Every finding on record at Huntsville Health Care Center

Based on observation, interview and record review the facility failed to ensure each resident and the facility provided food prepared by methods that conserve nutritive value, flavor, and appearance, and failed to ensure food and drink was palatable, attractive, and at a safe and appetizing temperature in the facility's only kitchen reviewed for dietary services. The facility failed to ensure water was not added as an additive when preparing pureed food. This failure could place resident's at risk of not receiving the nutritive value and flavor in foods, which could make them less appealing and lead to weight loss.Observation on 08/04/26 at 11:53 AM revealed CK H put water in the puree country fried pork. During an interview on 08/04/26 with CK H, she advised she always added a little water to the food before pureeing it. She stated she did not know the facility policy stated not to do so. She said she also used gravy, broth, milk, or a commercial thickening to the food if needed. She said she followed the recipes provided by the corporate office. She said adding water to the recipes could cause a decrease in nutritive value which may cause weight loss in residents. During an interview on 08/06/26 at 8:12 AM with the DM, she said the facility policy stated they did not add water to prepare pureed foods. She stated CK H was trained in this and did not know she used water as an additive to prepare pureed foods. She said they were to use either commercial thickener, milk, gravy, or a broth as an additive when needed. She stated the importance of not adding water as an additive to a prepared food recipe was to ensure the food-maintained appeal and nutritive value. She stated not maintaining food appeal and nutritive value could lead to residents losing weight. During an interview on 08/06/26 at 8:44 AM with the ADM, she said she didn't think water was to be added to a pureed diet but would check to make sure. She stated she was sure CK H was trained on this and did not know she used water as an additive to prepare pureed foods. She stated she wasn't familiar with preparing pureed diets for residents but knew their food should taste the same and be just as appealing and have the same nutritive value as regular food, which could lead to weight loss. Record review, on 08/06/26, of the Puree food preparation (undated) revealed the following:Policy and guidelines:It is the policy of this facility to provide puree food that has been prepared in a manner to conserve nutritive value, plateable flavor, and attractive appearanceEach resident must receive and the facility must provide food that is prepared by methods that conserve nutritive value, flavor, and appearance.Do not use water as an additive to prepare puree foods. Refer to your department's dietary services manual for additional policy and procedures.

Based on interview and record review the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 of 4 residents (Resident #2) reviewed for PASARR assessments. The facility failed to ensure Resident #2 was referred to the mental health authority after receiving a new diagnosis of schizoaffective disorder, bipolar disorder on 09/06/25. This failure could place residents at risk for diminished quality of life and not receiving needed care and services in accordance with individually assessed needs.Findings include: Record review of Resident #2's admission Record, dated 08/05/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included acute embolism and thrombosis of unspecified deep veins of left lower extremity (a blood clot formed in a deep vein in your lower left leg or calf), schizoaffective disorder, bipolar type (a chronic mental health condition combining symptoms of schizophrenia [such as hallucinations, delusions, or disorganized thinking] with episodes of mania and often major depression), diabetes (a group of diseases that result in too much sugar in the blood), and muscle wasting and atrophy (the loss of muscle tissue and strength, typically caused by inactivity, malnutrition, aging (sarcopenia), or diseases affecting nerves or muscles). Record review of Resident #2's quarterly/5-day MDS assessment, dated 06/27/26, reflected Resident #2 had a BIMS score of 15, which indicated the resident was cognitively intact. Resident #2 required set up or clean up assistance for eating and personal hygiene and partial to moderate assistance with toileting and personal hygiene. Resident #2 had a diagnosis of Schizophrenia. Record review of the Resident #2's care plan, dated 07/09/26 and revised on 08/02/26, reflected Focus: Resident #2 had a mood problem r/t disease process (bipolar disorder/schizoaffective). Goal: Resident would have improved sleep pattern by reporting adequate rest or fewer documented episodes of insomnia through the review date. Interventions: Observe for signs and symptoms of mania or hypomania racing thoughts or euphoria; increased irritability; frequent mood changes; pressured speech; flight of ideas; marked change in need for sleep; agitation or hyperactivity. Record review of Resident #2's PASRR Level 1 Screening dated 08/05/25 reflected 0 under Section C: PASRR Screening questions C0090, C0100, C0200, and C0300 which indicated Resident #2 had no diagnosis of dementia as the primary diagnosis or any evidence of Resident #2 having a mental illness, intellectual disability, or developmental disability. During an interview on 08/06/26 at 9:22 AM, LVN A stated she was responsible for ensuring PASARR assessments were completed correctly and correcting them if they were not. She stated when Resident #2 got a new diagnosis of schizoaffective/bipolar type, she should have completed a new PL1 and the local authority should have been notified. She stated Resident #2 received a new diagnosis of schizoaffective disorder/bipolar type and she missed completing and submitting a new PL1. She stated a new PL1 should have been submitted so that the local authority could have come out to the facility and evaluated Resident #2 to see if she was PASARR positive and if Resident #2 would have been eligible for services. She stated Resident #2 was not evaluated by the local authority. She stated if a resident's PASARR assessment was not completed correctly, the resident could have missed out on any specialized services they could have gotten from the local authority. During an interview on 08/06/26 at 9:49 AM, the DON stated LVN A was responsible for completing the residents PASARR assessments and LVN A was trained on completing the residents PASARR assessments accurately. He stated he was aware Resident #2 had a diagnosis of schizoaffective disorder/bipolar type and Resident #2 was diagnosed not too long ago. He stated with a new diagnosis of schizoaffective disorder/bipolar type, Resident #2 should have a new PL1 completed and sent to the local authority so the local authority could have come out to the facility and evaluated Resident #2 to see if she was eligible for specialized services. He stated if a PL1 had not been redone and submitted to the local authority after Resident #2 was newly diagnosed with schizoaffective disorder/bipolar type, Resident #2 could have missed out on services she could have been eligible to receive. Record review of the facility policy, dated 2023, and titled Resident Assessment - Coordination with PASARR Program reflected Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include: a. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis). b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR. c. A resident transferred, admitted , or readmitted to the facility following an inpatient psychiatric stay or equally intensive treatment.

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 for 1 of 4 residents (Resident #34) reviewed for care plans. The facility failed to develop a care plan to include Resident #34 had a large mass to the left side of her neck on 08/05/26. This failure could place residents at risk for not receiving necessary care and services or having important care needs identified and met.Findings include:Record review of Resident #34's face sheet, dated 08/04/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #34 had diagnoses which included dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), diabetes (a group of diseases that result in too much sugar in the blood), congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs), and chronic kidney disease (long standing disease of the kidneys leading to renal failure).Record review of Resident #34's quarterly MDS assessment, dated 07/15/26, reflected Resident #34 had a BIMS score of 11, which indicated the resident's cognition was moderately impaired. Resident #34 required set-up or clean-up assistance for eating and substantial/maximal assistance for toileting, showering, and personal care.Record review of Resident #34's care plan reflected Resident #34's large mass to the left side of Resident #34's neck was not included in her plan of care.During an interview and observation on 08/05/26 at 12:17 PM, Resident #34 stated the mass on the left side of her neck had been there and she had seen the doctor about it, but she did not know where it came from or what caused it. She stated the mass did not hurt her at all, just sometimes reminded her it was there. She stated the mass had not caused any issues for her so far with eating or swallowing. She stated she did not want surgery for the mass due to her age and the fact it did not cause her any pain. She stated the staff at the facility treated her well and she felt safe. She stated she had no concerns.During an interview on 08/06/26 at 9:22 AM, LVN A stated she was responsible for completing residents care plans and the DON also assisted. She stated she was trained in completing residents care plans accurately. She stated she was aware Resident #34 had a large mass on the left side of her neck. She stated she was not aware of what the actual diagnoses was for the area on Resident #34's neck, but she knew Resident #34 was evaluated by the physician. She stated she was not sure what would have been caused for Resident #34's large mass to the side of the neck not being care planned.During an interview on 08/06/26 at 9:49 AM, the DON stated the IDT looked over the care plans and it was a group effort for completing the care plans. He stated all of the IDT were trained on completing care plans correctly. He stated he was aware Resident #34 had a large mass on the left side of her neck and he believed it was either a goiter (an abnormal enlargement of the butterfly-shaped thyroid gland located at the base of the neck) or lipoma (a slow-growing, non-cancerous lump made of fat cells that forms just beneath the skin) but there was no definitive diagnosis. He stated Resident #34 was [AGE] years old and according to her family, Resident #34 had dealt with that mass her entire life. He stated Resident #34 was evaluated by the physician regarding the mass and the wound care nurse assessed the area weekly. He stated the mass had never caused Resident #34 any issues with eating or swallowing to his knowledge and he had not believed the mass could have affected Resident #34 negatively. He stated the mass to the left side of Resident #34's neck should have been care planned. He stated if the mass to the left side of Resident #34's neck had not been care planned, he did not feel like it could have affected Resident #34 in any way.Record review of the facility policy, dated 2025 and revised December 2009, titled Comprehensive Care Plans reflected Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the residents' strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. All services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality, and incorporate culturally competent and trauma-informed care as indicated. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen reviewed for dietary services. The facility failed to ensure food items stored in the pantry were discarded by their established use-by date.The facility failed to ensure food-contact equipment was cleaned and sanitized properly. These failures could place residents at risk of food born illnesses. Findings Included: Observation of the kitchen pantry on 08/04/26 at 9:17 AM revealed there was one opened bag of cereal with an opened date of 05/27/26 and an expiration date of 08/01/26. Observation of the kitchen on 08/04/26 at 11:24 AM revealed that CK rinsed the food blender, used for preparing residents' puree diets, and then wiped it with a towel in the sink that was labeled NOTICE: food preparation sink only. During an interview with the DA on 08/04/26 at 9:55 AM, she said she was trained on food labeling and dating. She said that once a package of cereal was opened in the pantry, the date that it was opened and the expiration or used by date was written on the package, which was normally 90 days from the opened date. She said that because the cereal had fruit in it, that may be why the used by date was earlier. The DA said she did not know the cereal was dated 08/01/26 and was not thrown away. She said the importance of ensuring dates were corrected on food packages was to ensure that the facility did not serve expired food to the residents, which could cause them to get sick. The DA concluded that she was not trained on puree preparations and did not assist the cooks, who were responsible for preparing the food. During an interview with the DM on 08/04/26 at 10:08 AM, she said the facility had a food storage and labeling policy. She said that after a package of cereal was taken out of the original box, the opened package should have an opened date and an expiration date, which was. She said the cereal should be thrown away on the expiration date and did not know why it wasn't. She stated the importance of ensuring the dates were correct on all food was to prevent residents from consuming expired food, which could make them sick. During an interview on 08/04/26 at 12:02 PM with CK, she said she normally just washed and rinsed the blender after each puree in the sink next to the counter. She said she did not pay attention to the sign on the sink that said: NOTICE: food preparation sink only. She stated she did not know that she had to disassemble each part, wash them, rinse them, and sanitize them after each use but would start today. She said she was trained on preparing pureed meals for residents but may have forgotten that part of it. She said that it was important to clean the blender used in preparing pureed diets correctly to prevent cross contamination, which could cause residents to get sick from foodborne illnesses. During an interview on 08/06/26 at 8:12 AM with the DM, she said the the sink next to the counter by the stove is was for food preparation only, including which included washing food and should not be used for any other purpose. She said that the proper way to clean the blender used for pureed diets was to disassemble all removable parts and wash them, rinse them, and sanitize them properly after each use in the three-compartment sink in the dishwashing area. The DM said she did not know why CK did not wash the blender correctly, because she was trained on it several times and prepared pureed foods for residents for years. The DM said that it was important to wash, rinse, and sanitize the blender used for pureed diets correctly to prevent cross contamination of foods. She stated that this placed the residents requiring pureed diets at risk for foodborne illness, which could make them very ill. The DM said that all kitchen staff were trained on food preparation and checking food temperatures. She stated that the pork chop should have registered between 135 degrees and 165 degrees. She stated that food should not exceed 170 degrees. The DM said that CK had to be nervous because she knew to check the temperature before plating the food. The DM said that the importance of checking the food temperatures to make sure they were appropriate was to prevent it from being under cooked, which could lead to pathogens and food borne illnesses that which could cause the residents to become ill. The DM said it was important to make sure food temperature did not exceed 170 degrees to prevent them from eating foods too hot which could make the food less appealing and lead to reduced intake and poor nutrition or could scald their mouth. During an interview with the ADM on 08/06/26 at 8:44 AM, she said the facility had a food storage and handling policy. She said she was not sure about what the dates were but knew that packages that were out of the original box should have an open date and a throw away date. She said that the package of food should be thrown away on the thrown away date. She said she did not know there was an opened package of cereal in the package with an expiration date of 08/01/26. She said the importance of ensuring food was thrown away by the throw away date was to ensure residents did not eat outdated food, which could lead to food borne illnesses and make them sick. ADM said she did not know the sink next to the counter in the kitchen was marked NOTICE: food preparation only and was unaware that CK did not wash the puree blender correctly. The ADM said she was not exactly sure how to wash the puree blender but would find out. The ADM said the importance of cleaning and sanitizing the blender correctly was to prevent cross-contamination, which could make the residents ill.Record review of the food safety requirements policy (revised 02/2023) revealed the following: Policy:It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state, and local authorities. Food will also be stored, prepared, distributed, and served in accordance with professional standards for food service safety (refers to handling, preparing, and storing food in ways that prevent foodborne illnesses). Policy explanation and compliance guidelines:Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the residents. Elements of the process include the following:Storage of food in a manner that helps prevent deterioration or contamination of the food, including growth of microorganism.e. Equipment used in handling food, including dishes, utensils, mixers, grinders, and other equipment that comes in contact with food.6. All equipment used in the handling of food should be cleaned and sanitized and handled in a manner to prevent contamination.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #1) and 2 of 4 staff (CNA A and CNA B) reviewed for infection control. 1.The facility failed to ensure CNA A and CNA B followed EBP for Resident #1 when providing care on 12/15/2025. 2. The facility failed to ensure CNA A and CNA B changed gloves and washed or sanitized their hands when providing care to Resident #1 on 12/15/2025.These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings included:Record review of an admission Record for Resident #1, dated 12/15/2025, indicated he admitted on [DATE] and was [AGE] years old with diagnoses of cerebral infarction (stroke), hemiplegia affecting right dominant side (paralyzed on right side of the body), and type 2 diabetes.Record review of active physician orders for Resident #1 dated 12/15/2025 indicated he had an order for EBP enhanced barrier precautions due to wound: ulcer to left foot that started on 11/11/2025.Record review of a Quarterly MDS Assessment for Resident #1, dated 11/21/2025, indicated he had moderate impairment in thinking with a BIMS score of 11. He was totally dependent on staff for toileting hygiene. He was always incontinent of urine and bowel.Record review of a care plan for Resident #1, dated 11/19/2025, indicated he was on enhanced barrier precautions related to a diabetic ulcer of his left foot. Interventions included enhanced barrier precautions: PPE for EBP was necessary when performing high-contact care activities that included providing hygiene and changing briefs. Staff were to utilize PPE appropriate for EBP: gown and gloves.During an observation on 12/15/2025 at 10:19 a.m., Resident #1 had a sign on his door for EBP. CNA A and CNA B were in the hallway gathering supplies to provide incontinent care for Resident #1. CNA A sanitized her hands and placed gloves on both hands and entered the room. CNA B donned (put on) gloves on both hands and did not sanitize her hands before they were applied and entered the room. On the wall in the room by the door were gloves and gowns. CNA B aided with turning and repositioning. CNA B opened the brief and pulled it down between his thighs. CNA B removed wipes from the package and wiped down both of his inner thighs and placed the dirty wipe in the trash. CNA B removed more clean wipes and wiped Resident #1's penis in a circular motion and placed the dirty wipe in the trash. Resident #1 was rolled onto his left side and assisted by CNA A. Resident #1 had a large bowel movement and CNA B removed multiple clean wipes from the package and cleaned Resident #1's buttocks and rectal area. CNA B rolled the brief underneath his buttocks and removed it and placed it in the trash. CNA B placed a clean brief with the same dirty gloves under the resident's buttocks. Resident #1 was rolled onto his back and the brief was secured. Resident #1 was repositioned in bed by both staff. CNA B touched his pillows and fluffed them under his head and placed his cap on his head and pulled the linens back over the resident. CNA A removed her gloves and placed them in the trash and washed her hands. CNA B gathered the trash, removed her gloves, placed them in the trash and washed her hands.During an interview on 12/15/2025 at 10:31 a.m., CNA A said Resident #1 was on EBP and she should have worn a gown during the care provided. She said she did not wear a gown because she forgot. She said there was a risk of spreading infections if staff did not follow EBP. She said she was trained on EBP and Resident #1 had a wound that required the staff to wear a gown and gloves when care was provided.Record review of a skills checklist for CNA A, dated 4/30/2025, indicated she was satisfactory with personal hygiene.During an interview on 12/15/2025 at 10:33 a.m., CNA B said she worked for an agency and was assigned this facility from time to time. She said hand hygiene should be performed before and after care was completed, which included hand washing or using hand sanitizer. She said she did not perform hand hygiene before she donned gloves to provide care to Resident #1. She said she forgot to sanitize her hands. She said when she changed tasks after cleaning and removing the dirty brief before she touched clean items, she should have changed her gloves and washed her hands. She said she kept the same gloves on during care and forgot about changing them. She said Resident #1 was on EBP and she should have worn a gown. She said usually PPE was in a container in the hallway and she did not see the sign on the door that indicated the resident was on EBP. She said residents were at risk for infections and cross contamination if staff did not follow infection control practices.During an interview on 12/15/2025 at 2:17 p.m., the ADON said staff received competency checks on hire and yearly thereafter. She said the DON and the IP conducted training on infection control with the staff. She said she conducted training on 12/15/2025 for hand hygiene and EBP with the staff and was aware of the care that was provided to Resident #1. She said Resident #1 was on EBP related to an open wound to his foot and staff should wear a gown and gloves when direct patient contact was provided.Record review of a facility in-service, dated 11/6/2025, on handwashing and hygiene and EBP revealed CNA A was in attendance by her signature on the sign in sheet.During an interview on 12/15/2025 at 2:29 p.m., the DON said he and the IP were both responsible for training staff on infection control and EBP. He said CNA A was present at the last training on EBP and hand hygiene. He said hand hygiene should be performed before and after care and when going from dirty items to clean. He said staff should never touch clean items with dirty gloves and should remove their gloves and wash their hands. He said Resident #1 was on EBP, and staff should have worn a gown and gloves when direct care was provided. He said there was a risk for spreading infections if they did not follow infection control and hand hygiene along with touching clean items with dirty gloves.During an interview on 12/15/2025 at 2:44 PM, the Administrator said the DON, ADON, and IP were all responsible for training staff on infection control. He said he expected the staff to perform and follow infection control practices. He said outside of the rooms of the residents on EBP the posted sign had instructions for the staff to follow.Record review of a facility policy titled Enhanced Barrier Precautions undated indicated, .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and gloves use during high contact resident care activities. 4. High-contact resident care activities include: d. providing hygiene; e. changing briefs.Record review of a facility policy titled Hand Hygiene undated indicated, .all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub. 6. A. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Hand hygiene table: when coming on duty; after handling contaminated objects; before performing resident care procedures.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for 1 of 5 residents reviewed for accidents and supervision. (Resident #1)The facility failed to provide adequate supervision for Resident #1 who was assessed for 2 staff members for care. CNA A did not have another staff member to provided care to Resident #1, left Resident #1 to obtain more supplies for care, and the resident rolled off of the bed. Resident #1 sustained a fracture of the left thigh bone near the knee. An IJ was identified on 10/29/25. The Administrator was notified and the IJ template was provided to the facility on [DATE] at 04:40 p.m. While the IJ was removed on 10/30/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm due to the facility's needed to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving the amount of supervision or assistance required to prevent serious injury and/or actual harm. Findings included:Record review of a face sheet dated 10/29/25 indicated Resident #1 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body and is usually the result of brain damage)/hemiparesis (one-sided muscle weakness) due to cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off) affecting left side, pain, peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside of the heart and brain to narrow, block, or spasm), and hypertension (condition in which the force of the blood against the artery walls is too high).Record review of the state optional MDS dated [DATE] indicated Resident #1 required extensive assistance of 2 persons for bed mobility. Record review of a Fall Risk Screener dated 09/05/25 indicated Resident #1 was low risk for falls with a score of 9 out of 31 (0-9-low risk; 10-31-high risk).Record review of the quarterly MDS dated [DATE] indicated Resident #1 was dependent for toileting hygiene and required substantial-maximum assistance for roll left-to-right. Record review of an incident report dated 10/22/25 indicated Resident #1 while receiving peri-care from CNA A at 03:20 a.m., resident was rolled onto her side to provide care after an incontinent episode. While the resident was on her side, she suddenly had a large bowel movement in the middle of care. CNA A turned to get some more supplies from the cart he had in the doorway. During that time, the resident attempted to reach for something on her bedside table and rolled off the bed. Nurse was notified and upon arrival, performed a head to toe assessment. No injuries nor bruising noted on assessment. Vitals are normal, respiration was even and unlabored. Resident was assisted back to bed with the help of 2 staff. Resident #1 indicated she hurt all over and PRN pain medication was given as previously ordered by the physician. Record review of Progress Notes indicated a nurse note entry dated 10/22/25 at 03:44 a.m. resident slipped and fell as aid was performing peri care. No injuries nor bruising noted on assessment. Vitals are normal, resp is even and unlabored. Resident is assisted back to bed, pain medication given. Resident is stable condition.Record review of a Post Fall Review dated 10/23/25 at 08:00 a.m. indicated Resident #1 was awake, alert, and oriented to person, place, and time. Her vital signs and neuro checks were normal for the resident with no abnormal findings. Record review of neuro check monitoring documentation from 10/22/25 at 04:00 a.m. through 10/23/25 at 11:00 a.m. indicated no abnormal findings. Record review of Progress Notes with a nurse note entry dated 10/23/25 at 11:18 a.m. indicated Note Text : This nurse presented to patient's room during rounds, patient observed to be lethargic and responsive to painful stimuli only. Vitals were checks - BP: 145/84 HR:125 O2:88MD [name] contacted, verbal orders for ER send out for evaluation and treatment received along with 2L O2 via nasal canula.[Name] EMS contacted 1110[Name] EMS arrival 1120RP - [Name] notified 1118Report called in to ER nurse 1121Patient left facility via stretcher at 1128. During an interview on 10/29/25 at 10:25 a.m. the DON said Resident #1 did not have a fall. He said she was part way out of the bed. He said she was assisted back into bed with no complaints of pain or discomfort. He said the next day she started showing altered mental status, so they sent her to the hospital, and she had a UTI. He said nothing was said about her having a fracture until several days after she was admitted to the hospital. He said the x-ray report he received did not indicate the age of the fracture but did indicate she was osteopenic. He said he was trying to get a determinate of age of the fracture to know if it happened at the facility or at the hospital since he was told she possibly had a fall at the hospital.Record review of a hospital Imaging Report dated 10/23/25 provided by the DON via email on 10/29/25 at 12:37 p.m. indicated Resident #1 had a 2 view x-ray of the left femur at 06:34 p.m. with clinical history of fall injury. Findings were the femur was osteopenic (condition where the bone lacks enough minerals to be strong) and there was a fracture of the femoral (thigh bone) shift near the knee.During a phone interview on 10/29/25 at 01:33 p.m. CNA A said he was making his last 2 hour round on his residents. He said he knew Resident#1 required 2 staff for care. He said when he went to clean Resident #1 he was not able to find any other staff to assist because they were in other rooms. He said he went to clean her up and she had a large bowel movement which he needed more supplies to clean her. He said he lowered the bed but she would raise it up. He said his supply cart was at the room door so he went to get another trash bag and get more supplies. He said Resident #1 screamed and he saw her on the floor so he got the nurse. Resident #1 was not observed or interviewed as she was transferred to another facility from the hospital.The following Plan of Removal was submitted by the facility and accepted on 10/30/25 at 11:30 a.m.1. Facility completed an AD-HOC QAPI on 10/29/2025 at 5:00pm. Facility reviewed policies and procedures prior to in-services.2. The DON immediately audited all care plans and identified all residents who are listed as a 2 person assist. The facility has initially identified 20 residents who are care planned as 2-person assist. The initial care plan review was completed October 29, 2025, at 6:25pm. Facility MDS Coordinator was in-serviced by the regional director of clinical services on October 29, 2025, at 7:00pm, Additional care plan audits will be completed on 10/30/2025 to review accuracy.3. On 10/29/2025 at 5:45pm the facility DON, ADON began in-servicing staff on duty on all residents who require assistance with ADL care, 2- person assistance with ADLs care was also, included in this in-service. Nursing staff will ensure that they have the required nursing staff and supplies present prior to performing care, transfers and any other activity where 2 people would be required. Staff were also in-serviced on returning the bed to a low position when cares were complete, or if staff had to leave the residents unattended for any reason while providing care. Nursing staff were provided with a quick reference sheet of residents requiring 2-person assistance. 4. The DON, ADON and [NAME] Director of Clinical Services verified all staff members understood the incidents and Accidents policy. Upon confirming training, staff members were asked to verbalize their understanding of the policy. The facility DON, ADON and Regional Director of Clinical Services. Direct care staff will complete a written post-test to verify understanding. 5. Staffing Coordinator was in-serviced and directed to contact all agency employees prior to their shift and provide direction on completing the required in- services and sign offs.6. A reference binder has been set up for nursing staff to quickly access the policy on changes of condition. New Hires, Agency Staff and existing staff will be oriented to the location of the information and will be in-serviced by DON, ADON or Designee. The binder will be maintained at the nurses station.7. Direct care nursing staff will not be allowed to provide direct care to work until training has been completed.Monitoring: Record review and interviews of completed:Record review of a QAPI review dated 10/29/25 indicated the Administrator, DON, ADON, and Medical Director via telephone reviewed IJ F689.Record review of a Sign In Sheet for Weekly IDT Meeting dated 10/30/25 with an attached Resident List by hall indicated all residents' care plans were reviewed for an ADL care plan.Record review of In-Services dated 10/29/25 included the following:* 1. Any resident identified as requiring 2 people for care, you must get 2 people to assist before providing care.; 2. Incident/Accident-report all incidents to nursing staff; and 3. Changes of Condition and an attachment of 2 Person Assistance List indicated the AD, LVN B, CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, LVN J, and LVN K received the in-services.* Safe Resident Handling and Transfers indicated the AD, ADON, MDS Nurse, SC, LVN B, CNA F, LVN L, RN N, RN P, and MA Z received the in-service.* Incidents and Accidents indicated the AD, ADON, MDS Nurse, SC, LVN B, CNA F, LVN L, and RN P received the in-service.* Change in Condition or Status indicated the MDS Nurse, RN N, RN O, CNA S, and MA Z received the in-service.* Peri Care indicated the AD, ADON, MDS Nurse, SC, CNA H, RN N, CNA R, and MA AA received the in-service.During an interview on 10/29/25 at 06:00 p.m. LVN B (6a-6p shift), CNA C (6a-6p shift), CNA D (6a-6p shift), CNA E (6a-6p shift), CNA F (6a-6p shift), CNA G (6a-6p shift), LVN J (6p-6a shift), LVN K (6p-6a shift) and LVN L (6p-6a shift) said they received in-services regarding 2 person care, Incidents/Accidents reporting, and Change in Condition-reporting. Record review of in-service post test completed by staff dated 10/30/25 included the following:* Incident and Accidents Inservice indicated the AD, MDS Nurse, SC, WCN, LVN B, LVN K, LVN L, LVN M, RN N, RN O, RN P, CNA A, CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, CNA J, CNA Q, CNA R, CNA T, CNA U, CNA X, CNA BB, and MA AA received the in-service.* ADL Inservice indicated the AD, ADON, MDS Nurse, SC, WCN, LVN B, LVN K, LVN L, LVN M, RN N, RN O, RN P, CNA A, CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, CNA J, CNA Q, CNA R, CNA T, CNA U, CNA X, CNA BB, MA AA, MA S, and MA Z received the in-service.* Peri Care the AD, ADON, MDS Nurse, SC, WCN, LVN B, LVN K, LVN L, LVN M, RN N, CNA A, CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, CNA J, CNA Q, CNA R, CNA T, CNA U, CNA X, CNA BB, and MA AA received the in-service.* Safe Resident Handling the AD, ADON, SC, LVN B, LVN K, LVN L, LVN M, RN N, RN O, RN P, CNA A, CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, CNA J, CNA Q, CNA R, CNA T, CNA U, CNA X, and CNA BB received the in-service.* Change of Condition Inservice indicated the AD, ADON, MDS Nurse, SC, WCN, LVN B, LVN K, LVN L, LVN M, RN N, RN O, RN P, CNA A, CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, CNA J, CNA Q, CNA R, CNA T, CNA U, CNA X, CNA BB, MA AA, MA S, and MA Z received the in-service.Interviews conducted on 10/30/25 indicated the following:* at 01:30 p.m. the AD said she had received in-services on Incidents/Accidents, ADLs, Peri Care, Safe Resident Handling, and Change of Condition. She verbalized understanding of the trainings.* at 01:50 p.m. RN N said she worked 6a-6p shift and had received in-services on Incidents/Accidents, ADLs, Peri Care, Safe Resident Handling, and Change of Condition. She verbalized understanding of the trainings.* at 02:10 p.m. LVN B and RN O said they worked 6a-6p shift and had received in-services on Incidents/Accidents, ADLs, Peri Care, Safe Resident Handling, and Change of Condition. They verbalized understanding of the trainings.* at 02:45 p.m. the WCN said she worked 8a-5p and had received in-services on Incidents/Accidents, ADLs, Peri Care, Safe Resident Handling, and Change of Condition. She verbalized understanding of the trainings.* at 02:45 p.m. CNA Q, CNA T, CNA U, and MA Z said they worked 6a-6p and had received in-services on Incidents/Accidents, ADLs, Peri Care, Safe Resident Handling, and Change of Condition. They verbalized understanding of the trainings.* at 02:50 p.m. CNA H, CNA R, and MA S said they worked 6a-6p and had received in-services on Incidents/Accidents, ADLs, Peri Care, Safe Resident Handling, and Change of Condition. They verbalized understanding of the trainings.During an observation and interview on 10/30/25 at 03:15 p.m. CNA H was going to provide a transfer and incontinent care on Resident #5. CNA H said Resident #5 required 2 persons for care. She obtained CNA T to assist her. A gait belt was placed on Resident #5. CNA H took one side and CNA T took the other side. Resident #5 was transferred with 2 CNAs appropriately. The CNAs then provided incontinent care on Resident #5 using appropriate techniques. Record review of a letter head form dated 10/29/25 indicated the SC was to confirm and verify that all direct care nursing staff have completed in service trainings related to F656 and F689 prior to their next scheduled shift. The SC was to make contact with any agency nursing staff and provide directions on completing in-services, and the location of the quick reference binder at the nurse station. During an interview on 10/30/25 at 05:58 p.m. the SC said she staffed CNAs according to what was told as to how many she could staff per shift. She said she had received Incidents/Accidents, ADLs, Peri Care, Safe Resident Handling, and Change of Condition trainings. She verbalized understanding of the trainings and said she was to ensure agency staff had received the trainings before working on the floor.Observation and record review on 10/30/25 at 06:00 p.m. indicated a reference binder containing policy on Changes in Condition was located at the nurse station.Interviews conducted on 10/30/25 indicated the following:* at 06:10 p.m. LVN M, CNA X, and CNA BB said they worked the 6p-6a shift and had received in-services on Incidents/Accidents, ADLs, Peri Care, Safe Resident Handling, and Change of Condition. They verbalized understanding of the trainings.* at 06:10 p.m. CNA V, CNA W, and LVN Y said they were agency staff. They said had received in-services on Incidents/Accidents, ADLs, Peri Care, Safe Resident Handling, and Change of Condition. They verbalized understanding of the trainings.The Administrator and DON were informed the Immediate Jeopardy was removed on 10/30/25 at 06:55 p.m. The facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm due to the facility's needed to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 10 residents (Resident #1, Resident #2, and Resident #3) reviewed for care plans.The facility failed to ensure that Resident #1's, #2's and #3's care plans were initiated and included appropriate interventions for ADL Care.This failure could place residents who required assistance with care at risk of serious harm and injury. Findings included:1. Record review of a face sheet dated 10/29/25 indicated Resident #1 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body and is usually the result of brain damage)/hemiparesis (one-sided muscle weakness) due to cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off) affecting left side, pain, peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside of the heart and brain to narrow, block, or spasm), and hypertension (condition in which the force of the blood against the artery walls is too high). Record review of the care plan initiated on 05/21/25 for Resident #1 did not address her ADL assistance requirements. Record review of the state optional MDS dated [DATE] indicated Resident #1 required extensive assistance of 2 persons for bed mobility. Record review of the quarterly MDS dated [DATE] indicated Resident #1 was dependent for toileting hygiene and required substantial-maximum assistance for roll left-to-right. Record review of an incident report dated 10/22/25 indicated Resident #1 while receiving peri-care from CNA A at 03:20 a.m., resident was rolled onto her side to provide care after an incontinent episode. While the resident was on her side, she suddenly had a large bowel movement in the middle of care. CNA A turned to get some more supplies from the cart he had in the doorway. During that time, the resident attempted to reach for something on her bedside table and rolled off the bed. Nurse was notified and upon arrival, performed a head to toe assessment. No injuries nor bruising noted on assessment. Vitals are normal, respiration was even and unlabored. Resident was assisted back to bed with the help of 2 staff. Resident #1 indicated she hurt all over and PRN pain medication was given as previously ordered by the physician. Record review of Progress Notes indicated a nurse note entry dated 10/22/25 at 03:44 a.m. resident slipped and fell as aid was performing peri care. No injuries nor bruising noted on assessment. Vitals are normal, resp is even and unlabored. Resident is assisted back to bed, pain medication given. Resident is stable condition.Record review of a Post Fall Review dated 10/23/25 at 08:00 a.m. indicated Resident #1 was awake, alert, and oriented to person, place, and time. Her vital signs and neuro checks were normal for the resident with no abnormal findings. Record review of neuro check monitoring documentation from 10/22/25 at 04:00 a.m. through 10/23/25 at 11:00 a.m. indicated no abnormal findings. Record review of Progress Notes with a nurse note entry dated 10/23/25 at 11:18 a.m. indicated Note Text : This nurse presented to patient's room during rounds, patient observed to be lethargic and responsive to painful stimuli only. Vitals were checks - BP: 145/84 HR:125 O2:88MD [name] contacted, verbal orders for ER send out for evaluation and treatment received along with 2L O2 via nasal canula.[Name] EMS contacted 1110[Name] EMS arrival 1120RP - [Name] notified 1118Report called in to ER nurse 1121Patient left facility via stretcher at 1128. During an interview on 10/29/25 at 10:25 a.m. the DON said Resident #1 did not have a fall. He said she was part way out of the bed. He said she was assisted back into bed with no complaints of pain or discomfort. He said the next day she started showing altered mental status, so they sent her to the hospital, and she had a UTI. He said nothing was said about her having a fracture until several days after she was admitted to the hospital. He said the x-ray report he received did not indicate the age of the fracture but did indicate she was osteopenic. He said he was trying to get a determinate of age of the fracture to know if it happened at the facility or at the hospital since he was told she possibly had a fall at the hospital.Record review of a hospital Imaging Report dated 10/23/25 provided by the DON via email on 10/29/25 at 12:37 p.m. indicated Resident #1 had a 2 view x-ray of the left femur at 06:34 p.m. with clinical history of fall injury. Findings were the femur was osteopenic (condition where the bone lacks enough minerals to be strong) and there was a fracture of the femoral (thigh bone) shift near the knee.During a phone interview on 10/29/25 at 01:33 p.m. CNA A said he was making his last 2 hour round on his residents. He said he knew Resident#1 required 2 staff for care. He said when he went to clean Resident #1 he was not able to find any other staff to assist because they were in other rooms. He said he went to clean her up and she had a large bowel movement which he needed more supplies to clean her. He said he lowered the bed but she would raise it up. He said his supply cart was at the room door so he went to get another trash bag and get more supplies. He said Resident #1 screamed and he saw her on the floor so he got the nurse. Resident #1 was not observed or interviewed as she was transferred to another facility from the hospital. 2. Record review of a face sheet dated 10/29/25 indicated Resident #2 was a admitted on [DATE] with a diagnoses of wedge compression fracture (the front part of a spinal bone collapses slightly, making the bone look like a wedge) of the of T9-T10 thoracic vertebrae (the twelve spine bones located in the middle section of the spine), dementia (loss of cognitive functioning), and anxiety (persistent and excessive worry that interferes with daily activities). Record review of the admission MDS dated [DATE] indicated Resident #2 was dependent on staff for personal hygiene and bathing and required maximum assistance with toileting and dressing. Record review of the care plan initiated 10/18/25 did not address Resident #2's ADL assistance requirements. During an observation and interview on 10/29/25 at 11:55 a.m. Resident #2 was up in her wheelchair in the dining room for lunch. She said she was doing fine and everyone was nice. She said staff assisted her when needed. 3. Record review of a face sheet dated 10/29/25 indicated Resident #3 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia (loss of cognitive functioning), falls, and muscle weakness. Record review of the admission MDS dated [DATE] indicated Resident #3 required substantial to maximum assistance with lower body dressing and bathing, moderate assistance with upper body dressing and footwear, and touch assistance with toileting and eating. Record review of the care plan initiated on 09/30/25 did not address Resident #3's ADL assistance requirements. During an observation and interview on 10/29/25 at 11:58 a.m. Resident #3 was sitting in her wheelchair in the dining room. She said she was doing okay and had no unmet needs. She said staff would help her when needed. During an interview on 10/30/25 at 05:56 p.m. the DON said he was responsible for care plans and they were a collaboration of several people who met and developed the care plan according to the residents' needs and reviewed them at least quarterly or when there was a change in the resident or their needs. A policy for comprehensive care plans was requested but a Baseline Care Plan policy was provided by the Administrator.

Based on interview and record review the facility failed to report an allegation of neglect to HHSC for 1 of 5 residents reviewed for neglect. The facility did not report when CNA A did not have another staff member to provided care to Resident #1, left Resident #1 to obtain more supplies for care, and the resident rolled off of the bed. Resident #1 sustained a fracture of the left thigh bone near the knee.This failure could place residents at risk of harm due to delays in reporting neglect. Findings included:Record review of a face sheet dated 10/29/25 indicated Resident #1 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body and is usually the result of brain damage)/hemiparesis (one-sided muscle weakness) due to cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off) affecting left side, pain, peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside of the heart and brain to narrow, block, or spasm), and hypertension (condition in which the force of the blood against the artery walls is too high).Record review of the state optional MDS dated [DATE] indicated Resident #1 required extensive assistance of 2 persons for bed mobility. Record review of a Fall Risk Screener dated 09/05/25 indicated Resident #1 was low risk for falls with a score of 9 out of 31 (0-9-low risk; 10-31-high risk).Record review of the quarterly MDS dated [DATE] indicated Resident #1 was dependent for toileting hygiene and required substantial-maximum assistance for roll left-to-right. Record review of an incident report dated 10/22/25 indicated Resident #1 while receiving peri-care from CNA A at 03:20 a.m., resident was rolled onto her side to provide care after an incontinent episode. While the resident was on her side, she suddenly had a large bowel movement in the middle of care. CNA A turned to get some more supplies from the cart he had in the doorway. During that time, the resident attempted to reach for something on her bedside table and rolled off the bed. Nurse was notified and upon arrival, performed a head to toe assessment. No injuries nor bruising noted on assessment. Vitals are normal, respiration was even and unlabored. Resident was assisted back to bed with the help of 2 staff. Resident #1 indicated she hurt all over and PRN pain medication was given as previously ordered by the physician. Record review of Progress Notes indicated a nurse note entry dated 10/22/25 at 03:44 a.m. resident slipped and fell as aid was performing peri care. No injuries nor bruising noted on assessment. Vitals are normal, resp is even and unlabored. Resident is assisted back to bed, pain medication given. Resident is stable condition.Record review of a Post Fall Review dated 10/23/25 at 08:00 a.m. indicated Resident #1 was awake, alert, and oriented to person, place, and time. Her vital signs and neuro checks were normal for the resident with no abnormal findings. Record review of neuro check monitoring documentation from 10/22/25 at 04:00 a.m. through 10/23/25 at 11:00 a.m. indicated no abnormal findings. Record review of Progress Notes with a nurse note entry dated 10/23/25 at 11:18 a.m. indicated Note Text : This nurse presented to patient's room during rounds, patient observed to be lethargic and responsive to painful stimuli only. Vitals were checks - BP: 145/84 HR:125 O2:88MD [name] contacted, verbal orders for ER send out for evaluation and treatment received along with 2L O2 via nasal canula.[Name] EMS contacted 1110[Name] EMS arrival 1120RP - [Name] notified 1118Report called in to ER nurse 1121Patient left facility via stretcher at 1128. During an interview on 10/29/25 at 10:25 a.m. the DON said Resident #1 did not have a fall. He said she was part way out of the bed. He said she was assisted back into bed with no complaints of pain or discomfort. He said the next day she started showing altered mental status, so they sent her to the hospital, and she had a UTI. He said nothing was said about her having a fracture until several days after she was admitted to the hospital. He said the x-ray report he received did not indicate the age of the fracture but did indicate she was osteopenic. He said he was trying to get a determinate of age of the fracture to know if it happened at the facility or at the hospital since he was told she possibly had a fall at the hospital.Record review of a hospital Imaging Report dated 10/23/25 provided by the DON via email on 10/29/25 at 12:37 p.m. indicated Resident #1 had a 2 view x-ray of the left femur at 06:34 p.m. with clinical history of fall injury. Findings were the femur was osteopenic (condition where the bone lacks enough minerals to be strong) and there was a fracture of the femoral (thigh bone) shift near the knee.During a phone interview on 10/29/25 at 01:33 p.m. CNA A said he was making his last 2 hour round on his residents. He said he knew Resident#1 required 2 staff for care. He said when he went to clean Resident #1 he was not able to find any other staff to assist because they were in other rooms. He said he went to clean her up and she had a large bowel movement which he needed more supplies to clean her. He said he lowered the bed but she would raise it up. He said his supply cart was at the room door so he went to get another trash bag and get more supplies. He said Resident #1 screamed and he saw her on the floor so he got the nurse. Resident #1 was not observed or interviewed as she was transferred to another facility from the hospital.During an interview on 10/30/25 at 05:08 p.m. the Administrator said any violation of neglect of a resident should be reported to HHSC. He said he was originally told Resident #1 did not have a fall because only her legs were hanging off the bed when CNA A provided care. He said he had been told several different stories about Resident #1 since then regarding what happened during her care. He said the resident's RP said she had two fractured legs a few days later. The Administrator said he did not know if they happened at the facility or at the hospital.Record review of an undated Abuse, Neglect, and Exploitation policy indicated: .VII. Reporting/ResponseA. The facility will have written procedures that include:1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, orb. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #1) and 2 of 4 staff (CNA A and CNA B) reviewed for infection control. 1.The facility failed to ensure CNA A and CNA B followed EBP for Resident #1 when providing care on 12/15/2025. 2. The facility failed to ensure CNA A and CNA B changed gloves and washed or sanitized their hands when providing care to Resident #1 on 12/15/2025.These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings included: Record review of an admission Record for Resident #1, dated 12/15/2025, indicated he admitted on [DATE] and was [AGE] years old with diagnoses of cerebral infarction (stroke), hemiplegia affecting right dominant side (paralyzed on right side of the body), and type 2 diabetes.Record review of active physician orders for Resident #1 dated 12/15/2025 indicated he had an order for EBP enhanced barrier precautions due to wound: ulcer to left foot that started on 11/11/2025.Record review of a Quarterly MDS Assessment for Resident #1, dated 11/21/2025, indicated he had moderate impairment in thinking with a BIMS score of 11. He was totally dependent on staff for toileting hygiene. He was always incontinent of urine and bowel. Record review of a care plan for Resident #1, dated 11/19/2025, indicated he was on enhanced barrier precautions related to a diabetic ulcer of his left foot. Interventions included enhanced barrier precautions: PPE for EBP was necessary when performing high-contact care activities that included providing hygiene and changing briefs. Staff were to utilize PPE appropriate for EBP: gown and gloves.During an observation on 12/15/2025 at 10:19 a.m., Resident #1 had a sign on his door for EBP. CNA A and CNA B were in the hallway gathering supplies to provide incontinent care for Resident #1. CNA A sanitized her hands and placed gloves on both hands and entered the room. CNA B donned (put on) gloves on both hands and did not sanitize her hands before they were applied and entered the room. On the wall in the room by the door were gloves and gowns. CNA B aided with turning and repositioning. CNA B opened the brief and pulled it down between his thighs. CNA B removed wipes from the package and wiped down both of his inner thighs and placed the dirty wipe in the trash. CNA B removed more clean wipes and wiped Resident #1's penis in a circular motion and placed the dirty wipe in the trash. Resident #1 was rolled onto his left side and assisted by CNA A. Resident #1 had a large bowel movement and CNA B removed multiple clean wipes from the package and cleaned Resident #1's buttocks and rectal area. CNA B rolled the brief underneath his buttocks and removed it and placed it in the trash. CNA B placed a clean brief with the same dirty gloves under the resident's buttocks. Resident #1 was rolled onto his back and the brief was secured. Resident #1 was repositioned in bed by both staff. CNA B touched his pillows and fluffed them under his head and placed his cap on his head and pulled the linens back over the resident. CNA A removed her gloves and placed them in the trash and washed her hands. CNA B gathered the trash, removed her gloves, placed them in the trash and washed her hands.During an interview on 12/15/2025 at 10:31 a.m., CNA A said Resident #1 was on EBP and she should have worn a gown during the care provided. She said she did not wear a gown because she forgot. She said there was a risk of spreading infections if staff did not follow EBP. She said she was trained on EBP and Resident #1 had a wound that required the staff to wear a gown and gloves when care was provided.Record review of a skills checklist for CNA A, dated 4/30/2025, indicated she was satisfactory with personal hygiene.During an interview on 12/15/2025 at 10:33 a.m., CNA B said she worked for an agency and was assigned this facility from time to time. She said hand hygiene should be performed before and after care was completed, which included hand washing or using hand sanitizer. She said she did not perform hand hygiene before she donned gloves to provide care to Resident #1. She said she forgot to sanitize her hands. She said when she changed tasks after cleaning and removing the dirty brief before she touched clean items, she should have changed her gloves and washed her hands. She said she kept the same gloves on during care and forgot about changing them. She said Resident #1 was on EBP and she should have worn a gown. She said usually PPE was in a container in the hallway and did not see the sign on the door for EBP. She said residents were e at risk for infections and cross contamination if staff did not follow infection control practices.During an interview on 12/15/2025 at 2:17 p.m., the ADON said staff received competency checks on hire and yearly thereafter. She said the DON and the IP conducted training on infection control with the staff. She said she conducted training on 12/15/2025 for hand hygiene and EBP with the staff and was aware of the care that was provided to Resident #1. She said Resident #1 was on EBP related to an open wound to his foot and staff should wear a gown and gloves when direct patient contact was provided.Record review of a facility in-service, dated 11/6/2025, on handwashing and hygiene and EBP revealed CNA A was in attendance by her signature on the sign in sheet.During an interview on 12/15/2025 at 2:29 p.m., the DON said he and the IP were both responsible for training staff on infection control and EBP. He said CNA A was present at the last training on EBP and hand hygiene. He said hand hygiene should be performed before and after care and when going from dirty items to clean. He said staff should never touch clean items with dirty gloves and should remove their gloves and wash their hands. He said Resident #1 was on EBP, and staff should have worn a gown and gloves when direct care was provided. He said there was a risk for spreading infections if they did not follow infection control and hand hygiene along with touching clean items with dirty gloves.During an interview on 12/15/2025 at 2:44 PM, the Administrator said the DON, ADON, and IP were all responsible for training staff on infection control. He said he expected the staff to perform and follow infection control practices. He said outside of the rooms of the residents on EBP the posted sign had instructions for the staff to follow. Record review of a facility policy titled Enhanced Barrier Precautions undated indicated, .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and gloves use during high contact resident care activities. 4. High-contact resident care activities include: d. providing hygiene; e. changing briefs.Record review of a facility policy titled Hand Hygiene undated indicated, .all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub. 6. A. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Hand hygiene table: when coming on duty; after handling contaminated objects; before performing resident care procedures.

Based on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 3 of 15 residents reviewed for quality of care, (Resident #14, Resident #36 and #209) in that: The facility failed to remove worn, damaged and bleached mechanical lift slings from service for Residents #14, Resident #36 and #209. This deficient practice could result in a loss of quality of life due to injuries. Findings included: Record review of a facility's face sheet dated 6/17/25 for Resident #14 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: End Stage Renal Disease (a permanent condition where the kidneys can no longer filter waste from the blood, and require a kidney transplant or dialysis to survive), Type 2 Diabetes Mellitus (a problem in the way the body regulates and uses sugar as a fuel), and Acquired absence of left leg below the knee. Record review of a Medicare 5-day MDS assessment dated [DATE] for Resident #14 indicated that he had a BIMS score of 10 indicating he had moderately impaired cognition. The assessment also indicated that he was totally dependent with transfers. Record review of a comprehensive care plan dated 5/08/25 indicated that Resident #14 was totally dependent on a mechanical lift with the assistance of 2 persons for transfers. Record review of a facility face sheet dated 06/17/2025 indicated Resident #36 was a [AGE] year-old male that admitted to the facility on [DATE] with diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), Type 2 Diabetes Mellitus (a problem in the way the body regulates and uses sugar as a fuel) and chronic obstructive pulmonary disease (a condition that limits airflow into and out of the lungs). Record review of a comprehensive care plan initiated 05/01/2025 indicated Resident #36 required transfer assist of 2 staff with a mechanical lift. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #36 had a BIMS score of 05 indicating severely impaired cognition. The resident required maximal assistance with transfers. Record review of a facility's face sheet dated 6/17/25 for Resident #209 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Left side hemiplegia following cerebral infarction (the pathologic process that results in an area of necrotic (death of tissue) tissue in the brain resulting in weakness or inability to use the left side of the body), heart failure (the heart muscle doesn't pump blood as well as it should), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of an admission MDS assessment dated [DATE] for Resident #209 indicated that she had a BIMS score of 15 indicating she was cognitively intact. The Assessment also indicated that she was totally dependent with transfers. Record review of a comprehensive care plan dated 5/21/25 indicated that Resident #209 was totally dependent on a mechanical lift with the assistance of 2 persons for transfers. During an observation on 06/16/2025 at 11:30 AM, of a mechanical lift sling under Resident #14 while he was sitting in his wheelchair, the colored straps were faded and light in color. During an observation on 06/16/2025 at 11:33 AM, of a mechanical lift sling under Resident #36 while he was sitting in his wheelchair, the colored straps were faded and light in color. During an observation on 06/16/2025 at 11:35 AM, of a mechanical lift sling under Resident #209 while she was sitting in her wheelchair, the colored straps were faded and light in color. During an observation and interview on 06/17/25 at 10:30 AM Resident #14 was in the common area of the facility watching TV dressed neatly. He denied any problems with staff. He was sitting in a wheelchair with a mechanical lift sling underneath him. The straps were faded in color and they all appeared to be a light blue- not bright blue, bright purple, or bright green. During an interview on 6/16/2025 at 12:00 PM with CNA E, she said she did use slings to assist with transfer of residents by mechanical lift. She stated the slings were inspected prior to use for any rips, tears or damage. She was not aware that the slings should also be inspected for fading. She did agree that the slings did have some fading to the sling but was unaware that faded slings should be taken out of service. During an interview on 6/17/2025 at 10:20 AM with the Housekeeping Supervisor, she said she had been working at the facility for 2 months. She stated lift pads were normally washed using the blanket setting, that did not include bleaching agent in the cycle. She stated if a lift pad was soiled then the pad cycle was used and a bleaching agent was used in the pad washing cycle. She said the nursing staff was responsible for inspecting lift pads prior to use and removing any damaged lift pads from service. During an interview on 6/17/2025 at 10:30 AM with Laundry Aide D, she said she has been working at the facility for 8 months. She said she always washed the lift pads on the blanket cycle. She stated a bleaching agent was not to be used with the lift pads. She stated lift pads were washed and hung to air dry. She said the nursing staff was responsible for removing damaged lift pads from service. During an interview on 6/17/2025 at 10:45 AM with the Director of Nursing, he said the staff was responsible for inspecting lift pads for any damage to the pad prior to placing under a resident. He stated staff were to inspect lift pads and remove from service any pad that showed signs of wear such as fraying, tearing or rips. He said the staff had not been instructed to look at straps for fading. He stated the laundry was the first line of inspection and should remove any pads that had visible signs of wear and tear. He stated laundry staff should not use any bleaching agents while laundering the lift pads. He stated the laundry supervisor was new to her position and education would be provided to her on the laundering and inspection of lift pads by the laundry staff. During an inspection of a faded lift sling that was under Resident #14, the Director of Nursing agreed the color of the connection tabs was faded. He said all mechanical lift slings in the facility would be inspected and all faded and worn slings would be replaced. During an interview on 6/18/2025 at 9:15 AM with CNA G, she said prior to using a mechanical lift pad, she inspected the pad for any worn or stringy parts. She stated if the pad was worn or damaged the pad was taken to the supervisor and a new pad was used for the resident. She stated that they were now monitoring for fading of connection tabs on the lift pads. She stated a lift pad that was worn, torn or faded could put the resident at risk for injury during transfer. During an interview on 6/18/2025 at 9:25 AM CNA H stated the slings were inspected prior to use for any wear and tear or any faded loops. She stated any altered slings were taken to the supervisor to be taken out of service and a new sling was used for the resident. She said the resident was at risk for injury if a damaged sling was used with the mechanical lift. During an interview on 6/18/2025 at 9:35 AM CNA K stated mechanical slings were inspected by laundry staff and nursing staff. She stated laundry staff was to inspect pads for any wear and tear and if any damage was noted then the laundry was to take the lift pad out of service. She stated the nursing staff also inspected the lift pads prior to use for any rips, tears and fading. She said any damaged pads were removed from service and replaced with a new lift pad. She said the resident was at risk for injury if a damaged or altered lift pad was used during transfer. During an interview on 6/18/2025 at 9:45 AM with the Director of Nursing, he stated new lift slings were ordered. He stated the staff was also in serviced on inspecting the lift pads for tears, fraying and fading. He said any lift pads with signs of fading or tears were to be removed from service immediately. He said the resident could be at risk of injury if a worn or faded lift pad was used. He said laundry personnel and nursing staff were responsible for inspecting lift pads and removing them from service. He stated CNA K was responsible for ordering lift pads and would monitor the conditions of the lift pads in the facility and ensure replacement lift pads were available to staff. During an interview on 6/18/2025 at 9:55 AM, the administrator said she discussed the concerns of the faded lift slings with the DON . She stated that she was aware that staff was inspecting the slings prior to use but she was not aware that the slings were faded. She said that an altered lift sling could put a resident at risk for injury during use. She stated that 10 new slings had been ordered and that all slings would be inspected for tears, worn areas and fading prior to use by the laundry staff and direct care staff and any lift slings that were faded or worn would be taken out of service immediately. Record review of the facility's policy titled Safe Resident Handling/Transfers copyright 2023 reads .Slings will be laundered according to manufacturer's instructions and any damaged, broken or unsafe slings will be removed from service and replaced. Record review of manufacture guidelines Full Body Slings - Instructions for use accessed at www.medline.com on 06/18/25 read .Always inspect slings prior to each use. Signs of rips, tears, or frays indicate sling wear which is unsafe and could result in injury. Signs of color fading, bleached areas, or permanent wrinkles on the straps indicate improper laundering which is unsafe and could result in injury. Any slings with signs of wear or improper laundering should be immediately removed from use .

Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #15) and 1 of 5 staff (Nurse Manager) reviewed for infection control. Nurse Manager performed direct care to Resident #15 and failed to remove Personal Protective Equipment (PPE, gown, and gloves) prior to exiting Resident #15's room on 06/16/2025. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings included: Record review of an admission Record for Resident #15 dated 06/17/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Hemiplegia and Hemiparesis following cerebral infarction, Muscle wasting and Atrophy, Cognitive Communication Deficit, Hypertension. Schizoaffective Disorder, Bipolar Type, Epilepsy, Major Depressive Disorder and Dysphagia. Record review of a Quarterly MDS Assessment for Resident #15 dated 04/17/2025 indicated she had severe impairment in thinking with a BIMS score of 3. She was dependent on staff for application of nonsurgical dressings and personal hygiene (ADL care). Record review of a care plan for Resident #15 dated 11/29/2022 indicated she had an ADL self-care performance deficit related to a Cerebral Infarction with right side hemiplegia, bowel, and bladder incontinence. During an observation and interview on 6/16/2025 at 10:25 AM, the Nurse Manager did not follow the Enhanced Barrier Precautions for disposing of used PPE supplies consisting of a gown and gloves. The Nurse Manager exited Resident #15's room with contaminated PPE (gown and gloves) still on and took them off in the hallway and proceeded to put the contaminated PPE in the trash can on the medication cart across the hall. The Nurse manager said she just completed care on Resident #15's PICC line . During an interview on 06/16/2025 at 10:27 AM, with the Nurse Manager she said the PPE supplies did not have to be disposed of in a special trash can and could be disposed of in any trash can. During an interview on 06/18/2025 at 7:56 AM, with CNA A she said staff should use PPE supplies prior to performing direct care on a resident with ordered precautions. Once staff have competed resident care, staff should take off all PPE in the room and dispose of the PPE in a biohazard bag , wash their hands, and then exit the room. She said if the Resident has a physicians order for EBP the staff should use PPE supplies when providing care to the resident. She said if the PPE supplies are no used or discarded appropriately it may cause a spread of bacteria and germs to residents and staff that could cause residents and/or staff to become ill. During an interview on 06/18/2025 at 8:01 AM, with the Nurse Manager she said she read the enhanced barrier policy, and she did not follow the proper procedures when disposing of PPE supplies after performing direct care on Resident #15. She said if the PPE supplies were not used and disposed of correctly it could potentially spread germs. During an interview on 06/18/2025 at 8:05am with RN B she said if a patient had orders for precautions the staff should use appropriate PPE when performing direct care to a resident and should dispose of used PPE in the trash can in the resident's room and wash their hands prior to exiting the room. She said residents could become ill from the spreading of germs and bacteria as well as staff could be exposed to germs and bacteria that could cause them to become ill. During an interview on 06/18/2025 at 8:12am with MA C she said staff was supposed to use PPE when providing direct care to a resident on EBP. She said staff should remove PPE and wash their hands before exiting the resident's room. She said if the proper PPE procedures were not used the potential to spread germs increased and other residents could become ill. During an interview on 7/31/2024 at 10:04am with the ADON she said if staff were making direct contact with a resident that had orders for Enhanced Barrier Precautions staff should use PPE supplies. She said staff should put the PPE supplies on prior to rendering direct care to the resident. She said staff should dispose of used PPE in the trash can by the door in the patient's room. She said if PPE supplies were not used or disposed of properly it could cause infection control issues and possibly get other resident's sick. During an interview on 7/31/2024 at 10:10am with the Administrator, she said when staff entered the room of a resident on EBP they should be using EBP supplies prior to providing direct care. She said they should take used PPE off in the room and put it in the trash can in the resident's room. She said staff should never wear used PPE outside the room. She said when staff was done with resident care, they should wash their hands or use sanitizer prior to exiting the room or going on their next task. She said if PPE was not used or disposed of correctly there was a potential to spread infections. Record review of a facility policy titled Enhanced Barrier Precautions dated 2025 indicated, .3. D. Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for one of four hallways (Hallway 200) reviewed for physical environment. The facility failed to maintain the walls, ceiling, and floor in the shared restroom for rooms [ROOM NUMBERS] located on the 200 hallway. The facility failed to remove a broken dresser from room [ROOM NUMBER] located on the 200 hallway. The potential outcome statement goes here Findings included: During an observation on 06/16/2025 at 9:53 AM, the shared restroom for room [ROOM NUMBER] and 210 had 6 holes one inch to one and a half inch in diameter in the sheetrock wall beside the toilet, the floor was dirty, discolored gray, brown with no visible wax or coating and worn. Black-brown dirt debris substance was around the bottom of the toilet that had clear caulk over it. Dirt-dust debris was on the wall underneath the sink. There was a 6-inch area on the ceiling where the ceiling texture was flaking off from prior water damage. During an observation on 06/16/2025 at 10:15 AM, room [ROOM NUMBER] had a dresser with a broken top, a ten-inch area of particle board was exposed which would not allow proper cleaning and disinfection of the surface and the vinyl trim was hanging loose from the left side edge of the dresser. During an interview on 6/17/2025 at 10:30 AM, LVN L said the dresser had been damaged due to staff raising and lowering the electric bed while providing care and catching the dresser edge. She said the dresser needed to be replaced due to it could not be properly cleaned. She said the dresser should be moved to another area in the room to prevent more damage. During an interview on 06/17/2025 at 11:30 AM, CNA M said she had only worked at the facility for a few weeks. She said she thought the broken dresser was not appropriate but did not know if it was acceptable or not or who exactly to report the broken dresser to. She said the broken dresser could not be properly cleaned and did not look nice. During an interview on 06/17/2025 at 2:30 PM, the Director of Maintenance said he had worked at the facility for a couples of months and had been busy making repairs needed. He said he was not aware of the needed repairs to the bathroom shared by rooms [ROOM NUMBERS] but he would put it on his list. During an interview on 6/18/2025 at 10:30 AM the Administrator said she expected the bathrooms to be maintained and furniture to be in good condition in the resident rooms. She said she would have the shared bathroom for room [ROOM NUMBER] and 210 holes cleaned and repaired. The Administrator said she had ordered new dressers for the resident rooms and would replace the dresser in room [ROOM NUMBER] She said the risk to the residents was to live in an environment that was not sanitary and safe. Record Review of an undated facility policy titled, Resident Rooms reflected .Resident bedrooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents .10. Resident rooms will be furnished with functional furniture and arranged according to resident needs and preferences .

Based on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff through a communication system which relays the call directly to a staff member or a centralized staff work area from toilet and bathing facilities for 1 of 8 residents reviewed for call lights. (Resident #8). The facility failed to ensure Resident #8's emergency call light in the bathroom would reach the floor. The call light cord for Resident #8 was three feet above the floor level. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life. Findings include: Record review of a face sheet dated 6/18/2025 indicated that Resident #8 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: dementia (confusion due to aging with inability to remember), muscle weakness, difficulty ambulating, and muscle wasting. Record review of a Quarterly MDS assessment dated [DATE] for Resident #8 indicated that she had a BIMS score of 3, indicating that she had severe cognitive impairment. The MDS indicated that the resident required supervision or touch assist of one person for toilet use. Record review of a comprehensive care plan with a revision date 6/06/2025, revealed Resident #8 was at risk for injuries related to falls and had a fall on 5/20/2025 with no injuries. During an observation on 06/17/25 at 10:57 a.m., the emergency call light in Resident #8's bathroom was approximately 3 feet above the floor and not accessible if lying on the floor. Resident #8 was ambulating independently in her room. Resident #8 said she used her restroom with minimum assistance and would call for help if needed. During an interview on 06/18/25 at 10:46 am LVN L said that the string being too short could cause the resident not to be able to reach it and not to be able to call for help if they had a fall in the bathroom. During an interview on 6/18/25 at 9:00 am, the Director of Maintenance said the call lights in bathrooms needed to be accessible because if a resident were to fall, they needed to be able to reach the string to call for help. He said he had only worked at the facility for a few months and would make a facility sweep to correct all strings to the required length. During an interview on 6/18/25 at 11:00 am, the Administrator said that call lights needed to be accessible always in case the resident needed assistance or if there were an emergency. She said the call lights in the bathroom needed to be accessible for a resident lying on the floor. The Administrator said if a resident were to fall, they needed to be able to reach the string to call for help. She said going forward, she would expect her staff to follow proper policy and procedure. Record review of an undated facility policy titled Call Lights indicated .7. The call system must be accessible to the resident at each toilet and bath or shower facility. The call system should be accessible to a resident lying on the floor .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements and kitchen sanitation. 1. The facility failed to ensure the DA effectively wore a hair net to cover all his hair on 5/20/2024 and the Dietary Manager effectively wore a hair net to cover all her hair on 5/20/2024 and 5/21/2024. 2. The facility failed to ensure foods stored in the refrigerators, freezers and dry pantry were labeled, dated, and not kept past their expiration dates. 3. The facility failed to ensure containers of oil and sugar were sealed properly. 4. The facility failed to ensure frozen green bean and frozen egg and cheese omelets were sealed and stored properly in freezer. 5. The facility failed to ensure celery and bell peppers were stored properly and not kept beyond use by date. 6. The facility failed to ensure foods in the freezer were not stored under a dripping pipe. 7. The facility failed to ensure proper sanitation of the food processor between pureeing each food item. 8. The facility failed to ensure proper hand washing between tasks. These failures could place residents at risk of foodborne illness and food contamination. Findings included: During an observation on 5/20/2024 at 10:10 a.m. the DA and DM were observed in the kitchen wearing a hair net that did not completely cover their hair. They had hair that was sticking out on the sides of their heads by their ears and at the back of their head. During an observation and interview on 5/20/2024 at 10:12 AM, sugar was observed stored under a table with the lid half off and cooking oil was observed with no lid. The DM said someone had just used them for breakfast and left them off. During an observation 5/20/2024 at 10:20 AM the freezer had a pipe in the back wrapped with tape and water was observed dripping and refreezing. An open uncovered box of green beans was observed unsealed with no label or date and a box of frozen egg and cheese omelets was observed sitting under a dripping pipe frozen over with a thick layer of solid ice. During an observation on 5/21/2024 at 10:50 AM kitchen staff (Cook, DA, and Dietitian) exited and reentered the kitchen several times during observation on 5/21/24 between 10:50 am and 11:45 am without washing or sanitizing their hands. During an observation and interview on 5/20/2024 at 10:35 AM, the refrigerator had 1 box of open uncovered celery with brown spots observed on most of the stalk and wilted with use by date of 4/18/2024, 1 box of open uncovered bell peppers with brown, black, and white spots with use by date of 4/18/2024, 3 loaves of bread with use by date of 4/8/2024. A cart observed sitting in the cooler had unlabeled and undated items on it, including: one pitcher of milk with no date or label, two pitchers of juice with no date or label, 6 glasses of juice with no date or label, 3 glasses of milk with no date or label. DM said items on cart were from breakfast and they would be discarding them immediately and that all undated or unlabeled items would be removed from the cooler and items would be dated and labeled in the future. During an observation and interview on 5/20/2024 at 10:40 AM, the dry storage area revealed 1 open bag of raisin bran cereal opened and sealed in zipper top bag with use by date of 4/30/2024, one package of rice crispies in sealed zippered plastic bag with use by date of 4/02/2024. DM said she did not know why they have raisin bran because they do not serve or have raisin bran on their menu. During an observation and interview on 5/20/2024 at 10:42, the dry storage area was observed with the sugar's lid half off and the vegetable oil was observed with no lid. The lid was observed laying away from the oil bottle on top of the storage shelf. The DM said that someone must have used it preparing breakfast and did not reseal it. During an observation and interview on 5/21/2024 at 10:50 AM, [NAME] was observed pureeing foods and failed to sanitize the food processor between each puree. She rinsed food processor with water and proceeded to puree next item. [NAME] was observed using ungloved hands when handling utensils to stir or dip out food for puree. During an interview on 5/21/2024 at 1:30 pm, Maintenance Director said the pipe was not dripping. He stated the water was condensation due to the kitchen staff getting deliveries, propping the door to the freezer open when unloading the delivery truck, and storing the food in the freezer prior to closing the door. During an interview on 5/21/24 at 3:00 pm, Dietician said not washing hands between tasks and not properly washing the food processor between foods could put residents at risk of cross contamination. He also said that improper food storage and outdated foods could put residents at risk of food borne illnesses. He said if dietary staff did not wear hair nets appropriately, foods could be contaminated with hair. He said he would ensure staff were educated and follow policy going forward. During an interview on 5/21/22 at 3:30 PM, DM said the ice came from condensation and they had that problem in the past. She also said she had removed the green beans and egg omelets from the freezer. During an interview on 5/22/24 at 12:30 pm, [NAME] said she should have put the food processor through the dishwasher after every puree and changed her gloves more often. She also said she should have washed her hands when exiting and re-entering the kitchen and between tasks. She said not washing hands between tasks and not properly washing the food processor between foods could cause residents to become sick. During an interview on 5/22/24 at 12:35 pm, DM said she should have removed all undated and unlabeled foods. She said going forward, she would date and label all items and she would check dates and discard any items that were past the use by date. She said out of date items and improper storage could make residents ill. She said not covering all hair with hair nets could cause hair to get in the food and contaminate it. She said not properly washing your hands or not properly wearing gloves could transfer germs and bacteria. Record review of the facility's policy titled Employee Sanitation dated October 1, 2018, read: .Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces .; .Employees must wash their hands and exposed portions of their arms at designated hand washing facilities at the following times: .During food preparation, as often as necessary to remove soil and contamination and prevent cross contamination when changing tasks .after engaging in other activities that contaminate the hands .; .gloves are not a substitute for thorough and frequent hand washing. When using gloves, always wash hands before touching or putting on new gloves . .Change gloves: i. between each food preparation task .iv. When leaving food preparation area for any reason . Record review of the facility's policy titled Food Receiving and Storage dated 2001 with revision date of November 2022 read: .Food may not be stored .g. under leaking water lines, including leaking automatic fire sprinkler heads, or under lines on which water has condensed .; .Refrigerated foods are labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded . Record review of the facility's policy titled General Kitchen Sanitation dated October 1, 2018, read .Clean and sanitize all food preparation areas, food-contact surfaces, dining facilities and equipment. After each use, clean and sanitize all tableware, kitchenware, and food-contact surfaces of equipment .

Based on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 3 of 4 residents reviewed for quality of care, (Resident #5, #39, and #41) in that: The facility failed to remove worn and damaged mechanical lift slings from service. The facility failed to obtain physician orders for mechanical lift transfers. This deficient practice could result in a loss of quality of life due to injuries. Findings included: Record review of a facility's face sheet dated 5/21/24 for Resident #5 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: dementia, depression, and type 2 diabetes. Record review of a Quarterly MDS assessment dated [DATE] for Resident #5 indicated that she was rarely/never understood and that Resident #5 was severely cognitively impaired. Assessment also indicated that she was totally dependent with transfers. Record review of a comprehensive care plan dated 8/21/23 indicated that she was totally dependent on a mechanical lift with the assistance of 2 persons for transfers. Record review of a physician order report dated 5/21/24 for Resident #5 indicated that she did not have a physician order for mechanical lift transfers. Record review of a facility face sheet dated 5/21/24 for Resident #39 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: dementia, muscle weakness, and type 2 diabetes. Record review of a Comprehensive MDS assessment dated [DATE] for Resident #39 indicated that he had a BIMS score of 5, which indicated that he had severely impaired cognition. Assessment also indicated that he was totally dependent with transfers. Record review of a comprehensive care plan dated 7/21/23 for Resident #39 indicated that he was dependent on a mechanical lift with the assistance of 2 staff members for transfers. Record review of a physician order report dated 5/21/24 for Resident #39 indicated that he did not have a physician order for mechanical lift transfer. Record review of a facility face sheet dated 5/21/24 for Resident #41 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (left side weakness/paralysis following a stroke), type 2 diabetes, and anxiety disorder. Record review of a Quarterly MDS assessment dated [DATE] for Resident #41 indicated that she had a BIMS score of 15, which indicated that she was cognitively intact. Assessment also indicated that she was totally dependent with transfers. Record review of a comprehensive care plan dated 8/21/23 for Resident #41 indicated that she required a mechanical lift with assistance of 2 staff members for transfers. Record review of a physician order report dated 5/21/24 for Resident #41 indicated that she did not have a physician order for mechanical lift transfer. During an observation on 5/20/23 at 11:45 am Residents #39 was observed in the dining area. Resident #39's mechanical lift sling straps were observed to be faded in color. Resident #39's sling was blue mesh and label indicated that it was a Medline brand sling. During an observation and interview on 5/20/24 at 12:33 pm, Resident #41 was observed in her room with mechanical lift sling underneath her in her wheelchair. The lift sling was observed to have straps that were faded in color. Label indicated that it was a Medline brand sling. Resident #41 said that she had not had any falls from the lift. During an observation on 5/21/24 at 10:00 am, Residents #39 and Resident #5 were observed in a common area. Resident #39 was up in his wheelchair and had a mechanical lift sling underneath him. Resident #39's sling was mesh and purple in color with multiple loose green strings noted along outer seam of sling, torn area next to hook straps, hook straps were noted to be faded in color, label was unreadable. Resident #5 was observed sitting up in a Broda (brand of wheelchair to assist with positioning) chair. She also had a mechanical lift sling underneath her. The mesh sling was observed to be purple in color, the label was unreadable, straps were faded in color (almost a grayish white), and multiple loose strings were observed along the edging of sling. During an interview on 5/21/24 at 10:06 am, Laundry Aide said she had been employed by the facility in laundry for [AGE] years. She said she would inspect mechanical sling pads for torn spots and loose strings before putting them out for use. She said if she observed any that she would take them out of service. She said she did not use bleach on the lift pad slings. She said worn sling pads could break during use causing residents to fall. During an interview on 5/21/24 at 10:10 am, DON observed the mechanical lift pads underneath Resident #5 and #39 in the common area and said they should not have been used to transfer the residents. He said sling pads should be inspected by the staff before using them to transfer a resident and that worn sling pads could put residents at risk for falls. During an interview on 5/22/24 at 12:15 pm, the Administrator said there could be a chance of the sling breaking if it was worn. She said they ordered new slings and the DON would be inspecting them routinely from then on. She said they educated the CNAs and they would be expecting the CNAs to inspect all slings prior to using them for a resident. During an interview on 5/22/24 at 1:00 pm, CNA D said she had been employed about a year and a half. She said she looked for signs of wear on the lift pads such as loose strings and faded coloring on the straps. She said if she observed any signs of wear, she would not use the lift pad to transfer a resident. She said worn pads could break causing a resident to fall. During an interview on 5/22/24 at 1:10 pm, CNA E said she had been employed for about a month. She said she would look for loose seams, faded colors, rips and tears on the lift pads before use. She said that lift pads that had faded coloring, loose seams, and rips or tears could break while using them, and a resident could fall. Record review of the facility's policy titled Lifting Machine, Using a Mechanical dated 2001 and revised July 2017 read .8. Make sure that all necessary equipment (slings, hooks, chains, straps and supports) is on hand and in good condition . and .Discard any worn, frayed or ripped slings . Record review of manufacture guidelines Full Body Slings - Instructions for use accessed at www.medline.com on 5/21/24 read .Always inspect slings prior to each use. Signs of rips, tears, or frays indicate sling wear which is unsafe and could result in injury. Signs of color fading, bleached areas, or permanent wrinkles on the straps indicate improper laundering which is unsafe and could result in injury. Any slings with signs of wear or improper laundering should be immediately removed from use . and .Do not remove sling labels. If sling labels are removed or no longer legible, sling must be immediately removed from use .

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #12) reviewed for infection control. The facility failed to ensure CNA C sanitized or washed her hands after changing gloves when providing incontinent care to Resident #12 on 5/20/2024. This failure could place residents at risk of exposure to communicable diseases and infections. Findings include: Record review of an Admission Record dated 5/21/2024 for Resident #12 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnosis of hemiplegia and hemiparesis following cerebral infarction (paralysis on one side following a stroke), gastrostomy status (tube placed into the stomach for feeding), end stage renal disease (kidneys are no longer able to function on their own) and autistic disorder (a developmental disorder that could cause the inability to communicate or interact). Record review of a Significant Change MDS assessment dated [DATE] for Resident #12 indicated he was rarely/never understood. He was dependent with all ADLs. He was always incontinent of bowel and bladder. Record review of a care plan revised on 5/15/2024 for Resident #12 indicated he had an ADL self-care performance deficit related to confusion, impaired mobility with interventions to provide personal hygiene/oral care and was totally dependent on one staff. He had bowel/bladder incontinence and interventions to check on rounds as required for incontinence. During an observation on 5/20/2024 at 11:20 AM, RN B and CNA C were present in Resident #12's room to provide wound care. RN B and CNA C sanitized/washed their hands and donned a gown and gloves. Wound care supplies were on waxed paper on the over bed table, supplies were placed on the wax paper. CNA C rolled Resident #12 onto his left side and pulled his brief down. RN B removed the dressing from his sacrum and placed it in the trash along with her gloves. RN B sanitized her hands and walked away from the bed to the door and removed gloves that was on the wall and placed gloves on both hands. RN B cleaned the sacral area with normal saline and gauze and placed it in the trash. RN B removed her gloves and placed them in the trash and sanitized her hands. RN B walked away from the bed to the door to get more gloves and applied them to both hands and used a gauze and patted sacrum area dry. CNA C removed wipes from a plastic bag and started wiping stool from his rectum front to back. CNA C placed the wipes in a trash bag and removed her gloves and put on gloves without washing or sanitizing her hands. RN B removed her gloves and placed in the trash, sanitized her hands, and walked to the door to get more gloves and applied them to both hands. RN B placed an alginate dressing to the wound bed and removed her gloves and placed them in the trash. RN B sanitized her hands and walked to the door to get more gloves and applied them to both hands. RN B applied a foam dressing. CNA C removed more wipes from the plastic bag and wiped his periarea in the front and removed gloves and placed in the trash. CNA C applied gloves to both hands without washing or sanitizing her hands. CNA C rolled the resident onto his right side and removed the brief and placed a clean brief underneath his buttocks and secured it. RN B removed her gloves and placed them in the trash. The resident was positioned in bed, and CNA C removed her gloves and placed them in the trash. Both RN B and CNA C removed their ppe and washed their hands. During an interview on 5/20/2024 at 4:25 PM, CNA C said she had been employed at the facility for a year and worked the hall where Resident #12 resided. She said during the incontinent care/wound care provided to him earlier she should have washed or sanitized her hands between gloves changes. She said she did not have sanitizer with her. She said she could not leave the resident to go and wash her hands because RN B kept leaving the bedside to get more gloves from the wall mount after she removed her gloves. She said she had a check off about 3 months ago on hand hygiene. She said residents could be at risk of infections if staff did not wash or sanitize their hands between glove changes. During an interview on 5/22/2024 at 11:06 AM, the ADON said she had been employed at the facility for 6 months. She said staff should be washing or sanitizing their hands before care, during and between, when putting a new brief, and when changing gloves. She said she was responsible for conducting the skills check offs with staff. She said she conducted in-service training on hand hygiene every 3 months. She said if staff did not perform hand hygiene, there was a risk of infections to the residents and cross contamination. She said going forward they would in-service staff and continue education. During an interview on 5/22/2024 at 11:21, the DON said he had been employed at the facility since April 2024. He said staff should be washing or sanitizing their hands before care, during care and between glove changes. He said they would continue to in-service staff on hand wash/hygiene. He said residents could be at risk for infections and staff transferring infections to other residents. During an interview on 5/22/2024 at 11:34 AM, the Administrator said staff should be sanitizing or washing their hands between care, when taking off gloves, and changing contact areas. She said going forward, they would continue to train, educate, in-service, and observe staff on hand hygiene. She said there was a risk of infections to the residents if staff did not follow proper hand hygiene. Record review of a competency evaluation dated 12/15/2023 for CNA C indicated that she was checked off on hand washing/hygiene by the ADON. Record review of the facility's policy titled Handwashing/Hand Hygiene revised August 2019 indicated, .This facility considers hand hygiene the primary means to prevent the spread of infection. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: a. Before and after coming on duty; m. After removing gloves; 8. Hand hygiene is the final step after removing and disposing of personal protective equipment .

Based on observation, interview, and record review, the facility failed to ensure that residents requiring respiratory care are provided care, consistent with professional standards of practices for 2 of 9 residents (Resident #17 and #34) reviewed for quality of care. 1.The facility failed to ensure Resident #17's oxygen concentrator had an external filter that was free of dust buildup on 5/21/2024 and 5/22/2024. 2. The facility failed to ensure Resident #34's oxygen concentrator had an external filter that was free of dust buildup on 5/21/2024 and 5/22/2024. This failure could place residents who require respiratory care at risk for respiratory infections, breathing in dust and allergens, decreased effectiveness of oxygen concentrators, and exacerbation of respiratory distress. Findings included: 1. Record review of an Admission Record dated 5/21/2024 for Resident #17 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnosis of COPD (lung disease that makes it difficult to breath), acute on chronic systolic congestive heart failure (heart is not able to pump effectively), myasthenia gravis (abnormal weakness of certain muscles) and pneumonia (lung infection). Record review of a Quarterly MDS assessment dated [DATE] for Resident #17 indicated he did not have any impairment in thinking with a BIMS score of 15. Special treatments, procedures and program for oxygen therapy indicated he used oxygen on admission and while a resident. Record review of a care plan revised on 4/9/2024 for Resident #17 indicated he required oxygen therapy related to CHF (heart not being able to pump effectively), pulmonary edema (swelling in the lungs) and respiratory failure. Interventions included oxygen settings: Oxygen via (through) nasal prongs at 2-4 L/minute prn as ordered. Record review of active physician orders dated 5/21/2024 for Resident #17 indicated he had an order that started on 4/14/2024 for oxygen: change oxygen tubing and clean filter on concentrator every week or when visibly soiled or malfunction present, every night shift every Sunday for dyspnea (difficulty breathing). Record review of a MAR dated 5/1/2024 to 5/31/2024 for Resident #17 indicated an order to clean the oxygen filter on concentrator q week was signed off by LVN A on 5/5/2024 and 5/19/2024 by a check mark and initials of staff. During an observation and interview at 5/21/2024 at 9:15 AM, Resident #17 was in bed, on oxygen via nasal cannula at 3 L/minute. The external filter had a thick buildup of dust. He said he did not remember the last time someone cleaned it. 2. Record review of an Admission Record dated 5/21/2024 for Resident #34 indicated he was [AGE] years old with diagnosis of CHF (heart's inability to pump effectively), dependence on supplemental oxygen (required the use of oxygen), and anxiety disorder. Record review of a Modification of Annual MDS assessment dated [DATE] for Resident #34 indicated he had moderate impairment in thinking with a BIMS score of 11. Special Treatments, Procedures, and Programs indicated while a resident within the 14-day look back period, he was used oxygen therapy. Record review of a care plan revised on 8/19/2022 for Resident #34 indicated he had oxygen therapy related to end stage CHF. Interventions included oxygen settings: oxygen via nasal cannula as ordered. Record review of active physician orders dated 5/21/2024 for Resident #34 indicated an order to administer Oxygen at 2 L/minute via nasal cannula to keep saturations above 90% that started on 7/25/2023. During an observation and interview on 5/21/2024 at 9:11 AM, Resident #34 was sitting up in a wheelchair in his room on oxygen via nasal cannula at 2 L/min and the external filter had a thick buildup of dust. Resident #34 said he cleaned the filters himself about every 2 weeks. He said the facility staff cleaned it before, but he usually did it himself. During a phone interview on 5/21/2024 at 9:36 PM, LVN A said she had been employed at the facility for 1 1/2 year and only worked the night shift from 6 pm to 6 am. She said she checked the oxygen concentrators and put water in the humidifier bottles. She said it was her understanding that maintenance was supposed to clean the oxygen filters. She said she had taken the spongy filters off before and cleaned them. She said she had never been told yes or no by anyone to clean them. She said if a concentrator started making a squealing noise, then she would check it to see what was wrong with it. She said every Sunday, the charge nurses were to change out the water for the humidifiers and the tubing on the concentrators. She said she did not clean the filters that past Sunday for Residents on Hall 200 where Resident #17 and #34 resided. She said she did not notice on the TAR if a resident had an order to clean the filter weekly. She said residents could be at risk of inhaling particles and dust as it could come through the concentrator and the filter was supposed to keep that from happening and cause lung issues such as pneumonia or shortness of breath. During an observation and interview on 5/22/2024 at 9:08 AM-9:10 AM, the Maintenance Supervisor said he had been employed at the facility since October 2023. He walked in the room of Resident #17 and said the oxygen filter was dusty. He went into the room of Resident #34 and checked the oxygen concentrator filter and said it was dusty. He said he had cleaned Resident #34's filter in the past month. He said he was responsible for cleaning the filters on the oxygen concentrators once a month and only cleaned the external filters. He said the last time he cleaned the filters for the residents in the facility was about two weeks ago. He said he did not keep a log and would just go around and check them. He said he was not sure if he had ever cleaned Resident #17's filter. He said the filter was on the concentrator to make sure contaminants did not get through. He did not know of a risk of the residents. During an interview on 5/22/2024 at 11:21 AM, the DON said he had been employed at the facility since April 2024. He said the oxygen filters were on the maintenance schedule to be cleaned weekly and they changed the filters per the manufacturer's guidelines. He said nursing staff were responsible for cleaning the filters. He said he would in-service staff on checking the filters weekly. He said there was a risk of the filters being dirty and it could jam up the machine and make them not work properly if they were not cleaned. During an interview on 5/22/2024 at 11:34 AM, the Administrator said the oxygen concentrator filters were the responsibility of maintenance to clean and should be done monthly and as needed. She said if they were not clean, the concentrators could not function properly. She said going forward, maintenance would have a list of residents in the facility on oxygen to check. Record review of the facility's policy titled Oxygen Concentrator undated indicated, .An oxygen concentrator is a medical device that extracts oxygen from room air by filtering out or separating the nitrogen form the oxygen. The oxygen passes through a filter system and is then stored within the device for delivery based on the flow meter setting. 5. Care of the Concentrator: a. Follow manufacture recommendations for the frequency of cleaning filters and servicing the device .

Based on observation, interview, and record review, the facility failed to assure that residents who were fed by enteral feeding, received appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 resident (Resident #12) reviewed for quality of care. The facility failed to ensure that Resident #12's feeding tube bags were labeled which included the initials of staff that hung the bag and the time it was hung to ensure residents maintain nutritional status within optimal parameters on [DATE]. This failure could place residents receiving enteral feedings at risk of not receiving feeding care in a timely manner and receiving old or expired feed. Findings included: Record review of an Admission Record dated [DATE] for Resident #12 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnosis of hemiplegia and hemiparesis following cerebral infarction (paralysis on one side of the body following a stroke), gastrostomy status (tube inserted into the stomach for feeding), end stage renal disease (kidneys are no longer able to function on their own) and autistic disorder (a developmental disorder that can cause the inability to communicate or interact). Record review of a Significant Change MDS assessment dated [DATE] for Resident #12 indicated he was rarely/never understood. He was dependent with all ADLs. He was always incontinent of bowel and bladder. He had a feeding tube while a resident during the 7-day look back period. Record review of a care plan revised on [DATE] for Resident #12 indicated he required tube feeding related to CVA with dysphagia. Interventions included to administer enteral feeding, medications, and water flushes as ordered. Interventions also indicated to change feeding set/syringe/tubing daily and as needed. Record review of active physician orders dated [DATE] for Resident #12 indicated he was on a NPO diet, g tube (feeding tube) continuous feeding of Nepro 1.8 at 55 cc/hr x18 hours. During an observation on [DATE] at 11:10 AM, Resident #12 was in bed awake but nonverbal. He had tube feeding of Nepro on a pump infusing at 55 ml/hr with 30 ml water flush every 1 hr. A 1000 ml feeding bag that had approximately 500 ml of formula with a label dated [DATE], no time noted on bag or initials of who hung it. A 1000 ml bag of water noted with approximately 800 ml did not have a label on it. During a phone interview on [DATE] at 9:36 PM, LVN A said she had been employed at the facility for 1 ,d+[DATE] year and only worked the night shift from 6 pm to 6 am. She said the nursing staff were responsible for hanging feeding bags and labeling them. She said she took care of Resident #12 on the night of [DATE] and morning of [DATE]. She said her shift ended at 6 am on [DATE]. She said on Monday morning [DATE] at 4 am, she hung a new bag of feeding for him along with water. She said she always just placed a label on one of the bags because the bags came together as a set of two. She said the label should include the resident's name, date, time, rate of feeding, type of feeding and the initials of the staff that hung the bag. She said she did not realize that she did not put a time on the bag and probably should have labeled both bags. She said she had a skills check off in the past on medication administration with g-tubes and it included labeling the feeding bags. She said residents could be at risk of receiving incorrect feedings, incorrect flow rates or getting a feeding that was old if it was not labeled properly. She said residents could be at risk of GI issues because they ould not want to give a resident curdled milk. During an interview on [DATE] at 11:06 AM, the ADON said she had been employed at the facility for 6 months. She said feeding tubes should be labeled and that included the resident's name, type of feeding, water flush, rate of feeding, the time it was hung, date, and initials of staff. She said both the feeding and water bag should be labeled. She said there was a risk of potentially getting old feedings if there was not a time indicated and it should have been immediately changed and an assessment completed on the resident. She said nursing was responsible for labeling the feedings and water. She said going forward, she would in-service staff to make sure the labels were complete and give them more education. During an interview on [DATE] at 11:21 AM, the DON said he had been employed at the facility since [DATE]. He said g-tube feeding labels should include the initials of staff, time, type of feeding, date, and rate of flow, and the water bag should have a label also. He said the bags should be changed every 24 hours and the label should have a time to indicate when it was hung. He said going forward, he would in-service staff to ensure the feedings were labeled properly. During an interview on [DATE] at 11:34 AM, the Administrator said maintenance of feeding tubes were the responsibility of the nursing staff. She said there was a risk of a feedings being old if there was not a time on it to show when it was hung. She said going forward, they would be monitoring along with the DON to ensure they were labeled properly. Record review of a RN/LPN Competency Checklist dated [DATE] for LVN A by the ADON indicated she was competent in set up and maintain oxygen and maintenance of g-tubes. Record review of the facility's policy titled Care and Treatment of Feeding Tube dated [DATE] indicated, .It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible .

Based on interviews and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 1 of 15 staff (the DON) reviewed for develop and implement abuse policies. The facility failed to ensure HR implemented the facility's abuse/neglect policy and procedure when she failed to complete a Criminal History check for the DON upon hire. This failure could place residents at risk for abuse, neglect and/or exploitation. Findings included: Record review of the personnel file for the DON indicated he was hired at the facility on 4/8/2024 and his criminal history check was not done until 5/21/2024. During an interview on 5/22/2024 at 10:55 AM, HR said she started at the facility October 2023 but did was not assigned HR duties until January 2024. She said she was responsible for new hires and conducting background checks. She said the criminal history checks were to be completed before the new hire came into the facility for orientation and then yearly thereafter. She said she did not know what happened and why the DON's criminal history was not checked. She said it was checked on yesterday 5/21/2024 when they realized he did not have one. She said she received training from the previous Administrator on completing the criminal history and background checks. She said going forward she would make sure everyone had their backgrounds check and would check before and after they were hired. During an interview on 5/22/2024 at 11:34 AM, the Administrator said background checks and criminal history checks were the responsibility of HR. She said she was not sure why the DON did not have a criminal history check when he was hired at the facility. She said the criminal history check should be checked within 2 days of an offer letter and prior to starting employment. She said there could be a risk of hiring someone that has a criminal background. She said residents could be at risk for exploitation or abuse. She said going forward, the HR had a check list to use, and she was in-serviced on yesterday 5/21/2024 on background checks. Record review of an in-service dated 5/21/2024 on background checks was conducted by the Administrator to HR. Record review of the facility's policy titled Abuse, Neglect, Exploitation, and Misappropriation of Property Prevention, Protection and Response Policy and Procedures revised 12/17/2018 indicated, .1. Screening Issues: B. Criminal background checks as required . Record review of the facility's policy titled Background Screening Investigation revised March 2019 indicated, .Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on all applicants for positions with direct access to residents. 2. Background and criminal checks are initiated within two days of an offer of employment or contract agreement, and completed prior to employment .

The facility failed to ensure that all written grievance decisions included date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusion regarding the resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued for 1 of 8 residents (Resident # 10) reviewed for grievances. The facility failed to provide rationale or response to the residents on their concerns or requests. This failure could place residents who file grievances at risk of frustration, a decreased confidence in administration and a decrease in resident rights. Findings include: Record review of a face sheet dated 4/4/23 for Resident #10 revealed that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Schizophrenia (mental disorder in which people interpret reality abnormally), osteoarthritis (joint pain), and peripheral vascular disease (poor circulation). Record review of a quarterly MDS dated [DATE] for Resident #10 revealed that she had a BIMS score of 15, indicating that she was cognitively intact with no impaired thinking. During an interview on 4/02/2023 at 2:00 P.M. Resident #10 voiced concerns that administration did not listen to or follow up on her grievances. During an interview on 4/03/2023 at 3:45 p.m. the SW said she was the grievance officer and had been in this position since January of 2023. She said she would always file a grievance form anytime a resident or family member came to her with a concern. She said it was their policy to have grievances resolved and followed up on within 5 days of it being filed. She said the resident or family member filing grievances would be notified of the resolution within those 5 days. During an interview on 4/03/2023 at 3:50 p.m. the ADON said she would always file a grievance when a resident or family member came to her with any issues. She said if there were any concern with abuse or neglect issues, she would immediately report to Administrator due to being a short window to get those issues reported to the State Agency. During an interview on 4/3/23 at 4:00 p.m. the DON and ADM both stated they always filed formal grievances when a resident or family member came to them with a grievance. Both said they always followed up with residents when investigations were completed and resolved. The ADM said she was not responsible for grievances, that it was the SW who was responsible for grievances and follow up. The DON said there could be a risk of psychosocial issues to residents who felt like they were not listened to and it could discourage them from coming forward with concerns. During an interview with Resident #10 on 04/04/23 at 10:40 AM she said she had filed multiple grievances regarding the food and nurse aide's being rude to her and she had not been given a written copy or been followed up with verbally on any of her grievances. During an interview on 4/4/23 at 10:58 a.m., the SW said she did not provide a written copy of the investigation and resolution for grievances unless the resident or family member requested one. She said she normally did not ask them if they wanted a copy, but she would just check no in that spot of the form if they did not specifically ask for one. She was unsure as to why there were blanks in the grievance form for 2/1/23 for Resident #10. She said that she must have overlooked them. She said she would ask going forward if the resident would like a copy provided to them. The SW clarified verbally that the blank in their facility policy should read 5 working days (please see below). She said she could not think of any harm that could come to the residents by not following up on grievances. Record review of grievance log for January 1, 2023 through March 31, 2023 revealed the following: Grievance dated 2/1/23 for Resident #10, with .date written opportunity presented to grievance official . left blank; .date of response . left blank; and .written decision of grievance requested . checked no. Record review of facility policy titled Grievances/Complaints, Recording and Investigating dated 2001, revised April 2017 revealed: .The Administrator has assigned the responsibility of investigating grievances and complaints to the Grievance Officer .a written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office

Based on observation, interview, and record review the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 4 residents reviewed for accidents and supervision. (Resident #1) The facility failed to notify medical transportation about a cancelled appointment for Resident #1. The resident was taken to the cancelled appointment on 8/10/2022. After being dropped off by medical transportation, she left the appointment and was lost for approximately 28 hours and later found by police on 8/11/2022 at approximately 2:30 PM in a wooded area behind an empty lot lying on the ground on her back. She was taken to a hospital by EMS. The facility failed to recognize Resident #1 had not returned from an appointment for approximately 9 hours. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 8/25/2022. While the IJ was removed on 8/26/2022, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated. This failure placed Resident #1 at risk of injury and death. Findings included: Record review of an Admission Record dated 8/12/2022 for Resident #1 indicated she was readmitted to the facility on [DATE] with an original admitted [DATE] and was [AGE] years old with diagnoses of transient cerebral ischemic attack (symptoms of a stroke), chronic combined systolic and diastolic heart failure (heart not being able to pump effectively), [CONDITION(S)] disorder (mood disorder), hypertension (high blood pressure), presence of cardiac pacemaker (a device in the heart that makes it pump) and [CONDITION(S)] (poor circulation in the blood vessels). Record review of a Quarterly MDS Assessment for Resident #1 dated 6/15/2022 indicated a BIMS score of 13 meaning no cognitive impairment. She required set up help only with bed mobility, transfers, dressing, toilet use and personal hygiene. Balance during transitions and walking indicated she was not steady, but able to stabilize without staff assistance and did not require any mobility devices. Record review of an Admission MDS Assessment for Resident #1 dated 1/12/2022 indicated a BIMS score of 13 meaning no cognitive impairment. She required set up help only with bed mobility, eating, and toilet use. Balance during transitions and walking indicated she was not steady, but able to stabilize without staff assistance and did not require any mobility devices. She did not have any behaviors related to wandering and there was not any change in behavior or other symptoms. Record review of a social service progress note for Resident #1 by SW was created on 7/29/2022 at 12:09 PM indicated Resident #1 had a scheduled appointment on 8/10/2022 and transportation had been arranged. Record review of a new care plan for Resident #1 dated 8/12/2022 indicated she was an elopement risk/wanderer related to history of attempts to leave the facility unattended, did not resident on a secure unit, and had impaired safety awareness of diagnoses of [CONDITION(S)] disorder with impulsive behaviors. Interventions included to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Record review of a care plan for Resident #1 dated 10/28/2019 and revised on 8/11/2022 reflected the resident had poor judgement related to [CONDITION(S)] disorder. Interventions included to observe for any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness. Record review of a care plan for Resident # 1 undated indicated she was a fall risk and had an actual fall on 8/1/2022 with a laceration over her right eye-8 stitches. Record review of a care plan for Resident #1 dated 8/11/2022 for behaviors indicates she has a diagnosis of [CONDITION(S)] disorder, resident will have varying mood outbursts, resident can be noncompliant with care, refusing to not go outside unattended, resident will make her own appointments and transportation arrangements and not notify staff until the last minute. Record review of a physician's order summary report dated 8/12/2022 indicated Resident #1 was an elopement risk, resident to be on one on one ordered on 8/11/2022. Record review of a MAR dated 8/1/2022-8/31/2022 for Resident #1 indicated on 8/10/2022 she missed taking these medications as indicated by a blank box or by a number 1 or 3 that she indicated she was absent from the facility: 1. [MEDICATION(S)] (blood thinner) 5 mg given one tablet by mouth two times a day for heart failure was due to be given at 9:00 PM. 2. [MEDICATION(S)] 12.5 (heart medication) mg give one tablet by mouth every 12 hours for hypertension was due to be given at 9:00 PM. 3. [MEDICATION(S)] (for sleep) 5 mg give two tablets by mouth at bedtime for [CONDITION(S)] was due to be given at 9:00 PM. 4. Requip (restless legs) 10 mg give one capsule by mouth one time a day for hypertension was due to be given at 9:00 PM. 5. [MEDICATION(S)] (for sleep or depression) 150 mg give one tablet by mouth at bedtime for [CONDITION(S)]/depression was due to be given at 9:00 PM. 6. [MEDICATION(S)] (muscle spasms) 10 mg give one tablet by mouth every 12 hours for muscle spam was due to be given at 9:00 PM. 7. [MEDICATION(S)] sodium (stool softener) 100 mg give one tablet by mouth two times a day for constipation was due to be given at 9:00 PM. 8. [MEDICATION(S)] (acid reducer) 40 mg give one tablet by mouth every 12 hours for ulcer was due to be given at 9:00 PM. 9. Acetaminophen-[MEDICATION(S)] (pain medication) 300 mg/30 mg give one tablet by mouth three times a day for pain was due to be given at 2:00 PM and 9:00 PM. 10. [MEDICATION(S)] (nerve pain medicine) 300 mg give one capsule by mouth three times a day for pain was due to be given at 2:00 PM and 9:00 PM. 11. [MEDICATION(S)] (coating for stomach) 1 gram give one tablet by mouth before meals for GERD was due to be given at 11:00 AM and 4:00 PM. 12. [MEDICATION(S)] hcl (blood pressure) 25 mg give one tablet by mouth every 6 hours for hypertension was due to be given at 11:00 AM, 5:00 PM and 11:00 PM. Record review of a MAR dated 8/1/2022-8/31/2022 for Resident #1 indicated on 8/11/2022 she missed taking these medications as indicated by a blank box or by a number 1 or 3 that she said she was absent from home: 1. [MEDICATION(S)] 5 mg give one tablet by mouth two times a day for heart failure was due to be given at 9:00 AM. 2. Calcium-vitamin d 600 mg/200 mg-unit give one tablet one time a day for [CONDITION(S)] was due to be given at 9:00 AM. 3. [MEDICATION(S)] suspension (allergy nose spray) 50 mcg/act two sprays in both nostrils in the morning for allergic rhinitis was due to be given at 9:00 AM. 4. Folic acid (vitamin) 1 mg give one tablet by mouth in the morning every Monday and Thursday for [CONDITION(S)] was due to be given at 9:00 AM. 5. [MEDICATION(S)] (fluid pill) 20 mg give one tablet by mouth one time a day for heart failure was due to be given at 9:00 AM. 6. [MEDICATION(S)] (blood pressure) 10 mg give one capsule by mouth one time a day for hypertension was due to be given at 9:00 AM. 7. Senna tablet (stool softener) 8.6 mg give one tablet by mouth one time a day for constipation was due to be given at 9:00 AM. 8. Vitamin C 500 mg give one tablet by mouth in the morning for supplement was due to be given at 9:00 AM. 9. [MEDICATION(S)] (heart medication) 12.5 mg give one tablet by mouth every 12 hours for hypertension was due to be given at 9:00 AM. 10. [MEDICATION(S)] 10 mg give one tablet by mouth every 12 hours for muscle spasms was due to be given at 9:00 AM. 11. [MEDICATION(S)] sodium 100 mg give one tablet by mouth two times a day for constipation was due to be given at 9:00 AM. 12. [MEDICATION(S)] 40 mg give one tablet by mouth every 12 hours for ulcer was due to be given at 9:00 AM. 13. Acetaminophen-[MEDICATION(S)] 300 mg/30 mg give one tablet by mouth three times a day for pain was due to be given at 9:00 AM and 2:00 PM. 14. [MEDICATION(S)] 300 mg give one capsule by mouth three times a day for pain was due to be given at 9:00 AM and 2:00 PM. 15. [MEDICATION(S)] tablet 1 gram give one tablet by mouth before meals for GERD was due to be given at 7:30 AM and 11:00 AM. Record review of nurse progress notes did not indicate an appointment for Resident #1 on 8/10/2022 or a cancellation of an appointment on 8/10/2022. Record review of a nurse progress note for Resident #1 by the DON indicated it was created on 8/11/2022 at 1:12 PM with an effective date of 8/10/2022 at 6:19 PM. She indicated at approximately 6:15 PM, this writer received a phone call from a nurse at the facility, stating that Resident #1 had not returned from her appointment early during the day. Resident #1 was transported to an appointment via outside transportation service. Her appointment was at 10:30 AM and she was picked up by the transportation company at approximately 9:30 AM. This nurse called the transportation service and verified that Resident #1 was picked up and dropped off to her appointment. Record review of a nurse progress note for Resident #1 by LVN B indicated it was created on 8/11/2022 at 1:11 AM with an effective date of 8/11/2022 at 1:10 AM. She indicated upon arriving in building for shift, Resident #1 was not in facility, notified DON. Record review of the facility appointment book for the resident's indicated Resident #1 had an appointment scheduled for 8/10/2022 at 10:30 AM with a GI doctor. The location and contact information were present. Transportation was not needed by the facility and indicated the name of the transport company, reservation number and pick up time at the facility from 9:00-9:30 AM. The book was kept in MR office. Record review of a police report dated 8/18/2022 indicated Resident #1 was reported missing to the police department on 8/10/2022 at 12:39 PM. The nursing facility where she resided was contacted and they were told that Resident #1 was transported to an appointment by a transportation company. Resident #1 was dropped off by the transportation company on 8/10/2022 for a 10:30 am appointment and was supposed to be picked up around 11:30 am on 8/10/2022. Resident #1's son said after learning she had never been picked up, he contacted the police department and drove to the doctor's office looking for her. Resident #1's son reported that her mental state appeared to be declining as she would argue with him about her birthday. While the officer was on the scene, it was learned that at approximately 10:20 am on 8/10/2022 there had been a welfare check matching the description of Resident #1 in the area of the doctor's appointment. A citizen called in to report an elderly female matching the description of Resident #1 was seen walking in the area. Officers were dispatched to the location and arrived in minutes. The area was checked thoroughly, and the female described by the citizen was not located. Officer's spoke to [NAME] working in the area and they advised the female told them she was trying to get to any eye appointment. Officers checked the surrounding areas and Resident #1 was not located. The process for a silver alert was also started and with the information obtained a silver alert for Resident #1 was issued. On 8/11/2022 the search continued, and an area was searched close to the original location and while searching the wooded area around the creek they heard a person yell from the woods or in a back yard of one of the houses. One of the detectives yelled that they were the police department looking for a response and Resident #1 responded, and she was located on the other side of the fence directly behind an empty lot. She was found lying on the ground on her back, but she was alert and conscious. Resident #1 was able to state her name and birthday. EMS arrived on scene and some fence pickets had to be removed in order for them to access the area where Resident #1 was located. Her walker was about 50 yards through the woods that she had left in a thick pile of limbs. Resident #1 was taken to the hospital and dispatch was notified that she was located and to remove her as missing and to cancel the silver alert. Resident #1's son was contacted and notified that she was located and would be transported to the hospital. During an interview on 8/12/2022 at 10:20 AM, the Administrator said they were having a meeting today with Resident #1's family to discuss alternate placement or admission to a psych facility for treatment. She said she was concerned about her being a flight risk now and she would walk away from the facility. She said she was PASSR positive for mental illness for [CONDITION(S)] disorder but refused services. She said they had been unable to reason with her and she was on one on one and prior to the incident she did not require any supervision. She said she was with it enough to know what was going on and knew every code to the exit doors in the facility. She said she was very manipulative and psych services was seeing her at the facility. She said she had been going to appointments on her own and did not have any issues until now. She said she was scheduled for an appointment on 8/10/2022 to see a GI (gastrointestinal stomach) specialist, but the appointment was cancelled the evening before on 8/9/2022. She said for their managed care insurance residents they had been utilizing the transportation services with them and she had transportation scheduled for pick up that morning on 8/10/2022 for Resident #1. She said there was some miscommunication because the transportation pick-up person arrived at the facility that morning to pick Resident #1 up. She said he called to the facility to let them know that he was there to take her to the appointment. The Administrator stated the receptionist told the charge nurse and the nurse assisted Resident #1 to get ready and she left with the driver. She said she was taken to the doctor's office. She said the driver waited in the parking lot for her and she never came out of the doctor's office and the driver left after she did not come out and they were never notified that the resident was not going to be brought back to the facility. She said a construction worker in the area spotted her initially on 8/10/2022 shortly after her 10:30 AM appointment and notified the police about a welfare check. She said the police notified the facility that Resident #1 was reported in the area earlier that day and they started a search for the resident. She said Resident #1 was found by the police on 8/11/2022 at approximately 2:30 PM coming out of the woods in the area where she was originally spotted. She said Resident #1 had been a resident at the facility for a long time. She said she had left the facility before and would go outside but staff would follow her. She said on one occasion she left the premises and walked to the store down the road and bought some cigarettes and a lighter. She said the resident did not qualify for a wander guard. She said she was in a gray area (knew what was going on most of the time but would make irrational decisions) and could not be treated at their facility. She said it was more of a mental illness and they were going to try and send her to a psych facility. She said the family had a lot of dynamics going on right now, but they had been talking to her son who was the RP. During an interview on 8/12/2022 at 10:30 AM, the DON said medical records was responsible for scheduling appointments. She said they were still investigating trying to figure out what happened with Resident #1. She said she was more confused with whoever took the call about the cancellation. She said Medical Records said she knew it was cancelled on 8/9/2022. She said Medical Records told her she forgot to cancel transportation for Resident #1. She said the breakdown was when the appointment was cancelled, and it should have been put on the calendar to notify whomever, by phone of the cancellation. She said they called transportation to get the timeframe for drop off and pick-up time and the pick-up time was at 11:30 AM on 8/10/2022, and when the driver made it back to the doctor's appointment, Resident #1 was not there. She said dispatch nor the driver called the facility to notify them that Resident #1 was not at the doctor's office when he arrived. She said when the camera footage at the nursing facility was reviewed from that morning on 8/10/2022 to see exactly what time she left, the receptionist went outside to verify who the driver was because the driver had called the facility and talked to him. She said the transportation driver had the number to the facility. She said the receptionist, being newer to the facility told a nurse to get the resident for her appointment. She said the police notified them on 8/10/2022 at 8:20 PM that a welfare check was called at 10:32 AM on 8/10/2022 and an officer arrived at the location, and she could not be found. She said she found out Resident #1 was missing when the nurse at the facility called her about 6:00 PM-6:15 PM on 8/10/2022. She said she was worried and was trying to find out where Resident #1 was. She said she then tried calling the clinic where the appointment was supposed to be and could not leave a message. She said she called the hospitals in the area to make sure she was not admitted to a hospital. She said a family member notified the police after trying to figure out where she was. She said she did not call the family member initially but notified family after she was not at the hospitals. She said she asked him if they knew where she could be, and he said he was going to call other family members to see if they knew anything. She said she notified the Administrator that the resident's family member was going to call the police. During an interview and observation on 8/12/2022 at 10:43 AM, Resident #1 and her family member were present. Resident #1 was lying in bed resting with her eyes closed, easily aroused. Said she had been at the facility for about 3 years. A skin tear was above her right eye, but she said it was there before she left the facility the other day. A faded bruise was on her right cheek. Multiple scratches were on both arms and legs, and she said she got those while she was out of the facility. She was alert and oriented to person, place, and time. When asked to tell the events that happened on 8/10/2022 she said she left the facility with a transportation driver on 8/10/2022, and it was normally the same driver that came. She said he was supposed to take her to the hospital to have her pacemaker checked but he took her to another place, and it was a clinic but the wrong one. She said when she walked in for the appointment, she sat down and waited for a little while and then checked in with the receptionist and was told she was at the wrong place. She said she was told that her appointment was for her heart and was told the name of the clinic. She said she left that clinic and started walking in the direction she thought the appointment was. She said she walked across the area, crossed the highway to get to the other clinic for the appointment and said there was not any place to stand or walk on the side of the road. She said she walked in the grass and talked to a person who was working and asked him for directions to her appointment and was told to go up and cross the next intersection and the office would be there. She said when she started going up there, she saw some electric workers working in the area and asked them for directions and they told her to go all the way up and across the street but said it was a long way. She said she walked a little further and when she arrived to where she thought the appointment was, she could not find it. She said she was lost and tried to go back to the first place and could not get back. She said she evidently turned in a different area and could not get back. She said she walked all night trying to find the way and it was dark and there was not any light. She said she was in the wrong area trying to find it. She said the transport driver never came back and he would usually leave his number for her to call him to come back to pick her up. She said the morning of 8/10/2022 when the medical transportation arrived at the facility, she was outside watering the flowers and was told that she needed to come up front because she had an appointment. She said she knew there was a cancelled appointment because they had told her the day before and she thought it was for another appointment that had been scheduled for her eyes or heart. She said she had never left the facility before and them not know where she had gone. She said she was walking through the woods that night trying to figure out a way to get out. During an interview on 8/12/2022 at 10:50 AM with Resident #1's family member, she said they were notified that Resident #1 was missing on Wednesday night (8/10/2022) at 7:38 PM by the Administrator and said she talked to her spouse. She said her spouse told her that Resident #1 was missing. She said the Administrator said Resident #1 had been taken to the GI doctor and could not verify if she had been to the doctor and the driver returned in an hour and she was never brought back outside. She said they were told Resident #1's appointment was at 10:30 AM on 8/10/2022 and the driver dropped her off at 10:07 AM and he came back at around 11 AM and she was not downstairs waiting outside. She said that night on 8/10/2022 they started towards the city where the appointment was located and were given the address of the doctor's office. She said within 5 minutes of them leaving, they called the police to report a missing person and met the patrol office there around 8 PM that evening. She said the officer was there but had not been there long. She said the BOM, and DON were present and came to where the police officer was. The family member said they said there were other people in the area looking for Resident #1. She said they were in constant communication with the Administrator. She said they stayed until close to midnight and through the officer's investigation they were trying to see if they had enough information to elevate the missing person to a silver alert. She said the silver alert was issued at 1:23 AM on 8/11/2022. She said the officer told them at 10:20 AM on 8/10/2022 an alert was called in to the local police about an elderly lady walking in the area matching her description earlier that day. She said they drove back to the nursing facility and discovered that Resident #1 had left her cellphone and they checked her messages and call log to see if there had been any information that would indicate where she might have been. She said Resident #1 was told on Tuesday 8/9/2022 that her appointment was cancelled, and she was taken to her appointment anyway on Wednesday 8/10/2022. She said Resident #1 knew the appointment for the GI doctor was cancelled and she was not prepared for the appointment and when medical transportation came to the facility to pick her up, she was confused and thought it was another appointment and not for the GI doctor. She said Resident #1 thought it could have been for her eyes or something else because she had those appointments scheduled as well but not for that day. She said the only thing her family was concerned about was that the facility discovered that she was missing after 5 PM on 8/10/2022 because the doctor's office was closed. She said her spouse was not notified until 7 PM that Resident #1 never came back from a 10:30 AM appointment and they never called the police. She said her husband called the police to notify them. She said once the search started, the nursing facility staff was wonderful to them. During an interview on 8/12/2022 at 1:26 PM, the facility Receptionist said he worked and the facility Monday-Friday from 8 AM-5 PM. He said he received a phone call from a gentleman from a transportation company on 8/10/2022 and said he was there to pick up Resident #1 and he told him he would investigate that. He said there was a car with their logo that was parked outside the facility, and he went outside and talked to him to find out where the resident was going. He said the driver told him that Resident #1 had a gastro appointment, and he went back inside the facility and looked for Resident #1, but she was not in her room. He said Resident #1 was not at the smoking area, and he spoke a nurse who helped look for her. He said he went back outside and told the driver they were trying to find her. He said a nurse and not Resident #1's charge nurse came around the corner and Resident #1 was inside, and that nurse escorted her to the car, and they left the facility. He was unable to identify who the nurse was. During an interview on 8/12/2022 at 1:35 PM LVN A said she worked for a staffing agency and had been working at the facility for almost a year. She said she worked on the day Resident #1 was missing on Wednesday 8/10/2022. She said she worked the morning of 8/10/2022 and she received a report from the night nurse that did not mention anything about any appointment for the residents she was taking care of that day. She said the only thing she was told was about a lab for someone and it was scheduled at 5:45 AM. She said normally if residents had an appointment, the nurses were aware, and information would be shared in morning report that a resident had an appointment and would know to have their paperwork ready for the appointment. She said the night nurse did not know anything about an appointment either. LVN A said Resident #1 was gone to an appointment and no one ever told her about an appointment for Resident #1. She said on the morning of 8/10/2022, Resident #1 was given an inhaler by her. She said normally when she had an appointment, Resident #1 would remind them to have her paperwork ready. She said Resident #1 never mentioned anything to her about an appointment when she gave her morning dose of the inhaler. LVN A said she asked the ADON about 4 PM-5 PM if she had heard or seen Resident #1 and she said she had not. She said she proceeded on with her day. LVN A said at 6 PM when her shift was ending, she gave report to the incoming nurse that Resident #1 was still gone to an appointment. LVN A said she received a call at about 8 PM from the DON that they were looking for Resident #1 and told her she did not find out about her being at an appointment until around 2 PM. She said she would make a progress note when a resident left the facility and when they returned. She said the facility did not have an appointment book at the nurse's station, so they just relied on the nurse report. She said someone received a call from the physician's office that Resident #1's appointment was cancelled but she couldn't specify when the phone call was received. During an interview on 8/12/2022 at 2:03 PM HR/BOM said she had been employed at the facility for 2 years. She said she was responsible for personnel files, financing, hiring, payroll and paying bills. She said she frequently answered phone calls at the facility. She said she did take the call from the physician's office late Tuesday evening on 8/9/2022 and it was a random pick-up call because the phone was ringing. She said she did not ask for the name, they just said they were cancelling the appointment for Resident #1 that was scheduled for 8/10/2022 at 10:30 AM because they did not accept her insurance. She said she finished up what she was doing and came out of the office and saw Resident#1 and told her the physician had cancelled her appointment because of her insurance and told her to come see her in the morning so they could figure out her insurance. HR/BOM said there was a nurse doctoring Resident #1's face and she was talking to Resident #1. She said Resident #1 and a nurse were behind the nurse's station and she was talking to Resident #1 and told her they had cancelled her appointment. She said Resident #1 was not too thrilled about the cancellation and she assumed that the nurse heard the conversation about the cancelled appointment. She said she did not know who would was responsible for cancelling transportation, but if she received a call like that then she would notify the resident and the nurse. During an interview on 8/12/2022 at 2:11 PM, MR said she had been employed at the facility for 5 months. She said she became responsible for appointments for the residents about a week ago. She said she just learned that her job duties included cancelling medical transportation. She said she was responsible for setting up the appointments. She said if an appointment was cancelled then usually, she was notified by whoever took the call or received the cancellation notice. She said a nurse told her on Wednesday 8/09/2022 that Resident #1's appointment on 8/10/2022 had been cancelled and she would not be able to go because it was something about her insurance. She said she never called and set up transportation initially and did not know to call and cancel it. She said she was the transportation driver at the facility and drove the facility's vehicle. She said she just took over that current position and Resident #1's appointment on 8/10/2022 was already set up. She said she only received a few minutes of training from the previous SW who was responsible for it before. She said currently she had 5 different positions that she was responsible for at this time. During an interview on 8/12/2022 at 3:44 PM, the dispatcher with the medical transportation company said a driver was dispatched to pick up Resident #1 on Wednesday 8/10/2022 and arrived at the facility at 9:15 AM and left at 9:21 AM. She said Resident #1 was dropped off at her appointment at 10:08 AM, she was using a walker and was able to assist herself. She said the driver stayed in the area as they were not allowed to go with the residents to their appointments. She said they were a curb to curb transport. She said sometimes if the resident needed assistance, then they would help them out of the vehicle and into the appointment but would not stay with them. She said the driver left and went to a restaurant across the street and hung out in the area until 11:30 AM-11:45 AM. She said he called the physician's office and told them he had to leave, and he was told that Resident #1 did not have an appointment and the physician did not see Resident #1. She said they did not think much about it at the time as it was not unusual for family to pick up their loved ones or they ended up getting admitted to the hospital. She said they did not hear from the nursing facility until about 7 PM on 8/10/2022 regarding being unable to locate Resident #1. She said it happened a lot, and they were not notified unless they called and asked. During an interview on 8/12/2022 at 4:11 PM, a driver with medical transportation said he picked up Resident #1 on Wednesday morning 8/10/2022 at the nursing facility and dropped her off at the clinic. He said he then left and went to get something to eat in the area because she did not have a pick-up scheduled for another hour. He said he called the clinic that was on file for Resident #1 and was told she did not have an appointment that day, so he figured they had entered the wrong number or something for her. He said he contacted dispatch to let them know and was told to go ahead to his next stop. He said if they went over the allotted time, then the dispatch would send another driver. He said he did not call the nursing home because he knew she was not there because he had dropped her off at the doctor's appointment. He said the only time he spoke to the nursing facility staff was that morning when he arrived to pick her up. During an interview on 8/12/2022 at 4:45 PM, the Administrator said going forward appointments would be placed on a dashboard in the computer charting system and no resident would be allowed to be transported by themselves without her prior approval. She said a resident could be at risk for injury if they were transported to an appointment by themselves. She said the facility would no longer use the medical transportation company that picked up Resident #1 to transport any of their residents to appointments. Record review of a facility policy titled Wander and Elopements with a re

Based on interview and record review, the facility failed to consult with the physician regarding a resident's physical status and the deterioration in physical status for 1 of 8 residents reviewed for notification of changes. (Resident #1) The facility did not consult with the physician for treatment orders when Resident #1 was admitted with an open area on his coccyx (bone connected to the bottom of the sacrum) and did not notify the physician when the area worsened. Resident #1 was admitted with a healing open area to his coccyx measuring 2.5 cm and 12 days later the wound had developed to an unstageable pressure injury measuring 10 cm x 14 cm. This failure contributed to Resident #1's unstageable pressure injury to his sacrum necessitating excision (cut out) completely down to the muscle. This failure could place residents at risk of not receiving needed services and treatments. Findings included: A progress note dated 12/17/18 indicated Resident #1 was transferred to an acute care facility for evaluation and treatment for [REDACTED].#1 did not return to the facility. An admission record dated 12/05/18 indicated Resident #1, admitted [DATE], was [AGE] years old and had a healing open area to his coccyx measuring 2.5 cm. A physician order [REDACTED].#1 did not contain any orders or treatments of his pressure injury. A skin observation tool dated 12/06/18 completed by the treatment nurse indicated Resident #1 had a healing open area on his coccyx. The skin observation tool indicated a dressing to the area was removed, the area was cleaned, and a clean dressing applied. The observation tool did not include a description or measurement of the wound. A baseline care plan dated 12/06/18 indicated Resident #1 was at risk for pressure injuries with interventions of turning and repositioning. The baseline care plan did not address the open area on Resident #1's coccyx. A skin observation tool completed by the treatment nurse dated 12/11/18 indicated Resident #1 had redness on his coccyx area with slight discomfort noted. The observation tool indicated the area was cleaned, barrier cream applied, and a foam sacral dressing was applied for padding. The resident was positioned on his side with pillows in place for cushioning. The observation tool did not include a description or measurement of the area. The MDS dated [DATE] indicated Resident #1 had severe cognitive impairment. The MDS indicated Resident #1 was frequently incontinent of bladder and bowel and required extensive assistance with bed mobility, dressing, personal hygiene and locomotion on and off the unit. The MDS indicated Resident #1 was at risk for developing pressure injuries and did not have a pressure injury. An undated care plan indicated Resident #1 had the potential for pressure injury development on his coccyx/sacral area related to history of pressure injury and immobility. Goals included Resident #1's pressure injury would show signs of healing and/or remain free from infection by/through the review date. Interventions included to avoid positioning Resident #1 on his back. An emergency department provider note dated 12/17/18 at 3:14 p.m., completed by a physician at an acute care hospital indicated Resident #1 had a large deep soft tissue wound in the sacral region. A wound care evaluation/progress note dated 12/18/18 at 8:39 a.m., completed by a wound/ostomy/continence registered nurse indicated Resident #1 had an unstageable pressure wound with nonhealing/black/dark edges and a fragile, purple wound bed measuring 10 cm x 14 cm with a small amount of moderately odorous drainage. An operative report dated 12/21/18 indicated Resident #1 had a stage 4 sacral decubitus ulcer (pressure injury). The report indicated Resident #1 had an excisional debridement of the wound due to necrotic (dead) tissue that required removing skin, fat, and muscle. The report indicated the decubitus ulcer on the sacrum was excised completely down to the muscle. During an interview on 12/21/18 at 11:00 a.m., the treatment nurse said Resident #1 was unable to reposition himself without extensive assistance. The treatment nurse said she was checking Resident #1 daily due to his history of wounds on his coccyx/sacral area. She indicated the area was closed and appeared pink but mushy. She said she did not measure the area, but it was the approximate size of a 50-cent piece. The treatment nurse said she was applying a foam dressing to the area daily to protect it from breakdown. She said she did not document this care and there was no order for the treatment. The treatment nurse said she never notified the physician of her concerns. During an interview on 12/21/18 at 1:00 p.m., the DON said the facility had a treatment nurse who worked Monday through Friday and a weekend RN that completed wound care on the weekends. The DON said as far as she knew Resident #1 had a reddened area upon admission and the treatment nurse was monitoring the area daily and applying a protective dressing. The DON said the facility had recently had pressure injury prevention training and had no residents with pressure injuries in the facility. The DON said she expected the physician to be notified any time there was a new wound and when there was a change in a wound. She said the physician should be notified if a wound worsened. The DON said every patient that was incontinent was on every 2-hour turning and repositioning routine. A revised facility policy dated 7/17 entitled Prevention of Pressure Ulcers/Injuries indicated the following: .Identify any signs of developing pressure injuries (i.e. nonblanchable [DIAGNOSES REDACTED]). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency., evaluate, report, and document potential changes in the skin. The website http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ accessed 01/04/18 indicated: .Pressure Injury: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry,

Based on interview and record review, the facility failed to ensure necessary treatment and services consistent with professional standards of practice to promote healing of a pressure injury was provided for 1 of 8 residents reviewed for pressure injury. (Resident #1) The facility did not identify a pressure injury for Resident #1 on the MDS (comprehensive) assessment, obtain a physician order [REDACTED].#1 was admitted with a healing open area to his coccyx (bone connected to the bottom of the sacrum) measuring 2.5 cm and 12 days later the wound had developed to an unstageable pressure injury measuring 10 cm x 14 cm. This failure contributed to Resident #1's unstageable pressure injury to his sacrum necessitating excision (cut out) completely down to the muscle. This failure could place residents receiving preventive skin care at risk for developing pressure injuries. Findings included: A progress note dated 12/17/18 indicated Resident #1 was transferred to an acute care facility for evaluation and treatment for [REDACTED].#1 did not return to the facility. An admission record dated 12/05/18 indicated Resident #1, admitted [DATE], was [AGE] years old and had a healing open area to his coccyx measuring 2.5 cm. A physician order [REDACTED].#1 did not contain any orders or treatments of his pressure injury. A skin observation tool dated 12/06/18 completed by the treatment nurse indicated Resident #1 had a healing open area on his coccyx. The skin observation tool indicated a dressing to the area was removed, the area was cleaned, and a clean dressing applied. The observation tool did not include a description or measurement of the wound. A baseline care plan dated 12/06/18 indicated Resident #1 was at risk for pressure injuries with interventions of turning and repositioning. The baseline care plan did not address the open area on Resident #1's coccyx. A skin observation tool completed by the treatment nurse dated 12/11/18 indicated Resident #1 had redness on his coccyx area with slight discomfort noted. The observation tool indicated the area was cleaned, barrier cream applied, and a foam sacral dressing was applied for padding. The resident was positioned on his side with pillows in place for cushioning. The observation tool did not include a description or measurement of the area. The MDS dated [DATE] indicated Resident #1 had severe cognitive impairment. The MDS indicated Resident #1 was frequently incontinent of bladder and bowel and required extensive assistance with bed mobility, dressing, personal hygiene and locomotion on and off the unit. The MDS indicated Resident #1 was at risk for developing pressure injuries and did not have a pressure injury. An undated care plan indicated Resident #1 had the potential for pressure injury development on his coccyx/sacral area related to history of pressure injury and immobility. Goals included Resident #1's pressure injury would show signs of healing and/or remain free from infection by/through the review date. Interventions included to avoid positioning Resident #1 on his back. An emergency department provider note dated 12/17/18 at 3:14 p.m., completed by a physician at an acute care hospital indicated Resident #1 had a large deep soft tissue wound in the sacral region. A wound care evaluation/progress note dated 12/18/18 at 8:39 a.m., completed by a wound/ostomy/continence registered nurse indicated Resident #1 had an unstageable pressure wound with nonhealing/black/dark edges and a fragile, purple wound bed measuring 10 cm x 14 cm with a small amount of moderately odorous drainage. An operative report dated 12/21/18 indicated Resident #1 had a stage 4 sacral decubitus ulcer (pressure injury). The report indicated Resident #1 had an excisional debridement of the wound due to necrotic (dead) tissue that required removing skin, fat, and muscle. The report indicated the decubitus ulcer on the sacrum was excised completely down to the muscle. During an interview on 12/21/18 at 11:00 a.m., the treatment nurse said Resident #1 was unable to reposition himself without extensive assistance. The treatment nurse said she was checking Resident #1 daily due to his history of wounds on his coccyx/sacral area. She indicated the area was closed and appeared pink but mushy. She said she did not measure the area, but it was the approximate size of a 50-cent piece. The treatment nurse said she was applying a foam dressing to the area daily to protect it from breakdown. She said she did not document this care and there was no order for the treatment. The treatment nurse said she never notified the physician of her concerns. During an interview on 12/21/18 at 1:00 p.m., the DON said the facility had a treatment nurse who worked Monday through Friday and a weekend RN that completed wound care on the weekends. The DON said as far as she knew Resident #1 had a reddened area upon admission and the treatment nurse was monitoring the area daily and applying a protective dressing. The DON said the facility had recently had pressure injury prevention training and had no residents with pressure injuries in the facility. The DON said she expected the physician to be notified any time there was a new wound and when there was a change in a wound. She said the physician should be notified if a wound worsened. The DON said every patient that was incontinent was on every 2-hour turning and repositioning routine. A revised facility policy dated 7/17 entitled Prevention of Pressure Ulcers/Injuries indicated the following: .Identify any signs of developing pressure injuries (i.e. nonblanchable [DIAGNOSES REDACTED]). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency., evaluate, report, and document potential changes in the skin. The website http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ accessed 01/04/18 indicated: .Pressure Injury: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed.

Based on interview and record review, the facility failed to provide services that meet professional standards of quality for 1 of 8 residents reviewed for pressure injury. (Resident #1) The facility did not identify a pressure injury for Resident #1 on the MDS (comprehensive) assessment, obtain physician orders [REDACTED]. Resident #1 was admitted with a healing open area to his coccyx (bone connected to the bottom of the sacrum) measuring 2.5 cm and 12 days later the wound had developed to an unstageable pressure injury measuring 10 cm x 14 cm. This failure contributed to Resident #1's unstageable pressure injury to his sacrum necessitating excision (cut out) completely down to the muscle. This failure could place residents receiving preventive skin care at risk for developing pressure injuries. Findings included: A progress note dated 12/17/18 indicated Resident #1 was transferred to an acute care facility for evaluation and treatment for [REDACTED].#1 did not return to the facility. An admission record dated 12/05/18 indicated Resident #1, admitted [DATE], was [AGE] years old and had a healing open area to his coccyx measuring 2.5 cm. A physician order [REDACTED].#1 did not contain any orders or treatments of his pressure injury. A skin observation tool dated 12/06/18 completed by the treatment nurse indicated Resident #1 had a healing open area on his coccyx. The skin observation tool indicated a dressing to the area was removed, the area was cleaned, and a clean dressing applied. The observation tool did not include a description or measurement of the wound. A baseline care plan dated 12/06/18 indicated Resident #1 was at risk for pressure injuries with interventions of turning and repositioning. The baseline care plan did not address the open area on Resident #1's coccyx. A skin observation tool completed by the treatment nurse dated 12/11/18 indicated Resident #1 had redness on his coccyx area with slight discomfort noted. The observation tool indicated the area was cleaned, barrier cream applied, and a foam sacral dressing was applied for padding. The resident was positioned on his side with pillows in place for cushioning. The observation tool did not include a description or measurement of the area. The MDS dated [DATE] indicated Resident #1 had severe cognitive impairment. The MDS indicated Resident #1 was frequently incontinent of bladder and bowel and required extensive assistance with bed mobility, dressing, personal hygiene and locomotion on and off the unit. The MDS indicated Resident #1 was at risk for developing pressure injuries and did not have a pressure injury. An undated care plan indicated Resident #1 had the potential for pressure injury development on his coccyx/sacral area related to history of pressure injury and immobility. Goals included Resident #1's pressure injury would show signs of healing and/or remain free from infection by/through the review date. Interventions included to avoid positioning Resident #1 on his back. An emergency department provider note dated 12/17/18 at 3:14 p.m., completed by a physician at an acute care hospital indicated Resident #1 had a large deep soft tissue wound in the sacral region. A wound care evaluation/progress note dated 12/18/18 at 8:39 a.m., completed by a wound/ostomy/continence registered nurse indicated Resident #1 had an unstageable pressure wound with nonhealing/black/dark edges and a fragile, purple wound bed measuring 10 cm x 14 cm with a small amount of moderately odorous drainage. An operative report dated 12/21/18 indicated Resident #1 had a stage 4 sacral decubitus ulcer (pressure injury). The report indicated Resident #1 had an excisional debridement of the wound due to necrotic (dead) tissue that required removing skin, fat, and muscle. The report indicated the decubitus ulcer on the sacrum was excised completely down to the muscle. During an interview on 12/21/18 at 11:00 a.m., the treatment nurse said Resident #1 was unable to reposition himself without extensive assistance. The treatment nurse said she was checking Resident #1 daily due to his history of wounds on his coccyx/sacral area. She indicated the area was closed and appeared pink but mushy. She said she did not measure the area, but it was the approximate size of a 50-cent piece. The treatment nurse said she was applying a foam dressing to the area daily to protect it from breakdown. She said she did not document this care and there was no order for the treatment. The treatment nurse said she never notified the physician of her concerns. During an interview on 12/21/18 at 1:00 p.m., the DON said the facility had a treatment nurse who worked Monday through Friday and a weekend RN that completed wound care on the weekends. The DON said as far as she knew Resident #1 had a reddened area upon admission and the treatment nurse was monitoring the area daily and applying a protective dressing. The DON said the facility had recently had pressure injury prevention training and had no residents with pressure injuries in the facility. The DON said she expected the physician to be notified any time there was a new wound and when there was a change in a wound. She said the physician should be notified if a wound worsened. The DON said every patient that was incontinent was on every 2-hour turning and repositioning routine. A revised facility policy dated 7/17 entitled Prevention of Pressure Ulcers/Injuries indicated the following: .Identify any signs of developing pressure injuries (i.e. nonblanchable [DIAGNOSES REDACTED]). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency., evaluate, report, and document potential changes in the skin. The website http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ accessed 01/04/18 indicated: .Pressure Injury: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed.