 had a diagnosis of Metabolic Encephalopathy (brain dysfunction caused by a chemical imbalance), Vascular Dementia (condition that affects memory, thinking, and behavior), Low Back Pain, Anorexia (eating disorder that causes people to obsess about weight and what they eat), Fracture of shaft of Right Humerus (upper arm bone), Fracture of Left Forearm (bone between elbow and wrist), and Anxiety Disorder (mental health condition that causes uncontrollable feelings of fear or anxiety). Record review of Resident #1's Quarterly MDS Assessment, dated 11/05/24, reflected Resident #1 had a BIMS score of 13, meaning Resident #1's cognition was intact. The MDS also reflected Resident #1 received a scheduled pain regimen and noted that pain assessments should be conducted. Nothing else was noted on the MDS regarding pain management. Record review of Resident #1's Care Plan dated, 12/31/24, with an effective date of 05/02/24, reflected Resident #1 had a problem with pain management. Resident #1's care plan noted a goal for staff to actively participate in assessment of pain. An intervention noted on Resident #1's care plan was for staff to observe for behaviors that may indicate pain (rubbing, moaning, crying, guarding, withdraw, or agitation). Record review of a hospital document dated 11/08/24 reflected Resident #1 was treated a week prior for a Left Wrist Fracture, and it noted a splint was in place. Record review of a hospital document dated 11/12/24 reflected Resident #1 was treatment for a Right Humerus Fracture (long bone in upper arm), to be treated with immobilization. Record review of Resident #1's physician orders reflected the following: Tramadol 50 MG tablet, every six hours starting on 11/20/24 Tylenol Extra Strength 500 MG tablet, two times daily, starting on 11/20/24 Acetaminophen Extra Strength 500 MG, 1 tablet rectal two times daily, starting 10/29/24, RP notified PRN fever > 100 and pain A treatment order dated 11/01/24 for Resident #1 to be turned and repositioned every 2 hours by shift A pain assessment order dated 11/01/24 for Resident #1 to be assessed for pain Can Verbalize by shift Monitor for pain level and pain location Observation of a video dated 11/23/24 at 8:55 (unknown if it's AM or PM) reflected Resident #1 as she was turned and repositioned on her left side, in bed by Caregiver B. Resident #1 can be seen and heard yelling out in pain as she was returned. Resident #1 stated, You are trying to kill me. Observation of a video dated 11/24/24 at 9:51 (unknown if it's AM or PM), reflected two staff members turning Resident #1 to her left side. Resident #1 yelled out in pain and appeared to put her hand on her hip area. Record review of the nurse notes on Resident #1's electronic record reflected the following: 11/22/24 at 22:38 (10:38 PM) Patient was assessed for pain when she expressed discomfort after being transferred into the bed. Patient was given PRN acetaminophen. 11/25/24 at 14:20 (2:20 PM) During routine care, resident exhibited signs of discomfort during repositioning, nurse asked resident if she was in pain, resident verbalized pain localized to the right hip. Careful assessment done, no visible swelling, no redness or deformity observed in the right hip area at the time of assessment. Nurse administered scheduled pain medication. (Family Member) requested to transport resident to (hospital name) ER for further evaluation and treatment. Further review revealed there were no nurse notes on 11/23/24 or 11/24/24 on Resident #1's electronic record. Record review of the Resident #1's Pain Assessments for November 2024 reflected the following: dated 11/02/24 noted Resident #1 had a pain face of zero and did not specify how often pain medication was needed dated 11/11/24 noted Resident #1 had a pain face of 4, noting that meant her pain level was between mild and moderate. It noted Resident #1 needed pain mediation multiple times per day. dated 11/12/24 noted Resident #1 had a pain face of 2, noting that meant her pain level was mild and did not specify how often pain medication was needed dated 11/22/24 noted Resident #1 was able to verbalize a pain level of 5, noting pain medication was needed once daily Pain assessment dated [DATE] noted Resident #1 was able to verbalize a pain level of 4, noting pain medication was needed once daily dated 11/24/24 noted Resident #1 was able to verbalize a pain level of 4, and did not specify how often pain medication was needed dated 11/25/24 noted Resident #1 had a pain face of 4, noting that meant her pain level was between mild and moderate and did not specify how often pain medication was needed Record review of the Hospital document dated, 11/25/24, reflected the following: Chief Complaint Hip Pain (non-traumatic) Per EMS patient reports sudden onset of right hip pain. History of Present Illness The patient, (Resident #1's name) presents with a chief complaint of right leg pain, specifically noting tenderness in the right hip area upon palpation. Additionally, the patient exhibits some confusion and difficulty answering basic questions, which is thought to be associated with her history of dementia. Past Medical History Diagnosis Osteoarthritis Vitamin D deficiency Physical Exam Musculoskeletal: Cervical back: Normal range of motion and neck supple. Comments: Left wrist in a Velcro splint. Right arm in a sling. Right hip tender to palpation and pain with range of motion. Neurovasc intact distally. Final Result Impression: Right subcapital hip fracture. Findings: Subcapital fracture of the right hip. Spoke with patient's (family member) regarding test results and she right the bedside. Reviewed images with her. Discussed with Dr. and he consulted in the ER with plan for surgery tomorrow. In an interview on 12/31/24 at 4:22 PM, Resident #1's Family Member stated Resident #1 did not have any hip pain on Friday, 11/22/24. The Family Member stated she was not aware Resident #1 had additional pain from other areas other than her arm injuries. The Family Member stated Resident #1 was already taking pain medications for those injuries. Family Member stated she was notified by facility staff on 11/25/24 that Resident #1 had hip pain. In an interview on 01/02/25 at 11:19 AM, Resident #1's Physician stated she was informed of Resident #1's hip or leg pain on 11/25/24 by facility staff. The Physician stated the resident had recent arm injuries and had pain from that, but the hip pain was new. In an interview on 01/02/25 at 6:03 PM, the DON stated she batched printed all the pain assessments in the electronic record for Resident #1. She stated those are all the pain assessments that were available for Resident #1. The DON stated there was a physician's order for Resident #1 to be assessed three times a day for pain, but when she looked at the electronic record, she could not locate all of the pain assessments. The DON stated staff would look at a resident's face for pain indicators if a resident was not able to verbalize pain. The DON stated if a caregiver tended to a resident, and the resident was yelling out in pain, then the caregiver would have verbally told a nurse, then nurse should have documented she was informed of pain, ensure the resident had taken their scheduled pain medication as ordered. The DON stated then the nurse could give PRN pain medication, and there was an area on the MAR to document that. The DON did not see any PRN medication given for pain for Resident #1. The DON stated that both of Resident #1's arms were fractured at the time, so the staff may have assumed those injuries caused the pain. The DON stated the nurse documentation helped with follow-ups, but she did not feel that not documenting put the resident at a greater risk. The DON stated on 11/23/24, Resident #1 received her scheduled pain medications, Tylenol and Tramadol. She stated she did not receive any PRN medication on 11/23/24. The DON stated no PRN medication was given on 11/24/24 for pain. In an interview on 01/02/25 at 6:29 PM, Caregiver B stated Resident #1 usually screamed anytime staff touched her. Caregiver B stated Resident #1 had been like that a while. Caregiver B stated she tried to be as gentle as possible, but Resident #1 would scream the moment anyone touched her. She stated Resident #1 had injured arms, so she thought that was why she was in pain. Caregiver B stated she did not see or hear Resident #1 complain of hip pain. She stated she did not see her grab her hip. Caregiver B stated she always reported concerns of pain of a resident to the nurse. Caregiver B stated she did not remember which nurse she informed about Resident #1's pain. Caregiver B stated it was her job to tell a nurse, and then it was the responsibility of the nurse to document that concern and to assess the resident. Caregiver B stated sometimes the nurse would say Resident #1 already had pain medication. In an interview on 01/02/25 at 7:00 PM, RN C stated she worked with Resident #1. She stated she would have assessed a resident if a caregiver told her the resident was in pain. She stated she would check a resident's face for grimaces if a resident was non-verbal or didn't communicate a lot. RN C stated she would document the pain level. She stated if the pain was abnormal for the resident, then she would have documented in the nurse notes. RN C stated if the pain was not abnormal, then she probably would not document in the nurse notes. RN C stated in the past, when she assessed Resident #1, she hardly ever said she was in pain, and always would say she was okay. She stated generally, Resident #1 did not like to be moved and would try to do things herself. RN C stated Resident #1 would be stubborn at times. RN C stated maybe the resident would yell in pain when being moved, but if she was not in motion when she was assessed by a nurse, she might not have a higher pain level at the time of the assessment. In an interview on 01/02/25 at 7:30 PM, the Administrator stated if a resident was in pain, a caregiver should have reported it to a nurse. She stated the nurse should have assessed a resident after a caregiver told the nurse. The Administrator stated the pain assessments should be noted in the notes or on a pain assessment form. The Administrator stated she had not reviewed Resident #1's chart and had not seen all of the videos. She stated Resident #1 discharged from the facility after her last hospital visit. The Administrator stated she did not know if yelling out was the norm for Resident #1, so she could not say if there were any risks or concerns of pain management. Record review of the facility's policy titled, Pain Management, dated 03/2016, reflected the following: Pain Management 1. A pain assessment must be completed for a patient upon admission, including re-admission, the onset or an increase in pain, quarterly and with any significant change in the patient's condition. 2. Every patient must be assessed for pain utilizing the pain intensity scale (faces/ 0-10) for the nonverbal, cognitively impaired patient. a. Every shift b. Prior to and one hour following the administration of as needed pain medication. c. Prior to and immediately following any invasive procedure, including dressing changes 3. If a Patient's Pain intensity score is ? 1 or has been assessed with non- verbal/non-cognitive signs of Pain; the Pain must be addressed through pharmacological and/or non-pharmacological Pain interventions and documented. 4. If a Patient is assessed with Pain that limits function, the Patient must be screened by appropriate therapy disciplines. 5. If a Patient is assessed for unrelieved Pain, the nurse must notify the attending physician to obtain an order for appropriate Pain management.

Based on observation, interview, and record review, the facility failed to treat residents with respect and dignity for 1 of 4 (Resident #1) residents reviewed for dignity in that: The facility failed to ensure staff did not stand over Resident #1 while assisting the resident with her meal in her room on 11/13/2024. This failure could affect residents who require assistance with activities of daily living and place them at risk for psychosocial harm due to a diminished quality of life. The findings were: Record review of Resident #1's electronic face sheet, dated 12/31/24 reflected a [AGE] year-old female, who admitted to the facility on [DATE]. Resident #1 had a diagnosis of Metabolic Encephalopathy (brain dysfunction caused by a chemical imbalance), Vascular Dementia (condition that affects memory, thinking, and behavior), Low Back Pain, Anorexia (eating disorder that causes people to obsess about weight and what they eat), Fracture of shaft of Right Humerus (upper arm bone), Fracture of Left Forearm (bone between elbow and wrist), and Anxiety Disorder (mental health condition that causes uncontrollable feelings of fear or anxiety). Record review of Resident #1's Quarterly MDS Assessment, dated 11/05/24, reflected Resident #1 had a BIMS score of 13, meaning Resident #1's cognition was intact. Record review of Resident #1's Care Plan dated, 12/31/24, with an effective date of 05/02/24, reflected Resident #1 had a problem with weight loss. The goal noted on the care plan was for staff to supervise/provide cues and encouragement while Resident #1has food/supplement/snack. The care plan also noted to feed Resident #1 if Resident #1 was not able to feed herself. Resident #1's care plan noted Resident #1 had impaired mobility and required assistance with ADL's and mobility. The care plan noted Resident #1 needed extensive assistance at meals. Observation of a video dated 11/13/24 at 9:52 (unknown if it is AM or PM), reflected Caregiver A standing at Resident #1's bedside with one hand on her hip, as she fed the resident. On 01/02/25 at 2:19 AM, a telephone call was attempted to Caregiver A. Caregiver A did not answer and did not return the phone call. In an interview on 01/02/25 at 5:15 PM, the DON stated she was not aware that Caregiver A stood as she fed Resident #1. The DON stated she would re-educate the staff on feeding. The DON stated the resident and staff should be at eye level during the feeding. The DON stated the resident nor the family informed the facility of any concerns regarding feeding, and now Resident #1 is no longer at the facility. She stated Resident #1 was discharged to a different facility. She stated the resident wanted to go to another facility prior to admitting to this facility, so Resident #1 decided to move to the original desired facility when it became available. The DON stated it was a social type of risk associated with standing while feeding residents. The DON stated the facility had an upcoming skills fair, and she would address the proper way to feed a resident. In an interview on 01/02/25 at 7:30 PM, The Administrator stated the facility had no policy on feeding residents. She stated the staff member who fed the resident should not have been standing. The Administrator stated she was unaware of any issue, and she stated Resident #1 had discharged to a different facility. The Administrator stated she had no major concerns with Caregiver A standing when she fed Resident #1. Record review of the facility's policy titled, Resident Rights, dated 2001, with a revision date of 02/2021, reflected the following: Policy Statement Employees shall treat all residents with kindness, respect, and dignity.

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #3) of 8 residents reviewed for ADLs. The facility failed to ensure Resident #3 had his fingernails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: A record review of Resident #3's Quarterly MDS assessment dated [DATE] reflected Resident #3 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included cerebral infarction (a loss of blood flow to part of the brain, which damages brain tissue), hemiplegia (paralysis of one side of the body), and other lack of coordination. Resident #3 had a BIMS score of 15 which indicated Resident #3's cognition was intact. He required extensive assistance with personal hygiene. A record review of Resident #3's Comprehensive Care Plan, revised 04/18/24, reflected the following: problem: Personal hygiene - [Resident #3] requires extensive assistance. Goals: [Resident#3] will have oral hygiene, hair combed, and other personal hygiene needs met daily. An observation and interview on 08/06/24 at 10:40 AM revealed Resident #3 was laying in his bed. The nails on both hands were approximately 0.6 centimeter in length extending from the tip of his fingers. The nails were discolored tan and the underside had dark brown colored residue. Resident #3 did not answer the question when he was asked about the nail care. Interview on 08/06/24 at 10:50 AM, RN C stated CNAs were allowed to cut the residents' nails if they were not diabetic. RN C stated she would clean and trim Resident #3's nails right then. RN C stated the risk for not performing nailcare was increased risk of infection. In an interview with the DON on 08/07/24 9:30 AM revealed her expectation was that nail care should be provided as needed, especially during shower time. She stated that CNAs were responsible for doing nail care unless the resident had diagnosis of diabetes. She also stated that as the DON, either herself or her designee were responsible to do routine rounds for monitoring. The DON stated it was the resident's right to have clean and trimmed fingernails. Record Review of the facility policy titled Bath-Bed dated March 2013 reflected, . Care of fingernails and toenails is part of the bath. Be certain nails are clean. Fingernails and toenails of diabetic patients are cut by the licensed nurses

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services for one (Resident #1) of five residents reviewed for urinary catheters. The facility failed to drain Resident #1's suprapubic urine catheter bag, 18 out of the 76 prescribed and scheduled opportunities; which contributed to the increase in bladder spasms and pain. Review of Resident #1's MDS, undated, provided by the facility 04/08/2022, reflected she was a [AGE] year-old female admitted to the facility 03/09/2022. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was moderately cognitively intact, with a BIMS score of 12. Resident #1 required extensive assistance and two or more staff for bed mobility, dressing, toilet use, and personal hygiene. Record review of Resident #1's Comprehensive Care Plan Report, dated 03/10/22, revealed [Resident #1] has a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . skin breakdown . Interventions . Staff to provide all ADL care. Additionally . At risk for infection . catheter use and hx of recurrent [CONDITION(S)] . interventions . change drainage bag . record output per shift. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's TAR, dated 04/08/2022 at 3:15pm revealed the facility failed to drain Resident #1's Suprapubic catheter per shift a total of 18 times out of 76 prescribed opportunities. The facility failed to drain Resident #1's Suprapubic catheter the following times: 03/16/2022 evening shift, 03/16/2022 night shift, 03/17/2022 day shift, 03/19/2022 evening shift, 03/19/2022 night shift, 03/20/2022 day shift, 03/20/2022 evening shift, 03/21/2022 evening shift, 03/26/2022 day shift, 03/26/2022 evening shift, 03/27/2022 day shift, 03/27/2022 evening shift, 04/02/2022 evening shift, 04/03/2022 day shift, 04/04/2022 day shift, 04/04/2022 evening shift, 04/05/2022 day shift, and 04/05/2022 evening shift. In observation and interview with Resident #1 on 04/08/2022 at 10:12am revealed resident resting in bed. Positioned off to the right side of the resident, hanging off the bed, was resident's suprapubic catheter bag. The bag was full, at capacity, with urine backed up into the tubing. Resident #1 stated the facility was very bad about emptying her urine catheter bag. She stated it had not been emptied this morning. She stated in the past, the bag has burst. Resident #1 stated she was in pain and was having bladder spasms. She stated this occurs when her urine catheter bag was full and does not effectively drain her urine, causing her painful spasms. Resident #1 then pushed the call light and by 10:28am, RN M walked in Resident #1's room. Resident #1 requested pain medicine for her bladder spasms. RN M performed a pain assessment and then provided Resident #1 with pain medicine. RN M did not appear to assess the urine catheter bag before or after resident care. In an observation and interview on 04/08/2022 at 1:39pm, Resident #1's urine catheter bag was still full, at max capacity, with urine backed up into the tubing. The CPN of the facility was brought into the room for observation and she stated that the bag should not be that full . In an interview with Resident #1's nurse on 04/08/2022 at 1:42pm, RN M stated she, just now, drained 2000 ml of urine from the urine catheter bag. RN M stated Resident #1 was provided pain medication for her urinary spasms earlier in the morning, around 10:30am . When asked if she checked Resident #1's urine catheter bag at that time, she stated she did not, but she should have, as it can be a source of pain and autonomic dysfunction. She stated that it was primarily the CNAs responsibility to drain the urinary catheter bag. She stated the current CNA, CNA N, was usually on top of it, but they were short staffed today. In interview with CNA N, on 04/08/2022 at 1:50pm, she stated that she usually checked Resident #1's urine catheter bag twice per shift. She stated that she drained the bag earlier that morning but it keeps filling up. When asked for the amount drained, she was unable to give a specific number but provide, it was more than 650 but less than 1000. When asked how she charted that amount she stated she had not charted it yet. CNA N then became defensive and stated she was behind all day as there were normally 2 aides on the hall, and that she was working by herself that day. She did state it was her primary responsibility to drain the urine catheter bags but re-iterated that she cannot drain them in a timely manner when she worked alone on the hall . In interview with Resident #1 on 04/08/2022 at 2:00pm, she stated that her urine catheter bag had not been drained this morning or afternoon until RN M drained it during observation. She stated it has caused her pain and spasms all morning due to the urine backing up into her bladder. In observation and interview on 04/08/2022 at 1:39pm and 2:00pm the facility's CPN stated her expectations were for the CNA and nurse monitor and drain the bag so it does not ever get that full. She stated that if the urine catheter was not drained, it can back up into the bladder and cause infection. In interview with CPN on 04/08/2022 at 2:00pm, she stated there was no specific policy on urine catheter management/drainage, but it was best practice to drain bag as needed when it filled up. Review on 04/25/2022 at 5:19pm of Cleveland Clinic's, [CONDITION(S)] Bladder, rev. 02/15/2022 stated, What causes [CONDITION(S)] bladder? . Other conditions include: spinal cord injuries . trauma/accidents . What complications are related to [CONDITION(S)] bladder? People who have [CONDITION(S)] bladder are at higher risk for other urological problems including repeated infections, kidney damage, vesicoureteral reflux . (https://my.clevelandclinic.org/health/diseases/ -[CONDITION(S)]-bladder) Review on 04/25/2022 at 5:21pm of Mayo Clinic's, Vesicoureteral reflux, rev. 02/11/2022 stated, Vesicoureteral reflux is the abnormal flow of urine from your bladder back up to the tubes (ureters) that connect your kidneys to your bladder. Normally, urine flows from your kidneys through the ureters down to your bladder. It's is not supposed to flow back up . Symptoms . Urinary tract infections commonly occur . these signs and symptoms can include: A strong, persistent urge to urinate . Pain in your side or abdomen. (https://www.mayoclinic.org/diseases-conditions/vesicoureteral-reflux/symptoms-causes/syc- 819)

Based on observation, record review, and interview, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, and the residents' goals and preferences, for one (Resident #1) of three residents reviewed for pain management. The facility failed to drain Resident #1's suprapubic urine catheter bag, 18 out of the 76 prescribed and scheduled opportunities; which contributed to the increase in bladder spasms and pain. Review of Resident #1's MDS, undated, provided by the facility 04/08/2022, reflected she was a [AGE] year-old female admitted to the facility 03/09/2022. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was moderately cognitively intact, with a BIMS score of 12. Resident #1 required extensive assistance and two or more staff for bed mobility, dressing, toilet use, and personal hygiene. Record review of Resident #1's Comprehensive Care Plan Report, dated 03/10/22, revealed [Resident #1] has a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . skin breakdown . Interventions . Staff to provide all ADL care. Additionally . At risk for infection . catheter use and hx of recurrent [CONDITION(S)] . interventions . change drainage bag . record output per shift. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's TAR, dated 04/08/2022 at 3:15pm revealed the facility failed to drain Resident #1's Suprapubic catheter per shift a total of 18 times out of 76 prescribed opportunities. The facility failed to drain Resident #1's Suprapubic catheter the following times: 03/16/2022 evening shift, 03/16/2022 night shift, 03/17/2022 day shift, 03/19/2022 evening shift, 03/19/2022 night shift, 03/20/2022 day shift, 03/20/2022 evening shift, 03/21/2022 evening shift, 03/26/2022 day shift, 03/26/2022 evening shift, 03/27/2022 day shift, 03/27/2022 evening shift, 04/02/2022 evening shift, 04/03/2022 day shift, 04/04/2022 day shift, 04/04/2022 evening shift, 04/05/2022 day shift, and 04/05/2022 evening shift. In observation and interview with Resident #1 on 04/08/2022 at 10:12am revealed resident resting in bed. Positioned off to the right side of the resident, hanging off the bed, was resident's suprapubic catheter bag. The bag was full, at capacity, with urine backed up into the tubing. Resident #1 stated the facility was very bad about emptying her urine catheter bag. She stated it had not been emptied this morning. She stated in the past, the bag has burst. Resident #1 stated she was in pain and was having bladder spasms. She stated this occurs when her urine catheter bag was full and does not effectively drain her urine, causing her painful spasms. Resident #1 then pushed the call light and by 10:28am, RN M walked in Resident #1's room. Resident #1 requested pain medicine for her bladder spasms. RN M performed a pain assessment and then provided Resident #1 with pain medicine. RN M did not appear to assess the urine catheter bag before or after resident care. In an observation and interview on 04/08/2022 at 1:39pm, Resident #1's urine catheter bag was still full, at max capacity, with urine backed up into the tubing. The CPN of the facility was brought into the room for observation and she stated that the bag should not be that full . In an interview with Resident #1's nurse on 04/08/2022 at 1:42pm, RN M stated she, just now, drained 2000 ml of urine from the urine catheter bag. RN M stated Resident #1 was provided pain medication for her urinary spasms earlier in the morning, around 10:30am . When asked if she checked Resident #1's urine catheter bag at that time, she stated she did not, but she should have, as it can be a source of pain and autonomic dysfunction. She stated that it was primarily the CNAs responsibility to drain the urinary catheter bag. She stated the current CNA, CNA N, was usually on top of it, but they were short staffed today. In interview with CNA N, on 04/08/2022 at 1:50pm, she stated that she usually checked Resident #1's urine catheter bag twice per shift. She stated that she drained the bag earlier that morning but it keeps filling up. When asked for the amount drained, she was unable to give a specific number but provide, it was more than 650 but less than 1000. When asked how she charted that amount she stated she had not charted it yet. CNA N then became defensive and stated she was behind all day as there were normally 2 aides on the hall, and that she was working by herself that day. She did state it was her primary responsibility to drain the urine catheter bags but re-iterated that she cannot drain them in a timely manner when she worked alone on the hall . In interview with Resident #1 on 04/08/2022 at 2:00pm, she stated that her urine catheter bag had not been drained this morning or afternoon until RN M drained it during observation. She stated it has caused her pain and spasms all morning due to the urine backing up into her bladder. In observation and interview on 04/08/2022 at 1:39pm and 2:00pm the facility's CPN stated her expectations were for the CNA and nurse monitor and drain the bag so it does not ever get that full. She stated that if the urine catheter was not drained, it can back up into the bladder and cause infection. In interview with CPN on 04/08/2022 at 2:00pm, she stated there was no specific policy on urine catheter management/drainage, but it was best practice to drain bag as needed when it filled up. Review on 04/25/2022 at 5:19pm of Cleveland Clinic's, [CONDITION(S)] Bladder, rev. 02/15/2022 stated, What causes [CONDITION(S)] bladder? . Other conditions include: spinal cord injuries . trauma/accidents . What complications are related to [CONDITION(S)] bladder? People who have [CONDITION(S)] bladder are at higher risk for other urological problems including repeated infections, kidney damage, vesicoureteral reflux . (https://my.clevelandclinic.org/health/diseases/ -[CONDITION(S)]-bladder) Review on 04/25/2022 at 5:21pm of Mayo Clinic's, Vesicoureteral reflux, rev. 02/11/2022 stated, Vesicoureteral reflux is the abnormal flow of urine from your bladder back up to the tubes (ureters) that connect your kidneys to your bladder. Normally, urine flows from your kidneys through the ureters down to your bladder. It's is not supposed to flow back up . Symptoms . Urinary tract infections commonly occur . these signs and symptoms can include: A strong, persistent urge to urinate . Pain in your side or abdomen. (https://www.mayoclinic.org/diseases-conditions/vesicoureteral-reflux/symptoms-causes/syc- 819)

Based on observation, interview, and record review the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for three (Residents #166, #4, and #165) of five residents reviewed for pressure ulcers. The facility failed to ensure: 1. nursing staff obtained physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. nursing staff provided pressure ulcer treatment as ordered by the physician to Residents #4 and #165. An Immediate Jeopardy (IJ) was identified on 11/03/21 at 3:00 PM. The Administrator, the DON, and the Regional Nurse were notified of the IJ, and the Administrator was provided with the IJ template. While the IJ was removed on 11/05/21, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectives of their Plan of Removal. These failures also placed residents at risk for developing new pressure ulcers, pain, deterioration in existing pressure ulcers, infection and hospitalization . Findings included: 1. Review of Resident #166's undated Admission MDS Assessment, but signed as completed on 11/04/21 by the DON, reflected Resident #166 was a [AGE] year-old male admitted to the facility on [DATE]. His BIMS score was 15, indicating he was cognitively intact. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section M of the MDS assessment reflected the resident had two Stage 4 pressure ulcers on admission, one unstageable pressure ulcer, and diabetic foot ulcer(s). Review of Resident #166's hospital records, dated 10/14/21, reflected Resident #166 did not have a documented wound to his right heel at the time of discharge on 10/14/21. Review of the Nursing Admission Assessment, dated 11/05/21 and signed by LVN A on 10/15/21 reflected Resident #166 was admitted from the hospital due to infection of decubitus ulcer. The musculoskeletal assessment reflected Resident #166's left leg, right leg, left arm, and right arm muscle strength were equal. The wound assessment reflected Resident #166 did not have a documented wound to his right heel and had wounds to his left bottom, bilateral lower extremities, and left left. All of the wounds were coded as pressure wounds, and none had measurements included. Resident #166's BRADEN Assessment (scale used to predict pressure ulcer risk) reflected Resident #166 had no sensory impairment, was occasionally moist, was bedfast, his mobility was slightly limited, and his BRADEN score was 16 indicating Mild Risk. Review of Resident #166's Clinical Notes Report .10/1/2021 [to] 11/4/2021, dated 11/04/21, reflected the following: a. [LVN A] .10/15/2021 . infection of decubitus ulcer .able to make needs known, he is bed bound and required repositioning . admitted under care of [Physician B] . he has multiple wounds, a large wound to the left buttock, bilateral (both sides) [lower extremities], left side and amputation to left toes heels b. [LVN C] . 10/17/2021 . pressure ulcer wound to coccyx/[CONDITION(S)] .spoke with surgeon [Physician D] new order for wound vac to be placed weekly on [Monday, Wednesday, Friday] continuous 126mmhg approval for wet to dry dressing with Dakins [solution to treat/prevent skin infections] PRN when vac is not in place or malfunctioning c. [Treatment Nurse E] . 10/19/2021 . New admit skin assessment completed, multiple wounds observed during assessment, resident noted with [Stage] 4 pressure injury to left buttock measuring 6.0 x 5.8 x 2.0 . wound vac applied [at] 125mmhg . [Stage] 4 pressure injury to right buttock measuring 3.0 x 4.5 x 2.0 . collagen and calcium alginate applied to wound bed and covered with dry dressing . wound to left flank measuring 0.3 x 0.3 x [undetermined depth] . diabetic ulcer noted to right side of foot measuring 1.3 x 1.2 x [undetermined depth], stable eschar located on wound . diabetic ulcer located on top of left foot measuring 1.8 x 0.7 x [undetermined depth], stable eschar located on wound . unstageable pressure injury located to right heel measuring 2.0 x 2.1 x [undetermined depth], scant [amount] of [serosanguineous] drainage noted to wound, [approximately] 50% slough [dead tissue] noted to wound bed, site cleaned, skin prep applied, silver alginate applied and covered with dry dressing . Wife [responsible party] in facility and is aware of all wounds and orders, TAR and care plan updated d. [ADON F] . 10/28/2021 . Completed wound care per MD order on [right] heel now measures 0.1 x 0.1 x 0cm slight [amount] of dried blood noted on dressing that was removed no odor applied clean [dressing] per MD order. [Right] heel is improving e. [LVN C] . 11/01/21 . patient states I may [do] heel wound care . heel has purulent drainage though dressings are in place [and] protective boots [remain] in place f. [ADON G] . 11/02/2021 [6:21 PM] . Wound [doctor] made aware of resident wound treatment orders and new orders received . Cleanse wound to right heel with normal saline pd dry apply calcium alginate and cover with dry dressing . g. [ADON G] . 11/03/2021 [12:15 PM] Follow up with [Physician D] this morning with resident wound orders from yesterday and Physician D stated that was okay and that he is going to see the resident today in the clinic . h. [ADON G] . 11/03/2021 [12:18 PM] Additional orders obtained from MD to do CRP [C-reactive protein test] and STAT X-RAY to right heel due to wound to right heel . i. [Treatment Nurse H] . 11/03/2021 [2:16 PM] . Resident seen by [Wound Physician I] today during rounds. Complaint of wound to heel need to be checked. Wound was checked and [treatment] in place. [Wound Physician I] also voiced the need for resident to get x-ray to [rule out [CONDITION(S)] (bone infection)] . Review of the facility provided Skin Report, dated 10/21/21 to 10/27/21, reflected Resident #166 was not included on the report. Review of Resident #166's Care Plan Report, dated 11/2/21, reflected the following: Diabetic ulcer to right outer foot and left top of foot . Perform treatments per order, if no improvement x 2 weeks report to MD . Assess skin weekly and record findings in clinical record . risk for skin breakdown related to . incontinence . impaired mobility . [history] of pressure ulcers . skin desensitized to pain or pressure . diabetes Monitor for [incontinence] q2 [hours] and PRN, change promptly . assist with repositioning as needed . turn and reposition Q2 [hours] . pressure ulcer: Stage 4 located right and left buttock . treatment to pressure ulcer per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #166's November 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #166's October 2021 Treatments and November 2021 Treatments records reflected Resident #166 did not have any documented treatments to his right heel. In an interview and observation on 11/02/21 (Tuesday) at 12:01 PM, Resident #166 was sitting in bed with the head of bed elevated. He had a low air loss mattress and foot pillows in place to both his feet. Resident #166 stated had been in the facility for almost 3 weeks receiving IV antibiotics for infected wounds to his buttocks. He stated he had a wound vac in place to his buttocks. There was a catheter drainage bag hanging off the right side of the bed and the resident had a PICC line to his left upper arm. Resident #166 stated he also had a [CONDITION(S)] in place, and he was paraplegic. He could not move his lower extremities and had no feeling from the waist down. Resident #166 stated he was most concerned about a wound to his right heel worsening because his dressing was supposed to be changed every day, but only the weekend nurse (LVN C) was changing the dressing. An observation of Resident #166's right foot revealed he had an adherent dressing in place to his right heel which was not dated nor initialed. Resident #166 also stated his right heel was to be seen by the facility's wound care doctor, Wound Physician I, two weeks ago, but they told him he wasn't on the list and he was not seen. Resident #166 said he saw an outside wound doctor, Physician D, for his buttocks' wounds, however, Physician D did not treat feet. He stated he had told the DON and the ADON F his right heel needed to be seen by Physician I last Tuesday (10/26/21) when they had changed his buttocks wound vac dressing and they had ensured him he would be seen. In an interview and observation on 11/02/21 at 1:48 PM, ADON G and LVN J entered Resident #166's room and informed him they would be completing his wound care. Resident #166 denied pain and told the nurses he had no feeling from the waist down. Resident #166 said to the nurses he was never turned and was on his back all day. He said he could not turn himself. LVN J assisted Resident #166 to turn onto his left side. The wound vac transparent dressing was dislodged along the lower border and the draw sheet under the resident had an area of greenish-brown drainage where the dressing was not intact. There also a bright red section of drainage on the draw sheet where the upper area of the dressing was. ADON G removed the transparent dressing and foam from Resident #166's buttocks and three open areas were noted. He had a deep open wound to his left buttocks with a beefy red wound bed, dark red blood drainage, and yellowish white ligament visible. He had a shallow open wound to his left buttocks with bright red blood drainage which was approximately 1.5 cm wide and 0.25 cm long, and a deep open wound to his right buttocks with a beefy red wound bed and a small amount of light tan colored drainage. ADON G cleaned the wounds with gauze and NS, cut pieces of foam and inserted the foam into the large wounds on Resident #166's right and left buttocks. ADON G joined the two foams with a long piece of foam and covered the area with an adherent transparent dressing. Resident #166 said he needed Wound Physician I to look at the wound on the back of his heel. He said, last week [the DON] told me I was supposed to see [Wound Physician I] and they told me I wasn't on the list. ADON G told Resident #166 he would make sure he saw Wound Physician I tomorrow (11/03/21) ADON G turned on the wound vac and the setting was 125 mm/HG. After completing wound care to Resident #166's buttocks, ADON G cleaned the bed with a dry and wet wash cloth and replaced the draw sheet. ADON G and LVN J then replaced Resident #166's hospital gown. ADON G and LVN J were leaving Resident #166's room when HHSC Surveyor intervened and asked if they would be completing wound care to Resident #166's wound. ADON G returned to Resident #166 and removed the foot pillow from his right foot. Resident #166 said, That one's gotten a lot worse since nobody's taking care of it. That started out looking like a bruise on the back of my heel. I was wanting to see [Wound Physician I] last week, but nobody cared enough to let her know. Nurse on weekends said it was supposed to be done every day. But they don't do it during the week. After observing the dressing to Resident #166's right heel, ADON G left the room. When ADON G returned, he washed his hands and donned clean gloves. He then removed the dressing to Resident #166's posterior right heel and revealed a circular open wound which was approximately 2cm in diameter and had white and pale yellowish-green slough (dead tissue). The skin at the wound bed and surrounding skin appeared moist and macerated (skin softened by liquid). ADON G cleaned the wound with gauze and NS, and then applied Calcium alginate to the right heel wound bed and covered the wounds with a foam adherent wound dressing. In an interview on 11/02/21 at 3:47 PM ADON G stated he reviewed the doctors' orders prior to completing Resident #166's wound care. ADON G stated the treatment he applied to Resident #166's right heel was what was ordered. When asked if he could locate the order for Resident #166's right heel, ADON G stated, I'm going to be honest, he doesn't have any. ADON G stated he had just put in a call to Wound Physician I and was waiting on her to respond with orders for Resident #166's right heel wound. In an interview on 11/02/21 at 5:25 PM, HHSC Surveyor requested, from the ADON and Regional Nurse T, Resident #166's consultation reports from his outside wound physician, Physician D. The ADM stated she would get with medical records because those were not yet scanned into their electronic health records. In an interview on 11/03/21 at 7:45 AM, Treatment Nurse H revealed she was at this facility today assisting with treatments and would be rounding with the doctor. Treatment Nurse said she knew who the Wound Physician needed to see by looking at the form title, Skin Report. When HHSC Surveyor requested a copy of the form, Treatment Nurse H said the form had not yet been updated. HHSC Surveyor again requested the Skin Report, and Treatment Nurse H said she would need to get with Regional Nurse T and refused to provide a copy of the form. In an observation and interview on 11/03/21 at 11:10 AM, Wound Physician I, Physician B, and Treatment Nurse H were in Resident #166's room. Wound Physician I was observing the wound to Resident #166's posterior heel. Resident #166 stated to Wound Physician I, They told me you were going to see me last week. Now you're here, now that it's down to the bone. Wound Physician I told Resident #166, We were under the impression [Physician D] was going to look at [the right heel wound]. Resident #166 responded to Wound Physician I he had told the nurses, including the DON, Physician D was not going to treat his feet and that is why he requested to see her (Wound Physician I). In an observation on 11/03/21 at 11:15 AM, ADON G and the DON were sitting at the nurses' station. Wound Physician I requested Resident #166's face sheet and orders. The nurses printed out documents and handed them to Wound Physician I. In an interview on 11/03/21 at 11:33 AM, Wound Physician I stated she saw Resident #166 on 11/03/21 at Physician B's request who notified her he needed to be seen. Wound Physician I stated, One to two weeks ago Resident #166 was added to her list to be seen, but he was immediately removed from her list because she was told he was seen by an outside wound doctor. Wound Physician I stated she could not recall who told her Resident #166 did not need to be seen. She stated there had been some miscommunication because Resident #166's outside wound physician only treated his buttocks and not his feet. Wound Physician I stated she saw Resident #166's right heel and saw a Stage 4 pressure ulcer with necrotic tissue to that ligament. The wound measured 2cm x 1.5cm x 0.1 cm. Wound Physician I said Nobody told me [Resident #166] needed orders for his right heel wound. Wound Physician I stated she could not state if there had been deterioration to Resident #166's right heel wound since his admission because she had only seen it today and without knowing what the wound looked like on admission, she wouldn't be able to say. Wound Physician I stated if a wound went untreated, she would be worried about deterioration to a higher stage or a deep tissue injury becoming unstageable necrosis which can be Stage 3 or 4. In the case of open wounds, we would worry about infection. Wound Physician I stated, as soon as she found out Resident #166 had a wound to his right heel, she saw him. She further said she was at the facility every Wednesday morning. Wound Physician I stated Resident #166 was added to her list to be seen today, like just now when they asked me to see him. Review of Resident #166's Initial Wound Evaluation, dated 11/03/21, reflected Resident #166 was assessed by Wound Physician I and she documented the following: . Stage 4 pressure wound of the right, posterior heel . Wound Size . 2.0 x 1.5 x 0.1 cm . Surface area . 3.0 cm [squared] . Thick adherent devitalized necrotic tissue . 80% . Granulation tissue . 10% Other viable tissues . 10% (bone) . Will get an x ray of the heel . Further review reflected Wound Physician I debrided (surgically removed) the necrotic tissue from Resident #166's right heel wound. In an interview on 11/04/21 at 9:40 AM, Resident #166 said the DON changed his wound vac last Tuesday (10/26/21) and he told her he needed to be seen by the facility's wound physician for his right heel wound. He was told he would be seen the next day, Wednesday 10/27/21, by Wound Physician I. He said ADON F put a dressing on his right heel maybe last Thursday (10/28/21). Resident #166 said when he was admitted to the facility on [DATE], the wound to his right heel was a bruise. He stated he did not think the admitting nurse looked at his right heel. Resident #166 stated he was dependent on nursing staff to assess and treat his skin because he could not see his feet and he had no feeling at all from his waist down. Resident #166 said, They told me the wound care doctor comes on Wednesday's and I said she doesn't have to change my wound vac as long as she looks at my heel. That's what I'm concerned about. He said prior to his admission, during an orientation over the phone, he was told there was a wound care doctor at the facility that came every Wednesday and they would work in conjunction with his wound care doctor. In an interview on 11/03/21 at 3:10 PM, HHSC Surveyor again requested Resident #166's consultation reports from his outside wound physician, Physician D. The ADM stated they did not have the reports at the facility but had requested the documents from the outside provider. In an interview on 11/04/21 at 2:27 PM, Treatment Nurse E said she worked at the facility from 09/29/21 until 10/25/21. She stated she had assessed Resident #166 and his wounds were really bad when he came in and they made the orders for me to do the wound vac which I had to bridge one on each side of his buttocks. Treatment Nurse E said Resident #166 had the following wounds on admission: Stage 4 to right buttock, Stage 3 or 4 on left buttock, eschar on right outer foot, dried blisters on the sides of his rib cage, an unstageable wound to his right posterior ankle, but nothing on the right heel itself. Treatment nurse E stated she added Resident #166 to the list to be seen by Wound Physician I and he said he did not want to be seen for his sacral wound because he was going to be seeing his own doctor. Treatment Nurse E said she was not aware Resident #166 outside wound care doctor did not treat feet and she did not know if she asked for a referral for podiatrist or not. In an interview on 11/04/21 at 1:58 PM, LVN J said he had worked at the facility for three weeks on the 6:00 a.m. to 2:00 shift and had worked with Resident #166 all this week. LVN J said he completed wound care to Resident #166's right outer foot on 11/01/21. LVN J said he did not do a treatment to Resident #166's right heel. He said, Since I didn't see any order for his right heel, so I didn't look at his heel. LVN J stated he was not aware Resident #166 had a wound to his right heel and on 11/03/21 was the first time he knew Resident #166 had a wound to his right heel. He stated no one had ever reported to him Resident #166 had a wound to his right heel. LVN J said he did not complete weekly skin assessments; he said the wound care nurse completed weekly skin assessments. LVN J stated he was not aware there was not a wound care nurse at the facility, he said, I saw a nurse doing rounds with the wound doctor, so he assumed that was the wound care nurse. LVN J said if a wound does not get treated the wound can get aggravated, it can actually grow in size. LVN J said Resident #166 had no feeling in his legs, did not express pain on his lower extremities. In an interview on 11/04/21 at 11:33 AM, LVN A, who was the admitting nurse for Resident #166, said he had worked at the facility for 2 years. He stated when he admitted Resident #166, he assessed him for pain, discomfort, vital signs, and a head to toe skin assessment. He stated there is an admission assessment form in the computer that has every assessment on there, but he also wrote a note. LVN A said he was responsible for documenting all skin alterations. He said Resident #166 had a wound to his coccyx, and an amputation to his left foot. LVN A said he did not document a full assessment of Resident #166's wounds because he had a lot of admissions so it escaped [his] mind to document specific locations and measurements. He said he did not want to make his documentation more complicated and the wound care nurse would document the details of each wound, so [he] just [documented] there is a wound in the general area. LVN A said skin assessments were done weekly by the wound nurse. LVN A said since there is not a wound nurse, he did not know who is responsible for doing admission skin assessments or weekly skin assessment but stated it would not be him or the floor nurse. LVN A said since there was wound nurse that does completed wound care, he never looked at wounds. When asked how he would know if a wound dressing needed to be replaced if he never looked, LVN A said most of the time I depend on the CNAs to tell me what's going. When working 700 hall I'm also assigned to work the 600 hall and 800 hall and I'm very busy. In an interview on 11/04/21 at 4:31 PM, CNA K stated she had worked at the facility for almost 2 years and she frequently worked with Resident #166. She stated she was assigned to work with Resident #166 on the day he was admitted . She stated she was told Resident #166 had an amputated toe to his foot and he had his whole foot wrapped. CNA K said she was present when LVN A completed the admission assessment for Resident #166 because she had to help with the skin assessment. CNA K said Resident #166 had a wound to his bottom. CNA K said she gave Resident #166 a sponge bath while he was here. CNA K said, Honestly I never checked [his feet] so she was unaware if Resident #166 had any wounds to his feet. In an interview on 11/05/21 at 10:25 AM, Physician B said she was Resident #166's physician while he was at the facility. She said wounds were usually handled by the wound care physician. She stated she knew Resident #166 had wounds to his sacrum and hip and last week when I came, I heard about his right heel wound. She stated Resident #166 refused to let her assess the wound to his right heel because that was the wound care physician's job, and he told her he was going to be seen by Wound Physician I on Wednesday, 10/27/21. Physician B said she was never called by nurses to obtain wound care orders for Resident #166. In an interview on 11/05/21 at 10:48 AM, Regional Nurse T said he did not have an update on the requested consultation reports from outside wound doctor, Physician D. Regional Nurse T also said he did not have the contact information for Physician D and wound get with the ADM to get an update and the contact information. In an interview on 11/05/21 at 5:28 PM, ADON G said every resident with a wound had a weekly wound assessment and residents without wounds had a weekly head to toe skin assessment. In an interview on 11/05/21 at 6:02 PM, the DON said she never knew [Resident #166] had a wound to his right heel. When HHSC Surveyor told the DON that an observation revealed Resident #166 had a dressing in place to his right heel on 11/02/21, the DON said it was probably there from when he was in the hospital. When shown Wound Assessment, dated 10/19/21, the DON said Treatment Nurse E wrote there was a treatment order for Resident #166's right heel on the wound assessment form, but Treatment Nurse E never wrote the order. She said if nurses noted a skin alteration on admission, they should immediately call the wound care doctor and do a telemedicine. The DON said the facility had not received any of the outside wound physician's (Physician D) consultation reports and because of that she was not aware if Physician D had provided any new orders for Resident #166 while he was at the facility. 2. Review of Resident #4's undated MDS assessment, signed as completed by the DON on 04/05/21, reflected Resident #4 was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her cognitive skills were documented as severely impaired. She required extensive two-person physical assistance with bed mobility, transfers, and toilet use. She was incontinent of bowel and bladder. Section M of the MDS assessment reflected Resident #4 had a risk for developing pressure ulcers and did not have any unhealed pressure ulcers. Review of Resident #4's Clinical Notes Report . 10/01/2021 [to] 11/04/2021, dated 11/4/21, reflected the following: a. Treatment Nurse E . 10/06/2021 . Followed by [Wound Physician I] for wound to right buttock and right ischium [posterior lower hip] . b. Treatment Nurse E . 10/13/2021 . Followed by [Wound Physician I] for wound to right ischium and sacrum, wound to sacrum is resolved at this time, wound to right ischium shows improvement since last visit [as evidence by] decreased surface area, [received] new order for negative pressure wound therapy to be applied three times a week [at] 125 mm Hg continuous, see MAR, Care Plan updated, RP notified. c. Treatment Nurse E . 10/20/2021 . Followed by [Wound Physician I] for wound to right ischium, wound has deteriorated since last visit AEB increased undermining, surface area measurements remain unchanged since last visit, negative pressure wound therapy continues and applied three times a week [at] 125 mm Hg continuous, RP notified. d. ADON Q . 11/02/2021 [4:31 PM] Notified that wound vac to coccyx stopped working notified md received order for wet to dry dressing. Order updated in chart. Review of Resident #4's November 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . apply to coccyx while wound vac is on hold . telephone - read back by [ADON Q] . 11/02/2021 10:10 [AM] . Review of Resident #4's Care Plan Report, dated 11/2/21, reflected the following: . totally dependent on staff for re positioning and use of pillows necessary .monitor skin ongoing for any redness or issue with integrity and notify Dr/RP . reposition frequently . is bedfast . turn and reposition [Resident #4] q 2 hours . [Resident #4] at risk for skin breakdown . monitor for [incontinence] q 2 [hours] and prn, change promptly . 9/22/21 stage 2 to sacrum [treatment] as ordered by physician . Stage 4 pressure ulcer to right ischium . assess and record size [length x width x depth], amount and characteristics of exudates, and pain status . check for incontinence; clean and dry is wet or soiled . perform complete skin assessment and record . Provided care according to the protocol for Stage 3 pressure ulcer . wound vac as ordered by physician Review of Resident #4's Wound Evaluation and Management Summary reflected the following: a. 10/06/21 . Stage 4 pressure wound of the right ischium . wound size . 2.0 x 2.0 x 2.1 cm . surface area . 4.0 cm [squared] .undermining . 2.3 cm at 11 o'clock . wound progress improved . Dressing Treatment Plan . Collagen powder apply once daily for 30 days; Alginate calcium apply once daily for 30 days . gauze island [with border] apply once daily for 30 days . Recommendations Off-load wound; reposition per facility protocol . b. 10/13/21 . Stage 4 pressure wound of the right ischium . wound size 2.5 x 2.0 x 1.7 cm . Surface area . 5.0 cm [squared] . undermining . 2.8 cm at 11 o'clock . Wound progress improved . Dressing Treatment Plan . Negative pressure wound therapy apply three times per week for 30 days : at 125 mm hg continuous with good seal . Recommendations Off-load wound; reposition per facility protocol . c. 10/20/2021 . Stage 4 pressure wound of the right ischium . wound size . 2.5 x 2.0 x 1.7 cm . Surface area . 5.0 cm [squared] . Undermining . 3.5 cm at 11 o'clock . Wound progress: Deteriorated . Dressing Treatment Plan . Negative pressure wound therapy apply three times per week for 23 days : at 125 mm hg continuous with good seal . Recommendations Off-load wound; reposition per facility protocol . d. 10/27/ . Stage 4 pressure wound of the right ischium . wound size . 2.0 x 2.0 x 1.4 cm . Surface area . 4.0 cm [squared] . Undermining . 2.7 cm at 11 o'clock . Wound Progress: Improved . Dressing Treatment Plan . Negative pressure wound therapy apply three times per week for 16 days : at 125 mm hg continuous with good seal . Recommendations Off-load wound; reposition per facility protocol . Review of Resident #4's November 2021 TARs dated 11/05/21 reflected Resident #4's wound vac dressing was changed by LVN L on 11/01/21 day shift. It also reflected LVN L checked the wound vac placement and patency on the day shift for 11/01/21 and 11/02/21. LVN R signed he checked the wound vac for placement and patency on 11/01/21 evening shift. Review of the facility provided Skin Report, dated 10/21/21 to 10/27/21, reflected Resident #4 was included on the report in-house acquired pressure wounds to her sacrum (onset date 09/22/21) and right ischium (onset date 07/20/21). In an observation and interview on 11/02/21 at 4:11 PM, Resident #4 was lying in bed on her back with her head of bed elevated approximately 45 degrees. She had a low air loss mattress and foot pillows in place to both feet. The resident was not offloaded from her wound to her right posterior hip. There was a wound vac on the floor to the right side of the bed. HHSC Surveyor intervened and notified LVN R that Resident #4's wound vac was not on. LVN R and CNA S turned Resident #4 onto her left side and the transparent wound vac dressing and foam was completely dislodged from the resident's right ischium (lower posterior hip area) wound and the wound was uncovered. LVN R said the 6 to 2 nurse was responsible for replacing wound vac dressings and said, I will tell the wound nurse to come here and do it. In an interview and observation on 11/02/21 at 4:38 PM, LVN R said he was going to apply a wet to dry dressing to Resident #4's right ischium wound, and he had told his supervisor (ADON Q). LVN R and CNA S entered Resident #4's room. CNA S turned Resident #4 onto her left side. LVN R cleaned Resident #4's ischium wound with gauze and NS. LVN R then covered Resident #4's right ischium wound with a dry adherent gauze dressing. Wet gauze was not applied to Resident #4's wound bed. In an interview on 11/02/21 at 4:40 PM, LVN R said the morning nurse does the wound vac. When asked why he had not re-applied the wound vac to Resident #4's wound, LVN R said the wound vac was not functioning and he had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN R was asked what part of the wound care he completed for Resident