Every finding on record at Ignite Medical Resort Fort Worth, LLC

Based on observation, interview, and record review, the facility failed to respect the resident's right to personal privacy for three (Residents #1, #2 and #3) of seven residents reviewed for resident rights. The facility failed to ensure RN A did not leave Residents #1, #2 and #3's empty medication cards on top of her unattended medication cart that was viewable for anyone to see. The medication cart was in front of room [ROOM NUMBER] then RN A opened room [ROOM NUMBER]'s door and walked up to the medication cart. This failure could place residents at risk of having their medical information disclosed by residents and visitors which could cause embarrassment, frustration, and feelings of decreased privacy, resulting in a decline in their health and psycho-social well-being. The findings included: 1) Record review of Resident #1's admission MDS assessment dated [DATE] revealed, a [AGE] year-old female who admitted [DATE]. She had a BIMS score of 15 (no cognitive impairment) and had medically complex conditions. Record review of Resident #1's MAR dated July 2026 revealed she took 10 mg dicyclomine, 1 capsule by mouth three times per day for irritable bowel syndrome. 2) Record review of Resident #2's face sheet 07/16/26 revealed, a [AGE] year-old female who admitted [DATE]. Record review of Resident #2's MAR dated July 2026 revealed she took 100 mg Gabapentin, 1 capsule by mouth one time a day for neurotic [sic] (nerve) pain. 3) Record review of Resident #3's admission MDS assessment dated [DATE] revealed, an [AGE] year-old female who admitted [DATE]. She had a BIMS score of 15 (no cognitive impairment) and had medically complex conditions. Record review of Resident #3's MAR dated July 2026 revealed she took 10 mg Atorvastatin Calcium by mouth in the evening for hyperlipidemia. Observation on 07/16/26 at 10:05 am, revealed an unattended medication cart that was at the closed door of room [ROOM NUMBER]. On the medication cart were three medication cards, viewable for anyone to see that were sitting up against the pill crusher and the medication cart handle. The Medication cards were on top of the left side of the med cart. And there was 1 female staff that passed by the medication cart and went into Resident #3's room. Interview and observation on 07/16/26 at 10:09 am, revealed RN A opened room [ROOM NUMBER]'s door and walked up to the medication cart and grabbed the three medication cards to tear them up. The medication cards revealed Resident #1's dicyclomine 10 mg, Resident #2's gabapentin 100 mg and Resident #3's atorvastatin 10 mg. RN A tore the tops of the medication cards off and placed them inside the medication cart. She stated as soon as the medication cards were empty she should have torn the names off and put them into the shredder or just left the medication cards in the medication cart. She stated she felt like leaving the medication cards on the medication cart without her around was a HIPAA violation because anyone could have walked up to her medication cart to look at what type of medications the residents took. She stated with the residents' names and medication information on them, anyone could do something with that information but was not really sure what. She stated she was not sure when her last HIPAA training was. She stated her plan to prevent this from happening again was to leave the medication cards in the medication cart until she had time to take them to the shredder in the medication room. Interview on 07/16/26 at 5:25 pm, the CNO stated they did not have any issues with HIPAA noncompliance. She stated the medication cards should be stored in the medication cart until the nurses could properly put them in the shredder in the medication room at the nurses' station. She stated she was not aware RN A had left 3 of the residents' medication cards on top of the med cart while she was in a resident's room. She stated that was a HIPAA violation because someone else could have walked up and saw the residents' medication information. She stated the residents' names medication names, dosages and pharmacy info were on the medication cards and she expected the facility to maintain 100% protection of all resident's medical information. She stated HR did the HIPAA trainings that were done before the employees were hired. She stated everyone was responsible for HIPAA compliance but ultimately the Administrator and herself were responsible for ensuring everyone were HIPAA compliant. Interview on 07/16/26 at 6:10 pm, the Administrator stated the facility did not have any issues with compliance and if she saw or heard them not being compliant, she would educate them immediately. She stated the nurses knew they should have torn the names off the medication cards to shred and to throw away the rest of the medication cards. She stated she was not aware RN A left the residents' empty medication cards on an unattended medication cart. She stated the expectation for HIPAA compliance was for all residents' info to be protected and added it was the staff's responsibility for residents' names to never be out for anyone to see them. She stated even empty medication cards needed to be locked up in the medication cart until the name on them was shredded. She stated she was responsible for ensuring this facility was HIPAA compliant and said they have had HIPAA trainings with the staff, upon hire and throughout the year. She stated medication cards left out could result in a person not involved in the resident's care to read resident's personal health information. She stated this could lead to identity theft with the pharmacy information on them. She stated the residents needed privacy because they were residents at the facility. She stated she was going to educate RN A and monitor her to ensure her compliance with their HIPAA policy. She stated she was also going to report this HIPAA problem to QAPI for them to further discuss on what they could do to address this issue. Record review of the facility's Performance Form dated 07/16/26 revealed, Action outlined: RN A received coaching for policy violations/policy attached.Described what happened: Above employee with coaching on the importance of maintaining HIPAA at all times. Above employee educated to ensure that when she goes into a Guest's room that she ensures her computer screen is always locked or computer screen is always down. Above employee educated at no time she is to keep empty medication cards on top of the medication carts. Above employee educated on HIPAA policy and that it is completed with all staff annually and upon hire. The DON and RN A signed this document dated 07/16/26.Record review of the facility's Resident Rights policy revised 5/2023 revealed, GENERAL: To ensure each resident is treated with dignity and respect. This includes providing activities and interactions from staff, temporary agency or volunteers that is focused on assisting in maintaining and enhancing self-esteem, self-worth, individualizing goals, preferences, and choices.Responsible Party: Interdisciplinary Clinical Team. Protecting and respecting privacy space: Document in health records that are secure and accessible to only those involved in collaboration of the care planning process.Record review of the facility's Notice of HIPAA Practices revised date 05/2023 revealed, Policy: This facility is required by the privacy regulations issued under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to maintain the privacy of each of our elder's medical information and to provide elders with notice of the facility legal duties and privacy practices with respect to each elder's medical information.Protecting the confidentiality of each elder's personal information has been, and always will be, a top priority for this facility. All staff members of this facility treat protected information with respect and concern for each elder's privacy.This facility does not disclose any nonpublic personal information about any elder to anyone, except as permitted or required by law.Record review of the facility's Medication administration policy revised 04/2023 revealed, GENERAL: All medications are administered safely and appropriately to aid residents to and help in overcome illness, relieve and prevent symptoms and help in diagnosis. POLICY: .27. Empty any medication packaging with private health information into the appropriate shred bin.

Based on interview and observation, the facility failed to label drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 2 medication carts (Medication Cart#1) reviewed for labeled drugs. The facility failed to ensure insulin stored on Medication Cart #1 was dated when opened. This failure could place residents at risk of taking expired medication. Findings included:During an observation and interview on [DATE] at 6:59 AM, LVN A stated she checked resident blood sugars first. She stated she would then go back and pass medications. Observation of Medication Cart #1 revealed two Novolog insulin vials that were not dated, one Lispro Kwik insulin pen not dated, and one Glargine insulin injection pen not dated. LVN A stated the insulin should be dated when the insulin was opened. LVN A stated the nurse that put the insulin on the medication cart was responsible for writing the date. LVN A stated the insulin should stay on the medication cart for up to 30 days. During an interview on [DATE] at 1:00 PM, the Administrator stated the facility did not have a policy about dating insulin. The Administrator stated it was standard practice to date the insulin when it was opened and discard insulin after 30 days. During an interview on [DATE] at 1:20 PM, the DON stated the nurse that opened the insulin was responsible for dating the pen or vial. The DON stated the nurse assigned to the cart should check expiration dates daily. The DON stated medication could be ineffective if used after 30 days. The DON stated she was responsible for in-service with the nursing staff. Record review of a facility in-service record for Medication cart and insulin medications, dated [DATE], reflected, .all insulin pens and vials are to be dated when opened. Record review of the National Library of Medicine's MedlinePlus at https://medlineplus.gov/ency/patientinstructions/000962.htm reflected the following: Insulin and syringes - storage and safety.You can store most opened insulin at room temperature for a maximum of 28 days.Discard insulin after 28 days from the date of opening.

Based on interview and observation, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 2 medication carts (Medication Cart#1) reviewed for drug storage. The facility failed to dispose of a Lantus SoloStar (insulin pen), which was dated 05/30/26, which had exceeded the 28 days the pen could be kept at room temperature. This failure could place residents at risk of being administered expired medications. Findings included:During an observation and interview on 07/02/26 at 6:59 AM, LVN A stated she checked resident blood sugars first. She stated she then would go back and pass medications. Observation of Medication Cart #1 revealed one Lantus SoloStar (a long-acting insulin pen used to control blood sugar in people with type 1 and type 2 diabetes), dated 05/30/26, with no resident name. LVN A stated the nurse, who put the insulin pen in the medication cart, was responsible for writing the date and name. LVN A stated the insulin could stay on the medication cart for up to 30 days. During an interview on 07/02/26 at 1:00 P.M., the Administrator stated the facility did not have a policy about dating insulin. The Administrator stated it was standard practice to date the insulin when it was opened and discard insulin after 30 days. During an interview on 07/03/26 at 1:20 P.M., the DON stated the nurse assigned to the cart should check expiration dates daily with the nursing staff. Record review of facility in-service, dated 07/26, titled, Medication cart and insulin medications, reflected, .all insulin pens and vials are to be dated when opened. Record review of the manufacturer's Patient Information for Lantus SoloStar, revised May 2025, reflected the following: .Storing and Disposing LANTUS?Unopened vials should be thrown away after 28 days if they are stored at room temperature.Store in-use (opened) LANTUS vials in a refrigerator.for up to 28 days.The LANTUS vial you are using should be thrown away after 28 days of if the expiration date has passed, even if it still has insulin left in it.

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 in that: The facility failed to ensure food items, placed in the refrigerator, were sealed, dated, and labeled appropriately.The facility failed to ensure food items, placed in the dry storage area, were sealed and kept off the floor. These failures could place residents at risk for food-borne illnesses. Findings included: In an observation on 2-10-2026 at 8:22 AM, revealed the facility's only walk-in refrigerator had a box of lettuce opened, unsealed, scattered outside the box, and on the floor, a plastic container of potato salad, unlabeled and undated, and 11 plastic containers of chocolate pudding undated and unlabeled. The dry storage area had a pack of 17 Styrofoam cups unsealed on the floor, 1-96 oz plastic jar of amber honey, with a cracked lid, which leaked onto the floor, and an orange on the floor underneath the storage shelves. The reach-in refrigerator had a pitcher of lemonade and tea which were undated and unlabeled. In an interview, on 2-12-2026 at 1:50 PM, it was revealed that the Dietary Manager had worked at the facility for only a few days. The Dietary Manager stated she was responsible for ensuring food items in the walk-in and reach-in refrigerators, and the dry storage area, were sealed, labeled, dated, and stored correctly. The Dietary Manager said she was new and didn't have time to make corrective changes. The Dietary Manager said the concern for residents, if proper food storage standards were not met, was that cross-contamination could occur causing food-borne illness. In an interview on 2-12-2026 at 2:00 PM, [NAME] C said she had worked at the facility for 2 weeks. [NAME] C said it was the responsibility of everyone working in the kitchen to ensure food was dated, labeled, sealed, and kept off the floor. [NAME] C said the concern for residents, if proper food storage standards were not met, was that they don't get bad food. In an interview on 2-12-2026 at 3:00 PM the Administrator said it was the Dietary Manager's responsibility to ensure foods were properly dated, labeled, sealed, and kept off the floor. The Administrator's expectations were that food be kept fresh by proper storage, dating, and labeling. Record review of the facility's policy titled: Food Storage dated 6-1-2019 stated: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal, and US Food Codes and HACCP guidelines. Procedure: 1. Dry storage rooms. d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers much be labeled and dated. h. Store all items at least 6 above the floor with adequate clearance between goods and ceiling. 2. Refrigerators. d. Date, label, and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. Review of the U.S. Public Health Service Food Code, dated 2022, reflected: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. (C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest prepared or first-prepared ingredient. (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request.

Based on observation, interview, and record review, the facility failed to keep garbage storage receptacles in a sanitary condition according to professional standards: 1. The facility failed to keep the outside garbage storage area clean.2. The facility failed to ensure garbage receptacles in the kitchen had lids on them, when trash was in the containers, not being used. These failures could place residents at risk of attracting rodents, insects, and contracting food-borne illnesses.Findings included: In an observation on 2-10-2026 at 8:25 AM, revealed the facility's only kitchen was observed having a large trash can, with a liner containing trash, open and unsealed. A smaller closed trash can, next to the handwashing sink, was observed to have an open-box full of trash on top of it. A third smaller trash can was observed with the lid propped up containing trash. On 2-10-2026 at 8:30 AM, an observation was made of the facility's only outside trash dumpster area. The trash dumpster was full, had two sliding doors that were open, and trash bags hanging outside the doors. Various trash items were found on the ground around the trash dumpster to include: used latex gloves, used to-go Styrofoam food containers, open boxes of trash, and trash bags that were leaking liquid on the ground. In an interview on 2-10-2026 at 9:00 AM, the Maintenance Director stated he had worked at the facility for 2 weeks. The Maintenance Director said he was responsible for ensuring the outside trash dumpster and surrounding areas were maintained and trash was disposed of properly. The Maintenance Director said if trash was not disposed of properly, it could attract insects and rodents potentially causing health hazards at the facility. In an interview on 2-12-2026 at 1:50 PM, the Dietary Manager said the Dietary Manager was ultimately responsible for ensuring the trash cans in the kitchen had lids on them unless they were being used. The Dietary Manager said the concern for the residents, if trash can lids were not kept on the trash cans, would be the attraction of insects and potentially cause food borne illness. In an interview on 2-12-2026 at 3:00 PM, the Administrator said the Maintenance Director was responsible for keeping the outside dumpster and surrounding area clean to ensure trash was disposed of properly. The Administrator said the Dietary Manager was responsible for ensuring lids were kept on trash cans in the kitchen, unless they were in use. The Administrator said the potential harm to residents, for not maintaining proper disposal of refuse, was it could attract insects and rodents. The expectations of the Administrator were that lids be kept on trash cans in the kitchen, the trash dumpster doors be kept closed, and facility grounds kept free from trash debris. A record review of the facility's policy titled Garbage Receptacles, dated 6-1-2019, stated: Policy: The facility will maintain garbage receptacles in a clean sanitary manner to minimize the risk of food hazards. Indoor receptacles:Waste handling units for refuse and for use with materials containing food residue shall be durable, cleanable, insect and rodent resistant, leak proof, and nonabsorbent. Trash cans will be kept with lid in place when not in use. Outdoor receptacles: Outdoor storage surfaces for refuse shall.be constructed to have tight fitting lids, doors or covers and stored in a manner that is inaccessible to insect and rodents with doors/lids kept closed and no waste outside of the receptacle. Review of the U.S. Public Health Service Food Code, dated 2022, reflected: 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled; and (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT.

Based on observation, interview, and record review facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one of four medication carts (Med Cart A), One of two treatment carts (Treatment cart B) and 1 of 7 residents (Resident #94) reviewed for medication storage. 1.The facility failed to ensure Nurses Treatment Cart B was not left unlocked and unattended in the corridor by room [ROOM NUMBER] on 02/10/26. 2. LVN G failed to ensure the medication cart (Med Cart B) was not left unlocked and did not have a cup of medication left on top of the cart while out of view. 3. LVN G failed to ensure medications were not left at Resident #94's bedside while she was out of the resident's room. These failures could place residents at risk of lost medications, drug diversion, or harm due to accidental ingestion of unprescribed medications Findings included:1. Observation on 02/10/26 at 08:13 AM revealed the Nurses' Treatment Cart was observed unlocked and unattended with the lock mechanism out which indicated it was unlocked in the corridor outside of room [ROOM NUMBER]. CNA D was observed in the immediate vicinity. When drawers were pulled open, the cart did not contain narcotic medications. The cart included over the counter and prescription medications. CNA D stated it was a nurse's treatment cart, and she did not know who left it unlocked. The Nurses' Treatment Cart had multiple over the counter medications for wound care and one betadine (cleaning solution that can burn eye and mouth if splashed), and prescription strength medication. No residents were observed around the treatment cart. In an interview with the ADON on 02/10/26 at 12:17 PM revealed, she was one of two nurses working on the floor where Nurse Treatment Cart B was left unlocked and unattended. She said Nurse Treatment Cart B was different from the regular wound care cart and used by nursing when the wound nurse was not available. She said she did not know who left the wound cart unlocked. She said all nurses had keys and access to be able to unlock the cart if they needed supplies from it. She said Nurse Treatment Cart B was just overflow and did not have any medication, however it needed to be locked when unattended for security of the carts. She said all nursing was responsible for making sure all carts were locked and secured when not in use. In a phone interview with LVN E on 02/13/26 at 12:06 PM, she was the second nurse working on the hallway where Nurse Treatment Cart B was left unlocked and unattended. She said she did not know who left the wound cart open. 2. Record review of Resident #94's admission record, dated 02/11/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His primary diagnosis included metabolic encephalopathy (this is a brain disease that alters brain function or structure). His secondary diagnoses included bacterium (this is an infection of bacteria within the body) and gastrostomy status (this is a feeding tube that is placed through the abdominal cavity area into the stomach for nutritional purpose and medication for individuals who have difficulty swallowing). Record review of Resident #94's admission MDS, dated [DATE], did not reflect BIMS. Record review of Resident #94's active order summary for February 2026 reflected;-Amiodarone HCl Oral Tablet 100 MG. Give 1 tablet via G-Tube in the morning for arrhythmia [irregular heart rhythm]-Buspirone HCl Tablet 5 MG Give 1 tablet via G-Tube two times a day for anxiety-Metoprolol Tartrate Tablet Give 12.5 mg via G-Tube two times a day for High blood pressure Hold for SBP less than 110 or HR less than 55-Midodrine HCl Oral Tablet 5 MG. Give 1 tablet via G-Tube two times a day for hypotension [low blood pressure]-Sodium Bicarbonate Oral Tablet 650 MG. Give 1 tablet via G-Tube three times a day for acid reflux [heart burn] Record review of Resident #94's care plan, initiated 02/08/26, revealed a focus: Resident #94 had impaired cognitive function and/or impaired thought process. The goal was for Resident #94 to be able to communicate basic needs through the review date. The interventions included queueing, reorient, and supervision as needed. During continuous medication administration observation with LVN G on 02/11/26 at 08:13 AM, revealed she entered Resident #94's room and left her medication cart unlocked. She left 1 crushed pill in a medication cup (medication in cup unknown) on top of the medication cart (Med Cart A). LVN G did not have a direct view of Med Cart A, and it was out of sight as she entered Resident 94's room. There was a wall between the bedside table and where the medication cart was left. After checking Resident #94's g-tube placement, before starting to administer the medications via the g-tube, LVN G dropped the syringe on the floor. She stopped and secured the g-tube and said she had to go to the medication room and get a clean syringe. She removed her PPE and left all the medications on the bedside, unattended, in Resident #94's room. In an interview with LVN G on 02/11/26 at 08:45 AM, she stated she was very nervous being watched and even though she knew all the steps she was supposed to follow and to secure the medications in the room and the medication cart, she said she forgot. She said she was very nervous she forgot to lock the medication cart, and she forgot the cup of medicine on the cart. She said she was responsible for securing med carts when out of sight and she was responsible for securing medication before walking away. She said the risk was medication safety, and anyone could have access to them. In an interview with the DON on 02/12/26 at 12:23 PM, revealed she expected her staff to lock their medication carts, treatment carts and to secure all medications when unattended and take the keys with them. She said all nurses were responsible for securing medications and herself plus ADONs were responsible for monitoring that was done. She said the risk was anyone could have access to the medications. She said medication safety was necessary to prevent unauthorized access. Record review of the facility's policy titled Medication Storage in The Facility: ID1: Storage of Medication, revision date January 2019, reflected Medication and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medications supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access.

Based on observation, interview and record review, the facility failed to ensure each resident received, and the facility provided food that was palatable and attractive, for five of twenty-four residents (Residents #81, #83, #88, #93, and #95) reviewed for food and nutrition services. The facility failed to provide attractive and palatable regular diet items for the main and alternate regular diet meals for lunch on 02/11/26. This failure could place residents at risk for not enjoying meals and experiencing weight loss. Findings include: 1. Review of Resident #81's admission record, dated 02/12/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #81 had diagnoses which included infection and inflammatory reaction due to internal right knee (knee infection surgery became infected), protein-calorie malnutrition (lack of sufficient intake of protein and/or calories, which can interfere with muscle healing, and make the body more vulnerable to infection), type 2 diabetes (a type of diabetes usually linked to diet and lifestyle), heart disease, and a pacemaker (an internal device which regulates heart activity.) Review of Resident #81's annual MDS assessment, dated 02/06/26, reflected he was able to understand others, and be understood by others. Resident #81 had a BIMS score of 15, which indicated intact cognition. Review of Resident #81's care plans reflected the following:- A care plan for potential for alternations in nutrition and hydration, dated 02/03/26, with interventions of evaluating weight changes, monitoring/documenting/reporting signs of malnutrition, and evaluation and recommendations by a registered dietician. Review of Resident #81's Mini Nutritional Assessment, dated 02/04/25, reflected he was at risk for malnutrition. Review of Resident #81's admission comprehensive nutrition assessment, dated 02/11/26, reflected he was on a regular heart-healthy diet, and his current food intake was between zero and 25% of his meals. It was noted in the document that the resident's family brought him food once daily, he had a significant history of eating high-sodium fast foods. Interventions of a liberalized diet to promote nutritional intake and honor preferences, and a multi-vitamin supplement were recommended. Review of Resident #81's order summary, dated 02/12/26, reflected he was ordered a regular diet, with regular texture and consistency. 2. Review of Resident #83's admission Record, dated 02/12/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #83 had diagnoses which included sepsis (an infection which started as infection in one part of the body, and became widespread potentially causing damage to tissues and organs), chronic obstructive pulmonary disease with acute exacerbation (a progressive, irreversible lung disease which causes difficulty breathing), protein-calorie malnutrition, and type 2 diabetes. Review of Resident #83's admission MDS assessment, dated 01/27/26, reflected she was able to understand others, and was understood by others. Resident #82 had a BIMS score of 15, which indicated intact cognition. Review of Resident #83's care plans reflected the following:- A care plan for potential for alternations in nutrition and hydration, dated 02/01/26, with interventions of evaluating weight changes, monitoring/documenting/reporting signs of malnutrition, and evaluation and recommendations by a registered dietician. Review of Resident #83's Mini Nutritional Assessment, dated 01/26/26, reflected she was at risk for malnutrition. Review of Resident #83's order summary, dated 02/12/26, reflected she was ordered a regular, low-salt, heart-healthy diet. 3. Review of Resident #88's admission record, dated 02/12/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #88 had a primary diagnosis which included metabolic encephalopathy (brain dysfunction caused by other illness, organ failure, or chemical imbalance, such as liver/kidney disease, diabetes, or infection), and secondary diagnoses which included fluid overload (an excess of fluid (blood/water) in the body, commonly characterized by swelling (edema) in limbs, abdominal bloating, and high blood pressure), type 2 diabetes mellitus (a chronic disorder characterized by high blood sugar (hyperglycemia) caused by insulin resistance-where body cells do not respond properly to insulin-and eventual insulin deficiency), and end stage renal disease (the final, irreversible stage of kidney failure where kidney function drops below 15% of normal capacity). Review of Resident #88's care plan, dated 02/02/26, reflected Resident #88 had potential for alterations in nutrition, to monitor for any weight changes, and to get dialysis treatment five days a week. 4. Review of Resident #93's admission record, dated 02/12/26, reflected an [AGE] year-old male who was admitted to the facility on [DATE] with primary diagnoses which included acute chronic systolic combined congestive and diastolic congestive heart failure (a severe, complex, and high-risk state where the heart suffers from both weakened contraction [systolic] and stiff relaxation (diastolic], with a sudden worsening of chronic symptoms), with secondary diagnoses which included acute respiratory failure with hypoxia (the body cannot absorb oxygen from the lungs properly, causing a lack of oxygen in the blood), type 2 diabetes mellitus, acute kidney disease (loss of kidney function, leading up to waste build-up and fluid imbalance in the blood), and dependence on dialysis (a mechanical means of removing waste and fluid buildup from the blood, by filtering blood with a machine). Review of Resident #93's MDS Assessment, dated 02/06/26, reflected a BIMS Score of 15, which indicated being cognitively intact. 5. Review of Resident #95's admission record, dated 02/12/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #95 had a primary diagnosis which included acute pancreatitis without necrosis (inflammation of the pancreas), and secondary diagnoses which included unspecified severe protein-calorie malnutrition, severe sepsis with septic shock (a life-threatening infection which causes organ damage, or failure or inadequate blood flow to tissues), and type 2 diabetes mellitus. Review of Resident 95's MDS assessment, dated 01/28/26, reflected Resident #95 had a BIMS score of 15, which indicated he was cognitively intact. An observation and interview on 02/10/26 at 10:00 AM, revealed Resident #88 was leaning off the side of her bed throwing up over a trash bucket. Resident #88 said she was sick because of her dialysis treatment, not the food, but the food sucked and made her feel unwell. Observation of test trays on 02/11/26 at 12:55 PM by four state surveyors revealed the regular diet test plate contained thick slices of a turkey product (no meat fibers, and little variation in texture of any kind was visible), green peas, which had a muted green color to them, making them appear overcooked, and noodles, which appeared pale, bloated, limp, and had only sparse dark flecks which might indicate any sort of seasoning. The turkey product had a texture which was spongey, slightly gelatinous, and did not have a mouthfeel of meat. The flavor was mostly of salt, and it had little turkey flavor. The noodles had little flavor, having a very mushy, soft texture. The peas were mushy. The overall appearance of the plate was lacking color. The alternate test plate included a meat patty with brown gravy. The meat patty, fell apart in the mouth, and had a rough, grainy texture, and did not resemble the texture or taste meat. It had little flavor, aside from an unpleasant flavor the surveyors were unable to identify, and of the salt in the gravy. An interview and observation on 02/10/26 at 10:40 AM revealed Resident #95 said the food at the facility was terrible, and had no taste, and made him feel gross. Resident #95 directed the state surveyor to look at his breakfast plate which was on his rolling bedside table. An observation of Resident #95's breakfast plate revealed it appeared to be untouched. Resident #95 said he only took one bite of the food as it was not edible. Resident #95 said the food was so bad he had to have his family bring him food so he would have something he could eat. An interview and observation on 02/10/26 at 10:53 AM revealed Resident #83 in her bed, with her breakfast tray still on her overbed table. She showed the state surveyor she had left almost the entire meal, and she said the food was terrible at every meal. She said she hardly ate, and it was not worth asking for anything different because the same people made that too. Resident #83 said she was on a heart-healthy, low sodium diet, and she understood she could not have salt, but she said there were many seasonings the facility could use to make the food taste better, and they didn't bother. She said the meat didn't taste like meat should taste, and she pointed at her toast which did not appear to have any browning on it from being toasted and only appeared dry. She named a brand of salt-free seasoning mix commonly available at grocery stores, and said that brand had a lot of nice flavors, and it was easy to get. She continued, saying the food was so bad, and it seemed the staff just boil things, and throw them on the plate. She said the vegetables were boiled too long, and they did not even bother to put any margarine or anything on them for flavor. An interview and observation on 02/10/26 at 12:49 PM, revealed Resident #93 was observed lying in his bed with a sheet covering his body. Resident #93 said the food was very bland and was as bad as he'd ever had. He said it tasted terrible and made him feel like choking. An anonymous interview on an undisclosed date and undisclosed time revealed the resident said they felt they had the right to have some edible food, and were not at all happy with the food at the facility, which was really bland. An interview and observation on 02/11/26 at 1:04 PM with the Dietician revealed she tasted the items on the regular lunch plate. She said the noodles were very plain and she could see a little bit of parsley in them. She said the turkey matched the packaging it came in, which was a frozen round turkey, but not a true turkey and she felt the texture was almost like bologna, and it had a salt flavor, and she could taste a little bit turkey flavor. She said this was only her fourth time in the building, and she was working with the kitchen staff, who were new, to get things working properly in the kitchen. She said the food distributor they bought from was not the one she was used to in the company's buildings, and she would have to look into the quality of the food they were receiving. She said the kitchen staff had recipes out while they were preparing the food, and she believed they were following them. She said the responsibility to have palatable food was on the Dietary Manager, and it was important because if the food was not palatable, the patients might not eat it, and they needed the nutrition to heal from their illnesses and injuries. An interview on 02/12/26 at 2:00 PM with [NAME] C revealed the cooks were responsible for ensuring food was cooked correctly and tasted good. She said the food should be flavorful, and the negative effect for the residents was if the food did not taste good, it might cause them to not eat, get weak, and not heal properly. An interview on 02/11/26 at 2:09 PM with Resident #81 revealed, he complained his lunch was not at all good, and it did not look good, but he tasted one noodle and spat it out because it was so bland. An interview on 02/11/26 at 2:23 PM with Resident #81 revealed he was not at all happy with the food. He said his breakfast that morning had a hard, stale slice of bread cut in two. He said only the fruit and tea from his lunch were good that day, and the noodles were ugly and mushy so he did not eat. Resident #83 said he usually did not eat the facility's meals, and his family member came once or twice every day and brought him fast food or something else to eat, so he was getting enough to eat. He said because he would be leaving soon, he did not feel it was worth complaining to the staff. He said he felt sad for people who did not have someone to bring them different food. An interview on 02/11/26 at 3:38 PM with the Hospitality Director revealed she had some complaints about food, but she felt the complaints she got were more about preferences, usually came from people who were on the heart-healthy diet, and were not anything out of the ordinary. She said when they got food complaints, they addressed them with the individual, and when people complained she referred them to the Dietitian and Chef. She said recently they had changed someone to a liberalized diet, instead of their prescribed heart-healthy diet, to accommodate their preferences. An interview on 02/12/26 at 8:40 AM with the Administrator revealed the facility had been going through a tremendous amount of change recently, and the Chef was new at being a dietary manager, and the Dietician was also new. He said in addition to that, they hired six new dietary staff in the past week. He described some problems he found in the facility when he started, which included the dietary staff being cut back so much that the former kitchen manager had been functioning more like just another one of the kitchen staff and he had to get some new leadership in the kitchen. He said corporate dietary leadership were in the facility recently, and would be coming back, to help get the kitchen running smoothly again. He said the facility tried to present an elevated experience and it was frustrating to hear the food was not good. He said the food was important, because if it was bad, people would not want to eat it, and they were in the facility to heal and get stronger, which required good nutrition. He said he was ultimately responsible for the quality of the meals, and he would be getting test trays going forward, so he would know the quality of what was being served. An interview on 02/12/26 at 1:50 PM with the Dietary Manager revealed the cooks were responsible for making sure the food looked good on the plate and tasted good. She said if residents did not like it, they probably would not eat, and if they didn't eat, they might get weak. She said her expectation was for the residents to like the food and want to request second helpings. Review of the policy Food & Nutrition Services; Meal Service; Food Palatability- Hot Food Temperatures, copyright 2021, reflected: POLICY: The healthcare community prepares and serves food and beverages that is palatable, attractive and at safe and appetizing temperature. Review of the policy Food & Nutrition Services; Food Preparation; Seasoning in Food Preparation, copyright 2021, reflected POLICY: Cooks and chefs may experiment with salt-free seasonings, spices, herbs and flavor enhancers for the purpose of enhancing the flavor of the food [.] PROCEDURE: Examples of seasonings that may be adjusted on standard recipes are: black pepper, white pepper, cayenne pepper, paprika, onion powder, garlic powder, oregano, thyme, basil, dill, chili powder, cumin, curry, mustard powder, cinnamon, Italian seasoning, poultry seasoning, [name of commercially available brand] spice blends, [name of commercially available salt substitute], lemon juice, etc. Seasonings that may not be increased or added are: salt, garlic salt, onion salt, celery salt, seasoning salt, salt substitute, soy sauce, Worcestershire sauce, monosodium glutamate. The ingredients of spice blends are examined to assure that they do not contain salt or sodium (i.e., lemon pepper seasoning and Cajun seasoning often list salt as the first ingredient and therefore are not appropriate).Other ingredients may be added to improve flavor and appearance include chopped parsley, chopped red peppers, onion, garlic etc. The above lists are not comprehensive. Any questions about adding or changing an ingredient may be referred to the dietitian to determine the nutritional content and appropriateness.

Based on interview and record review the facility failed to ensure the resident had the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options to choose the alternative or option he or she preferred for one of three residents (Resident #101) reviewed for consent to receive psychotropic medications. The facility failed to obtain a written consent form for Resident #101 before starting the medications alprazolam (for treating anxiety), bupropion (for treating depression), hydrocodone-acetaminophen (an opiate pain killer), and zolpidem tartrate (to aid in sleeping). This failure could place residents at risk of being unable to exercise their rights to make informed decisions regarding their treatment.Findings include: Review of Resident #101's admission record, dated 02/12/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His admitted diagnoses included pneumonia (a lung infection), chronic respiratory failure (difficulty breathing), kidney failure, and heart disease. His face sheet reflected no psychiatric diagnoses. Review of Resident #101's admission MDS, dated [DATE], reflected he was usually understood by others, and usually able to understand others, and had a BIMS of 10, which indicated moderate cognitive impairment. His depression indicator score was 13, which indicated a moderate level of depression. He had no behavioral problems and showed no signs of psychosis. The document reflected no active psychiatric diagnoses. He had not received pain medication in the five-day look-back period. Resident #1 was taking an antidepressant. Review of Resident #101's order summary, dated 02/12/26, included the following:- Start date 02/03/26, end date 02/17/26- Alprazolam Oral Tablet 0.25 MG- Give 1 tablet by mouth every 8 hours as needed for anxiety for 14 Days- Start date 01/22/26, no end date noted- Bupropion HCI ER (XL) Tablet Extended Release 24 Hour 150 MG Give 1 tablet by mouth one time a day for depression-Start date 01/22/26, no end date noted- Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for severe pain- Start date 02/10/26, no end date noted- Zolpidem Tartrate Oral Tablet 10 MG (Zolpidem Tartrate) Give 1 tablet by mouth as needed for insomnia at bedtime Review of Resident #101's care plans reflected the following:- Hypnotic therapy (Zolpidem Tartrate), initiated 02/01/26, including monitoring for adverse effects of daytime drowsiness, confusion, loss of appetite in the morning, increased risk of falls and fractures, dizziness,- Antidepressant medication (bupropion), initiated 01/31/26, including monitoring for adverse effects of change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movementproblems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, weight loss, dry mouth, dry eyes- Opioid medications (Hydrocodone- acetaminophen), initiated 01/31/26, including monitoring for adverse effects of altered mental status, anxiety, constipation, depression, dizziness, lack of appetite, nausea, vomiting, pruritus, respiratory distress/decreased respirations, sedation, urinary retention- Antianxiety medication (Alprazolam), initiated 02/03/26, including monitoring for adverse effects of drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion, and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision, or unexpected side effects of mania, hostility, rage, aggressive or impulsive behavior, or hallucinations Review of Resident #101's electronic medical record reflected no consent forms for alprazolam, bupropion, hydrocodone-acetaminophen, or zolpidem. An interview on 02/12/26 at 4:24 PM with the DON revealed she had been unable to find the consent forms for Resident #101 but was going to continue to look for them. She said the ADON, who was on leave for a major life event and not available for interview, was the person responsible for getting the medication consents. She said when a resident was admitted , the ADON did the consents, and if they were admitted at night, she did the following morning. She said they went over the ones from the last 24 hours in the morning meetings, and on Monday mornings they went over the ones from the weekend. She said the ADON did a very good job of keeping up with them, and if they were not done, she did not have an idea of why. The DON said if they were not done, they were at worst delayed. She said on the weekends, the weekend supervisors did them on admission. She said there was a form in their electronic medical software, which they printed to have the resident sign. She said the consents were important because they made the patients aware of the effects and side-effects of medications, and what to expect from the medications. Review of the Psychotropic Medications policy, most recently reviewed in January of 2026, reflected Any and all psychotropic medication orders will be initiated by the facility only after the physician has completed and returned an Informed Consent related to the drug with the elder and/or responsible party/family. The drug order will include a start date on completion of the Informed Consent Form. [.] Psychotropic medications include drugs from the following classes: hypnotics, antipsychotics, long and short-acting benzodiazepines, sedatives/anxiolytics and antidepressants.

Based on observation, interview, and record review, the facility failed to ensure the resident received reasonable accommodation of needs and preferences, for 1 of 17 Residents (Resident #62) reviewed for accommodations of needs. The facility failed to ensure Resident #62 had a call light within her reach. This failure could place residents at risk of not getting their needs met and diminishing their quality of life.Findings included: A record review of Resident #62's face sheet dated 2-10-2026 revealed a [AGE] year-old female who re-admitted to the facility on [DATE] with a primary diagnosis of encounter for orthopedic aftercare following surgical amputation and secondary diagnoses of absence of right leg above knee, sepsis (a life-threatening medical emergency occurring when the body's immune system overreacts to an infection, causing widespread inflammation, tissue damage, and organ failure), type 2 diabetes mellitus(disorder where the body develops insulin resistance and cannot use insulin properly), and cerebral infarction (stroke). Record review of Resident #62's Comprehensive MDS revealed a BIMS score of 11, which indicated Resident #62 was moderately impaired. Record review of Resident #62's care plan dated 1-16-2026 stated Resident #62 was at risk for falls and instructed staff to ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. In an observation and interview on 2-11-2026 at 1:10 PM, Resident #62 was observed lying on her bed in a tilted-up position with her call light on the floor underneath her bed. Resident #62 said she used her call light and did not know where it was. Resident #62 said she did not feel safe because she could not reach her call light. In an interview on 2-11-2026 at 1:18 PM, CNA A said she had been working at the facility for 6 months, worked the 6AM-6PM Shift, and was the CNA responsible for Resident #62's room. When CNA A saw Resident #62's call light was on the floor underneath her bed, she said the Administrator was responsible for ensuring resident's call lights were kept within reach. CNA A said when a call light was in a location where a resident could not reach it, the resident would be put in harm's way because they would not be able to receive help when needed. CNA A said the way staff ensured resident's call lights were kept within reach was by making rounds every two hours. In an interview on 2-11-2026 at 1:30 PM, LVN B said she had worked at the facility for 4 days, worked the 6:00 AM - 6:00 PM shift, and was the nurse responsible for Resident #62's room. LVN B said all staff, especially direct care staff, were responsible for ensuring Resident's call lights were kept within reach. LVN B said the risk to residents, for not having their call lights kept within reach, was it could put them at risk of falling. In an interview on 2-12-2026 at 12:45 PM, the DON said she had worked at the facility for 4 months. The DON said it was the responsibility of every staff member who came into a resident's room to ensure the call light of a resident was kept within reach before they left the room. The DON said the risk to a resident who could not reach their call light, might be they could need something and not get it. The DON said her expectations were for staff to ensure a resident's call light was within reach before they left the room. In an interview on 2-12-2026 at 3:00 PM, the Administrator said every caregiver who went into a resident's room was responsible for ensuring their call light stayed within reach. The Administrator said the concern for residents, who could not reach their call light, was they could not call for help if they needed it. The Administrator said his expectations were that all residents' call lights be kept within reach by all staff. A record review of the facility's call light policy titled Call Light Response dated 1-2023 and revised 1-2024, 1-2025, and 1-2026 stated: Policy/Procedure:1. It is the expectation that all staff members respond to call lights.2. If the request is outside the scope of practice for the person answering the light, the appropriate personnel will be contacted immediately to respond to the resident's needs, and the call light may remain engaged until the resident's needs have been met.3. Call lights will be answered in a timely manner.

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 two of six residents (Residents #8 and #81) reviewed for infection control. 1. The facility failed to ensure LVN E wore a gown for EBP before accessing an indwelling catheter (foley) to collect urine from Resident #8 on 02/10/26. 2.The facility failed to ensure LVN D wore a gown for EBP before accessing Resident #81's Central Venous Catheter (this is a flexible tube inserted in the vein for intravenous medication therapy) IV to administer intravenous antibiotics on 02/11/26. These failures could place residents at risk of Multidrug-resistant Organisms infections. Findings included:1. Record review of Resident #8's admission record, dated 02/12/26, reflected an [AGE] year-old female with an initial admission of 10/23/25 and readmitted to the facility on [DATE]. Resident #8's had diagnoses which included metabolic encephalopathy (this is a brain disorder caused by a chemical imbalance in the blood that affects brain function), unspecified open wound to the left hand and unspecified organism sepsis (this is a life-threatening complication of an infection). Record review of Resident #8's quarterly MDS, dated [DATE], reflected a BIMS score of 15, which indicated intact cognition. Resident #8 was able to understand others and could be understood by others. Resident #8 had an active additional diagnosis which included Sepsis, and she had an unspecified open wound in the left hand. Record review of Resident #8's active order summary for February 2026 reflected:- Wound cleanser, pat dry apply xeroform and calcium alginate cover with ABD pad and kerlix dressing as needed reapply if soil. Ordered 01/29/26.- Wound care: Cleanse trauma open wound to left lateral leg with normal saline or wound cleanser, pat dry, apply xeroform cover with dry dressing as needed. Reenforce if soiled or dislodged. Order date 01/16/26.-Insert foley catheter and maintain, measure output and report to PA [name of PA] one time only for 3 Days. Order date 02/10/26. Record review of Resident #8's care plan, initiated 01/26/26, reflected a focus of Resident #8 was on Enhanced Barrier Precautions related to foley catheter and IV therapy. The goal was for Resident #8 to not experience complications related to condition/device(s) requiring EBP. The intervention was to provide Enhanced Barrier Precautions as indicated involves the use of personal protective equipment (PPE) specifically gowns and gloves during high contact resident activities. Observation and interview on 02/10/26 at 12:45 PM revealed Resident #8 had a sign on her door for Enhanced Barrier Precaution. There was no PPE cart observed outside the resident's room. The resident was lying in her bed. LVN E said Resident #8 did not void (urinate) overnight and this morning. LVN E said she notified the PA of not voiding and obtained an order to insert a foley catheter and obtain a sample of urine analysis for UTI. LVN E put on gloves, but she did not wear a gown for EBP. She attached a statlock (sticky stabilizing device) to the foley tubing and secured it to the resident's right leg. She sanitized the foley bag opening and took some urine in a cup for the UA. In a phone text interview with LVN E on 02/13/26 at 12:06 PM, She said she was supposed to wear a gown and gloves when collecting urine. When LVN E was asked what the risk was if EBP was not implemented, she said increased risk of infection. 2. Record review of Resident #81's admission record, dated 02/12/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #81 had a primary diagnosis which included infection and inflammatory reaction due to internal right knee (knee infection surgery became infected), protein-calorie malnutrition (lack of sufficient intake of protein and/or calories, which can interfere with muscle healing, and make the body more vulnerable to infection), type 2 diabetes (a type of diabetes usually linked to diet and lifestyle), heart disease, and a pacemaker (an internal device which regulates heart activity). Record review of Resident #81's admission MDS assessment, dated 02/06/26, reflected Resident #81 had a BIMS score of 15, which indicated intact cognition. Resident #81 was able to understand others. Record review of Resident #81's active order summary for February 2026 reflected:- Enhanced Barrier Precautions (IV ACCESS) every shift. Order date 2/6/26- Normal Saline Flush Solution. Use 10 ml intravenously every shift for CVC Line Patency as well as before and after each infusion. Order date 02/07/26- Cefazolin Sodium Solution Reconstituted 1 GM Use 20 ml intravenously every 8 hours for bacteremia in right lower leg until 03/10/2026 05:59 2 gram/20ml solution. Order date 02/07/26- IV CVC LEFT CHEST: Monitor site and dressing. Document in progress to note any signs and symptoms of infection, notify provider of s/sx of infection. Every shift per protocol. Order date 02/07/26. Record review of Resident #81's care plan, initiated 02/03/26, reflected a focus: Resident #81 was on Enhanced Barrier Precautions related to CVC left chest and surgical incision on right lower extremity. The goal was for Resident #81 to not experience complications related to condition/device(s) requiring EBP. The intervention was to provide Enhanced Barrier Precautions as indicated involves the use of personal protective equipment (PPE) specifically gowns and gloves during high contact resident activities Observation on 02/11/26 at 2:09 PM revealed door signage for Enhanced Barrier Precaution for Resident #81. There was no PPE cart outside the resident's room. The resident was lying in his bed. Resident #81 had a CVC IV port on his chest which was clean and intact. It was dated 02/10/26. Resident #81 said he liked having the central line so he did not get poked for blood draws. LVN D verified all information with the resident before administering his antibiotics. LVN D wore gloves, but he did not wear a gown before accessing Resident #81 central line IV for flushing and administering antibiotics (Cefazolin 2 gm). In an interview with LVN D on 02/11/26 at 2:17 PM, he said he forgot to put on his gown. He said it was important to put PPE on (gown) for residents on EBP for infection control. In an interview with the DON on 02/12/26 at 12:23 PM, revealed if a resident was on EBP, it meant staff were to wear gloves and gowns while providing care. She stated all staff were expected to wear PPE to prevent the spread of infection. She said all procedures were in place to prevent infection, and all nursing staff were responsible for making sure EBP was followed. The DON said she had completed services on EBP a few weeks ago. She said she was the infection control preventionist and was responsible for monitoring infection processes that were being followed. Interview on 02/12/26 at 03:45 PM with the Administrator revealed all staff members were expected to follow the infection control protocol as indicated. He said the risk of staff not following standard infection control protocols could cause a spread of infection. Record review of In-Service, dated 2/03/26, led by DON titled Enhanced Barrier Precautions, Hand Washing/Hand Hygiene revealed staff were trained on Enhanced Barrier Precaution signage which included Staff to wear gloves and gown for the following High contact Resident care activities: Dressing, Bathing/Showering, changing linens, providing hygiene, changing briefs or assisting with toileting. Device care or use: Central lines, urinary catheter, feeding tube, tracheostomy. Wound care: Any skin opening requiring dressing, 11 Staff signed the Inservice including LVN D and LVN E. Record review of the facility's policy titled Infection Control Policy, revision date May 2023, reflected . All Staff: Any/all staff who provide direct care and indirect care functions, contracted staff, consultants, volunteers, others who provide care and services to residents on behalf of the facility and students.are responsible for complying with isolation precautions and for tactfully calling observed variances to policy to the attention of any person(s) not following the policy. Record review of the facility's policy Implementation of Standard and Transmission-Based Precautions, dated 03/24, reflected, .EBP are indicated for residents with any of the following: 1. Infection or colonization with a CDC-targeted MDRO .Wounds and/or indwelling medical devices even if a resident is not known to be infected or colonized with a MDRO .post signage .high-contact resident care activities requiring gown and glove use

Based on interview and record review the facility failed to ensure that a resident who required dialysis received such services, consistent with professional standards of practice for 1 (Resident #1) of 1 resident reviewed peritoneal dialysis.The facility failed to ensure nursing staff received training to administer, monitor and intervene for Resident #1 who required PD (During peritoneal dialysis, a cleansing fluid flows through a tube into part of the stomach area, also called the abdomen. The inner lining of the abdomen, known as the peritoneum, acts as a filter and removes wastes from blood. After a set amount of time, the fluid with the filtered waste flows out of the abdomen and is thrown away). Resident #1 was admitted to the hospital with peritonitis (bacteria into the peritoneum).The facility failed to ensure Resident #1 had dialysis supplies available on 01/25/26 and 01/26/26 to perform PD. Resident #1 was not dialyzed on 01/25/26 and 01/26/26 because she did not have supplies (cycler) available. This failure could place residents at risk of not receiving life-sustaining medical treatment which could diminish the quality of life. Findings included:Record review of Resident #1's face sheet dated 02/05/26 reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of cerebral infarction (stroke caused by a blockage in a blood vessel supplying the brain), end stage renal disease (permanent stage of kidney failure), type 2 diabetes (a chronic condition where the body develops insulin resistance and fails to produce enough insulin causing high blood sugar levels), and heart failure (the heart cannot pump blood efficiently causing fluid buildup, fatigue, and shortness of breath).Record review of Resident #1's care plan dated 1/20/26 reflected she needed dialysis. The goal was for Resident #1 to have immediate intervention should any s/sx complications from dialysis occur. Resident #1 would have no s/sx complications from dialysis. Intervention was to monitor PD catheter site redness/drainage, report cloudy effluent, inadequate drainage or inflows problems, sudden weight gain or loss, shortness of breath, abdominal pain, fever. Monitor/document report PRN any s/sx of infection to access site, redness, swelling, warmth or drainage, renal insufficiency. PD dialysis 6p-6am, guest to complete independently and supply own supplies.Record review of Resident #1's comprehensive MDS assessment dated [DATE] reflected that she had a BIMS score of 15 (Cognitively Intact). Hemodialysis was indicated while a resident. Record review of hospital H&P dated 2/01/26 reflected, admission date 01/31/26 chief complaint: Abdominal pain, nausea/vomiting. Patient was recently admitted at [local hospital] from 01/11 to 01/20 for LLE weakness + possible peritonitis from PD catheter- cranial imaging showed bilateral MCA + left PCA watershed infarcts, neurology was consulted + started patient on DAPT. ID was consulted and obtained PD fluid studies which were negative for peritonitis. Patient reports during this hospitalization had generalized abdominal pain which was thought to be opioid-induced constipation improved with PRN antiemetics + bowel regimen. Patient was eventually discharged to [facility] but reports during the time she was there she was not eating much food due to continued abdominal pain. Patient's [family] at bedside reports patient's decreased oral intake at the [facility] was more so from the food's suboptimal taste instead of abdominal pain as she was eating some of the food she was bringing, but over the last 3 days she was unable to eat much due to the abdominal pain. Patient also denies any pain around her PD catheter site or any discolored fluid coming out of her PD catheter. Due to these worsening symptoms, patient was brought to [local] ED for further evaluation. CT of adb/pelvis was obtained and showed small-moderate free intraperitoneal air from PD or from possible perforation along with free fluid in the abdomen, and mild diffuse wall thickening of the colon.* In an interview with Resident #1 on 02/04/2026 at 4:19 PM she stated she did her own dialysis. She stated the nursing staff did not monitor her when she did her dialysis. She stated they did not come to check on her to during the process. She stated earlier in the week about Monday or Tuesday, she could not remember the exact date, she did not have the equipment she needed to do her dialysis. She stated she did not have the Clycler (machine automates peritoneal dialysis by performing fluid exchanges overnight while a patient sleeps) because the one she was using was broken and she was waiting for her family to bring the supplies from home. She stated she did not ask the facility for any supplies because her family was supposed to bring them to her. She stated her family would usually bring supplies to last about five days at a time. She said that she told the DON that she had missed two or three days in the past and she did not have any issues. She stated the nurses took her vitals and listened to her chest and sent her chest x-rays after she had missed her days of dialysis. She stated she could not remember when she was sent for x-rays. She stated on Friday she vomited what she thought was bile. She stated she was assessed by the nursethen she was sent to the hospital . She stated that she knew that not doing the dialysis caused her to retain more fluid and it could be dangerous to her health.In an interview with CNA-B on 02/05/2026 at 2:10 PM, she stated that Resident #1's family would hook her up to the dialysis machine and leave the facility . She stated that the family would get upset because they would be waiting for them to unhook Resident #1 from the machine so they could provide care. She stated that they tried to explain to the family that it was dangerous for the resident to be moved during her dialysis time, her blood pressure could drop to low. She stated that if the family was late returning to the facility in the morning, Resident #1 would have to disconnect herself. In an interview with the DON on 02/05/2026 at 10:50 AM, she stated the facility was able to meet the needs of Resident #1. She stated that the treatment was not staff assisted and admission to the facility was contingent upon Resident #1 or designated family member's ability and willingness to perform all aspects of the PD treatment independently. She stated when Resident #1 was admitted the admission paperwork was not signed. She stated she did not know why the paperwork was not signed. She stated the previous marketing director did not complete the paperwork. She stated the nurses were responsible for monitoring not assisting Resident #1 with her dialysis. She stated that per the doctor's orders monitoring consisted of reminding Resident #1 to hook up or unhook the dialysis system. She stated the evening shift would remind the resident to hook up to the machine and the morning shift would remind her to unhook the machine. She stated that the nurses would only need to document if the patient had an issue, such as if the dialysis started late. She stated that weekly weights were done on Resident #1, she was at the facility for nine days. She stated Resident #1 missed two days of dialysis during the winter storm, the family did not bring the supplies and stated they could not get to the facility because of the roads, and the cycler had been broken. She stated that Resident #1 stated she was fine with missing the two days of dialysis, stating she had missed two to three days in the past and there was no negative effect on her. She stated the facility did not have emergency PD equipment on site. She stated she had been trained on PD prior to working at this facility. She stated that when Resident #1 missed a treatment, they were to notify the PCP who will decide next steps. She stated when Resident #1 missed the treatments, the PCP was notified on 01/31/26 at 6:17 PM and an assessment was completed, Resident #1 received x-rays, and the results were clear. She stated Resident #1 was at risk of infection and that was the reason she was sent to the hospital. She stated that Resident #1 was admitted to the hospital for intractable nausea/vomiting and generalized abdominal pain suspect 2/2 viral gastroenteritis (a common, contagious intestinal infection causing watery diarrhea, cramps, nausea vomiting) vs peritonitis (severe, inflammation of the peritoneum, which is the thin membrane lining the inner abdominal wall and covering abdominal organs) vs gastroparesis (chronic disorder where the stomach takes too long to empty food into the small intestine) vs developing peptic ulcer (an open sore found on the lining of the stomach) or H pylori infection (infects the stomach lining, causing chronic inflammation, ulcers, and occasionally cancer). In an interview with RN-A on 02/06/26 at 10:03 AM, she stated that she was not aware that Resident #1 had an infection. She stated that part of her monitoring consisted of looking at the site to ensure there was no redness or drainage and she did vital signs, making sure the resident connected and disconnected to the machine . She stated she gave Resident #1 the vitals and Resident #1 would put the information into the dialysis machine. She stated that when Resident #1 was admitted to the facility the family said they would help her with her dialysis treatments. She denied she had been trained in how to connect, monitor, or disconnect the machine from the resident. Record review of Progress note written by RN-A dated 1/28/26 at 7:48 AM reflected no skin/wound alterations . Record review of Progress note written by LVN-B dated 1/31/26 at 17:21 (5:21 PM) reflected PA notified of [Resident#1] complaint of nausea/vomiting and poor appetite. New orders received as follows: 1.Phenergan 12.5mgx1 now, 2. STAT CBC, CMP, 3. Reglan 5mg TID. [Resident #1] made aware of new orders. Phenergan administered. STAT labs drawn at approximately 1730 (5:30 PM).Interview with MD/PCP on 02/06/2026 at 10:17 AM she stated that the facility could meet the needs of Resident #1 for care and rehabilitation. She stated that the family was asked to assist with PD if Resident #1 could not connect with the machine on her on. She stated that she had seen Resident #1 prior to the ice storm 01/24/26 and the resident informed her the machine had malfunctioned. She told her she was not able to do dialysis on Thursday prior. She stated the resident told her she had missed a few days of dialysis in the past and she (resident) was not concerned about it. She stated at first she had concerns about if Resident #1 was doing it correctly as far as keeping a sterile environment, so she watched her put the numbers in the machine and start the machine. She stated Resident #1 had been treated for peritonitis with abdominal pain. She stated that the resident had been treated at another hospital and discharged but the family was not satisfied and brought her to local area for a second opinion. She stated that it was during DON's conversation with the dialysis clinic in this area that it was determined that she did not have a pulmonologist doctor in this area. She stated that the nursing staff provided the resident with her morning and evening numbers to put into the machine. She stated that the resident would put herself on dialysis in the evening and come off in the morning she thought it was about 12-hour process. She stated that Resident #1 did not mention to her that she was lacking supplies. She stated that when the DON informed her that the resident had missed more treatments she made the decision to send her to the hospital because she needed to get the cultures from her stomach to determine if she had peritonitis. She stated that the resident not having the supplies to properly do her dialysis placed her at risk becoming septic. She stated the risk of admitting a resident with PD and the staff not being trained to administer/monitor/intervene would be that the staff would not know if the patient was doing it properly. Record review of facility Peritoneal Dialysis (PD) Essentials Inservice/Training dated 09/2025, reflected [Facility] supports the rights of residents to participate in their own care through self-performed or family-performed Peritoneal Dialysis (PD). The facility will provide a safe and sanitary environment and clinical oversight for these treatments. B. Storage and Environment 1. Supply Management: Residents/Families are responsible for ordering supplies. Facility staff will designate a clean, dry area in the resident's room for storage. C. Nursing Oversight & Documentation Nursing Staff are responsible for the following clinical surveillance: 1. Weights: Daily weights must be recorded on the same scale, in similar clothing, to monitor fluid trends. 2. Vital signs: Once per shift, the nurse must record patient vital signs. E. Emergency Protocols 3. Refusal or Inability to Perform: If the family/resident is unable to perform a scheduled treatment, the nurse must notify the physician. Facility staff are prohibited from attempting to perform the dialysis connection. Staff Education 1. All licensed nursing staff will receive annual PD Awareness training, focusing on recognizing peritonitis, exit site infections, and fluid volume overload. Record review of undated and unsigned admission acknowledgement of responsibility: Peritoneal Dialysis Self-Management reflected [Facility] does not provide staff-assisted Peritoneal Dialysis (PD). admission to the facility is contingent upon the patient's (or their designated family member's) ability and willingness to perform all aspects of the PD treatment. By signing below the Patient and/or Family Representative acknowledges the following: Performace of Treatment: The Patient/Family assumes 100% responsibility for the setup, administration, and breakdown of all PD cycles (manual or cycler-based). Supply Management: The Patient/Family is responsible for ordering, tracking, and storing all necessary dialysis supplies, including fluids, tubes, and machines. Equipment Maintenance: The facility is not responsible for the maintenance or troubleshooting of the dialysis machine. In the event of equipment failure, the Patient/Family must contact their dialysis clinic directly. Clinical Monitoring: While facility nursing staff will monitor vital signs as part of standard care, they will not perform the PD connection, disconnection, or site care. Emergency Contact: The Patient/Family must maintain active contact information for their outpatient Dialysis Center and Nephrologist for all clinical questions or complications. Facility staff are not trained or authorized to troubleshoot PD alarms or handle PD catheters. In the event of a medical emergency related to dialysis, the facility will follow standard emergency protocols, which may include transfer to an acute care hospital. Should the Patient or Family become unable or unwilling to perform the dialysis treatments as agreed, the facility may no longer be able to meet the patient's clinical needs. In such a case, a discharge plan to a more appropriate level of care will be initiated.Record review of Pertoneal Dialysis (PD) Essentials dated 1/5/2026, reflected the training was 1. What is PD? Peritoneal Dialysis uses the resident's own abdominal lining (the peritoneum) as a filter to remove waste and extra fluid. 2. The Golden Rule: Sterile Technique Infection is the #1 enemy. Peritonitis can be fatal for SNF residents. 3. The Three C's of Assessment Cloudy, Constipation, Catheter & Circuit. 4. Documentation Acknowledgement that patient started an ended the treatment, since [facility] does not provide staff-assisted Peritoneal Dialysis.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with state and federal laws in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 3 Residents reviewed for medication storage. LVN-C failed to ensure Resident #1's PICC line medication was secured in a locked compartment. This failure could place residents at risk for consuming or tampering with medications that could result in adverse medication reactions.Record review of Resident #1's face sheet dated 10/23/2025, reflected he was an [AGE] year-old male that was admitted on [DATE] with diagnosis including: infection and inflammatory reaction due to internal left knee prothesis, subsequent encounter (infection of other causes). Record review of Resident #1's quarterly MDS Assessment, dated 10/09/2025, reflected the resident BIMS score was 15 indicating his cognition was in-tact. Resident #1's ADL functioning required setup and clean up for oral hygiene, supervision and touching, depending on staff for showers. He required supervision and touching for toileting, lower body dress, and putting on footwear. Section M-skin conditions reflected he had a surgical wound, nutrition or hydration interventions, and applications of ointments. Section N-high risk drug class reflected he was taking antibiotics. Section O -special treatments, procedures, and programs, reflected resident was receiving IV medications (medical procedure where a needle or catheter is inserted in the vein to administer fluid.), IV access were addressed. Record review of Resident # 1's Care Plan dated 10/04/2025 reflected he was on Enhanced Barrier Precautions related to IV therapy and interventions included Provide Enhanced Barrier Precautions as indicated.Involves the use of personal protective equipment (PPE), specifically gowns and gloves, during high contact resident care activities (i.e., prolonged direct contact) Resident #1 was receiving IV medication(s).Vancomycin , ceftriaxone (a potent antibiotic used to treat serious bacterial infections.The resident will not have any complications related to IV.Intervene accordingly before discontinuing IV site. IV DRESSING: Observe dressing. Record review of Resident #1's MD orders reflected an order dated 10/04/2025 at 3:48 AM, Wipe mask, nasal pillows [NAME] with damp cloth Empty humidifier chamber. Fill humidifier with warm soapy water, shake well.Rinse, air dry in the morning. Record review of Resident #1's MD order dated 10/04/2025 at 5:39 PM reflected ceftriaxone Sodium Intravenous Solution Reconstituted 2 GM (Ceftriaxone Sodium) Use 2 gram intravenously in the afternoon for L knee infection until 11/11/2025 11:59 PM. MD orders dated 10/04/2025 at 5:43 PM reflected Change needleless connector every week with dressing change and following blood draws every day shift every 7 day(s) for per protocol.changes occurred on 10/05/2025, 10/12/2025, and 10/19/2025. Change PICC (a thin, flexible tube inserted into a vein in the upper arm and threaded into a larger vein near the heart.) line dressing every 7 days (sterile process disinfecting and sterilization of reusable medical instruments) every day shift every Sun for PICC Line IV PICC: order monitor site and dressing. Document in progress note any signs and symptoms of infection, notify provider of s/sx of infection every shift for per protocol. Normal Saline Flush Solution (Sodium Chloride saltwater Flush) every shift for PICC Line Patency (being open allowing for free flow of fluids, air, or blood) as well as before and after each infusion (a method of putting fluids including drugs into the bloodstream.) Change PICC line dressing every 7 days (sterile process) every day [NAME] every Sun for PICC Line. Check IV dressing each shift and PRN every shift. reflected Enhances Barrier Precautions-IV/PIPC every shift. Vancomycin HCI Intravenous Solution 750 MG/150ML (Vancomycin HCI) Use 1500 mg intravenously every 24 hours for L Knee joint Infection until 11/11/2025 11:59 PM. Record review of Resident #1's October MAR/TAR Vancomycin HCI (powerful antibiotic used to treat serious bacterial infections) Intravenous 24-hour use was administered on 10/23/2025, the day of the investigation at 12:00 PM, by LVN C. Ceftriaxone was administered on 10/23/2025 at 12:00 PM by LVN C During an observation and interview with Resident # 1 on 10/23/2025 at 1:15 PM revealed he was receiving antibiotic therapy via IV for infections. During an observation on 10/23/2025 at 1:17 PM revealed Resident #1's PICC line medication labeled Ceftriax 2G/100 ML was observed lying on the exit door handle located at the end of the resident hall. The medication was exposed to the sunlight reflecting through the glass door. The medication was prescribed to Resident #1. The medication was observed with a light blue sticker that stated, keep refrigerated. The nurse MDS nurse was notified of the concern. She went to observe the medication then left the hall to locate LVN-C. During an Interview with LVN-C on 10/23/2025 at 3:10 PM, revealed he was the assigned nurse that left the IV/PICC line medication on the door handle of the back door until he was able to destroy it appropriately. LVN-C said the medication was prescribed to Resident #1. LVN-C said he forgot that the medication was on the door handle until he was notified by the MDS coordinator. LVN-C said he destroyed the medication by cutting the valve that held the liquid and pouring the liquid down the toilet. LVN-C said that the medication could be discarded in the toilet. LVN-C said the failure could result in him forgetting the medication, and other residents accessing the medication and ingestion the liquids, or other adverse reactions. During an interview with the ADON on 10/23/2025 3:10 PM, she revealed her expectation was for staff administering medications to discard in the medication room container immediately. ADON said failure to discard and document medications immediately could lead to other residents' accessing the medication, resident's overdosing, and other adverse reactions. She said it was her responsibility to monitor and educate staff on medication protocol. She said the facility had completed in-services on medication administration and destruction. The surveyor asked for the in-service that was completed after the interview. During an interview with MDS on 10/23/2025 at 3:24 PM, she stated that she was a LVN and was familiar with procedures to destroy medication. MDS said she removed the medication from the door handle and took it to LVN-C to destroy. She also notified ADON and DON that the medication was left on the door handle. MDS said destruction of IV/PICC line medication included cutting the plastic globe and pouring down the toilet or taking it to the medication storage room and discarding in the container. During an interview with CNA on 10/23/2025 at 3:04 PM, she had not observed the IV PICC medications left by LVN-C. CNA stated that failing to store medications could result in resident's accessing the medications and digesting.During an interview on 10/23/2025 3:38 PM with DON revealed her expectation was for staff administering IV medications to document on the MAR. DON said medication should be discarded immediately when dropped or contaminated. DON stated that the failure placed residents at risk of having access to medication and possible adverse medical reactions, illnesses, and a medical emergency. DON said it was the responsibility of the DON and ADON to audit the medication carts and perform random checks ensuring medication protocol and storage protocol were followed. Interview on 10/23/2025 3:45 PM with ADM, he expected nursing staff to ensure medications were secured away from residents and destroyed according to policy.

Based on interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 3 (Resident #1, Resident #9, and Resident #22) of 4 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #1, Resident #9, and Resident #22 MDS were coded for BiPAP/CPAP treatments.The facility staff failed to ensure that Resident #9 was coded for a PICC line per MD orders. This failure could place residents at risk of receiving the incorrect care and treatments. During an observation and interview with Resident # 1 on 10/23/2025 at 1:15 PM his BIPAP/CPAP mask was on the floor on the left side of his bag. Resident #1 stated that he used the mask at night. Resident#1 said while he was s patient at the facility, he has not observed staff cleaning or bagging his CPAP mask. He does receive treatments from the machine at night. Resident #1 stated that he could not move or stand, due to surgery on his knee, and he could not have put the mask on the floor. Record review of Resident #1's face sheet dated 10/23/2025, reflected he was an [AGE] year-old male that was admitted on [DATE] with diagnoses including: infection and inflammatory reaction due to internal left knee prothesis, subsequent encounter (infection of other causes), Chronic Systolic (congestive) heart failure (condition of the heart muscle weakens overtime.), Hypertensive heart disease with heart failure (a condition where prolonged high blood pressure (hypertension) damages the heart muscle over time), and OSA Obstructive Sleep Apnea (Adult). (is a sleep disorder where the airway repeatedly collapses during sleep, leading to pauses in breathing. Record review of Resident #1's quarterly MDS Assessment, dated 10/07/2025, reflected the resident BIMS score was 15 indicating his cognition was in-tact. The resident required set up and clean up assistance for oral hygiene, personal hygiene, and eating, and partial to moderate assistance for showers. He required supervision and touching assistance for toileting, lower body dressing, and putting on footwear. Section O -special treatments, procedures, and programs, G1. reflected use of a Non-invasive Mechanical Ventilator while he was a resident, however, Sections O, G2. BiPAP and G3. CPAP were left blank, not identifying the specific treatment type. BiPAP (a non-invasive ventilation therapy that provides two different levels of air pressure to help patients with breathing problems.) CPAP (a treatment for sleep apnea that uses a machine to deliver pressurized air through a mask to keep airways open during sleep.) Record review of Resident #1's care plan dated 10/04/25 reflected he requires BiPAP .keep head of bed elevated, to prevent Shortness of Breath, Titrate and provide BiPAP/CPAP per physician orders. Record review of Resident #1's MD orders reflected 1. Wipe mask, nasal pillows, daily with damp cloth. 2 empty humidifier chambers, 3. Fill humidifier with warm soapy water, shake well. 4. Rinse, and air dry. Resident #9 During an observation 10/23/2025 at 1:20 PM of resident #9's BiPAP/CPAP mask was observed lying on his nightstand unbagged. Resident #9 stated that he could not recall the last use of the sleep apnea machine. Record review of Resident 9's face sheet dated 10/22/2025 reflected he was a revealed [AGE] year-old-male that was admitted on [DATE] with current DX: COPD (COPD is a chronic lung disease that causes ongoing inflammation and narrowing of the airways, making it difficult to breathe.), Osteomyelitis of Vertebra, lumbar region (infections of the bones in lower back). Sepsis (life threatening condition that occurs when the body's immune system overreacts to an infection.) Record review of Resident #9's quarterly MDS Assessment, dated 10/07/2025, reflected the resident BIMS score was 15 indicating his cognition was in-tact. The residents' ADL functioning required setup and cleaned up for oral hygiene, personal hygiene, eating, and partial to moderate assistance for showers. He required supervision and touching for toileting, lower body dress, and putting on footwear. Section O -special treatments, procedures, and programs: Resident #9's BiPAP (a device that provides air pressure to help patients with breathing problems.) and CPAP (machine used to deliver pressurized air through a mask to keep airways open during sleep.) were left blank. Section O4: Central PICC Line was left blank. (PICC lines are central lines designed for long-term therapies with different benefits and considerations.) Record review of Resident #9's care plan dated 10/09/2025 reflected he was receiving antibiotic therapy Cefazolin Sodium infections Solution.interventions administer the antibiotic medications as order by physician. Monitor and document side effects. Resident #9 was receiving IV medications Cefazolin. If IV is infiltrated: Antidote for vesicant/irritant med MAY be infused into IV catheter.prior to removal. Check nursing drug handbook or pharmacy for recommended antidote. Section: Respiratory reflected Resident #9 has altered respiratory status/difficulty breathing COPD.interventions -Admit to Cardiopulmonary Program.Monitor for difficulty breathing (Dyspnea) on exertion. Remind resident not to push beyond endurance.Monitor for s/s of potential respiratory infection.Monitor for s/sx of acute respiratory insufficiency: Anxiety, Confusion, Restlessness SOB at rest, Cyanosis (bluish discoloration of skin), Somnolence (strong drowsiness) . Monitor for s/sx of acute respiratory insufficiency.increased heart rate.Monitor vitals as orders.Monitor/document/report abnormal breathing patterns to MD. The care plan did not address BiPAP/CPAP. Record review of Resident #9's MD orders reflected dated 10/04/2025 Cefazolin Sodium Injection Solution Reconstituted 2 GM intravenously . Normal saline flush intravenously 10ml.Order dated 10/12/2025 Check PICC line dressing each shift.Change PICC line dressing every Monday, 7 days (sterile process). Change needleless connector every week with dressing change and flowing blood draws every Monday PICC LINE: measure upper arm circumference with dressing changes every Monday. IV PICC: Measure external catheter length with dressing changes every Monday. IV PICC: Monitor site and dressing document in progress note any s/sx of infection notify provider every shift. There was no order for BiPAP/CPAP. Resident #22 During an observation of resident #22's on 10/23/2025 at 1:30 PM, her CPAP machine mask was observed in the top drawer of her nightstand unbagged. Resident was wearing a nasal cannula receiving oxygen at the time. She stated that she uses her CPAP machine at night, and the mask had not been cleaned by staff. Record review of Resident 22's face sheet dated 10/23/2025 reflected she was a revealed [AGE] year-old-female that was admitted on [DATE] with current DX: Asthma (lung disease due to external agents), chronic respiratory failure ( a medical emergency where a person with a pre-existing, long-term lung condition experiences a sudden, severe worsening of their ability to breathe.), obstructive sleep apnea ( It is a sleep disorder characterized by pauses in breathing or instances of shallow breathing during sleep.). Record review of Resident #22's quarterly MDS Assessment, dated 09/30/2025, reflected the resident BIMS score was 15 indicating she was cognitively intact. The residents' ADL functioning required setup and cleaned up for oral hygiene, personal hygiene, and eating, and partial to moderate assistance for showers. She required supervision and touching for toileting, lower body dress, and putting on footwear. Section O -special treatments, procedures, and programs, did not address resident oxygen use nor BiPAP/CPAP treatments.Record review of Resident #22's care plan dated 10/03/2025 reflected she had an altered respiratory status/difficulty breathing, Asthma, CHF, and sleep apnea.interventions keep head of bed elevated, to prevent SOB.Maintain clear airway by encouraging resident to clear own secretions (mucus) with effective coughing. If secretions cannot be cleared, suction as ordered/required to clear secretions. Monitor for difficulty breathing. monitor for respiratory infections.monitor for respiratory distress, monitor vital signs.give medications as order by MD.Monitor/document/report/abnormal breathing patterns to MD increased rate, decreased rate, periods of apnea. Record review of Resident #22's MD orders reflected dated 09/28/2025 admission Protocol: may administer supplemental oxygen as needed. During an interview with the MDS on 10/23/2025 at 3:24 PM, she stated that coding section G1 Non-invasive Mechanical Ventilator while a resident was sufficient to identify the BiPAP or CPAP treatments. The MDS coordinator stated in section she checked Midline for the IV, therefore specifying the general treatment for antibiotic treatment via IV. She stated that the MD does write orders for the BiPAP and CPAP treatment for the resident. During an Interview on 10/23/2025 at 3:38 PM with the DON she stated the MDS Coordinator was responsible for completing timely and accurate MDS assessments. The DON stated that once the assessment was completed an RN would review for accuracy, then sign as completed. The negative outcome to residents when not completed accurately was not addressed by the DON. During an interview on 10/23/2025 at 3:45 PM the ADM revealed it was his expectation for the MDS coordinators to complete the MDS assessments accurately addressing the resident's care and treatment at the facility. The surveyor requested policies for Conducting Accurate assessments on 10/23/25 at 9:30 AM and again at 1:15 PM. The policy was provided, however, neither electronic copy would open to review facility policy.

Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 4 of 10 (Resident #1, Resident #9, Resident #14, and Resident #22) residents reviewed for respiratory care. The facility failed to ensure:Resident #1's, Resident #9's, and Resident #22's BiPAP/CPAP mask were stored properly when it was not in use, per facility protocol for sanitation. Resident #14's NC (a medical device that delivers supplemental oxygen through a flexible tube with two prongs that rest in the nostrils.) was discarded properly when changed, and dating the new NC tubing was installed.These deficient practices could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care. Resident #1 During an observation and interview with Resident # 1 on 10/23/2025 at 1:17 PM revealed his BIPAP/CPAP mask on the floor on the left side of his bag. Resident #1 stated staff administer his treatment at night for sleep and he did not know how the mask got on the floor. Record review of Resident #1's face sheet dated 10/23/2025, reflected he was an [AGE] year-old male that was admitted on [DATE] with diagnosis including: infection and inflammatory reaction due to internal left knee prothesis, subsequent encounter (infection of other causes), Chronic Systolic (congestive) heart failure (condition of the heart muscle weakens overtime. Hypertensive heart disease with heart failure (a condition where prolonged high blood pressure (hypertension) damages the heart muscle over time). Record review of Resident #1's face sheet dated 10/23/2025, reflected he was an [AGE] year-old male that was admitted on [DATE] with diagnosis including: Obstructive Sleep Apnea (Adult), Chronic Systolic (congestive) heart failure (condition of the heart muscle weakens overtime. Record review of Resident #1's quarterly MDS Assessment, dated 10/07/2025, reflected the resident BIMS score was 15 indicating his cognition was in-tact. The residents required set up and cleaned up assistance for oral hygiene, personal hygiene, and eating, and partial to moderate assistance for showers. He required supervision and touching for toileting, lower body dress, and putting on footwear. Section O -special treatments, procedures, and programs, G1. reflected use of a Non-invasive Mechanical Ventilator while he was a resident, however, Sections O, G2. BiPAP and G3. CPAP were left blank, not identifying the specific treatment type. BiPAP (a non-invasive ventilation therapy that provides two different levels of air pressure to help patients with breathing problems.) CPAP (a treatment for sleep apnea that uses a machine to deliver pressurized air through a mask to keep airways open during sleep.) Record review of Resident #1's MD order dated 10/04/25 reflected 1. Wipe mask, nasal pillows daily with damp cloth 2. Prescriber Empty Humidifier Chamber3. Fill humidifier with warm Written soapy water, shake well 4. Rinse, air dry in the morning. admission Protocol: may administer supplemental oxygen as needed. Resident #9 During an observation 10/23/2025 at 1:20 PM of resident #9's BiPAP/CPAP mask was observed lying on his nightstand unbagged. Resident #9 stated that he could not recall the last use of the sleep apnea machine. Record review of Resident #9''s face sheet dated 10/22/2025 reflected he was a revealed [AGE] year-old-male that was admitted on [DATE] with current DX: COPD, Chronic Bronchitis (a long-term lung condition characterized by persistent inflammation of the airways (bronchi), leading to excessive mucus production and a chronic cough.), Acute respiratory failure with hypoxia (faint), pneumonia (lung infection). Record review of Resident #1's quarterly MDS Assessment, dated 10/07/2025, reflected the resident BIMS score was 15 indicating his cognition was in-tact. The residents' ADL functioning required setup and cleaned up for oral hygiene, personal hygiene, and eating, and partial to moderate assistance for showers. He required supervision and touching for toileting, lower body dress, and putting on footwear. Section M-high risk drug class reflected he was taking antibiotics, anticoagulant, hypoglycemic, diuretic, and opioid as a resident. Section O -special treatments, procedures, and programs Resident #9's MDS was not coded for BiPAP/CPAP use. Record review of Resident #9's care plan dated 10/09/2025 reflected Resident #9 has altered respiratory status/difficulty breathing COPD.interventions Admit to Cardiopulmonary Program.Monitor for difficulty breathing (Dyspnea) on exertion. Remind resident not to push beyond endurance.Monitor for s/s of potential respiratory infection.Monitor for s/sx of acute respiratory insufficiency: Anxiety, Confusion, Restlessness SOB at rest, Cyanosis (bluish discoloration of skin), Somnolence (strong drowsiness). Monitor for s/sx of acute respiratory insufficiency.increased heart rate.Monitor vitals as orders.Monitor/document/report abnormal breathing patterns to MD. Record review of Resident #9's MD orders Record review of resident #9's MD orders dated 10/12/2025 reflected monitor vitals every shift (BP/P/R/T/02/sats). Resident #14 During an observation of Resident #14 on 10/23/2025 at 1:20 PM, the resident was wearing nasal cannula that was positioned in nostrils and tubing was not dated. A second NC was observed on the seat of the resident wheelchair. Resident stated that the overnight staff changed his tubing. Resident #14 has cognitive impairment and could not recall details such as date or person. Record review of Resident 14's face sheet dated 10/23/2025 reflected he was a revealed [AGE] year-old-male that was admitted on [DATE] with current DX: COPD (COPD is a chronic lung disease that causes ongoing inflammation and narrowing of the airways, making it difficult to breathe.), Acute Chronic Respiratory failure with hypercapnia ( is a condition where a patient with a pre-existing chronic respiratory problem experiences a sudden worsening of respiratory failure, leading to dangerously high levels of carbon dioxide in the blood.) Record review of Resident #14's quarterly MDS Assessment, dated 10/07/2025, reflected the resident BIMS score was 15 indicating his cognition was in-tact. The residents' ADL functioning required setup and cleaned up for oral hygiene, personal hygiene, and eating, and partial to moderate assistance for showers. He required supervision and touching for toileting, lower body dress, and putting on footwear. Section O -special treatments, procedures, and programs, addressed Resident #14's need for oxygen treatments.Record review of Resident #14's care plan dated 10/13/2025 reflected resident requires oxygen therapy, administer oxygen per MD orders, keep head of bed elevated to prevent shortness of breath, monitor vital signs as ordered, (skin color, pulse, airway functioning, degree of restlessness which may include hypoxia (passing out). Resident has altered respiratory status/difficulty breathing.interventions Monitor for difficulty breathing. monitor for respiratory infections.monitor for respiratory distress, monitor vital signs.give medications as order by MD.Monitor/document/report/abnormal breathing patterns to MD increased rate, decreased rate, periods of apnea. Record review of Resident #14's MD orders reflected dated 10/10/2025 MD orders dated 10/10/2025 reflected monitor 02 saturations every shift. Monitor 02 saturations as needed for s/sx of low 02 saturations. Continuous 02 via NC at 4 LPM every shift. change 02 tubing every night shift every Sunday and as needed. Resident #22 During an observation of resident #22's on 10/23/2025 at 1:30 PM, her CPAP machine was on her nightstand, and she was wearing a nasal cannula that was dated 10/19/2025. Her NC was connected to oxygen concentrator (medical device for therapy to provide supplemental oxygen to people with respiratory. Issues. Resident #22 stated that the mask had not been cleaned since being admitted to the facility. Record review of Resident 22's face sheet dated 10/23/2025 reflected he was a revealed [AGE] year-old-female that was admitted on [DATE] with current DX: Asthma (lung disease due to external agents), chronic respiratory failure ( a medical emergency where a person with a pre-existing, long-term lung condition experiences a sudden, severe worsening of their ability to breathe.), obstructive sleep apnea ( It is a sleep disorder characterized by pauses in breathing or instances of shallow breathing during sleep.). Record review of Resident #22's quarterly MDS Assessment, dated 09/30/2025, reflected the resident BIMS score was 15 indicating she was cognitively intact. The residents' ADL functioning required setup and cleaned up for oral hygiene, personal hygiene, and eating, and partial to moderate assistance for showers. She required supervision and touching for toileting, lower body dress, and putting on footwear. Section O did not address her need for BIPAP and CPAP treatment, and oxygen Record review of Resident #22's care plan dated 10/03/2025 reflected she altered respiratory status/difficulty breathing, Asthma, CHF, and sleep apnea.interventions keep head of bed elevated, to prevent SOB.Maintain clear airway by encouraging resident to clear own secerns (mucus) with effective coughing. If secretions cannot be cleared, suction as ordered/required to clear secretions. Monitor for difficulty breathing. monitor for respiratory infections.monitor for respiratory distress, monitor vital signs.give medications as order by MD.Monitor/document/report/abnormal breathing patterns to MD increased rate, decreased rate, periods of apnea.The care plan did not address the residents' use for oxygen and BiPAP and CPAP. Record review of Resident #22's MD orders dated 09/28/2025 reflected admission protocol: may administer oxygen as needed. Monitor vitals every shift (blood pressure, respirations, temperature, and 02 saturations . MD orders for 02 liters per minute. During an interview with CNA on 10/23/2025 at 3:04 PM she had not observed Resident #14's NC tubing in his wheelchair during rounds. She stated that both the nurse and aide conduct rounds, and medical equipment found that was old and not in use should be discarded immediately and notify the nurse. She said if a resident's mask was found on the floor, she would report to the nurse. During an interview on 10/23/2025 at 3:10 PM, with the ADON, she stated Resident's prescribed sleep apnea and oxygen should be cleaned by the nurse and observed for sanitation every shift. She stated that all masks should be stored in a plastic bag and dated when not in use. She stated the failure could cause residents to get an infection from when not stored and cleaned according to the facility policy for sanitation. She stated the overnight shift nurse changes the NC on Sundays, and the NC should be discarded immediately after administering the new to prevent resident access and a clean clinical environment. During an interview on 010/23/2025 at 3:38 PM, the DON said the nursing staff were responsible for ensuring a resident's oxygen tubing was changed weekly and tubing dated. She stated Resident #14's old NC should be discarded immediately upon removing and replacing the new NC. She expects nursing staff to follow MD orders for cleaning BiPAP/CPAP mask, and to store them in a dated plastic bag when not in use to prevent cross contamination. She stated the failing to follow procedure could result in the Resident's obtaining respiratory devices could result in respiratory infections. During an interview with the ADM on 10/23/2025 at 3:45PM revealed he expects the nursing staff to follow facility policies and MD orders for resident clinical needs. Record review of facility policy titled CPAP/BiPAP respiratory care, dated 07/2020. Policy reflected in morning, clean mask .Cleaning of unit Humidification chamber needs to be cleaned out frequently to prevent bacteria build-up and prevent calcification.Unplug unit before cleaning it.Using a damp cloth, wipe outside of unit.Remove chamber from humidifier carefully so water does not enter the CPAP machine.Open chamber and wash with warm, soapy water.Rinse well with water and allow to dry on a clean cloth or paper towel out of direct sunlight.Fill with distilled water (may also use filtered water Weekly humidifier chamber will be soaked in solution of 1 part white vinegar/3 parts water for 15-20 minutes prior to thoroughly rinsing with distilled water.Ensure unit is thoroughly dry before plugging it in again Immerse humidifier in warm, soapy water.Fill humidifier with soapy water and shake vigorously.Rinse with clean water and allow to air dry.Ensure BIPAP/CPAP mask and/or tubing and oxygen tubing is stored in a clean bag when not in use.Using oxygen If physician has ordered oxygen during CPAP/bi-level therapy, observe all fire and safety rules associated with oxygen use.Documentation Requirements Specific physician orders.Specific individualized instructions to staff on comprehensive individualized plan of care.Daily cleaning procedures performed.

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 one (Residents #1 and #2) of five residents reviewed for infection control. 1. The facility failed to ensure the WCN performed hand hygiene and used a clean technique to apply Triad paste (Triad is a for light-to-moderate wound exudate that helps maintain a moist wound healing environment) to the resident's buttocks during incontinence care for Resident #1. 2. The facility failed to ensure RN A changed gloves and performed hand hygiene during incontinence care for Resident #1.This failure could place residents at risk for healthcare associated cross contamination and infections.Findings include: 1. Review of Resident #1's Annual MDS Assessment, dated 07/10/25, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her cognitive skills for daily decision making were moderately impaired. The resident required maximum assist with toileting. The resident was always incontinent of bladder and bowel. The resident's diagnoses included liver cirrhosis (severe scarring of the liver tissue), diabetes, and malnutrition. The resident had two Stage I pressure injuries and two Stage II pressure injuries.Review of Resident #1's Order Summary Report, dated 07/02/25, reflected an order:07/02/25 Cleanse coccyx, pat dry, apply Triad paste every dayshift for wound prevention.Review of Resident #1's Care Plans, dated 07/01/25, reflected the following focus areas:07/01/25 Resident was incontinent. Facility interventions included to Check every 2-3 hours and as needed for incontinence. Wash, rinse and dry perineum. Change clothing as needed after incontinence episodes.07/03/25 Resident has actual impairment to skin integrity: Left heel pressure, Right heel pressure, and Coccyx - wound prevention.Facility interventions included to apply barrier cream after incontinent episodes per facility protocol. An observation and interview on 07/10/25 at 12:35 PM of Resident #1 revealed the WCN was showing the State Surveyor the wounds the resident had. The WCN said the resident was being treated for Stage II wounds on each heel and a Stage I wound on the buttocks. The resident's heels appeared to be healed. The WCN walked over to the resident to unfasten her brief. The resident was soiled of stool that was leaking from the brief. The WCN said she would change the resident and RN A entered the room to assist her. The resident had diarrhea. RN A said the resident had diarrhea because she used lactulose. Both RN A and the WCN put on gloves. The WCN and RN A unfastened the brief while the resident was lying on her back. The WCN cleaned the peri-area of the resident and changed her gloves. The WCN did not perform hand hygiene. The WCN had to use multiple wipes to clean the resident. The WCN used her soiled gloves to touch the wipes container and pull-out clean wipes. RN A also assisted to clean the peri-area of the resident. The resident was turned to her left side. The WCN cleaned more stool off the resident. The resident had redness on her bilateral buttocks. There was green-brown colored stool on the mattress. The WCN used her soiled gloves and pulled out more wipes. The WCN cleaned the soiled mattress and placed the soiled wipes on the resident's bedside table. The WCN used her soiled gloves to place a new draw sheet and brief beneath the resident. The WCN then removed the soiled wipes from the bedside table and placed them in the trash. The resident was turned to her right side and RN A cleaned stool off the resident and pulled out the soiled linen and brief. RN A used her soiled gloves to position the clean brief and draw sheet. The WCN used the same soiled gloves to apply Triad paste to the resident's buttocks and peri-area. The WCN changed gloves, but did not perform hand hygiene. RN A used her same soiled gloves to assist the WCN to pull up the sheets and place the resident's call light. RN A placed the soiled wipes container in the resident's drawer.An interview on 07/10/25 at 12:50 PM with the WCN revealed she was hired in February 2024. The WCN said she probably should have performed hand hygiene after changing gloves. The WCN said she did not perform hand hygiene between her glove changes because she usually double-gloved. The WCN said she had been trained to perform hand hygiene, but that she did not do patient care enough with changing briefs. The WCN said she soiled the wipes container, but that RN A threw the wipes container away. The WCN denied that she put soiled wipes on the bedside table. The WCN also denied using soiled gloves to apply the Triad paste. The WCN said failing to perform hand hygiene could place the resident at risk for infection.An interview on 07/10/25 at 12:55 PM with RN A revealed she had worked at the facility for just over a month. She said she did not change her gloves because while providing incontinence care she was working in a dirty field. RN A said that it was required that before cream was put on a resident, gloves were supposed to be changed. RN A refused to say if the WCN failed to change her gloves and perform hand hygiene prior to applying Triad paste to Resident #1. RN A said she did not need to change gloves or perform hand hygiene prior to putting on a new brief or pulling up the sheets because she was not working in a sterile field. RN A said she was going to clean Resident #1's bedside table.An interview on 07/10/25 at 2:00 PM with the Regional DON revealed she started covering the facility on 07/09/25. The Regional DON said staff were supposed to perform hand hygiene when changing gloves and were supposed to change gloves when going from dirty to clean during incontinence care. The Regional DON said applying Triad paste required clean gloves and that soiled wipes were supposed to be thrown in the trash and not placed on the bedside table. The Regional DON said the observed issues placed the resident at risk of transmission of infection. The Regional DON said the DON and nursing leadership had a shared responsibility for ensuring staff used infection control measures when caring for residents. She said the Infection Preventionist (not in the facility) performed hand hygiene observations quarterly and the staff had received in-services on infection control.Review of the Facility Policy, Infection Prevention and Control Program, dated 04/17/25, reflected: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.Review of the Facility Policy, Hand Hygiene, revised November 2024, reflected: Handwashing/hand hygiene is generally considered the most important single procedure for preventing healthcare associated infections. Antiseptics control or kill microorganisms contaminating skin and other superficial tissues. Although antiseptics and other handwashing/hand hygiene agents do not sterilize the skin, they can reduce microbial contamination depending on the type and the amount of contamination, the agent used, the presence of residual activity and the handwashing/hand hygiene technique followed. Antiseptics should not, as a rule, be used to disinfect inanimate surfaces.I. HANDWASHING When hands are visibly dirty or contaminated with proteinaceous material, are visibly soiled with blood or other body fluids, after going to the restroom, before eating, before performing an invasive procedure, and after providing care to a resident with a spore-forming organism (e.g., C. difficile), perform hand hygiene with either a non-antimicrobial soap and water or an antimicrobial soap and water.

Based on observation, interviews, and record reviews, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #1) of 3 residents reviewed for pressure ulcers, in that: 1. The facility failed to provide preventive care, consistent with professional standards of practice, to Resident#1 who was at risk for pressure injury development. On 04/24/25, Resident #1's admission progress note revealed skin integrity concerns that included, Resident #1 had redness to bilateral heels, Eschar (a hardened, dry, black, or brown dead tissue that forms a scab-like covering over deep wounds) to the left big toe, redness to the groin area, and redness to the buttock and coccyx (tailbone) area. 2. The facility failed to consult the Wound Medical Doctor (WMD) or implement additional pressure relieving devices for Resident #1 to prevent skin breakdown of the heels or coccyx and buttocks on 04/25/25. 3. The facility failed to monitor early signs of a pressure injury (PI) to promote the prevention of pressure ulcer (PU) development to Resident #1's right heel, left heel, and sacrum. On 05/09/25, the RP discovered altered skin integrity on Resident #1's right heel, left heel, and sacrum. On 05/09/25, the WCN inspected Resident #1 based on the RP's concern(s). The WCN took pictures and documented that Resident #1 had a pressure injury to the right heel, a pressure injury to the left heel, and a Stage 3 pressure ulcer to the sacrum. 4. The facility failed to appropriately place pressure offloading wedges when staff repositioned Resident #1 to reduce pressure on bony prominences. An Immediate Jeopardy (IJ) was identified on 05/30/25. The IJ template was provided to the facility on [DATE] at 3:00 PM. While the IJ was removed on 05/31/25, the facility remained out of compliance at a scope of Isolated and severity level of No Actual Harm with a potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures placed residents at risk of developing new or worsening pressure ulcers. Findings included: A record review of Resident #1's admission MDS Assessment, dated 04/27/25, revealed a [AGE] year-old female who admitted on [DATE]. Resident #1 had Medically Complex Conditions that included active diagnoses of Diabetes Mellitus (DM) (a chronic condition that affects the way the body processes glucose [blood sugar]); Stroke; Aphasia (a disorder that impairs the expression and understanding of language, as well as reading and writing abilities); Hemiplegia (refers to complete paralysis) or Hemiparesis (characterized by weakness on one side of the body) of the right side; and Malnutrition. A BIMS score of 05 suggested Resident #1 had severe cognitive impairment. Resident #1 was dependent in self-care and mobility needs. Resident #1 was always incontinent of bladder and occasionally incontinent of bowel. The admission MDS reflected Resident #1 did not have current unhealed pressure ulcers/injuries at any stage and was at risk of developing pressure ulcers/injuries. Resident #1 was transferred to the hospital on [DATE] for a non-wound related issue at the RP's request. Record review of Resident #1's Discharge MDS assessment, dated 05/13/25, revealed Resident #1 had one or more unhealed pressure ulcers/injuries. The Discharge MDS assessment reflected one Stage 3 pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough (a type of dead tissue that accumulates on the surface of a wound. It is typically soft, yellowish, or white) may be present but does not obscure the depth of tissue loss. May include undermining and tunneling) and four unstageable pressure injuries presenting as deep tissue injury (a unique form of a pressure injury that affects the underlying layers of skin, muscle, and other soft tissues) that were not present on admission. A record review of Resident #1's care plan report, initiated 04/25/25 reflected the following: [Resident #1] is incontinent. (Initiated: 04/25/25). Interventions included Brief Use: The resident uses disposable briefs. Change as needed.; Clean peri-area with each incontinence episode; Incontinent: Check every 2 - 3 and as needed for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes.; Skin: Provide skin care with each incontinent episode. (Initiated: 04/25/25). Goal: [Resident #1] will have minimal complications related to incontinence episodes through the review date. (Target Date: 06/22/25). [Resident #1] is at risk for alteration in skin integrity. (Initiated: 04/25/25). Interventions (Initiated: 04/25/25) included Apply barrier cream per facility protocol to help protect skin from excess moisture; Change bedding/clothing if moist; Do not allow linens to be creased/folded under resident, keep bedding as smooth as possible; Encourage/assist with turning and repositioning ever 2-3 hours; Guest refuses offloading and turning/re-positioning at times. Provide re-education and re-approach when care is refused.; Monitor skin when providing care, notify nurse of any changes in skin appearance; Provide skin/wound treatments as ordered. Goal: [Resident #1] will remain free of new skin impairment through the review date. (Target Date: 06/22/25). [Resident #1] has actual impairment to skin integrity r/t Poor Nutrition. 5/28/25 - DTI - left great toe, left heel, right heel; Stage 3 right lateral foot. (Initiated: 05/09/25). Interventions (Initiated: 04/25/25) included Evaluate and treat per physician's orders; LALM (Low Air Loss Mattress) as ordered (Initiated: 05/12/25); Prevalon boots as ordered (Initiated: 05/12/25); and Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observation by wound nurse or provider. Goal: [Resident #1] skin injury will be healed by review date -and- will have no complications r/t documented skin impairment through the review date. (Target Date: 06/22/25). A record review of Resident #1's Order Summary Report printed 05/19/25 reflected the following: Order date 04/24/25: Wound Consult as needed. Order date 04/25/25: Barrier Cream apply after Incontinent episodes every shift. Order date 04/27/25: Skin Checks Weekly every Day shift every Monday. Must open and document Skin Evaluation for each assessment (including no new areas found). Order date 05/08/25: Wound care to eval and treat coccyx area one time a day for wound care. [Discontinued 05/11/25] Order date 05/09/25: Monitor for LALM (Low Air Loss Mattress) every shift for wound healing. Order date 05/09/25: Monitor for Prevalon boots (for heel protection) every shift for wound healing. Order date 05/09/25: Cleanse right heel, pat dry, apply skin prep every Day shift for wound healing. Order date 05/09/25: Cleanse left great toe, pat dry, apply skin prep every Day shift for wound healing. Order date 05/09/25: Cleanse left heel every Day shift for wound healing. Order date 05/09/25: Cleanse right lateral foot every Day shift for wound healing. Order date 05/09/25: Cleanse sacrum, pat dry, apply collagen [did not indicate form or type of collagen] and Anasept (an antimicrobial skin and wound cleanser), cover with dry dressing every Day shift for wound healing. Order date 05/09/25: [Prescriber (Physician) Entered] Vascular consult. [Order status: Pending Confirmation] Record review of Resident #1's April 2025 MAR revealed a weekly skin check was completed on 04/28/25 and barrier cream was applied after incontinent episodes every shift as the order was written. Record review of Resident #1's May 2025 MAR revealed a weekly skin check was completed on 05/05/25 and barrier cream applied after incontinent episodes every shift were implemented as written. The orders to monitor for LALM and Prevalon boots every shift for wound healing was implemented 05/09/25 during the night shift and every shift thereafter as written. Record review of Resident #1's May 2025 TAR revealed orders to cleanse right heel, great toe, left heel and right lateral foot, pat dry, apply skin prep everyday shift for wound healing were implemented on 05/10/25 and performed daily as written. The order to cleanse sacrum, pat dry, apply collagen [did not indicate form or type of collagen] and Anasept, cover with dry dressing every day shift for wound healing was implemented 05/10/25 and performed daily as written. The WCN signed off on the order entered on 05/08/25 for Wound care to eval and treat coccyx area one time a day for wound care on 05/09/25. Record review of Resident #1's admission progress note, dated 04/24/25 at 8:59 PM, completed by RN A, revealed Resident #1 had skin integrity concerns that included, redness to bilateral heels, Eschar (a hardened, dry, black, or brown dead tissue that forms a scab-like covering over deep wounds) to left big toe, redness to groin area, and redness to buttock. RN A entered an order on 04/24/25 for a Wound Consult as needed. The Wound Care Nurse (WCN) completed a skin assessment on Resident #1 on 04/25/25. Record review of Resident #1's completed Weekly Skin Observations reflected: admission Skin Observation Date: Friday, 04/25/25. Completed by the WCN. Does the Resident have ANY Skin Issues Observed (including new and old)? No If No, Reason: No open wounds noted. Document and Describe ALL Skin Issues: Coccyx (tailbone) - Redness; Left toe(s) - Big toe has scab Other Observations: Skin clean dry and intact. The Wound Team was not notified and there were no intervention/treatment in place. admission Skin Observation Date: Monday, 04/28/25. Completed by LVN B. Does the Resident have ANY Skin Issues Observed (including new and old)? Yes MD notified: Yes Document and Describe ALL Skin Issues: Coccyx (tailbone) - Redness; Other Observations: No new skin issues noted at this time. The Wound Team was not notified. Intervention/treatment in place: Yes. Weekly Skin Observation Date: Monday, 05/05/25. Completed by the WCN. Does the Resident have ANY Skin Issues Observed (including new and old)? No If No, Reason: No open wounds noted. Document and Describe ALL Skin Issues: Right buttock - Redness; Left buttock - Redness; Other Observations: Skin clean dry and intact. The Wound Team was notified, and intervention/treatment was in place. Weekly Skin Observation Date: Monday, 05/12/25. Completed by LVN B. Does the Resident have ANY Skin Issues Observed (including new and old)? Yes MD notified: Yes Document and Describe ALL Skin Issues: Coccyx (tailbone) - Pressure Sore; Other (specify) - Eschar to multiple toes; Groin - Redness; Other (specify) - Redness/pressure sore to BIL heels (Boots applied); Other Observations: No new skin issues noted at this time. The Wound Team was not notified. Intervention/treatment in place: Yes. During an interview on 05/17/25 at 12:07 PM, LVN B said that she worked at the facility for 2 years. LVN B said that she was familiar with Resident #1. LVN B said that she completed the weekly skin assessments for Resident #1. LVN B said that she recalled Resident #1 had redness on her coccyx (tailbone) and CNAs applied barrier cream to the area to protect from breakdown. LVN B said that the CNAs should reposition, and offload pressure points every 2 hours. LVN B said that Resident #1 was at risk for skin breakdown because she had a poor nutritional intake, was incontinent, and made occasional slight changes in body position and was unable to make frequent changes independently. LVN B said the last skin assessment (05/12/25) she completed on Resident #1, the reddened area at the coccyx was open and the WCN documentation reflected a Stage 3 pressure ulcer. LVN B said that Resident #1 had dark discolorations at the heels, and she made sure that the Prevalon boots (heel protectors) were placed on Resident #1's feet before (LVN B) exited the room. LVN B said that all nursing staff was responsible for ensuring residents at risk for skin breakdown have appropriate interventions in place. LVN B said that the CNAs would use pillows to offload Resident #1's ankles before the Prevalon boots were ordered by the WCN. LVN B said that Resident #1 was turned and repositioned every two hours. LVN B said the purpose of turning and repositioning a resident every two hours was to prevent avoid skin breakdown. LVN B could not verbalize how she monitored if Resident #1 was repositioned, and offloading devices were properly placed. During an interview on 05/17/25 at 2:45 PM, Resident #1's RP stated that Resident #1 was admitted to the facility for nearly 3 weeks and was discharged to the hospital for a low blood pressure on 05/13/25. The RP said that he had electronic monitoring in Resident #1's room and was able to provide images of [Resident #1] slumped over to the right side in bed and the green (pressure offloading) wedges were not placed under Resident #1. The RP said that a (pressure offloading) wedge was at the foot of the bed and the other (pressure offloading) wedge was on a chair next to the bed. Record review of an undated and timed picture submitted by the RP, revealed Resident #1 asleep in bed. The head of bed was raised approximately 45 degrees. Resident #1 was in a semi-seated position with knees bent. Resident #1's upper body was leaned over to the right side. A green (pressure offloading) wedge was observed at the right-side foot of the bed. A corner of the (pressure offloading) wedge hung off the edge of the bed. At the left-side head of the bed, 2 green (pressure offloading) wedges were observed stacked on the chair resting on the left arm and the seat of the chair. During record review and an interview on 05/19/25 at 3:09 PM, the WCN said that she provided wound care, new resident skin assessments, measured and took pictures of wounds; performed weekly skin assessments on residents she followed for wound care and occasionally assisted nurses with weekly skin assessments if they became too busy. The WCN said that she took wound pictures every 7 days to monitor improvement and followed all altered skin integrity that included skin tears to pressure wounds. The WCN said that the nurses performed wound care in the WCN's absence and on the weekends. The WCN said that she conducted the admission skin assessment on Resident #1 and skin was intact. The WCN said that Resident #1 did not have redness to the right and left heels and although there was redness to the buttocks she was not concerned because the skin was intact. The WCN said that the facility policy and procedure for PU/PI prevention was to order a LALM for residents with actual skin breakdown, keep residents clean and dry if incontinent, turn and reposition every 2 hours to prevent skin breakdown if the resident could not reposition on their own. The WCN said that staff were aware of care plan interventions by reviewing the care plan. The WCN said that she did not participate in care plan develop or updates and did not monitor if care plan interventions were implemented for the management of skin. The WCN said the wound doctor was involved with intervention suggestions. The WCN said that she did not need to follow Resident #1 because she did not have any skin issues. The WCN said that the RP complained of bruises to Resident #1's right and left heels (on 05/09/25) and she told the RP that they were blood blisters. The WCN replied when asked if blood blisters were considered DTIs, she said no. The WCN went on to say that the RP was concerned about Resident #1's buttocks and the WCN said that she visualized the area and said that it looked like shearing from friction (a superficial injury that occurs when skin is dragged across a surface). The WCN stood up and demonstrated how a resident's brief could be placed incorrectly and rubbed against the skin when pulled across the bed. The WCN denied that was the situation with Resident #1 and said that she was just giving an example. The WCN said that she thought the shearing could have been caused by skin contact with the mechanical lift sling. The WCN said that she did not think that Resident #1's bottom would be bare on the mechanical lift sling and said that she was giving an example. The WCN said that she took pictures of the discovered areas and forwarded to the NP for guidance. The WCN said that the NP was unsure about Resident #1's altered skin issues. The WCN said that she documented the right and left heels as DTIs and the sacrum as a Stage 3 pressure ulcer. When the WCN was asked, what information was obtained to determine the altered skin integrity was a Stage 3, she said that she measured the wound and it looked like a Stage 3 (pressure ulcer). The investigator reviewed the picture of the sacrum with the WCN, asked about the measurements entered underneath the picture (6.00 cm length x 3.00 cm width x unknown depth), and if a depth of a wound was necessary to consider a pressure ulcer a Stage 3; the WCN said No, the depth was not needed to stage a wound. The WCN could not define in her own words the differences between Stage 1 & 2 (partial thickness), Stage 3 & 4 (full thickness), Unstageable/DTI, or eschar. The WCN said that she obtained orders from Resident #1's PCP and did not consult the Wound Medical Doctor (WMD). During an interview on 05/19/25 at 7:12 PM, CNA C stated she worked at the facility for 2 years. CNA C denied ever seeing the green (pressure offloading) wedges at the bottom of Resident #1's bed or on the chair beside the bed. CNA C said that the wedges must be placed underneath Resident #1 to prevent falls. CNA C said that the wedges were placed at the shoulders and at the hips. CNA C said that rounds were done every 2 hours and as needed. CNA C said if she observed the wedges placed incorrectly or not underneath the resident, she would immediately correct the issue. CNA C was unaware of the purpose for the wedges to help maintain a lateral side-lying position and to ensure proper offloading for pressure injury prevention. During record review and an interview on 05/19/25 at 7:53 PM, the CNO said that she expected nurses and the WCN to follow facility protocols for pressure ulcer prevention and skin management. The CNO said the green wedges were to be placed underneath Resident #1 to off-load pressure and prevent skin breakdown. The CNO said the green wedges were also used to support Resident #1 when sitting upright due to her stroke related left sided weakness. The CNO said, labeled Patient's Side, were not used properly in the pictures shown to her. The CNO stated if the green (pressure offloading) wedges were not placed properly underneath Resident #1, there was a risk of pressure ulcer development due to pressure on the skin for a long time. The CNO said that the LALM assisted with off-loading pressure to the resident to prevent wounds and avoid pre-existing wounds from worsening. The CNO said that the facility recently held a Skills Fair with nurses to ensure up-to-date knowledge and competency in skin management and wound care. The CNO said that Resident #1's wounds were unavoidable and that she started the documentation on 05/09/25 to reflect the factors that made the wounds unavoidable but did not complete the documentation. The CNO said that a resident should be assessed and evaluated at admission to determine if at risk for unavoidable PI/PU. The CNO said that Resident #1 was not assessed or evaluated during admission because the electronic health record, PCC, did not include that type of assessment at admission. The CNO said that the WMD did not need to be consulted for redness and could be treated by the WCN, but the WCN should have consulted the WMD on 05/09/25 when the altered skin integrity was discovered and if she had questions about wound staging. The investigator reviewed the picture of the sacrum with the CNO, and she said that the area to Resident #1's buttocks looked like a superficial skin injury and not a Stage 3. The CNO said that the measurements of a Stage 3 wound would include the length, width, and depth. The CNO said if there was not a measurable depth to a wound because the margins were even with the surrounding skin or was covered by slough or eschar, the wound would be considered unstageable and would require the WMD to be consulted. On 05/19/25, an outbound call to the NP was unanswered and forwarded to an automated service that prompted to leave a voicemail. A return call was not received prior to the exit on 05/31/25. Record review of the facility's Skin Integrity Management policy, revised October 5, 2016, reflected: Reposition residents at risk for pressure sore or with pressure sores at least every two (2) hours, if unable to turn themselves. Use pillows or foam wedges to keep bony prominences from direct contact . The presence of a pressure reducing device/specialty bed does not negate the need to turn/reposition the resident at least every two (2) hours in order to prevent pulmonary and renal complications as well as pressure sores . If eschar or necrotic tissue is present, debridement may be indicated. Physicians do surgical debridement only. The National Pressure Ulcer Advisory Panel ([NPUAP], 2016) revised the definition and stages of pressure injury. Review of the new definition of suspected DTI is: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Further description is also given: Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. (Reference: Edsberg LE, Black JM, [NAME] M, [NAME] L, [NAME] L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised Pressure Injury Staging System. J Wound Ostomy Continence Nurs. 2016; 43(6):585-597. doi:10.1097/WON.0000000000000281 https://pmc.ncbi.nlm.nih.gov/articles/PMC5098472/) The Centers for Medicare & Medicaid Services ([CMS], 2024), defined pressure ulcer/injury characteristics as: - Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema (redness). In darker skin tones, the PI may appear with persistent red, blue, or purple hues. The presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes of intact skin may also indicate a deep tissue PI. - Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon, or purple discoloration Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. These changes often precede skin color changes and 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 ulcer. Once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage. Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. (Reference: Centers for Medicare & Medicaid [CMS], State Operations Manual, Appendix PP. (Rev. 225; Issued: 08-08-24). F686 Skin Integrity, p. 298. https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/downloads/appendix-pp-state-operations-manual.pdf The NFA was notified of an Immediate Jeopardy (IJ) on 05/30/25 at 3:00 PM, due to the above failures and the IJ template was provided. The facility's Plan of Removal (POR) was accepted on 05/31/25 at 11:14 AM and included: [FACILITY NAME] is committed to ensuring the safety and well-being of all Residents and operates in substantial compliance with Federal and State laws and regulations. This removal plan constitutes [FACILITY NAME]'s written credible allegation of compliance for the immediate jeopardy noted. Policy Statement It is the facility's policy to ensure that residents receive care, consistent with professional standards of practice, to prevent pressure ulcers/injuries and do not develop pressure ulcers/injuries unless clinically unavoidable, and that residents with pressure ulcers/injuries receive necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing, in accordance with F686. Immediate Action for Affected Residents On 05/30/25: Resident #1 is currently hospitalized . Upon return to the facility, the resident will: o Receive a complete skin assessment by two licensed nurses o Have a new care plan developed addressing all areas of skin integrity o Be evaluated by the Wound Care Physician within 24 hours of readmission o Have pressure-relieving devices implemented including heel protectors and pressure-redistributing mattress o Receive repositioning every 2 hours and as needed Identifying Other Residents at Risk On 05/30/25: Conduct skin sweep of current residents completed by licensed nurses Review of current residents' medical records to identify those with diabetes, impaired mobility, or other risk factors for pressure injuries Creation of a facility-wide list of at-risk residents requiring enhanced monitoring Root Cause Analysis Root causes identified through staff interviews, record reviews, and process analysis on 05/30/25: Lack of communication between nursing staff and Wound Care Nurse Systemic Changes and Preventive Measures Effective 05/30/25: Revised skin assessment protocol requiring two-nurse verification of skin concerns on admission Residents with skin alterations will be reviewed during clinical stand-up meetings DON and or Designee will provide mandatory in-service education to all nursing staff until all nurses have been trained prior to next shift worked. o Pressure injury prevention and identification o Proper wound staging o Communication requirements o Documentation requirements o Reporting requirements DON and or Designee will provide mandatory in-service education to all Updated wound care policy requiring physician notification of identified skin concerns Implementation of wound care rounds weekly by WCN and or designee Monitoring and Evaluation Plan Beginning 05/30/25: Director of Nursing or designee will: o Audit 100% of new admissions for skin assessments daily for 2 weeks, then 50% weekly for 4 weeks o Review wound documentation daily for 2 weeks, then 3x/week for 4 weeks o Monitor physician notification compliance daily for 2 weeks o Observe random wound care rounds weekly for 8 weeks Quality Assurance Nurse And or Designee will: o Conduct random audits of 10 resident skin assessments weekly for 8 weeks o Review new pressure injuries for appropriate interventions and physician notification o Monitor staff compliance with new protocols weekly The Director of Nursing will report monitoring results to the QAPI committee weekly for 8 weeks, then monthly until sustained compliance is achieved for 3 consecutive months. The QAPI committee will adjust the plan as needed based on audit findings. On 05/31/25 the investigator began monitoring if the facility implemented their plan of removal sufficiently to remove the IJ by the following: Interviews conducted with nursing staff scheduled on 05/31/25 between 11:30 AM - 3:00 PM, included PRN and new hire staff [RN F, LVN G, LVN B, and LVN D] indicated they participated in the mandatory in-service education about Pressure Injury Prevention and Identification, Proper Wound Staging, Communication Requirements, Documentation Requirements, and Reporting Requirements. The nurses summarized the topic of discussion included policy, procedure, and the facility/leadership expectations. Each nurse stated in their own words the procedures for resident skin management to prevent pressure injury/ulcer development rather avoidable or unavoidable (pressure injury development or failure to heal because of the resident's clinical condition regardless of the interventions provided to treat or prevent development). Nurses said that they would notify the WCN and/or ADONs and notify the physician immediately of resident change in condition and verbalized steps on how to notify attending physician/NP/physician designee and the wound physician, if applicable, including what actions to take if unable to contact a physician. Observations on 05/31/25 of nurses [RN F, LVN G, LVN B, and LVN D] demonstrated in the chart how to locate observation documents, how to complete a weekly skin assessment, document skin observations in a daily skilled note, and how to enter an order for a wound consultation for the WCN to assess, evaluate, and treat. The WCN would consult the third-party WMD as needed. Observation on 05/31/25 of CNAs [CNA P and CNA E] performed pressure relief measures that included, resident positioning; support device placement to offload and prevent pressure to bony areas; and apply skin protectant to intact peri-wound skin during incontinent care. Interviews co[TRUNCATED]

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of quality of life for 4 (Resident #1, Resident #2, Resident #3, and Resident #4) of 9 reviewed for dignity. 1. The facility failed to ensure that Resident #1's gown was properly closed, which exposed her shoulder and upper chest areas. 2. The facility failed to provide Resident #2, Resident #3, and Resident #4 a privacy cover for the indwelling urinary catheter drainage bags on 05/30/25. These failures could place the residents at risk of psychosocial harm feeling uncomfortable, disrespected and could decrease residents' self-esteem and/or diminished quality of life. Findings included: Record review of Resident 1's face sheet, dated 05/17/25, revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] and discharged on 05/13/25. Resident #1's diagnoses included: Sepsis due to MSSA (a serious bloodstream infection that can lead to septic shock, a life-threatening condition),cerebral infraction (also known as a stroke or ischemic stroke, is a condition where a portion of the brain's tissue is damaged due to a blockage or narrowing of a blood vessel supplying blood to the brain), aphasia following cerebral infraction (aphasia, a language disorder affecting communication, can occur following a cerebral infarction (stroke), dysphagia following a cerebral infarction (dysphagia, or difficulty swallowing, is a common and potentially serious complication following a cerebral infarction (stroke), hemiplegia (complete) and hemiparesis (weakness) following cerebral infarction affecting left non-dominant side, ADL assistance for personal care, abnormalities in gait and mobility, syncope and collapse (syncope (fainting) is a sudden, temporary loss of consciousness due to decreased blood flow to the brain, while collapse can be caused by various factors, including syncope, but also other conditions like seizures, head injury, or medical issues), end stage renal disease (the final stage of chronic kidney disease where the kidneys can no longer function adequately to support life), and dependence on renal dialysis. Record review of Resident #1's MDS assessment, dated 04/27/25, revealed the resident had severe cognitive impairment with a BIMS score of 5. The assessment reflected Resident #1 needed assistance from staff with her ADL's, such as eating, oral hygiene, personal hygiene, toileting hygiene, shower/bath, upper and lower body dressing, and putting on/taking off footwear. The assessment reflected Resident #1 needed assistance from staff with functional abilities, such as being rolled from left and right, sitting to lying, lying to sitting in bed, and tub/toilet transfers. Record review of Resident #1's Discharge MDS assessment, dated 05/13/25, revealed that she was discharged from the facility on 05/13/25 to a Short-Term General Hospital. In Section C0500 there was no information indicating that Resident #1 w3as unable to complete the interview. In Section C - Cognitive Patterns, Section C0700 for Short-term Memory indicated Resident #1 had a memory problem. In Section C1000 for Cognitive Skills for Daily Decision Making was coded a 3 indicating Resident #3 cognition was severely impaired and she never/rarely made decisions. Record review of Resident #1's Care Plan dated 04/25/25 revealed the following: Focus: [Resident #1] had ADL self-care performance deficit and limitations in mobility. Date Initiated: 04/29/2025 Goal: The resident/guest will improve self-care and mobility function by the next review date. Date Initiated: 04/25/2025 Target Date: 06/22/2025 Interventions: Upper body dressing: Substantial/maximal assistance. Date Initiated: 04/25/2025 Lower body dressing: Substantial/maximal assistance. Date Initiated: 04/25/2025 Personal hygiene: Substantial/maximal assistance. Date Initiated: 04/25/2025 . Focus: The resident has the potential for altercations in psychosocial well-being. Date Initiated: 04/25/2025 Goal: The resident will have no indications of psychosocial well being problems by/through review date. Date Initiated: 04/25/2025 Target Date: 06/22/2025 Interventions: Allow the resident time to answer questions and to verbalize feelings, perceptions, and fears. Date Initiated: 04/25/2025 . In an interview with LVN B on 05/17/25 at 12:07 PM, she stated that she had been employed at the facility for 2 years. She stated that Resident #1 was admitted to the facility for about 3 weeks. LVN B stated that Resident #1 was a total care patient that required total assistance from staff. LVN B was shown photographs of Resident #1 and she stated that she was unaware that Resident #1 was laying in her bed with her gown being pulled down exposing her right shoulder and upper chest areas. LVN B stated that staff perform rounds on the floor with their assigned residents about every 2 hours, or more if needed. She stated that she had never observed Resident #1's gown being open, such as in the photograph she was shown. LVN B stated that it would be a resident rights and dignity issue anytime a resident had any part or parts of their body exposed for anyone to view. She stated that it can cause harm or hurt to a residents self-confindence if any part of their body was exposed for anyone to view, which can be harmful to a residents feelings. An email was sent to the Administrator and CFO On 05/17/2025 at 1:04 PM requesting the facilities policy for Resident Rights. An observation of Resident #1 at the hospital on [DATE] at 2:40 PM, revealed that she was asleep. In an interview with Resident #1's family member at the hospital on [DATE] at 2:45 PM, revealed that she was discharged from the facility on 05/13/25 due to having an irregular blood pressure. The family member stated that Resident #1 had been admitted to the hospital since her discharge from the facility. The family member stated that a Ring video was installed in Resident #1's room during her stay at the facility. The family member was able to provide the State Surveyor photographs, which according to themshowed [Resident #1] slumped over in her bed, wearing a gown wiith her upper arm and upper chest being exposed to anyone that enter Resident #1's room. The family member stated that the photographs also revealed that Resident #1 was asleep in her bed and her gown exposed her shoulder and upper chest area, which is unacceptable. Record review of a photograph (unknown date and time) taken by Resident #1's family member, revealed that Resident #1 asleep and wearing a yellow and red shirt with her right shoulder and upper breast being exposed. Resident #1 was laying forward in a crouched position with the top of the left side of her head laying on the bed rails. Resident #1's hair was disheveled and appeared to be matted. Record review of a photograph (unknown date and time) taken by Resident #1 ' s family member, revealed that Resident #1 was asleep and wearing a yellow and red gown with her right shoulder and upper breast being exposed. Resident #1 was lying forward in a crouched position with the top of the left side of her head laying on the bed rails. In an interview with CNA C on 05/19/25 at 7:12 PM, she stated that she had been employed at the facility for 2 years. She stated that the staff on the floor did routine rounds in each resident ' s room at least every 2 hours, or as needed. CNA C was shown a photograph of Resident #1 laying in bed with a yellow and red gown with her right shoulder and upper left breast exposed. CNA C stated that she had never observed Resident #1 in her bed, such as the photograph she was shown. CNA C stated that if she observed a resident laying in the bed with their gown open and exposing their right shoulder and upper chest areas, she would ensure that the resident is properly covered and would then notify the Nurse on duty of the condition she found the resident. CNA C stated that she had taken several In-Service Trainings on Abuse, Neglect, Exploitation and Resident Rights during her employment at the facility. CNA C stated that Resident #1's family member did not mention anything to her regarding concerns for the dignity of Resident #1. CNA C stated that Resident #1's family member never revealed any of the photograhs that were revealed to her by the State Surveyor. CNA C stated that Resident #1 could feel embarrased if anyone had entered her room with her gown being open exposing her right shoulder and upper chest areas. CNA C stated that Resident #1 could feel harmed if anyone walked into her room and saw her gown open exposing her right shoulder and upper chest areas. In an interview with the CFO on 05/19/2024 at 7:39 p.m., the CFO stated that Resident #1 had a stroke prior to being admitted to the facility and had paralysis (the loss of voluntary muscle movement) on her left-hand side and was required total care with her ADL's. The CFO was shown the photographs of Resident #1 that were provided to the State Surveyor. The CFO stated that he had never seen the photographs of Resident #1 that were provided by the State Surveyor. The CFO stated that it is her expectation for staff to do Care Rounds every 2 hours or more times in between, if needed to assist the residents with their needs. The CFO stated that Resident #1's family member never mentioned to her anything about the resident being observed in her room with her gown being open exposing her upper right arm and chest areas. The CFO stated that if Resident #1's family member would have shown her the photographs or informed staff on the day the photographs were taken, the issues or concerns would have been addressed immediatley. The CFO stated that she would have retrained and reeducated her staff via In-Service Trainings to ensure that the situation would not occur or happen again. The CFO stated that she would be doing some In-Service Training with her staff to address the issues that were of concern. She stated that in the photograph, there was an issue of Resident Rights relating to the residents dignity. The CFO stated that there is a risk of a resident's rights being compromised anytime they are in their room and someone walks into their room and the residents shoulder and upper chest areas are exposed. The CFO stated that she did not believe that there was any harm caused to Resident #1 due to her shoulder and upper chest areas are exposed, such as in the photograhs. On 05/19/25 at 8 PM, an attempted telephone call to the DOH was unsuccessful. On 05/19/25 at 8:17 PM the Survey Team exited the facility and did not receive a copy of the facility's Resident Rights Policy. A record review of Resident #2's admission MDS Assessment, dated 05/11/25, revealed an [AGE] year-old male who admitted on [DATE]. Resident #2 had a history and diagnoses of Diabetes (a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar (glucose) levels to be abnormally high); Acute Respiratory Failure with Hypoxia (having too little oxygen); and Retention of urine. A BIMS score of 15 suggested Resident #2 was cognitively intact. Resident #2 had an indwelling urinary catheter, present on admission, and was always incontinent of bowel. A record review of Resident #2's comprehensive care plan, initiated 05/13/25, reflected the following: [Resident #6] is on enhanced Barrier Precautions related to presence of indwelling urinary catheter. Interventions included Provide enhanced Barrier Precautions as indicated. (Date initiated: 05/31/25 The care plan did not reflect interventions to position catheter bag and tubing below the level of the bladder and in a privacy bag or ensure foley bag is in privacy bag. A record review of Resident #2's Order Summary Report printed 05/30/25 did not reflect indwelling urinary catheter orders. Record review of Resident #2 Physician progress note, date 05/09/25, revealed documentation of a New Foley (indwelling urinary catheter) for urinary retention and was unable to be weaned off the indwelling urinary catheter. During an observation on 05/30/25 at 10:19 AM, Resident #2 was in a semi-sitting position in bed. Resident #2 had an indwelling urinary catheter in place. The indwelling urinary catheter tubing laid across Resident #2's right leg connected to a closed system drainage bag that hung on the bed rail. The drainage bag did not have a privacy cover. A record review of Resident #3's admission MDS Assessment, dated 05/24/2025, revealed an [AGE] year-old male initial admission date of 11/13/23 and re-admitted on [DATE]. A BIMS score of 7 suggested Resident #3 had severe cognitive impairment. Resident #3 had diagnoses of Diverticulosis of intestine (a condition characterized by small pouches in the walls of the intestines); chronic kidney disease; and Benign Prostatic Hyperplasia (a condition that occurs when the prostate gland enlarges). The admission MDS Assessment revealed Resident #3 had an indwelling urinary catheter and was always continent of bowel. A record review of Resident #3's comprehensive care plan, initiated 09/12/24 to present, reflected: [Resident #3] has a urinary catheter - urinary retention (Resolved on 05/29/25). Interventions included . position catheter bag and tubing below the level of the bladder and away from entrance room door, check placement of tubing each shift, Monitor and document intake and output as per facility policy, and monitor/document for pain/discomfort due to catheter (Date Initiated: 05/27/25). A record review of Resident #3's Order Summary Report printed 05/30/25 at 5:30 PM, reflected the following: Order date 05/25/25: Change (indwelling urinary catheter) drainage bag as needed. Order date 05/29/25 (start date 05/30/25): Discontinue (indwelling urinary catheter) 5/30/25 AM. If guest does not void within 8 hours, re-insert (indwelling urinary catheter) and schedule an appointment with urologist. One time only for 1 day. Order date 05/25/25: (indwelling urinary catheter) Care to include anchoring tubing (catheter strap around leg to hold in place) and checking skin integrity every shift and PRN. Record review of Resident #3's May 2025 MAR printed 05/30/25 at 5:29 PM, did not reflect a nurse's initials that the (indwelling urinary catheter) was discontinued per the orders as written. During an observation on 05/30/25 at 10:34 AM, Resident #3 sat upright in a chair in his room. An ambulatory assistive device, rolling walker, was within reach at Resident #3's left side. Resident #3 (indwelling urinary catheter) tubing hung through the bottom of his left pajama pants leg attached to a drainage bag that hung on the bottom rail of the walker. There was approximately 200 cc amber urine in the catheter bag. The catheter bag did not have a privacy cover. Record review of Resident #3's progress notes reflected the following: Effective Date: 05/29/25 at 2:16 PM, documented: Called urologist in regards to removing Foley (indwelling urinary catheter) . Awaiting for a returned call to receive appointment date and time. Effective Date: 05/30/25 at 4:58 PM, LVN C documented: Guest [Resident #3] Foley (indwelling urinary catheter) DC (discontinued). Guest voided 500 cc on 6A - 6P shift. No c/o pain or discomfort voiced of urination or to pelvis area. Record review of Resident #4's Discharge MDS Assessment, dated 05/08/25, revealed a [AGE] year-old male initial admission date was 04/21/25. Resident #4 had diagnosis of chronic kidney disease. Resident #4 had an indwelling urinary catheter and a colostomy. A record review of Resident #4's Entry MDS Assessment, dated 05/20/25 reflected a re-admission date of 05/20/25 A record review of Resident #4's comprehensive care plan, initiated 04/22/25 to present, reflected: [Resident #4] is on enhanced Barrier Precautions related to presence of indwelling urinary catheter. Interventions included Provide enhanced Barrier Precautions as indicated. (Date initiated: 04/22/25) [Resident #4] has a urinary catheter. Interventions included . . position catheter bag and tubing below the level of the bladder and away from entrance room door, check placement of tubing each shift, Monitor and document intake and output as per facility policy, and monitor/document for pain/discomfort due to catheter. A record review of Resident #4's Order Summary Report printed 05/30/25 at 11:51 AM, reflected the following: Order date 04/23/25: Change (indwelling urinary catheter) drainage bag as needed. Order date 04/23/25: (indwelling urinary catheter) Care to include anchoring tubing (catheter strap around leg to hold in place) and checking skin integrity every shift and PRN. During an observation on 05/30/25 at 10:48 AM, Resident #4 was in a left lateral position in bed. Resident #4 had an indwelling urinary catheter in place. The catheter tubing laid across Resident #4's right leg connected to a closed system drainage bag that hung on the right side bed rail. The drainage bag did not have a privacy cover. Resident #4 was pleasant and willingly participated in an interview. Resident #4 was alert and oriented to person, place, time of day, and situation. Resident #4 said that the nurse provided catheter care every morning and the CNAs emptied the drainage bag before the shift change. Resident #4 denied pain or discomfort at the insert site or symptoms of an UTI. During an interview on 05/30/25 at 2:09 PM, CNA E said that he reviewed facility training videos on catheter care and it had been covered during in-services. CNA E said that he would empty the drainage bag when providing peri-care to a resident and would report how much, if the urine had an odor, and if dark in color because of a possible UTI to the nurse. CNA E said that there should be a blue cover on the catheter drainage bags for privacy and dignity. CNA E said it was the nurse and the CNAs responsibility to ensure a privacy cover was on the drainage bags. CNA E could not explain why Residents #2, #3, and #4 did not have privacy covers or why he did not retrieve a privacy cover and place over the drainage bag. During an interview on 05/31/25 at 2:19 PM, LVN D said he provided catheter care based upon standards of practice, physician orders, and the care plan. LVN D said that he was observed for catheter care competency during new hire training and orientation. LVN D said that he checked for placement, for signs of infection such as redness, discharge, or swelling at insert site, and urine characteristics when she provided catheter care daily. LVN D said that catheter drainage bags should have a privacy cover. LVN D could not explain why Resident's #2, #3, and #4 did not have a privacy cover on the drainage bag. LVN D said that all direct care staff were responsible for making sure a privacy cover was on the catheter drainage bag. LVN D said that he was the primary responsible person when assigned to the resident. LVN D said that he would place privacy covers on the drainage bags. Walking rounds revealed LVN D followed through with privacy covers and Resident #3's indwelling urinary catheter was to be removed. During an interview on 05/31/25 at 4:00 PM, the CNO said that the implementation of care plan interventions was reviewed every morning during the clinical meeting. The CNO said that a preceptor observed and monitored nurses for competency skills and would sign off on the competency skills check off when successfully met. The CNO said that nurses who were successfully checked off for catheter care competencies and skill sets were allowed to insert, provide care for, and remove indwelling urinary catheters. The CNO said that residents were assessed and evaluated if indwelling catheters were clinically indicated. The status of residents' catheter needs was discussed during IDT meetings. The CNO said that interventions in place for residents with indwelling catheters included water intake, supplements, and catheter care every shift. The CNO indicated that residents were at risk of UTI development if the catheter was not changed or managed appropriately. Record review of the facility's In-Service Training Record revealed that on 05/08/25, staff were In-Serviced on Abuse/Neglect and Exploitation's Policies and Procedures. Record review of the facility's policy, Abuse & Neglect, dated October 2022, revised April 2023, April 2024, April 2025, revealed, . o Attendance at a yearly in-service on the Abuse Policy and on Resident Rights is mandatory for all employees . at a minimum . All staff will be informed and will acknowledge procedures of resident rights . Orientation (Residents, Representatives and Staff) o Individuals will be provided orientation to the Abuse Policy and Resident Rights at the time of admission in a language/method that is understood . All staff will be required to attend an annual in-service presentation on resident rights; . All residents and their responsible parties are given a copy of resident rights information and the abuse and neglect reporting information at the time of admission in a language understandable by the resident and representative . Resident Rights will be reviewed with each resident and/or representative at least annually in a language understandable by the resident . Record review of the facility's policy, ADL, dated 11/2020, revised 10/2021, 08/2022, 04/2023, 04/2025, revealed, This facility will provide each resident with care, treatment and services according to the resident's individualized care plan. Based on the individual resident's comprehensive assessment, facility staff will ensure that each resident's abilities in activities of daily living do not diminish unless circumstances of the resident's clinical condition demonstrate that the decline was unavoidable, including: . o Dressing . Record review of the facility's Indwelling Catheter Protocol, dated November 2018 and last reviewed 11/2024, reflected: Policy: Residents with an indwelling catheter will be reassessed by a licensed nurse weekly for 30 days after insertion of the catheter, then monthly thereafter to determine further need for the recording of intake and output and the resident's progress and continued need for a urinary catheter. The physician is responsible for writing the order for placement of the Foley catheter. The registered nurse or licensed practical nurse is responsible for placing an indwelling urinary catheter (Foley catheter). The above personnel must have demonstrated the knowledge and skills to perform this procedure as evidenced by verification on a competency checklist. Procedure: The Foley drainage bag will be covered with a catheter drainage bag dignity cover and the cover will be changed daily and whenever appears soiled or stained.

Based on observations, interviews, and record reviews, the facility failed to ensure residents unable to carry out activities of daily living received the necessary services to maintain proper grooming, hygiene (personal and oral hygiene) and proper feeding for 1 (Resident#1) of 6 residents reviewed for activities of daily living care. 1. The facility failed to provide bed baths, grooming and hygiene for Resident #1 on a consistent basis according to the facility's ADL Schedule. 2. LVN B used an incorrect feeding technique to feed Resident #1. LVN B was observed standing up while assisting Resident #1 with feeding on 04/28/25. These failures could place the residents at risk of psychosocial harm feeling uncomfortable, disrespected and could decrease residents' self-esteem and/or diminished quality of life. Findings included: Record review of Resident 1's face sheet, dated 05/17/25, revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] and discharged on 05/13/25. Resident #1 ' s diagnoses included: Sepsis due to MSSA (a serious bloodstream infection that can lead to septic shock, a life-threatening condition), cerebral infraction (also known as a stroke or ischemic stroke, is a condition where a portion of the brain's tissue is damaged due to a blockage or narrowing of a blood vessel supplying blood to the brain), aphasia following cerebral infraction (aphasia, a language disorder affecting communication, can occur following a cerebral infarction (stroke), dysphagia following a cerebral infarction (dysphagia, or difficulty swallowing, is a common and potentially serious complication following a cerebral infarction (stroke), hemiplegia (complete) and hemiparesis (weakness) following cerebral infarction affecting left non-dominant side, ADL assistance for personal care, abnormalities in gait and mobility, syncope and collapse (syncope (fainting) is a sudden, temporary loss of consciousness due to decreased blood flow to the brain, while collapse can be caused by various factors, including syncope, but also other conditions like seizures, head injury, or medical issues), , end stage renal disease (the final stage of chronic kidney disease where the kidneys can no longer function adequately to support life), dependence on renal dialysis. Record review of Resident #1's MDS assessment, dated 04/27/25, revealed the resident had severe cognitive impairment with a BIMS score of 5. The assessment reflected Resident #1 needed assistance from staff with her ADL ' s, such as eating, oral hygiene, personal hygiene, toileting hygiene, shower/bath, upper and lower body dressing, and putting on/taking off footwear. The assessment reflected Resident #1 needed assistance from staff with functional abilities, such as being rolled from left and right, sitting to lying, lying to sitting in bed, and tub/toilet transfers. Record review of Resident #1 ' s Discharge MDS assessment, dated 05/13/25, revealed that she was discharged from the facility on 05/13/25 to a Short-Term General Hospital. In Section C0500 there was no information indicating that Resident #1 was unable to complete the interview. In Section C - Cognitive Patterns, Section C0700 for Short-term Memory indicated Resident #1 had a memory problem. In Section C1000 for Cognitive Skills for Daily Decision Making was coded a 3 indicating Resident #3 cognition was severely impaired and she never/rarely made decisions. Record review of Resident #1's Care Plan dated 04/25/25 revealed the following: Focus: [Resident #1] had ADL self-care performance deficit and limitations in mobility. Date Initiated: 04/29/2025 Goal: The resident/guest will improve self-care and mobility function by the next review date. Date Initiated: 04/25/2025 Target Date: 06/22/2025 Interventions: Eating, Setup or clean-up assistance. Date Initiated: 04/25/2025 Eating: Supervision or touching assistance Date Initiated: 04/25/2025 Eating: Partial/moderate assistance Date Initiated: 04/25/2025 Oral Hygiene: Substantial/maximal assistance Date Initiated: 04/25/2025 Toileting: Substantial/maximal assistance. Date Initiated: 04/25/2025 Shower/bathe self: Substantial/maximal assistance. Date Initiated: 04/25/2025 Upper body dressing: Substantial/maximal assistance. Date Initiated: 04/25/2025 Lower body dressing: Substantial/maximal assistance. Date Initiated: 04/25/2025 Putting on/taking off footwear: Substantial/maximal assistance. Date Initiated: 04/25/2025 Personal hygiene: Substantial/maximal assistance. Date Initiated: 04/25/2025 Roll left and right: Substantial/maximal assistance. Date Initiated: 04/25/2025 Chair/bed-to-chair transfer: Substantial/maximal assistance. Date Initiated: 04/25/2025 -uses wheelchair. Date Initiated: 04/25/2025 Focus: [Resident #1] is at risk for falls. Date Initiated: 04/25/2025 Goal: The resident/guest will remain free from injury related to falls through the review period. Date Initiated: 04/25/2025 Target Date: 06/22/2025 Interventions: Anticipate and meet the resident's needs. Date Initiated: 04/25/2025 . Focus: The resident has the potential for altercations in psychosocial well-being. Date Initiated: 04/25/2025 Goal: The resident will have no indications of psychosocial well being problems by/through review date. Date Initiated: 04/25/2025 Target Date: 06/22/2025 Interventions: Allow the resident time to answer questions and to verbalize feelings, perceptions, and fears. Date Initiated: 04/25/2025 Initiate referrals as needed for personal care, counseling, psych services as needed. Date Initiated: 04/25/2025 Provide opportunities for the resident and family to participate in care. Date Initiated: 04/25/2025. In an interview with LVN B on 05/17/25 at 12:07 PM, she stated that she had been employed at the facility for 2 years. She stated that Resident #1 was admitted to the facility for about 3 weeks. LVN B stated that Resident #1 was a total care patient that required total assistance from staff. She stated that Resident #1 received her showers 3 x ' s per week, which were on Mondays, Wednesdays and Fridays. LVN B stated that the CNA's are provided with a shower/bed baths sheets tofor residents. LVN B stated after the CNA's bath/shower a resident, the shower/bed bath sheets are completed for each and placed in their files. She stated that if a resident refused a Shower/Bed Bath, the CNA's will write Refused on the residents Shower/Bed Bath Sheet. She stated that Resident #1 ' s family member did not mention anything to her regarding any concerns regarding issues with Personal Hygiene including grooming, and Bed Baths not being given by staff. An email was sent to the Administrator and CFO On 05/17/2025 at 1:04 PM requesting the facility ' s policy for Resident Rights. An observation of Resident #1 at the hospital on [DATE] at 2:40 PM, revealed that she was asleep. In an interview with Resident #1 ' s family member at the hospital on [DATE] at 2:45 PM, revealed that she was discharged from the facility on 05/13/25 due to having an irregular blood pressure. The family member stated that Resident #1 had been admitted to the hospital since her discharge from the facility. The family member stated that there were some concerns regarding the ADL care Resident #1 was receiving from the facility. The family member stated the resident was at the facility for almost 3 weeks and did not receive her bed baths on a routine basis due to her assigned bathing days. The family member stated that Resident #1 ' s schedule bathing days were on Mondays, Wednesdays and Thursday. The family member stated that a Grievance was filed at the facility on 05/13/25 on the same day Resident #1 was discharged from the facility. The family member stated that they visited Resident #1 on a daily basis and her hair was disheveled throughout her stay at the facility. The family member stated that there were not any issues with Resident #1 having any body odors, but he stated that she should have been given a bath on her given scheduled days. The family member stated that a Ring video was installed in Resident #1 ' s room during her stay at the facility. The family member was able to provide the Ring video footage of Resident #1 during her stay at the facility. The family member stated that the Ring video footage revealed LVN B was standing up while feeding Resident #1. The family member stated that the photographs that were provided of Resident #1, showed [Resident #1] slumped over in her bed with her hair being matted and dishoveled. The family member stated that the photographs also revealed that Resident #1 was asleep in her bed and her gown exposed her shoulder and upper chest area, which is unacceptable. Record review of the facility ' s Grievance Log with an entry on 05/13/25 for Resident #1 regarding Nursing Care. Resident #1 ' s family member stated that they had a concern and was quite upset with the fact that staff were not assisting with keeping guest [Resident #1] fresh and clean. The Grievance Log Entry was completed by the DOH on 05/14/25. Record review of a photograph (unknown date and time) taken by Resident #1 ' s family member, revealed that Resident #1 was asleep and wearing a yellow and red gown with her right shoulder and upper breast being exposed. Resident #1 was lying forward in a crouched position with the top of the left side of her head laying on the bed rails. Resident #1 ' s hair was disheveled and appeared to be matted. Record review of a photograph (unknown date and time) taken by Resident #1 ' s family member, revealed that Resident #1 was asleep and wearing a yellow and red gown and she was asleep. Resident #1 ' s hair was disheveled and appeared to be matted. Record review of (unknown date and time) taken by Resident #1 ' s family member, revealed that Resident #1 alert and wearing a yellow and red gown and her hair was disheveled and appeared to be matted. Record review of Ring video footage on 04/28/25 (without a timestamp) in Resident #1 ' s room revealed that LVN B was standing up while feeding Resident #1. In an interview with CNA C on 05/19/25 at 7:12 PM, she stated that she had been employed at the facility for 2 years. She stated that the staff on the floor did routine rounds in each resident ' s room at least every 2 hours, or as needed. CNA C stated she gave Resident #1 a bed bath on her scheduled bathing days, which were Mondays, Wednesdays and Fridays. CNA C stated that a bed bath for residents includes washing, combing hair, cleaning and clipping nails and toenails. CNA C stated that she completed a Shower Sheet for each resident, including Resident #1 when they were given bed baths. CNA C stated that if a resident refused a bed/shower, she would write Refused on the resident ' s Bed Bath/Shower Sheet which will be in a Shower Log at the Nurses Station. CNA C stated that if Resident #1's hair was disheveled, she would comb her hair. She stated that she did not observe Resident #1's hair appearing to be disheveled or matted during her shifts. CNA C stated that she never observed the yellow and red gown on Resident #1 exposing her upper chest area. CNA C stated that she had never observed any staff standing up while feeding Resident #1. CNA C stated that she did not provide any feedings to Resident #1. CNA C stated that she had taken several In-Service Trainings on how to properly feed residents, but she could not remember the last In-Service Training she received on feeding residents. stated that she was trained via In-Service Trainings to sit while feeding residents. CNA C stated that Resident #1's family member did not mention to her any concerns regarding the ADL Care she was receiving during her stay at the facility. CNA C stated that if a resident was fed while standing up, there was a risk for a resident to cough, choke and possibly aspirate (the accidental inhalation of foreign substances, like food or liquid, into the lungs). In an interview with the The CFO on 05/19/2024 at 7:39 p.m., she stated that Resident #1 had a stroke and had paralysis on her left-hand side and needed assistance from staff to assist her with her ADL's. The CFO stated that staff who assist with feeding residents should not be standing up while feeding the resident. She stated that staff should be seated in a chair while feeding residents and it was her expectation that staff sit to assist residents while feeding. She stated that staff have received in-service trainings on the proper guidelines and her expectations for staff while feeding residents. The CFO stated that if residents are fed while standing, there was a potential risk for residents to choke, which can lead to the harm of choking and aspiration. The CFO was shown the photographs of Resident #1 that were of Resident #1 ' s during her stay at the facility. Int he photographs, Resident #1 was observed with disheveled and matted hair. The CFO stated that Resident #1 received her bed baths per her bathing schedule, which would have been 3 x's per week. The CFO stated that CNA's complete the tasks of giving the Bed Bath/Showers to residents and they complete a Bed Bath/Shower Sheet for each resident, which is kept in their files. She stated that grooming, which included cleaning of the nails(toes and fingers), and shampooing and combing of the hair. The CFO stated Resident #1's family member completed a Grievance on the same day that Resident #1 was discharged from the facility due to being transferred to the hospital. The CFO stated that Resident #1's family member did not mention to herself or her staff anything about having concerns regarding the ADL Care the resident was receiving during her stay at the facility. The CFO stated that her expectation is for the staff to provide ADL Care for the residents that require assistance and that the residents received their showers or bed baths per their shower/bed bath schedule. The CFO stated that if a resident is not bathed, he or she can have issues with their skin having a possible skin breakdown and possible wounds. On 05/19/25 at 8 PM, an attempted telephone call to the DOH was unsuccessful. On 05/19/25 at 8:17 PM the Survey Team exited the facility and did not receive a copy of the facility ' s Resident Rights Policy. In an interview with LVN B on 05/27/25 at 11:35 PM, she was advised that a video was provided to the Surveyor revealing that she was observed standing up while feeding Resident #1. She stated that she remembered on an occasion, she was standing up while feeding Resident #1. LVN B stated that she had received in-service training on feeding residents, which included not standing up while feeding residents. LVN B stated that she did not know why she was standing up while feeding Resident #1 on 04/28/25. LVN stated that her last in-service training was last week (after the State Surveyors exited the building) on the proper techniques on feeding residents and keeping eye contact with the resident during feeding. LVN B stated that if someone was standing up while feeding a resident, there was a risk of the resident could possibly choke on the food, which could lead to aspiration (the accidental inhalation of foreign substances, like food or liquid, into the lungs). Record review of the Shower Sheets for Resident #1 revealed that she was given a Bed Bath on 04/30/25 (Wednesday), signed by CNA C, 05/02/25 (Friday), signed by CNA C, 05/05/25 (Monday), 05/08/25 (Thursday), and 05/12/25 (Monday), signed by CNA C. Record review of the facility ' s In-Service Training Record revealed that on 05/08/25, staff were in-serviced on Abuse/Neglect and Exploitation ' s Policies and Procedure. Record review of the facility ' s policy, ADL, dated 11/2020, revised 10/2021, 08/2022, 04/2023, 04/2025, revealed, This facility will provide each resident with care, treatment and services according to the resident ' s individualized care plan. Based on the individual resident ' s comprehensive assessment, facility staff will ensure that each resident ' s abilities in activities of daily living do not diminish unless circumstances of the resident ' s clinical condition demonstrate that the decline was unavoidable, including: ·Bathing ·Dressing ·Grooming ·Transferring ·Locomotion ·Ambulation ·Toileting ·Eating · Communication including using speech, language or other functional communication systems specific to the needs of the individual resident.

Based on observations, interviews, and records review the facility failed to ensure a resident who was incontinent of bladder receives appropriate treatment and services for 3 of 3 residents (Resident #2, Resident #3, and Resident #4) reviewed for quality of care. 1. The facility failed to ensure Resident #2 and Resident #4 had an indwelling urinary catheter strap in place to prevent pulling or tugging on 05/30/25. These failures could place residents at risk for discomfort, urethral trauma, loss of dignity and urinary tract infections. Findings included: A record review of Resident #2's admission MDS Assessment, dated 05/11/25, revealed an [AGE] year-old male who admitted on [DATE]. Resident #2 had a history and diagnoses of Diabetes (a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar (glucose) levels to be abnormally high); Acute Respiratory Failure with Hypoxia (having too little oxygen); and Retention of urine. A BIMS score of 15 suggested Resident #6 was cognitively intact. Resident #6 had an indwelling urinary catheter, present on admission, and was always incontinent of bowel. A record review of Resident #2's comprehensive care plan, initiated 05/13/25, reflected the following: [Resident #6] is on enhanced Barrier Precautions related to presence of indwelling urinary catheter. Interventions included Provide enhanced Barrier Precautions as indicated. (Date initiated: 05/31/25 The care plan did not reflect interventions to position catheter bag and tubing below the level of the bladder and in a privacy bag or ensure catheter strap in place and holding so that tubing is not pulling on the urethra. A record review of Resident #2's Order Summary Report printed 05/30/25 did not reflect indwelling urinary catheter orders. Record review of Resident #2 Physician progress note, date 05/09/25, revealed documentation of a New Foley (indwelling urinary catheter) for urinary retention and was unable to be weaned off the indwelling urinary catheter. During an observation on 05/30/25 at 10:19 AM, Resident #2 was in a semi-sitting position in bed. Resident #2 had an indwelling urinary catheter in place. There was no indwelling urinary catheter strap in place to prevent pulling or tugging. The indwelling urinary catheter tubing laid across Resident #2's right leg connected to a closed system drainage bag that hung on the bed rail. A record review of Resident #3's admission MDS Assessment, dated 05/24/2025, revealed an [AGE] year-old male initial admission date of 11/13/23 and re-admitted on [DATE]. A BIMS score of 7 suggested Resident #3 had severe cognitive impairment. Resident #3 had diagnoses of Diverticulosis of intestine (a condition characterized by small pouches in the walls of the intestines); chronic kidney disease; and Benign Prostatic Hyperplasia (a condition that occurs when the prostate gland enlarges). The admission MDS Assessment revealed Resident #3 had an indwelling urinary catheter and was always continent of bowel. A record review of Resident #3's comprehensive care plan, initiated 09/12/24 to present, reflected: [Resident #3] has a urinary catheter - urinary retention (Resolved on 05/29/25). Interventions included . position catheter bag and tubing below the level of the bladder and away from entrance room door, check placement of tubing each shift, Monitor and document intake and output as per facility policy, and monitor/document for pain/discomfort due to catheter (Date Initiated: 05/27/25). A record review of Resident #3's Order Summary Report printed 05/30/25 at 5:30 PM, reflected the following: Order date 05/25/25: Change (indwelling urinary catheter) drainage bag as needed. Order date 05/29/25 (start date 05/30/25): Discontinue (indwelling urinary catheter) 5/30/25 AM. If guest does not void within 8 hours, re-insert (indwelling urinary catheter) and schedule an appointment with urologist. One time only for 1 day. Order date 05/25/25: (indwelling urinary catheter) Care to include anchoring tubing (catheter strap around leg to hold in place) and checking skin integrity every shift and PRN. Record review of Resident #3's May 2025 MAR printed 05/30/25 at 5:29 PM, did not reflect a nurse's initials that the (indwelling urinary catheter) was discontinued per the orders as written. During an observation on 05/30/25 at 10:34 AM, Resident #3 sat upright in a chair in his room. An ambulatory assistive device, rolling walker, was within reach at Resident #3's left side. Resident #3 (indwelling urinary catheter) tubing hung through the bottom of his left pajama pants leg attached to a drainage bag that hung on the bottom rail of the walker. There was approximately 200 cc amber urine in the catheter bag. Record review of Resident #3's progress notes reflected the following: Effective Date: 05/29/25 at 2:16 PM, documented: Called urologist in regards to removing Foley (indwelling urinary catheter) . Awaiting for a returned call to receive appointment date and time. Effective Date: 05/30/25 at 4:58 PM, LVN C documented: Guest [Resident #3] Foley (indwelling urinary catheter) DC (discontinued). Guest voided 500 cc on 6A - 6P shift. No c/o pain or discomfort voiced of urination or to pelvis area. Record review of Resident #4's Discharge MDS Assessment, dated 05/08/25, revealed a [AGE] year-old male initial admission date was 04/21/25. Resident #4 had diagnosis of chronic kidney disease. Resident #4 had an indwelling urinary catheter and a colostomy. A record review of Resident #4's Entry MDS Assessment, dated 05/20/25 reflected a re-admission date of 05/20/25 A record review of Resident #4's comprehensive care plan, initiated 04/22/25 to present, reflected: [Resident #4] is on enhanced Barrier Precautions related to presence of indwelling urinary catheter. Interventions included Provide enhanced Barrier Precautions as indicated. (Date initiated: 04/22/25) [Resident #4] has a urinary catheter. Interventions included . . position catheter bag and tubing below the level of the bladder and away from entrance room door, check placement of tubing each shift, Monitor and document intake and output as per facility policy, and monitor/document for pain/discomfort due to catheter. A record review of Resident #4's Order Summary Report printed 05/30/25 at 11:51 AM, reflected the following: Order date 04/23/25: Change (indwelling urinary catheter) drainage bag as needed. Order date 04/23/25: (indwelling urinary catheter) Care to include anchoring tubing (catheter strap around leg to hold in place) and checking skin integrity every shift and PRN. During an observation on 05/30/25 at 10:48 AM, Resident #4 was in a left lateral position in bed. Resident #4 had an indwelling urinary catheter in place. There was no indwelling urinary catheter strap in place to prevent pulling or tugging. The catheter tubing laid across Resident #4's right leg connected to a closed system drainage bag that hung on the right side bed rail. Resident #4 was pleasant and willingly participated in an interview. Resident #4 was alert and oriented to person, place, time of day, and situation. Resident #4 said that the staff never placed a strap to prevent the catheter tubing from getting pulled or tugged. Resident #4 said that the nurse provided catheter care every morning and the CNAs emptied the drainage bag before the shift change. Resident #4 denied pain or discomfort at the insert site or symptoms of an UTI. During an interview on 05/30/25 at 2:09 PM, CNA E said that he reviewed facility training videos on catheter care and it had been covered during in-services. CNA E said that he would empty the drainage bag when providing peri-care to a resident and would report how much, if the urine had an odor, and if dark in color because of a possible UTI to the nurse. CNA E said that there should be a blue cover on the catheter drainage bags for privacy and dignity. CNA E said it was the nurse and the CNAs responsibility to ensure a privacy cover was on the drainage bags. CNA E could not explain why Residents #2, #3, and #4 did not have a catheter securement device around the thigh and should report it to the nurse when noticed. During an interview on 05/31/25 at 2:19 PM, LVN D said he provided catheter care based upon standards of practice, physician orders, and the care plan. LVN D said that he was observed for catheter care competency during new hire training and orientation. LVN D said that he checked for placement, for signs of infection such as redness, discharge, or swelling at insert site, and urine characteristics when she provided catheter care daily. LVN D said residents with catheters should have a catheter support strap around the upper leg to hold the catheter tubing in place and prevent trauma or the catheter tubing from being pulled out. LVN D said that catheter drainage bags should have a privacy cover. LVN D could not explain why Resident's #2, #3, and #4 did not have a catheter stabilization device in place or a privacy cover on the drainage bag. LVN D said that he was the primary responsible person when assigned to the resident. LVN D said that he would ensure a leg support strap was in place. Walking rounds revealed LVN D followed through with catheter securement devices were placed and Resident #3's indwelling urinary catheter was to be removed. During an interview on 05/31/25 at 4:00 PM, the CNO said that the implementation of care plan interventions was reviewed every morning during the clinical meeting. The CNO said that a preceptor observed and monitored nurses for competency skills and would sign off on the competency skills check off when successfully met. The CNO said that nurses who were successfully checked off for catheter care competencies and skill sets were allowed to insert, provide care for, and remove indwelling urinary catheters. The CNO said that residents were assessed and evaluated if indwelling catheters were clinically indicated. The status of residents' catheter needs was discussed during IDT meetings. The CNO said that interventions in place for residents with indwelling catheters included water intake, supplements, and catheter care every shift. The CNO indicated that residents were at risk of UTI development if the catheter was not changed or managed appropriately. Record review of the facility's Indwelling Catheter Protocol, dated November 2018 and last reviewed 11/2024, reflected: Policy: Residents with an indwelling catheter will be reassessed by a licensed nurse weekly for 30 days after insertion of the catheter, then monthly thereafter to determine further need for the recording of intake and output and the resident's progress and continued need for a urinary catheter. The physician is responsible for writing the order for placement of the Foley catheter. The registered nurse or licensed practical nurse is responsible for placing an indwelling urinary catheter (Foley catheter). The above personnel must have demonstrated the knowledge and skills to perform this procedure as evidenced by verification on a competency checklist. Procedure: The catheter tubing will always be secured to the resident's thigh with approved catheter securement device to prevent movement, irritation, and decrease risk of infection.

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan for 2 of 6 residents (Resident #1, and Resident #4) reviewed for quality of care. 1. The facility failed to ensure Resident #1's ointment and betadine application, and wound dressing change was completed per physician orders. 2. The facility failed to ensure Resident #4's wound dressing change was competed per physician orders. These failures could place residents at risk of not receiving treatments and medications, worsening of wounds and a decline in health. Findings included: Resident #1 Record review of Resident #1's admission record, dated 02/05/2025, revealed an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included cellulitis (common bacterial skin infection), metabolic encephalopathy(brain disorder that occurs when a chemical imbalance of the blood affects the brain), and type 2 diabetes mellitus. The admission record indicated resident discharged on [DATE] to another facility. Record review of Resident #1's Admission MDS assessment, dated 12/31/2024, revealed a BIMS score of 8, indicating moderate cognitive impairment. Further review of section M - skin conditions of the MDS revealed resident had diabetic foot ulcer(s). Record review of Resident #1's care plan, dated 01/09/2025, revealed Resident #1 had actual impairment to skin integrity r/t vascular - diabetic right bottom foot, right lower leg back and front right top of foot. Record review of Resident #1's active orders, dated 12/05/2025, revealed the following orders: - Apply betadine to top of right foot, leave open to air every day shift for Wound healing start dated 12/28/2025 - Cleanse RLE with wound cleanser, apply adaptic, calcium alginate, ABD pad, wrap with kerlix every day shift every other day for Wound healing start date 02/01/2025 Record review of Resident #1's December 2024 TAR revealed blanks for the following treatment and days: - Cleanse right elbow, pat dry, apply calcium alginate, cover with dry dressing every day shift for Wound healing Order dated 12/27/24. There were blanks for this order on 12/28/24 and 12/29/24. Record review of Resident #1's January 2025 MAR and TAR revealed blanks for the following treatments and days: - Cleanse RLE with wound cleanser, ABD pad, wrap with kerlix every day shift every other day for Wound healing order dated 01/10/25. There was a blank for this order on 01/11/25. - Cleanse RLE with wound cleanser, apply adaptic, calcium alginate, ABD pad, wrap with kerlix Every day shift for Wound healing order date 12/27/25. There were a blanks for this order on 01/02/25, 01/06/25, and 01/10/25 - Apply betadine to top of right foot, leave open to air every day shift for Wound healing order date 12/27/25. There were a blanks for this order on 01/02/25, 01/06/25, 01/11/25, and 01/12/25. - Mupirocin External Ointment 2 % (Mupirocin) Apply to wounds to BLE topically every shift for wound care order date 12/26/25. There were a blanks for this order on 01/01/25, 01/02/25, 01/06/25, 01/07/25, 01/08/25 x2, 01/09/25, 01/10/25, 01/11/25, 01/12/25, 01/13/25, 01/14/25 x2, 01/15/25 and 01/16/25. Record review of Resident #1's progress notes did not indicate why treatments were not signed as completed on the MAR and TAR. Resident #4 Record review of Resident #4's admission record, dated 02/05/2025, revealed a [AGE] year-old male who admitted to the facility on [DATE] with muscle wasting and atrophy, traumatic ischemia of muscle(when the muscle has inadequate blood supply from trauma causing muscle damage), type 2 diabetes mellitus, and muscle weakness. Record review of Resident #4's progress note, dated 01/28/2025, revealed a BIMS score of 13 out of 15, indicating intact cognition. Record review of Resident #4's care plan, dated 01/27/25, revealed Resident #4 was at risk for alteration in skin integrity and Resident #4 had Diabetes Mellitus - Type 2. Record review of Resident #4's active orders, dated 02/05/2025, revealed Cleanse left second toe, pat dry, apply xeroform, cover with dry dressing every day shift every other day for Wound healing start date 02/02/25. Record review of Resident #4's January 2025 TAR revealed a blank on 01/29/2025 for the order to Cleanse left second toe, pat dry, apply calcium alginate w/silver every day shift for Wound healing dated 01/28/2025. Record review of Resident #4's progress note did not indicate why no treatment was provided on 01/29/2025. In an interview on 02/05/2025 at 2:04 pm, the Wound Care Nurse stated she worked Monday through Friday and did all the wound treatments. She said when she completed a resident's wound treatment, she signed off on the TAR. She stated a blank on the TAR meant the treatment did not get done and that it could have been on the weekend. The Wound care nurse then stated if she worked on the floor, the nurse on the hall was supposed to do wound care and sign it off on the TAR. When asked about blanks on Resident #1's TAR, she said she did not work on 01/06/25, she did wounds only and not any creams. She said the (Mupirocin) ointment was not for a wound. She stated she did wound care for Resident #1 on his legs and at first the treatment was xeroform and calcium alginate, then oil emulsion. She said the treatment was betadine on his toes. The Wound Care Nurse stated it was important to sign off on the MAR or TAR to ensure the medication or treatment was given. She said if she noticed any blanks, or that wound treatment had not been done she would notify the ADON and DON. In an interview on 02/05/2025 at 2:36 pm, the DON stated a blank on the MAR or TAR meant that it was not done, or staff just did not sign off. The DON went through the EHR and stated LVN A worked on 12/28/24, 12/29/24, 1/1/25, 1/6/25, 1/11/25, and 1/12/25 but was out of the country at that time. She said she should have signed off on the TAR. An attempted phone interview on 02/05/2025 at 3:12 pm with LVN A was unsuccessful. In an interview on 02/05/2025 at 4:42 PM, RN C stated when she gave medications or did treatments, she would sign off on the MAR and TAR when completed. She said a blank meant it was not done. RN C stated it was important to sign to make sure it was completed, and the necessary care and treatment was provided. She said if not done, it could delay treatment, healing and the residents could get worse by not being treated or getting regular medication. RN C stated if a medication or treatment was not done, then she would document the reason under the nurse's notes. In an interview on 02/05/2025 at 5:17 pm, LVN B stated she did not know what it meant when there was a blank on the MAR or TAR. LVN B stated when she did a treatment or administered a medication, she signed the MAR/TAR to show that it was done. She said if it was not given, she would document under progress notes. In an interview on 02/05/2025 at 5:36 pm, the DON and Administrator stated the person doing the treatment or administering the medication was responsible to sign the MAR and TAR. The Administrator stated the risk to the resident for treatment not being signed off was infection, possibly delay wound healing, or extend their stay. Record review of facility policy, titled Physician Orders revision/reviewed 05/2023, reflected 1. Orders may be called, hand-written, faxed, or electronically-generated by physician. 2. The physician's order must be documented completely with sufficient content to clearly convey the provider's intent. Indications for PRN orders should be included in the order. 3. After the authorized provider has completed the orders, the RN or LPN is responsible to promptly and accurately transcribe all written orders. The RN or LPN must include his/her signature, the date and time of the transcription and credentials. 4. Orders that are unclear must be clarified prior to implementation. 5. In the event of an emergency, including but not limited to: a. 911 calls b. Involuntary discharges c. Other notable emergencies (IE natural disasters, building emergencies etc) Documentation of the physicians order in the progress notes is sufficient. Documentation must state the reason for discharge.

Based on observations, interviews, and record review, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of six residents (Resident #1) reviewed for pain management. The facility failed to administer Resident #1's pain medication Acetaminophen 1000 mg and/or Tramadol 100 mg for pain before wound care. This failure could place residents at risk for increased pain due to not having their pain medication when it was available. Findings included: Resident #1 Review of Resident #1's admission record dated 09/04/2024, revealed a [AGE] year-old male who was readmitted to the facility on [DATE] with an initial admitted [DATE] . His diagnoses included abscess of the liver (this is a mass in the liver filled with pus), Type 2 diabetes mellitus (uncontrolled blood sugar), Parkinsonism (a progressive nervous system disorder, which affects the ability to move muscles), non-traumatic perforation of the intestine (loss of continuity of the bowel wall/a hole in the wall of the colon), acquired absence of other parts of the digestive tract (part of the digestive tract was removed), need for assistance with personal care, ileostomy status (this is a small surgical opening in the abdomen where part of the intestine is cut for bowel movement to come out due part of the colon being removed), anemia (low red blood cells), and neoplasm of the large intestine (cancer of large intestine). Review of Resident #1's Care plan dated 08/23/2024, reflected a BIMS score of seven out of fifteen, indicating Resident #1 had impaired cognitive function and/or impaired thought process. Goal-Resident #1 would be able to communicate basic needs daily through the review date 09/10/2024. Interventions included asking yes/no questions to determine the resident's needs. Date Initiated: 08/23/2024. The care plan also reflected Resident #1 had actual impaired skin integrity related to a surgical wound and Resident #1 had an ileostomy which was an excoriated site [damaged or removed part of top layer of skin] that caused appliances not to stick causing increased burning. Initiated 08/23/2024. Goal was that Resident #1's skin injury would be healed by review date 09/10/2024 and Resident #1 would have no complications r/t documented skin impairment through the review date 09/10/2024. Interventions included: Keep skin clean and dry. Use lotion on dry skin, nurse to assess record/monitor wound healing with dressing changes. Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements or declines to the MD . Date Initiated: 08/23/202 Pain: Evaluate residents for changes in pain level and if appropriate request a scheduled pain medication from the physician. Date Initiated: 08/23/2024 wound care consults and follow up as needed. Date Initiated: 09/03/2024. Record review of Resident #1's physician orders on 09/04/2024 reflected: 1.Acetaminophen Capsule 500 MG. Give 2 tablets by mouth every 8 hours as needed for Pain, Temp. Order Date-08/29/2024 1543. 2.Tramadol HCl Oral Tablet 50 MG (Tramadol HCl). Give 100 MG by mouth every 6 hours as needed for pain. Order Date- 08/20/2024 1805. 3. Tramadol HCl Oral Tablet 50 MG (Tramadol HCl). Give 50 MG by mouth every 6 hours as needed for pain. Order date 08/20/24. 4. Gabapentin oral capsule 300 MG. Give 1 capsule by mouth three times a day for nerve pain. Order date 08/20/2024. 5. Pack abdominal wound with calcium alginate, cover with dry dressing every day shift. Order date 09/02/2024. Record review of Resident #1's MARs/TARs revealed: Acetaminophen had not been administered since 08/30/2024 at 11:56 AM by LVN RN G pain rated at five out of ten. Tramadol 100 MG (2 tablets) were administered on 09/01/2024 at 11:00 AM for pain of five out of ten by RN G Tramadol 50 MG (1 tablet) was administered on 09/02/2024 at 11:14 AM by LVN E. Pain rated at seven out of ten. Tramadol 50 MG (1 tablet) was administered on 09/02/2024 at 05:39 PM by LVN E. Pain rated at five out of ten. Tramadol 100 MG (2 tablets) were administered on 09/03/2024 at 7:26 PM by LVN F. Pain rated six out of ten. Pain medications Tramadol and/or Acetaminophen were not administered on 09/04/2024 by RN G or by RN H before wound care. Gabapentin 300 MG for nerve pain was administered as ordered. Observation and interview with Resident #1 and RN H on 09/04/2024 at 10:45 AM, revealed Resident #1 lying in bed awake. Resident #1 could answer simple questions. RN H was at the bedside preparing to start ileostomy skin-adhere bag change. [this is the process where the ileostomy bag is stuck to the skin around the stoma/opening to be able to collect bowel movement into the bag]. Resident #1 had a white dressing in the middle of his abdomen. On the right side of his abdomen was his ileostomy bag. RN H asked Resident #1 if he had his fan to help with the pain of changing the ileostomy. RN H said that the small handheld fan helped to sooth the burning of Resident #1's skin during the ileostomy bag change. Resident #1 said that he had not had pain medication. RN H interjected and stated, yes you had pain medicine a little while ago, before wound care. Resident #1 then replied, oh ok, I guess I forgot. I need to get off these pain meds anyway. RN H then proceeded to remove the ileostomy bag that was stuck to his skin. After RN H removed the ileostomy bag, the skin was noted as bright, red, raw, with a top layer of skin missing around the ileostomy stoma and bright redness cascading towards the lower right side of Resident #1's abdomen. Resident #1 moaned and grimaced with pain for ten minutes as RN H removed the ileostomy bag from his skin, pat dried his skin, and covered the stoma with the new ileostomy bag. RN H told Resident #1 to use his fan for pain relief. Interview with Resident #1 on 09/04/2024 at 11:15 AM, he stated he did not remember getting any pain medication. He said he was not sure he was given pain medication before his colon bag change. He stated he was aware that he took his gabapentin for his leg pain due to diabetic nerve pain, but it did not help with the abdominal pain. Resident #1 did not state his pain level but he stated the procedure was painful. Interview with RN H on 09/04/2024 at 10:59 AM, she stated she was sure that RN G administered pain medication to Resident #1 this morning. RN H said that she did not check the MAR to verify pain medication administration before wound care. She said it was her responsibility as well as the attending nurse to make sure the resident was medicated before wound care. She said that the ileostomy bag on Resident #1 was changed up to 5 times a day because it was leaking around the stoma which was causing skin excoriation around the abdomen. She said that she was aware that Resident #1 had burning pain during the bag change and that was why she encouraged him to use the fan to help blow the stinging off his skin. RN H did not state the risk to Resident #1 not receiving pain medication before the procedure. In an interview with RN G on 09/04/2024 at 11:39 AM, she stated she had administered Resident #1's Tylenol [Acetaminophen] with all his other medications earlier when she administered his morning meds. RN G stated she gave the Tylenol because the nightshift nurse had already administered Tramadol during the night. RN G stated she documented the other medications given to Resident #1, but she forgot to document that she had administered the Tylenol. She stated she did not verify the time the Tramadol was last administered to Resident #1. She stated she was not aware the last dose of Tramadol was on 09/03/24 at 7: 26 PM. She stated residents have a right to their medication and that medication administration should be documented at the time of administration. She said the risk to the resident was that it appeared as if he did not get his pain medicine. She did not state Resident #1's pain level. She stated pain medication should be given before ileostomy care. In an interview with the DON on 09/04/2024 at 05:16 PM, she stated the nurses should document medication administration at the time of giving the medication. She stated that waiting to chart medication administration an hour or more later could cause the potential for a medication error. She stated the risk to Resident #1 was someone else could administer more pain medication to the resident not knowing that another nurse had already administered medication because it was not reflected on the MAR causing an adverse effect. The DON stated she expected the nursing staff to administer pain medication as ordered and the wound care nurse (RN H) was highly favored by the wound doctor because of her attention to detail. The DON sated RN H should have assessed Resident #1's pain before wound care. She stated she expected all nursing staff to do a pain assessment to determine the effectiveness of the pain medication. She said herself and the ADONs were monitoring pain assessments and auditing pain scales over five every week. She stated she expected the nursing staff to utilize the PRN pain medication until pain was acceptable . She said this failure could affect the resident by increasing his pain level. In an interview with the ADM on 09/04/2024 at 06:41 PM, she stated the DON and the ADON's had just done in-service training on pain management and pain assessments. She stated she expected all staff to follow the facility policies and to monitor pain effectively. She stated all staff should document everything they do . She stated nurses were responsible for pain management and assessments. ADM stated not following pain management and assessments protocols could cause residents increased pain. Record review of the facility's policy titled Pain Management dated 10/2022 (revised 5/2023, 05/2024) reflected .It is the policy of this facility to respect and support the resident's right to optimal pain assessment and management. This facility recognizes that residents may have decreased sensations or perceptions of pain. They may consider pain an inevitable part of aging. Chronic pain may produce anorexia, lethargy, depression, immobility, social isolation. Residents may not report pain due to fear of expense, possible treatment, or a fear of dependency or addiction. Residents often describe pain in non-medical terms such as hurt or ache. Each and every resident has a right to the assessment and management of pain.Pain Recognition Expressions of pain may be verbal or nonverbal and are subjective to the resident including but not limited to: ? Negative verbalizations and vocalizations (groaning, crying, whimpering, screaming) ? Facial expressions (grimacing, frowning, fright, clenching of jaw ? Changes in gait, skin color, vital signs, perspiration ? Behavior such as resisting care, distressed pacing, irritability, depressed mood, or decreased participation in usual physical and/or social activities ? Loss of function or inability to perform ADLs. ? Difficulty eating or loss of appetite. ? Difficulty sleeping .

Based on observation, interview, and record review, the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 of 9 residents (Resident #1, #2, and #3) reviewed for pain management. 1. The facility failed to provide medication oxycodone Oral tablet 10 MG per doctor's order for Resident #1 on 6-5-2024 after Resident #1 complained of continued pain and requested medication. Resident #1 admitted to the facility on [DATE] at 3:30 PM and only received Acetaminophen Capsule 500 MG for pain at 11:55 PM. Resident #1 did not receive oxycodone oral tablet 10 MG until 6-6-2024 at 1:20 AM, at which time Resident #1's pain level was at an 8. 2. The facility failed to provide effective medication for Resident #2 who admitted to the facility on [DATE] and received Tramadol oral tablet 50 MG per order starting on 5-13-2024 at 8:56 PM and Oxycodone oral tablet 5 MG for pain on 6-14-2024 at 1:59 PM. Resident #2's pain levels remained high from 6-14-2024 through 6-27-2024 without physician notification or intervention. 3. The facility failed to provide effective pain medication for Resident #3, who admitted to the facility on [DATE]. Resident #3 received Oxycodone-Acetaminophen oral tablet 5-325 MG from 6-1-2024 through 6-17-2024 with pain levels ranging from 5-9 and received Acetaminophen-Codeine tablet 300-600 MG only one time a day as needed. Resident #3's pain levels stayed elevated from 6-1-2024 through 6-27-2024 without intervention or physician notification. An Immediate Jeopardy (IJ) situation was identified on 6-28-2024 at 12:52 PM. The IJ template was provided to the facility on [DATE] at 12:52 PM. While the IJ was removed on 6-28-2024 at 3:53PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents on controlled pain medication at risk of not receiving appropriate pain management resulting in pain. Findings included: 1. Record review of Resident #1's face sheet dated 6-26-2024 revealed she was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included fracture of the right acetabulum, fracture of shaft of right ulna, pain due to internal orthopedic prosthetic devices, implants, and grafts, intracapsular fracture of right femur, and pelvic and perineal pain. Record review of Resident #1's MDS indicated a BIMS score of 15, revealing Resident #1 was cognitively intact. Resident #1's pain assessment interview indicated she was at a level 7. Record review of Resident #1's care plan dated 6-11-2024, indicated she was planned for pain indicating the facility should anticipate resident's need for pain relief and respond immediately to any complaint of pain, identify and record previous pain history, and management of that pain and impact on function, and identify previous response to analgesia including pain relief, side effects, and impact on function. Record review of Resident #1's orders revealed her pain medications ordered on the day of admission were: Oxycodone oral tablet 10 MG given by mouth every 6 hours as needed for pain. Record review of Resident #1's nursing notes dated 6-5-2024 at 11:00 PM, revealed Resident #1 was upset as she was in pain and not getting relief. Resident #1 stated she was informed that her pain medications would be available upon discharge from the hospital to the facility. Resident #1 spoke to her family indicating her desire to leave the facility due to lack of pain relief. On 6-7-2024 at 5:48 AM, Resident #1's nursing notes stated she was complaining of not getting effective pain medication. Record review of Resident #1's MAR dated 6-26-2024, indicated Resident #1 did not receive Oxycodone oral tablet until 6-6-2024 at 1:20AM. Resident #1 only received Acetaminophen 500 MG two tablets, on 6-5-2024 at 11:55 PM with a pain level of 8. The MAR further revealed pain levels of Resident #1 remained at levels 5-9 from 6-5-2024 through 6-24-2024. On 6-22-2024 and 6-23-2024 the record indicated Resident #1 received no pain medication. In an interview/observation on 6-26-2024 at 11:15 AM, Resident #1 stated she arrived at the facility on 6-5-2024 at 3:30 PM, was in pain, and did not get any pain medicine until around 11:30 PM. She stated it was a weaker medicine like Tylenol and she was still at a high pain level. Resident #1 stated she did not receive anything stronger until 6-6-2024 and was still at a high pain level. She stated her pain level was so bad that she sent a text message to the facility telling them she wanted to leave the facility as her pain level caused her to feel depressed. 2. Record review of Resident #2's face sheet dated 6-26-2024 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included fracture of right lower leg (tibia & fibula) with surgery, pain due to internal orthopedic prosthetic devices, implants, and grafts, low back pain, compression fracture of third lumbar vertebra, and osteoarthritis. Record review of Resident #2's MDS dated [DATE] revealed a BIMS score of 15, indicating she was cognitively intact. In the pain assessment interview for Resident #2 revealed her pain rating at a level 8. Record review of Resident #2's care plan dated 6-3-2024, indicated she is planned for pain stating: o Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. o Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects and impact on function. o Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Record review of Resident #2's MAR dated 6-27-2024 indicated she was ordered to receive Tramadol oral tablet 50 MG to be given by mouth every 4 hours for pain on 6-13-2024 and was ordered to receive Oxycodone oral tablet 5 MG to be given by mouth one every 6 hours as needed for pain. Resident #2's pain levels stayed elevated on 6-13-2024 to 6-27-2024 from level 5 to 10. In an observation and interview on 6-28-2024 at 2:20 PM, Resident #2 was observed grimacing in pain. Resident #2 stated she was in pain. Resident #2 said she has been at the facility since 06-13-2024. Resident #2 stated she was an LVN, had a motor vehicle collision, had a fracture in her back, had a broken tibia and fibula, and was in pain at a level 8. Resident #2 said she used her call light when she was in pain but by the time a nurse got to her, she would be at a level 10 for pain. Resident #2 stated many times when she had asked a nurse for pain medicine, she was told it wasn't time to get it or they gave her something weak like Tramadol which did not effectively stop the pain. Resident #2 stated the night nurse argued with her when she has told her that her pain level was too high. The night nurse started raising her voice toward her and it made her feel scared. Resident #2 stated another staff member, an LVN, told her not to use the call light too much because the facility was short staffed, and she must deal with other patients. When most nurses have come into her room, they do not ask her what her pain level was. She stated when she was at a level 10, it was too much. When she had not received adequate pain relief, she had thought she did not want to live, which caused her depression and panic attacks. Resident #2 stated she has not been able to speak to a doctor about getting better pain relief. Many times, when her pain level was high, no one responded to her call light, and this caused her to have to scream out for a staff member to come bring her pain medicine. 2. Record review of Resident #3's face sheet dated 6-27-2024 revealed a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included dislocation of the left shoulder joint, pain due to internal orthopedic prosthetic devices, implants, and grafts, atherosclerotic heat disease, chest pain, precordial pain (chest pain that can feel like a burning, stabbing, or throbbing sensation, and can occur under or in the left breast), and acute cystitis (urinary tract infection causing inflammation of the bladder). Record review of Resident #3's MDS dated [DATE], disclosed a BIMS score of 15, indicating being cognitively intact. During her pain assessment interview Resident #3 revealed she was at a level 7. Record review of Resident #3's care plan dated 6-3-2024, indicated she has the potential for pain and instructing staff to: 1- Anticipate the resident's need for pain relief and respond immediately to any complaints of pain 2- Identify and record previous pain history and management of that pain and impact on function. 3- Identify previous response to analgesia including pain relief, side effects and impact on function. 4- Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Record review of Resident #3's orders revealed that her pain medications included: Acetaminophen-Codeine tablet 300-600 MG to be given every 12 hours as needed for pain ordered on 5-28-2024, Oxycodone-Acetaminophen tablet 5-325 MG given every 6 hours as needed for pain ordered on 5-27-2024, Ibuprofen tablet 600 MG tablet given every 8 hours for pain ordered on 5-30-2024, and Ibuprofen table 800 tables given for pain every 8 hours as needed ordered on 6-18-2024. Record review of Resident #3's MAR, for the month of June, dated 6-27-2024 revealed her pain levels ranged from 5-9 from 6-1-2024 through 6-27-2024. In an interview/observation on 6-28-2024 at 2:15 PM Resident #3 was observed lying in bed grimacing in pain. Resident #3 said she was in a lot of pain, had nerve damage, and could not use her left arm. She said the last few days her pain had been worse. Resident #3 said her pain level was at an 8 and it had been up to a 10. She stated she told the staff earlier in the day that her pain was at an 8 and it was still at an 8 after 2:00 PM. Resident #3 stated when her pain level was that high, she would not want to do any physical therapy or activities. When the facility changed pharmacies, it caused delays for her getting pain medication. Resident #3 stated over the last 4 or 5 days getting her pain medication had been a big problem and she had to contact the DON because a nurse would not contact the doctor to get effective pain medicine. In an interview on 6-28-2024 at 1:34 PM, RN A stated her process for pain management was when a resident expressed pain, she checked to see when the last time a resident had the pain medicine. If it was not time yet, she would let the resident know. If a resident still complained she would let the doctor know. RN A stated she thought a resident needs to be at a level 9-10 before she believed a pain medicine isn't effective. RN A stated she was a PRN nurse and was not so familiar with the residents at the facility. She stated when she gave a pain medicine, she would wait for 30 minutes to an hour to see if it was working. She said she would call the doctor's office and the office would get in contact with the doctor to let the doctor know the patient was still in pain after receiving medicine. In an interview with LVN A on 6-26-2024 at 4:00 PM she stated if a resident was at a pain level 3, but the resident says she was still in pain, then the pain medicine was considered not effective. Her process for pain management was to check the orders and assess the patient to see how bad the pain was. If the pain was high, she just followed the orders. LVN A stated the nurse covering the patient was responsible for monitoring the patient's pain levels. If a CNA saw that a patient was in pain, they should come and tell a nurse. The nurse, doctor or nurse practitioner work together to determine if a different pain medication would be more effective. After showing LVN A the MAR for Resident #1 for 6-6-2024 showing a pain level 8 from 1:20 AM through 7:39PM with her initials indicating she administered Oxycodone 10 MG at 7:40 AM without any reduction in the level of pain - she stated, I must have mis-charted the MAR. LVN A said she did not remember that day well, but Resident #1 was upset because her pain medicines were not at the facility and Resident #1 had a rough night. LVN A did not remember if a doctor was notified or not. LVN A stated when the pain levels are at the level the MAR was showing for Resident #1, (a constant 8) a doctor should be notified. She stated the risk to Resident #1 is her blood pressure could rise and other health problems could occur. In an interview with CNA A on 6-26-2024 at 4:25 PM, it was revealed she worked 12 hour shifts from 6AM-6PM. She stated her pain management protocol was if a patient was in pain, she asked the patient where the pain was and how bad does it hurt them. CNA A then would tell a nurse. The nurse knew what pain medication the patient could or could not have and gave the patient what they could have. CNA A stated the nurses were the ones in charge of monitoring a patient's pain levels. She stated a pain level higher than a 7 would indicate a patient might need a higher dose or different pain medicine to be effective. She stated an example would be if a patient received pain medicine at 7:00 AM and the patient was still in pain by 7:30 PM, the facility would need to try something different. CNA A stsated the risk to the patient not getting adequate pain relief could be an infection problem, cause high vital signs, put them in a bad mood, cause them to not eat food, and can cause them to become non-compliant with the facility. On 6-27-2024 at 10:15 AM an interview was conducted with LVN B revealed she had worked at the facility for 2 years as a PRN nurse. She stated her protocol for pain management was when a patient has asked for pain medicine and if it was time for them to have it, she would give the patient the pain medicine. If, however, it was not time for the patient to receive pain medicine, she would explain to the patient the last time they had the pain medicine and would tell them when they would be able to get some more. She stated the nurses monitor the patients for pain, then ask the patient what pain level they were experiencing and document the MAR. LVN B considered a pain level of 10 to prove that pain medicine is not working for a patient. She stated the nurse determined if a higher dose of medicine was needed or if another pain medication would be needed. If she determined a pain medicine was not effective, she would text the doctor or NP. After showing LVN B the MAR for Resident #1 indicating LVN B gave Oxycodone one tablet 10 MG each time and marked a pain level of 8 on 6-6-2024 at 1:20AM, a pain level of 8 on 6-6-2024 at 7:39 PM, on 6-14-2024 showing a pain level of 7 at 1:09 AM, and on 6-17-2024 showing a pain level of 9 at 9:10PM, LVN B stated she marked those levels of pain but Resident #1 never told her the medicine was not working. LVN B conveyed the reason Resident #1 stayed at such high pain levels was because she had hip surgery and a broken arm. She stated when someone was at high pain levels, as Resident #1, she just gave them the pain medicine ordered if the patient does not complain. LVN B said she was not sure what the risk would be for a patient to stay at high pain levels, but they could get high blood pressure or something else could be going on. Attempted to call LVN H on 6-27-2024 at 2:00 PM and left a voice message but never received a call back. Record review of Resident #1's MAR, LVN H gave Resident #1 Oxycodone one tablet 10 MG each time and marked a pain level in the MAR on 6-8-2024 of 7 at 5:23 AM and level 7 at 10:20 PM, on 6-10-2024 a pain level of 5 at 1:00 AM, and on 6-13-2024 a pain level of 6 at 9:10 PM. In an interview on 6-27-2024 at 2:55 PM, the ADON said the process to follow for pain management was as soon as a patient comes into the facility, they receive their discharge orders and what pharmacy the resident uses. Then that information goes to the doctor, and they forward that information to the pharmacy. The ADON stated the facility used a newer system, that had a pharmacy, that is closer than the one in San [NAME]. She stated they followed the orders and the time frames of the orders. The ADON stated she could order pain medicine stat, if needed but it cost the facility more money. The ADON said Resident #1 was admitted to the facility on [DATE] between 3:00 PM-4:00 PM, learned about the stat fee, and got Resident #1's pain medicine sooner. She said the floor nurses are responsible for monitoring residents for pain. The ADON stated whenever she has been in a resident's room, she always asked how their pain is. If the patient was non-verbal, she looked at their blood pressure and other signs to see if they are in pain. She said the patient lets the staff know if the pain medicine isn't working. If a patient was constantly at a level 8, she would consider the pain medicine to be effective. She told the patients if you are hurting so bad you can't stand it, let her know. At that point, she would call the doctor and he would either strengthen the dose or shorten the time frames between doses. The doctors determine if a patient needs a different pain medicine or a different dose. After showing the ADON Resident #1's MAR from 6-5-2024 through 6-24-2024, she stated Resident #1's pain levels are somewhat high and she would consider increasing Resident #1's dosage for pain. The ADON said pain is subjective as some people take pain better than others. When asked why the physician was not called during the high pain levels recorded in Resident #1's MAR, the ADON said the only thing she can think of is when the nurses went back into Resident #1's room, Resident #1 did not complain of pain. The nurses do not pull of the MAR history the see the pain levels for patients. The ADON said the nurses should pull up the MAR history for patients to see the patterns of pain to adequately assess them. She stated when the patterns of pain are like that of Resident #1, she would have called a doctor to let him know and maybe get a dosage change or a change in medicine to be more effective. The ADON said the risk to patients if their pain isn't effectively managed would be they would not sleep well, would not do therapy, would be restless, and irritable. In an interview on 6-27-2024 at 3:26 PM, the DON stated she had worked at the facility for 2 years. The DON said the process the facility follows for pain management was to follow the doctor orders. Most of the orders come from the hospital and the facility follows them. She said sometimes the pain medicine works and sometimes it doesn't. It is a hot topic and varies with individuals. If a pain medicine was not working, the facility would know it sooner than later. The doctors and PA come to the facility twice a week, the NP is at the facility on Mondays and Fridays, and the PA is at the facility several times a week. If a patients pain medicine is not being managed, the doctors will change it. It is a team effort if pain management isn't working to make adjustments as needed. The DON stated whoever has the care of the patient at the time (the charge nurse) is responsible for monitoring the pain levels of the patient. When asked what level of pain a patient had to reach for the facility to consider pain management not being effective, the DON said the facility doesn't judge pain by a number on the pain scale. Pain is an individual thing. It depends on whether one is dealing with chronic pain opposed to someone who had surgery. The DON said the patient determines if the patient needs a different pain medicine. The nurse on duty only has what is in front of them and isn't looking at the MAR history of the patient. The nursing staff doesn't have time to do a full MAR history review of the patient. When the DON was shown the MAR for Resident #1, #2, and #3, showing high pain levels from 6-1-2024 through 6-27-2024 said without knowing who the patients are, she wouldn't know why those levels were as high as they were. When asked was a doctor called for Resident #1, #2, or #3 during the MAR levels of pain from 6-1-2024 to 6-27-2024 ranging from level 4-10, she said no - but they have been called now. As of today, the facility is doing in-servicing on pain management and all nurses have signed a pain management course. The DON said she will inform the nursing staff of how to look for more signs of pain after a patient has had surgery, and then follow up with residents to see how effective the pain medicine was. The DON stated she believes the doctor was not called for pain management being ineffective for Resident #1, #2, and #3, from 6-1-2024 through 6-27-2024, when the MAR indicated pain levels ranging from level 5-10 because the nursing staff did not connect the dots to realize they should. After showing the MAR for Resident #1, #2, and #3 with the pain levels being mostly above a 5 all the way to a 10 from 6-1-2024 through 6-27-2024, the DON said the nursing staff should have asked the patients where the pain was at, when did the pain start, was the pain medicine working, and was this a new pain. She said there should have been a more in-depth assessment of Resident #1, Resident #2, and Resident #3. The DON said the risk to the patient having levels of pain such as Resident #1, #2, and #3, was more of a mental thing. It would depend on where the pain was an acute pain or a continuation of what has already been there. Record review of the facility's Pain Management Policy dated 10-2022 (revised 5-2023) states: Policy: It is the policy of this facility to respect and support the resident's right to optimal pain assessment and management .Effective pain management can remove the adverse psychological and physiological effects of unrelieved pain .It is the responsibility of all clinical staff to assess and periodically reassess the resident for pain and relief from pain During the initial nursing assessment, the resident will be screened for identification of pain o If the resident does not indicate present or chronic pain, this will be noted on the initial assessment form. o The resident will have routine reassessments performed per policy weekly. o Admission assessment will include but is not limited to: ? History of pain and its treatment including non-pharmacological interventions ? History of addiction, past and/or ongoing and related treatment of OUD ? Characteristics of pain ? Impact of pain on quality of life ? Factors such as activities, care or treatment that precipitate or exacerbate pain as well as those that reduce or eliminate pain ? Additional symptoms associated with pain ? Physical and psychosocial issues ? Current medical conditions and medications including medication assisted treatment for OUD ? Resident's goals for pain management and resident's satisfaction with current level of pain control . Pain Recognition o Expressions of pain may be verbal or nonverbal and are subjective to the resident including but not limited to: ? Negative verbalizations and vocalizations (groaning, crying, whimpering, screaming) ? Facial expressions (grimacing, frowning, fright, clenching of jaw ? Changes in gait, skin color, vital signs, perspiration ? Behavior such as resisting care, distressed pacing, irritability, depressed mood or decreased participation in usual physical and/or social activities ? Loss of function or inability to perform ALDs ? Difficulty eating or loss of appetite ? Difficulty sleeping All other clinical department staff will also question the resident regarding pain during initial resident assessment activities and reassessment activities performed by the department's care provider If the resident has been identified with pain, the resident will undergo reassessment of pain at least once per shift and before and after every pain control mechanism employed by the resident's care providers. Healthcare providers from any department, that have implemented a pain control mechanism, will reassess the resident timely to determine the amount of pain control or relief achieved. Pain control mechanisms may include, but are not limited to: o Medications administered for the control or relief of pain o Medications administered for the control or relief of anxiety o Repositioning of the resident o Ambulation of the resident o Heat or cool therapy o Mild resident exercise o Therapeutic massage, i.e., back rub, etc. o Bathing or whirlpool bath o Diversion techniques, i.e., television or video tape viewing, reading, etc. o Therapeutic communication o Spiritual counseling o Visitation from family/significant others. Management of the resident's pain is an interdisciplinary process and is to be included on the resident's interdisciplinary care plan o Inclusion of this component of the resident's care process will alert and educate all members of the healthcare team regarding the resident's pain experience o Pain management issues will be included in topics of discussion during interdisciplinary care planning conferences and discharge planning . An Immediate Jeopardy (IJ) was identified on 6-28-2024 at 12:52 PM. The Administrator and DON were notified. The IJ template was provided to the administrator via email on 6-28-2024 at 12:52 PM and a POR was requested. The following Plan of Removal was submitted by the facility and accepted on 6-28-2024 at 3:53 PM: F697 - Pain Management Immediate Interventions: 1. Notification made to [Physician Name] and [Physician Name], physicians and Medical Directors, of Immediate Jeopardy on 6-28-2024 at 1:12 PM. 2 . Emergent Meeting conducted with action plan developed. This occurred at 1:15 PM on 6-28-2024. Attendance included: [Administrator Name] - Administrator [DON Name] - Director of Nursing Action Plan: Daily Pain Assessment will be completed on patients 3. Direct Care Nursing Staff in-serviced on Pain Management, pain medication follow up on effectiveness after medication administration, physician notification if no improvement in pain level after medication administration on 6-28-2024 by [DON], DON, [ADON A] ADON, and [ADON B] ADON. - All PRN Pain Medications require a pre and post administration pain assessment number (or Wong-Baker Scale) - This must be documented - All guest who have received PRN pain medication must have a follow-up to determine level of pain relief achieved. - If there was a little to no improvement with the level of pain, a call must be make to the guest's physician for further intervention. - Please document this in clinical record - If a guest is asking for pain medication sooner than ordered, a call must be made to the physician for further intervention. - Please document this in clinical record. 4. Meeting with the following managers to review Immediate Jeopardy on 6-28-2024. We reviewed Pain Management, notifying physician when Pain Medications are not effective. The following managers attended: a. [Administrator Name], Administrator b. [DON Name], Director of Nursing c. [DOR], Director of Rehabilitation d. [ADON A] Assistant Director of Nursing e. [ADON B], Assistant Director of Nursing f. [Activities Director], Activities Director g. [Dietary Manager], Dietary Manager h. [SW] Social Services i. [LVN Name], MDS Nurse j. [LVN Name], MDS Nurse Training: 1. [DON] Director of Nursing, to be in-serviced by [Corporate Nurse] [NAME] President of Clinical Services. [NAME] will be in-serviced on Pain Management, Physician Notification, Monitoring Pain management, and reviewing Pain Assessments. 2. An immediate in-service was initiated on 6/27/24 and 6/28/24 By [DON], Director of Nursing, on Pain Management and physician notification. 3. Beginning 6/28/2024 and on-going: A posttest will be completed by direct care nursing staff to ensure competency on Pain Management. Staff must answer all questions correctly before returning to work. 4. New staff will receive in-servicing prior to orientation on the floor. PRN staff will not be allowed to work in the facility until they have completed in-service training and post-test. 5. A payroll report listing current employees will be used to track in-service completion. Monitoring: 1. Nursing Administration ([DON], [ADON A], and [ADON B]) will interview random patients that receive pain medication to ensure effective pain management is in place. 2. [Administrator], Administrator, or appointed designee will review this process in the Clinical Meeting scheduled 5 times per week (Monday through Friday) to monitor for compliance, and to make changes based on the interdisciplinary team's decision. This will be on-going. [Facility Name] requests that the measures we have implemented be reviewed and that our allegation of removal of jeopardy be accepted as of 6/ 28/ 24. The facility was monitored for compliance with the POR on 6-28-2024 as follows: In an interview on 6-28-2024 at 3:28 PM, it was discovered that LVN C has worked at the facility for one year, was on vacation, returned today from vacation, and was not in-serviced on pain management yet. She said her procedure for pain management was to know when it is scheduled, give the medicine within a one-hour timeframe. If the medicine is PRN, she would only give it as the patient request it. She checks back 30 minutes to an hour to see if the pain level decreases. If the pain level was still above a level 6, she would call the doctor. LVN C stated the risk to a patient for having constant levels of pain above a 6 is the patient might not be able to do their therapy, it would affect their blood pressure, and the patient may have an infection. The nurses and CNAs are responsible for monitoring patient's pain levels by asking the patients where the pain is and how bad the pain is using the 0-10 pain scale. In an interview on 6-28-2024 at 3:45 PM RN B disclosed she had been in-serviced on pain management. RN B stated the procedure for pain management depends on whether it is a scheduled medicine or PRN. If the medicine is PRN, she would determine whether it was the right time to give it or not. If the medicine was scheduled, she would just follow the schedule. If the pain was a break through pain, occurs in less than 24 hours, and is at least a level 7, then the pain medicine would not be working, and changes would need to be made. RN B said he would notify a doctor if the pain medicine would not bring the patient's level of pain below a level 7. The risk to the patient for not getting pain relief would be increased vital signs, increased blood pressure, and unreliable statistics. RN B conveyed the nursing staff are responsible for monitoring patients pain levels by verbal communication, looking at vital signs, seeing sweating, agitation, and grasping at the same spot. In an interview on 6-28-2024 at 3:57 PM LVN D revealed he has worked at the facility for 3 months and was in-serviced on pain management. He stated the procedure for pain management was to assess a patient using a scale of 0-10. If a patient has more than one pain medication ordered, start with the weaker one and see if it reduces the pain level. LVN D said they he would check back with the patient and if the pain level did not decrease, he would notify the doctor. He stated the risk to patients for having constant pain levels was having behavioral problems, agitation, high blood pressure, or could be a sign of something else going on. The nurses are responsible for monitoring pain levels by looking for grimacing, groaning, breathing hard, and verbal communication. In an interview on 6-28-2024 at 4:20 PM, RN C stated she had been in-serviced on pain management. She[TRUNCATED]

Based on observation, interview and record review the facility failed to ensure residents had the right to be free from abuse and neglect for 2 of 5 residents reviewed (Resident # 7's and Resident # 26) for abuse and neglect. The facility failed to: 1. Respond and assist Resident #7 after a fall and constantly yelling out for help on 10/27/23. The resident was found by EMT, lying in feces and with partially dried blood to laceration on her head requiring 10 sutures. LVN F ignored the pleas for help according to the EMT. Resident #26 had to call 911 and guided the EMTs to Resident #7's room. 2. (Non IJ in IJ) Provide Resident #26 ostomy care during shift on 10/31/23 leaving the bag soiled that was connected due to him emptying independently. According to the EMT, on 10/27/23, they observed Resident #26 with a heavily soiled ostomy bag that was leaking. An Immediate Jeopardy (IJ) was identified on 11/01/23. The IJ template was provided to the facility on [DATE] at 4:30 PM. While the IJ was removed on 11/02/23, the facility remained out of compliance at a scope of isolated and the severity level of actual harm. The resident had to receive sutures, was covered in feces, and suffered the emotional distress of not receiving help from the facility. Resident #7 suffered actual harm. because all staff had not been trained on Abuse and Neglect, call light responding, and documenting abuse on 11/02/23. These failures could affect other residents in need of assistance and mobility limitations placing them at risk for abuse, physical harm, serious injuries, serious harm, serious impairment, pain, mental anguish, and infections. Findings included: In a review of Resident #7's face sheet dated 10/31/23 revealed a [AGE] year-old female with an admitted [DATE]. Diagnoses included: enterocolitis(inflammation of digestive tract) due to Clostridium difficile (bacterial infection of the colon), primary admitting dx recurrent other specified diseases of gallbladder,(disease involving the gallbladder digestive), unspecified dementia, (decline in cognition) unspecified severity, with other behavioral disturbance, acute kidney failure personal (kidney's not functioning) history of other venous thrombosis and embolism (artery blockage/blood clotting). In a record review of Resident #7's 3-day MDS assessment dated [DATE] revealed a BIMS score of 14, which indicated no cognitive impairment Resident #7's ADL function for transfer, repositioning, hygiene (bath/shower), toileting and dressing required extensive assistance from staff. Resident was coded as high risk for falls with an actual fall on 10/27/23. In a review of Resident #7's care plan dated 10/27/23 revealed the resident had an actual fall .self-attempt to transfer .Resident will resume usual activities without further incident through the review date. Staff will offer assistance to transfer and assist with toileting as needed .Nursing will Anticipate and meet resident needs. Ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed .The resident needs prompt response to all requests for assistance .Monitor/document /report PRN for 72 hours to MD for s/sx: Pain, bruises, change in mental status, new onset: confusion, sleep. In a record review of Resident #7's MD orders revealed an order for fall mats, Bed rails; date 10/30/23 at 8:11 PM . Also assist guest with safety exiting or entering bed . resident educated by Post Fall dated 10/27/23 at 10:19 PM . Skin checks weekly 10/27/23; weekly weights, wound consult as needed, Acetaminophen Oral -pain assessment every shift, neuro monitoring for 72 hours, evaluation for OT, PT, and OT Grab bars to assist guest to reposition self in bed upward/downward or turning side-to-side. Also assist guest with safety exiting or entering bed. every shift. Level of Care: Skilled monitor laceration to right forehead every shift for signs and symptoms of infection .-Report to MD if any. every shift for Wound care Prescriber Written Active 10/29/2023 10/29/23 Monitor skin tear to right palm every shift .Leave Steris trips in place till falls off on its own . Re-enforce as needed. every shift for Wound care Prescriber Written Active 10/29/23 10/29/23. Tablet Mirtazapine Seizures dated 10/17/2023 stated that she had a seizure activity after she started this medication 325 MG (Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for pain. In a record review of Resident #7's admission assessment dated [DATE] read Initial admission base line assessment no communication barriers, full code, pain, elopement, functions and needs, were addressed. Resident was oriented to use of call light and bed rails. Depression was addressed. No cognitive impairment. Review information on past falls and attempt to determine cause of falls. Record root causes. Alter and/or remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. In a recorded review of #7's progress notes dated 10/27/23 at 9:59 PM LVN-F Received a call from a dispatcher from [company name] at 7:30 PM about a resident calling for another guest who was screaming. EMT (Emergency Medical Technician) showed up at the facility at 7:35 PM, said they got a call from another Resident (#26) that Resident #7 was screaming. EMT found Resident #7 on floor adjacent to the bed with loose stool all over floor. She took her brief off, had her left hand in it, her right palm had a laceration with deep tissue bruising observed, and above her right eye had a big gash/laceration. When asked what she was trying to do, she said she 'know I should have waited but I was trying to get up. 'Call placed to MD N to notify and DON (Director of Nursing), CNO while CNA (Certified Nursing Assistant) assisted one of the EMT in cleaning. MD N okayed that guest needed to be sent to hospital. FM was notified that guest was on her way back to the hospital. EMT left with guest at 8:00 PM. In an interview of Resident #7's progress note dated 10/27/23 at 9:47 PM by LVN F reflected, FM was notified that Resident #7 was on her way to the hospital .EMT left with guest at 8:00 PM. In a record review of Resident #7's progress notes by LVN F dated 10/30/23 at 8:11 PM read Grab bars to assist guest to reposition self in bed upward/downward or turning side-to-side. Also assist guest with safety exiting or entering bed . resident educated by Post Fall dated 10/27/23 at 10:19 PM. Record review of EMT report dated 10/27/23 at 7:19 Titled response # 2989218 . EMT arrived at 7:30 PM .complaint (Fall from bed) Duration of Complaint (3 hours) primary symptoms: (head injury and multiple injuries) [company name] responded to a priority 5 sick person call at a nursing and rehab facility, called in by another patient at the facility. The patient was a [AGE] year-old female with a chief complaint of multiple injuries following a fall from bed. On scene, the patient is found on the floor, alert and disoriented, not in any respiratory distress and has obvious signs of trauma to her head and lower extremities. The caller stated that the patient has been yelling for help for approximately 3 hours and no one has come to assist the patient. The nurse for the patient states the patient was just a screamer, when she checked on her 30 minutes ago, she was fine. Upon assessment, some of the blood was dry on her head, the patient has soiled herself, has a head laceration, lacerations to her knees, unknown LOC (Level of Care), and family states she was on a blood thinner but can't remember the name of it. The patient was lifted to the stretcher with a blanket, with no injuries or incidents. The crew secured the patient to the stretcher with safety belts and safety rails and loaded the stretcher into the ambulance. The crew applied dressings to the wounds and wrapped the wounds. The patient agrees to be transported to hospital for further treatment and evaluation. The patient denies any pain, just discomfort where the laceration was located. During transport to hospital, the crew continued to monitor vital signs and no new complaints developed. In a record review of Resident #7's EMT patient care timeline reflected Symptom onset: 10/27/23 at 7:12 PM Unit Notified by Dispatch 10/27/23 at 7:12:PM PSAP Call. Unit En route 10/27/23 at 7:19 PM Dispatch Notified 10/27/23 at 7:26 PM Initial responder on scene 10/27/23 at 7:26 PM Unit Arrived on Scene 10/27/23 at 7:43: PM Arrived at Patient Exam. 10/27/23 at 7:45 PM Bandage -Application of bandage. 10/27/23 at 7:53 PM Vitals and departed. 10/27/23 at 8:18 PM transporting to hospital. 10/27/23 at 8:32 PM arrived at destination. At destination, the crew unloaded the stretcher from the ambulance with no injuries or incidents. The crew delivered patient information, a verbal report and obtained a signature for patient care from the receiving ER nurse. The patient is moved from the stretcher to the hospital gurney via the drawsheet method with no injuries or incidents. An APS report is started and was forwarded to proper channels to investigate negligence on the facility. Report number: 7818 In a record review of Resident #7's progress note dated 10/28/23 at 6:27 AM by LVN F read FM brought Resident #7 back from the hospital at 5:48 PM . Vitals assessed, 97.7, 88, 18, 152/61, 95% on RA. Forehead has 10 sutures, right palm is steri-stripped. Multiple bruises to BLE, skin tears to both knees. Dried skin tear to right anterior shin. Guest assisted to bed with Ax1. Informed MD N guest is back. No new orders at this time. Paperwork from the hospital placed in medical records basket. Report given to oncoming nurse. Follow up fall assessments conducted on resident. In a record review of Resident #7s progress note dated 10/28/23 11:52 PM by LVN F Resident continues fall follow up and neuro checks monitoring. No new c/o pain or discomfort voiced at this time. Vitals stable and documented. resident was found attempting to get out of bed again this evening, was easily re-directed, bed lowered to floor and floor mats in place on either side of the bed. Continues vancomycin as well for c-diff, afebrile. Continues to have loose stools. In a record review of Resident #7's MD notes dated 10/28/23 reflected she was admitted due to generalized weakness secondary to C-Diff (infection 10/21/23), Colitis (inflammatory bowel disease), cataracts (decreased vision from cloudiness of the eye), HLD Hyperlipidemia (high cholesterol), chronic pain, right knee, depression (mood feeling down), anemia (blood disorder due to transition of oxygen in blood), vitamin D deficiency ( inadequate nutrition value from sun), falls, dementia (cognitive decline w/o Behavior Disturbances, Congestive Heart Failure (heart disease and function), anorexia (thin in appearance lacking nutrients), Deep Vein Thrombosis (blood clotting), GERD (difficulty with digestion flow), frequent UTI (infection of urinary tract), HOH . Guest is AOX1-2, Guest can make needs known and engage in discussions related to her care. Upon admission, guest scored a 14/15 BIMS. Moderate to severe levels of confusion noted despite high BIMS score, guest was so confused that SW contacted FM to complete social services assessments. PHQ 9 Depression assessment) conducted, score is a 10, mild/moderate symptoms of depression noted. Discussed advanced directives, and Resident #7 desires to be a DNR status at this time. Resident #7's goal is to return home upon completion of skilled stay. Discussed general facility expectations with guest [family member], discharge planning, and SW role in care. Discussed home health services upon discharge. SW discussed general length of stay being 2-3 weeks, with the focus of IDT authorizing stays a week at a time. Current plan of care remains, SS to follow up as needed. Care plan meeting scheduled; guest notified of meeting scheduled. In an observation and interview with Resident #7 on 10/31/23 at 10:15 AM revealed the resident lying in bed on her back with visible injuries to her head above right eye, bandage on right hand, and both knees. Resident 7 stated that she fell on the floor injuring her head, hand, and knees. She was yelling for help over 45 minutes, and no one responded. She said EMT entered her room and assessed and assisted resident, then transported her to the hospital. She received sutures on her head. Resident #26 In a record review of Resident #26's face sheet dated 10/31/23 revealed he was a [AGE] year-old male admitted on [DATE] with current diagnoses: significant for end-stage renal disease on hemodialysis, benign essential hypertension (high blood pressure), chronic hepatitis-C (liver infection), and adenocarcinoma (cancerous tumor on the colon.) In a record review of Resident #26's MDS assessment dated [DATE] revealed a BIMS score of 15 indicating he was cognitively intact. Resident had an ADL deficit and required extensive assistance with dressing, transferring and toileting. In a record review of Resident #26's Care plan dated 10/18/23 reflected Resident #26 had ADL self-care performance deficits and limitations in physical mobility. The resident/guest will improve self-care and mobility function by the next review date. Toileting Hygiene: Substantial/maximal assistance -Shower/bathe self: Substantial/maximal assistance lower and upper body dressing: Substantial/maximal assistance Substantial/maximal assistance -Personal Hygiene: substantial/maximal assistance Date Initiated: 10/18/2023 -Roll left and right: Resident has an ostomy r/t adenocarcinoma of colon. Date Initiated: 10/18/23 Resident will have no complications with ostomy through the review date. Monitor for changes in consistency, odor, and/or color of stool and notify physician as needed. Nursing Monitor stoma color for any changes and notify doctor if necessary. Nursing Provide ostomy care per protocol. Nursing evaluation admission 10/17/23. In a record review of Resident #26's MD progress note by SW dated 10/25/23 11:54 AM Social Service Note Weekly Interdisciplinary Team meeting held today. IDT members present for this meeting: CNO, Social Worker, Director of Rehab, BOM, LNFA, and MD N. Admitting dx: Cervical spine fracture, DM2, ESRD, Hepatitis C, HTN, stroke. PT: for transfers and bed mobility. OT: for transfers and bed mobility. In a record review of Resident #26's discharge summary dated 10/31/23 at 2:49 PM Resident discharged to another facility. Report called to facility. Resident signed discharge paperwork. Advised guest that he will be transported to new facility right after dialysis. Resident verbalized understanding with no further questions or concerns. Copy of discharge papers given to guest. In an interview with Resident #26 on 10/31/23 at 10:30 AM revealed on the day of 10/27/2 3he was changing his ileostomy bag because the nursing staff don't answer the call light or make rounds and he does not want doo (bowel) on him. He stated that the bag constantly leaks, so he requested extra ileostomy bags to change it himself. He said he put the soiled bag inside the urinal on his bed side table and waited for a nurse or aide to come and discard. He said the nurse gave him the extra bag and he did not know her name. Resident #26 said on 10/27/23 he heard a Resident #7 yelling for help for over 3 hours. After a while he called 911 to ask for help because the crying did not stop. He spoke with EMT but did not know the Resident's room number. He guided them to his hall where they found Resident #7 on the floor. He said the EMT also came to his room to assess. He said the CNA and Nursing had not checked on the residents for over 3 hours. In an interview with EMT on 10/31/23 1:09 PM revealed on 10/27/23 another resident contacted 911 after hearing Resident #7 yelling for help. She stated that dispatch contacted the facility, and no one answered. EMT entered the building searching for the resident. EMT arrived at the nursing station at the top of the hall and observed LVN F sitting at the desk ignoring Resident's yell for help. EMT said she could hear a resident yelling for help. EMT asked LVN F do you hear the resident yelling? LVN F stated that they had another resident with behaviors of yelling. EMT said LVN F was ignoring the resident. EMT proceeded down the hall toward Resident #7's room following the yell for help. While simultaneously reporting to LVN F that a 911 call was received from a resident at the facility, reporting a resident had been lying on the floor yelling for help for hours. EMT entered Resident #7's room and found her on the floor with dried and fresh blood observed on the resident's forehead above the left eye, skin tear right palm, and both knees. Resident's brief was heavily soiled with feces. Resident #7 told EMT that she was sitting on the end of her bed and nose-dived on the floor. EMT then checked on Resident #26 on 10/27/23 after examining and assessing Resident #7 (EMT did not provide a time) and observed him with a heavily soiled ostomy bag that was leaking. EMT stated that both residents had been neglected and nursing failed to meet their needs and respond calls for help. In a telephone interview with LVN F on 10/31/23 at 2:12 PM, she stated when she arrived for work on 10/27/23 at 6:00 PM, she proceeded to prepare passport mediation for her unit a (device used to release resident medications by shift), due to LVN C completing final documentation for the end of shift report. LVN F stated LVN C told her that the Resident #7 was newly admitted and was on isolation. LVN F and LVN C, then completed shift reports. LVN F stated that neither nurse completed rounds to assess baseline conditions, which was the nursing protocol. LVN F said she did not hear any yelling out; however, she referenced knowledge of some residents displaying behaviors of yelling for help frequently. She did not respond to the resident's call for help, because she was reviewing shift medication for Resident administration. LVN F said she does not know why Resident # 14 yells out for help during shift. She said it was her responsibility to assist with call lights and follow up on residents calling out for safety to assist for current need. LVN F reported she did not know that Resident #7 fell , until she received a call from the [company name] dispatcher reporting the incident, resident location, and whereabouts, as a neighboring Resident called 911 for help saying a female resident was yelling for help for hours. LVN F stated shortly after the call, the EMT arrived with the same information, and they went together to Resident #7's room and found her on the floor. LVN F stated the EMT arrived after 7:00 PM and the resident was found on the floor, and soiled herself, and was trying to get up and slid from the floor to the bed She said the floor in Resident # 7 was room was soiled with feces (bowel). Resident reported to LVN F that she slid off the bed from a sitting position to the floor. LVN F observed injuries to her right palm with deep tissue pooling, both knees, and bleeding from a laceration to her forehead above her right eye. LVN F said she notified the MD of the fall and injuries. MD approved order for transfer to ER for treatment. EMT transported resident to hospital. The FM returned resident 10/28/23 at approximately 5:48 AM to the facility MD orders. In a telephone interview on 10/31/23 at 4:36 PM, LVN C stated she arrived at 6:00 PM. LVN C said she and LVN F did not conduct rounds due to end of shift report completion from two admissions. She said once she completed the new admissions assessments and documentation, notified LVN F that all reports were completed, and she left. She said the last time she observed Resident #7 was at 5:45 PM after setting up isolation precaution supplies outside the door, due to an infection to C-Diff. Upon exiting Resident #7's room, she placed call light near to reach. In an interview on 10/31/23 at 4:43 PM with CNA T revealed she was the assigned CNA for Resident #7 on 10/27/23 from 6:00 PM to 6:00 AM. She stated that she arrived at 6:15 PM and conducted rounds with CNA K. She was not aware that Resident #7 had a history and risk of falls, as she was a new admission and proceeded with answering call lights after report and rounds with CNA K. CNA T said she should be checking on Residents every 2 hours and as needed to prevent extensive exposure to the resident's skin that could result in skin damage. CNA T stated she did not hear yelling coming from Resident #7's room, but other residents were calling out and she responded and provided care. The expectation for aides upon arrival to shift, were to conduct rounds together while giving reports, then respond to call lights. She said a negative outcome from not answering call lights could lead to injuries. She said not cleaning resident's bag and discarding properly could result in infection. LVN T stated that call light responses depend on CNA's availability at the time, as she may be providing care to another resident. She said when hearing yelling, she responds as soon as she can. She said on 10/27/23, she had not checked on Resident #7 prior to EMT arriving. In an interview with the DON on 11/01/23 at 4:40 PM, she said she had not reported Resident #7's fall, injuries, and EMT, and ER visit from 10/27/23 to HHS, due to LVN F failing to report all of the details to the fall. LVN F did not report that she was not responding to Resident #7s yell for help, failure to conduct resident rounds, and condition resident was found in by EMT. The DON said LVN F did report that another Resident called 911 after hearing Resident #7 yell for help. The DON said she was not told that the Resident # 7 was lying on the floor yelling for over an hour for help until the EMT arrived and found the resident. She expected all staff to respond immediately to calls lights, resident yelling out to provide assessments, interventions, and care. The DON said that she and ADON's were responsible for overseeing LVN 's patient care as well as monitoring job task and needs for help. She reported that LVN C and LVN F should have conducted rounds at the top of the shift. The phone should have been answered, and more information should have been provided about the incident and it would have been investigated. In an interview on 11/01/23 at 4:45 PM, the Administrator stated she was notified that Resident #7 fell and EMT were present on 10/27/23 after the EMT left aby the DON. There was no additional information about staff not responding to the Resident yelling out for help, and EMT arriving seeking resident location as the nurse were not answering the phone. She stated it was her expectation for staff to answer when they hear yelling, call lights, and provide care immediately to the residents to prevent further injuries, and harm from occurring. The Administrator said that all staff were aware that she was the abuse coordinator. She expects the DON and ADON to monitor the clinical task and care of residents by monitoring and auditing, addressing concerns in IDT meeting to implement interventions. She said that residents should not be yelling for help and not getting immediate care. She said that additional task will be implemented to assure Resident safety and timely response from staff to meet medical needs and prevent accidents and injuries. In an interview with CNA J on 11/02/23 at 11:01 AM revealed she did not hear yelling from any resident's or calling out for help while working on 10/27/23. CNA J said the protocol for assisting residents with call lights and yelling out included an immediate response to assure the resident's safety, try to comfort and calm the resident. She said LVN C was observed counting medication with LVN F when she left at on 10/27/23 at 6:20 PM. She last saw Resident #7 upon her arrival at 4:45 PM. Record review of the facility's CNA and LVN assignments for 10/27/23, reflected CNA K relieved CNA T. LVN F relieved LVN C. Shifts were scheduled 6A to 6P. In a record review of the facility's in-service dated 11/01/23 revealed on abuse, neglect, call light response priority, and resident's yelling .find the source of the yelling, reporting abuse and neglect resident behaviors and implementing interventions .A resident lying on the floor and not responding is considered abuse. In an interview on 11/02/23 at 10:10 AM, Resident #7's family member, he reported that he followed the hospital transport of Resident #7 to facility for admission on 10/27/23 and the nursing staff educated and orientation him and Resident #7. Resident #7 understood call light usage for safety and waiting for assistance to prevent injuries. The FM said he was notified by LVN F of the fall and hospital location for Resident #7. On 10/27/23 around 8:00 PM. Resident #7 told FM that she should have asked for help, and she was sitting at the end of her bed and fell on the floor. Resident #7 told him that she tried to get up on her own, however, she was not successful. Resident #7 said when she could not get up, she yelled for help, as the call light was not nearby. The FM said the resident sustained injuries to the head requiring sutures and injuries to hand and knees. The FM said he transported the resident back to facility. In an interview with CNA K on 11/02/23 at 11:12 AM revealed she was working on 10/27/23, the date Resident #7 was admitted at 4:20 PM. She assisted Resident #7 by transferring her to bed, assessed her and orienting her on call light and asking for help. CNA K said the resident was not confused and she understood the call light process. She said at approximately 5:45 PM, Resident #7 used the call light for incontinent care. She responded immediately and provided care prior to shift ending at 6:00 AM. She said the resident was on isolation for C-Diff and called via call light frequently (Q 10 minutes) for care, due to the loose stool. She said CNA S and CNA T arrived at approximately 6:15 PM. They completed rounds and reports, then she left. CNA K said she did not hear any resident's yelling when she was leaving her shift. Staff were expected to respond regardless of the resident behaviors. She stated that call lights should be responded to immediately and the failure to respond could lead to a resident getting hurt. In a record review of the facility policy titled Abuse Neglect and Exploitation dated April 2023. reflected in part the following: Policy: It is the policy of this facility that each resident will be free from abuse, neglect, misappropriation of resident property and exploitation. Abuse may include verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. The facility will strive to educate staff members, volunteers, contractors, residents and family members and visitors and other applicable individuals in techniques to protect all parties. In a record review of facility policy titled To provide guidance on use of call light for residents dated 04/2023 reflected in part the following: 1 The call light system is provided as a tool for residents to communicate with staff. 2. Residents will be evaluated for ability to use call light on admission, quarterly and annually. 3. If residents are determined to be physically unable to use call lights, alternative call buttons (touch, whistle, etc.) will be provided. 4. If residents are determined to be cognitively unable to use call lights, residents will be monitored for needs by staff members during rounds and while delivering care. 5. Staff members will ensure that call lights are within reach of a resident who is able to cognitively use a call light each time they leave the room. This was determined to be an Immediate Jeopardy on 11/01/23 at 3:00 PM. The Administrator and the DON were notified. The Administrator and the DON were provided with the Immediate Jeopardy Template on 11/01/23 at 5:34 PM. The following Plan of Removal submitted by the facility was accepted on 11/02/23 at 11:50 AM: F 600 Allegation of Credible Compliance Immediate Interventions: 1. Notification made MD N and MD B, physicians, and Medical Directors, of Immediate Jeopardy on 11/01/2023 at 4:15 PM. 2. Emergent Meeting conducted with action plan developed. This occurred at 4:30 pm on 11/01/2023. Attendance included the following: Administrator DON 3. Direct Care Nursing Staff in-serviced on neglect, expectations in responding timely to calls for assistance. 11/01/2023 by DON and ADON 4. 11/01/2023 and 11/02/2023: Nursing staff educated on timely response to answering the phone. Education provided by DON. And LVN, ADON. 5. Nurse involved in incident with pt #7 has been suspended pending further facility investigation. This Nurse will be referred to the State Board of Nursing. This nurse will not return to work at [facility name]. 6. Further education to direct care staff to respond immediately to calls for help to prevent significant injuries, prolonged care, assessments, and treatment. Education provided by ADM, DON, ADON-A on 10/31/23 and 11/1/2023. 7. if EMT notifies facility of a resident call for help, an immediate staff response is required to ensure resident safety. Meeting with the following managers to review Immediate Jeopardy on 11/1/2023: a. Administrator b. Director of Nursing c. Director of Rehabilitation d. Assistant Director of Nursing e. Activities Director f. Dietary Manager g. Social Services h. Social Services i. MDS Nurse Training: 1. An immediate in-service was initiated on 10/31/23 and 11/01/2023, by the Director of Nursing, on Neglect and responding to calls for assistance. 2. 11/01/2023 and on-going: A post-test will be completed by direct care staff to ensure competency on Neglect education. Staff must answer all questions correctly before returning to work. 3. New staff will receive in-servicing prior to orientation on the floor. PRN staff will not be allowed to work in the facility until they have completed in-service training and post-test. 4. A payroll report listing current employees will be used to track in-service completion. Monitoring: 1. Nursing Administration (ADM, DON, and ADON) will review 24-hour report for any change in condition to ensure timely follow up and intervention occurs. The Care plan and the Nurse Aide Kardex will be updated at that time to reflect the intervention. 2 Administrator, or appointed designee, will review this process in the Clinical Meeting scheduled 5 times per week (Monday through Friday) to monitor for compliance, and to make changes based on the interdisciplinary team's (IDT) decision. Monitoring of the POR included the following: Record review of in-service titled Abuse and Neglect, dated 10/31/23, 11/01/23, and 11/02/23, reflected curriculum covered the facility's policy on abuse and neglect, fall response, answering calls, interventions and reporting abuse and behaviors of resident's that yell out or have behaviors. Additional training was conducted online with post testing about Abuse and neglect. Record review of in-service dated 10/31/23 conducted by DON and ADON B reflected Monitoring call lights, assure they are operational .Provide appropriate care/intervention to address behavior issues, and document. Notify ADM and DON as soon as possible when behaviors are exhibited. A total of 31 staff attended the training. Observations and interviews on 11/02/23 from 1:50 PM to 3:00 PM with Residents #7, #14, #21, #26, and #30 revealed no concerns for neglect They stated they were satisfied with the care they were receiving and denied being neglected and untimely response of call lights. Interviews were conducted on 11/0 [TRUNCATED]

Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect establish policies and procedures to investigate any such allegations for 2 (Resident 7 and Resident #26) of 5 residents reviewed for abuse and neglect in that: The facility failed to implement their abuse and neglect policy because Resident #7 and #26 were not free from abuse/neglect and failed to: 1. Respond and assist Resident #7 after a fall and constantly yelling out for help. on 10/27/23. The resident was found by EMT, lying in feces and with partially dried blood to laceration on her head requiring 10 sutures. LVN F ignored the pleas for help according to the EMT. Resident #26 had to call 911 and guided the EMTs to Resident #7's room. 2. (Non IJ in IJ) Provide Resident #26 ostomy care during shift on 10/31/23 leaving the bag soiled that was connected due to him emptying independently. According to the EMT Resident #26 on 10/27/23 observed Resident #26 with a heavily soiled ostomy bag that was leaking. EMT stated that both residents had been neglected and nursing failed to meet their needs and respond calls for help. An Immediate Jeopardy (IJ) was identified on 11/01/23. The IJ template was provided to the facility on [DATE] at 4:30 PM. While the IJ was removed on 11/02/23, the facility remained out of compliance at a scope of isolated and the severity level of actual harm. The resident had to receive sutures, was covered in feces, and suffered the emotional distress of not receiving help from the facility. Resident #7 suffered actual harm. because all staff had not been trained on Abuse and Neglect, call light responding, and documenting abuse on 11/02/23. Findings included: In a record review of the facility policy titled Abuse Neglect and Exploitation dated April 2023. reflected in part the following: Policy: It is the policy of this facility that each resident will be free from abuse, neglect, misappropriation of resident property and exploitation. Abuse may include verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. The facility will strive to educate staff members, volunteers, contractors, residents and family members and visitors and other applicable individuals in techniques to protect all parties. In a review of Resident #7's face sheet dated 10/31/23 revealed a [AGE] year-old female with an admitted [DATE]. Diagnoses included: enterocolitis(inflammation of digestive tract) due to Clostridium difficile (bacterial infection of the colon), , primary admitting dx recurrent other specified diseases of gallbladder,(disease involving the gallbladder digestive), unspecified dementia, (decline in cognition) unspecified severity, with other behavioral disturbance, acute kidney failure personal (kidney's not functioning) history of other venous thrombosis and embolism (artery blockage/blood clotting). In a record review of Resident #7's 3-day MDS assessment dated [DATE] revealed a BIMS score of 14, which indicated no cognitive impairment Resident #7's ADL function for transfer, repositioning, hygiene (bath/shower), toileting and dressing required extensive assistance from staff. Resident was coded as high risk for falls with an actual fall on 10/27/23. In a review of Resident #7's care plan dated 10/27/23 revealed the resident had an actual fall .self-attempt to transfer .Resident will resume usual activities without further incident through the review date. Staff will offer assistance to transfer and assist with toileting as needed .Nursing will Anticipate and meet resident needs. Ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed .The resident needs prompt response to all requests for assistance .Monitor/document /report PRN x 72h to MD for s/sx: Pain, bruises, change in mental status, new onset: confusion, sleep. In a record review of Resident #7's MD orders revealed an order for fall mats, Bed rails; date 10/30/23 at 8:11 PM . Also assist guest with safety exiting or entering bed . resident educated by Post Fall dated 10/27/23 at 10:19 PM . Skin checks weekly 10/27/23; weekly weights, wound consult as needed, Acetaminophen Oral -pain assessment every shift, neuro monitoring for 72 hours, evaluation for OT, PT, and OT Grab bars to assist guest to reposition self in bed upward/downward or turning side-to-side. Also assist guest with safety exiting or entering bed. every shift. Level of Care: Skilled monitor laceration to right forehead every shift for signs and symptoms of infection .-Report to MD if any. every shift for Wound care Prescriber Written Active 10/29/2023 10/29/23 Monitor skin tear to right palm every shift .Leave Steris trips in place till falls off on its own . Re-enforce as needed. every shift for Wound care Prescriber Written Active 10/29/23 10/29/23. Tablet Mirtazapine Seizures dated 10/17/2023 stated that she had a seizure activity after she started this medication 325 MG (Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for pain. In a record review of Resident #7's admission assessment dated [DATE] read Initial admission base line assessment no communication barriers, full code, pain, elopement, functions and needs, were addressed. Resident was oriented to use of call light and bed rails. Depression was addressed. No cognitive impairment. Review information on past falls and attempt to determine cause of falls. Record root causes. Alter and/or remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. In a recorded review of #7's progress notes dated 10/27/23 at 9:59 PM LVN-F Received a call from a dispatcher from [company name] at 7:30 PM about a resident calling for another guest who was screaming. EMT (Emergency Medical Technician) showed up at the facility at 7:35 PM, said they got a call from another Resident (#26) that Resident #7 was screaming. EMT found Resident #7 on floor adjacent to the bed with loose stool all over floor. She took her brief off, had her left hand in it, her right palm had a laceration with deep tissue bruising observed, and above her right eye had a big gash/laceration. When asked what she was trying to do, she said she 'know I should have waited but I was trying to get up. 'Call placed to MD N to notify and DON (Director of Nursing), CNO while CNA (Certified Nursing Assistant) assisted one of the EMT in cleaning. MD N okayed that guest needed to be sent to hospital. FM was notified that guest was on her way back to the hospital. EMT left with guest at 8:00 PM. In an interview of Resident #7's progress note dated 10/27/23 at 9:47 PM by LVN F reflected, FM was notified that Resident #7 was on her way to the hospital .EMT left with guest at 8:00 PM. In a record review of Resident #7's progress notes by LVN F dated 10/30/23 at 8:11 PM read Grab bars to assist guest to reposition self in bed upward/downward or turning side-to-side. Also assist guest with safety exiting or entering bed . resident educated by Post Fall dated 10/27/23 at 10:19 PM. Record review of EMT report dated 10/27/23 at 7:19 Titled response # 2989218 . EMT arrived at 7:30 PM .complaint (Fall from bed) Duration of Complaint (3 hours) primary symptoms: (head injury and multiple injuries) [company name] responded to a priority 5 sick person call at a nursing and rehab facility, called in by another patient at the facility. The patient was a [AGE] year-old female with a chief complaint of multiple injuries following a fall from bed. On scene, the patient is found on the floor, alert and disoriented, not in any respiratory distress and has obvious signs of trauma to her head and lower extremities. The caller stated that the patient has been yelling for help for approximately 3 hours and no one has come to assist the patient. The nurse for the patient states the patient was just a screamer, when she checked on her 30 minutes ago, she was fine. Upon assessment, some of the blood was dry on her head, the patient has soiled herself, has a head laceration, lacerations to her knees, unknown LOC (Level of Care), and family states she was on a blood thinner but can't remember the name of it. The patient was lifted to the stretcher with a blanket, with no injuries or incidents. The crew secured the patient to the stretcher with safety belts and safety rails and loaded the stretcher into the ambulance. The crew applied dressings to the wounds and wrapped the wounds. The patient agrees to be transported to hospital for further treatment and evaluation. The patient denies any pain, just discomfort where the laceration was located. During transport to hospital, the crew continued to monitor vital signs and no new complaints developed. In a record review of Resident #7's EMT patient care timeline reflected Symptom onset: 10/27/23 at 7:12 PM Unit Notified by Dispatch 10/27/23 at 7:12:PM PSAP Call. Unit En route 10/27/23 at 7:19 PM Dispatch Notified 10/27/23 at 7:26 PM Initial responder on scene 10/27/23 at 7:26 PM Unit Arrived on Scene 10/27/23 at 7:43: PM Arrived at Patient Exam. 10/27/23 at 7:45 PM Bandage -Application of bandage. 10/27/23 at 7:53 PM Vitals and departed. 10/27/23 at 8:18 PM transporting to hospital. 10/27/23 at 8:32 PM arrived at destination. At destination, the crew unloaded the stretcher from the ambulance with no injuries or incidents. The crew delivered patient information, a verbal report and obtained a signature for patient care from the receiving ER nurse. The patient is moved from the stretcher to the hospital gurney via the drawsheet method with no injuries or incidents. An APS report is started and was forwarded to proper channels to investigate negligence on the facility. Report number: 7818 In a record review of Resident #7's progress note dated 10/28/23 at 6:27 AM by LVN F read FM brought Resident #7 back from the hospital at 5:48 PM . Vitals assessed, 97.7, 88, 18, 152/61, 95% on RA. Forehead has 10 sutures, right palm is steri-stripped. Multiple bruises to BLE, skin tears to both knees. Dried skin tear to right anterior shin. Guest assisted to bed with Ax1. Informed MD N guest is back. No new orders at this time. Paperwork from the hospital placed in medical records basket. Report given to oncoming nurse. Follow up fall assessments conducted on resident. In a record review of Resident #7's progress note dated 10/28/23 11:52 PM by LVN F Resident continues fall follow up and neuro checks monitoring. No new c/o pain or discomfort voiced at this time. Vitals stable and documented. resident was found attempting to get out of bed again this evening, was easily re-directed, bed lowered to floor and floor mats in place on either side of the bed. Continues vancomycin as well for c-diff, afebrile. Continues to have loose stools. In a record review of Resident #7's MD notes dated 10/28/23 reflected she was admitted due to generalized weakness secondary to C-Diff (infection 10/21/23), Colitis (inflammatory bowel disease), cataracts (decreased vision from cloudiness of the eye), HLD Hyperlipidemia (high cholesterol), chronic pain, right knee, depression (mood feeling down), anemia (blood disorder due to transition of oxygen in blood), vitamin D deficiency ( inadequate nutrition value from sun), falls, dementia (cognitive decline w/o Behavior Disturbances, Congestive Heart Failure (heart disease and function), anorexia (thin in appearance lacking nutrients), Deep Vein Thrombosis (blood clotting), GERD (difficulty with digestion flow), frequent UTI (infection of urinary tract), HOH . Guest is AOX1-2, Guest can make needs known and engage in discussions related to her care. Upon admission, guest scored a 14/15 BIMS. Moderate to severe levels of confusion noted despite high BIMS score, guest was so confused that SW contacted FM to complete social services assessments. PHQ 9 Depression assessment) conducted, score is a 10, mild/moderate symptoms of depression noted. Discussed advanced directives, and Resident #7 desires to be a DNR status at this time. Resident #7's goal is to return home upon completion of skilled stay. Discussed general facility expectations with guest [family member], discharge planning, and SW role in care. Discussed home health services upon discharge. SW discussed general length of stay being 2-3 weeks, with the focus of IDT authorizing stays a week at a time. Current plan of care remains, SS to follow up as needed. Care plan meeting scheduled; guest notified of meeting scheduled. In an observation and interview with Resident #7 on 10/31/23 at 10:15 AM revealed the resident lying in bed on her back with visible injuries to her head above right eye, bandage on right hand, and both knees. Resident 7 stated that she fell on the floor injuring her head, hand, and knees. She was yelling for help over 45 minutes, and no one responded. She said EMT entered her room and assessed and assisted resident, then transported her to the hospital. She received sutures on her head. Resident #26 In a record review of Resident #26's face sheet dated 10/31/23 revealed he was a [AGE] year-old male admitted on [DATE] with current diagnoses: significant for end-stage renal disease on hemodialysis, benign essential hypertension (high blood pressure), chronic hepatitis-C (liver infection), and adenocarcinoma (cancerous tumor on the colon.) In a record review of Resident #26's MDS assessment dated [DATE] revealed a BIMS score of 15 indicating he was cognitively intact. Resident had an ADL deficit and required extensive assistance with dressing, transferring and toileting. In a record review of Resident #26's Care plan dated 10/18/23 reflected Resident #26 had ADL self-care performance deficits and limitations in physical mobility. The resident/guest will improve self-care and mobility function by the next review date. Toileting Hygiene: Substantial/maximal assistance -Shower/bathe self: Substantial/maximal assistance lower and upper body dressing: Substantial/maximal assistance Substantial/maximal assistance -Personal Hygiene: substantial/maximal assistance Date Initiated: 10/18/2023 -Roll left and right: Resident has an ostomy r/t adenocarcinoma of colon. Date Initiated: 10/18/23 Resident will have no complications with ostomy through the review date. Monitor for changes in consistency, odor, and/or color of stool and notify physician as needed. Nursing Monitor stoma color for any changes and notify doctor if necessary. Nursing Provide ostomy care per protocol. Nursing evaluation admission 10/17/23. In a record review of Resident #26's MD progress note by SW dated 10/25/23 11:54 AM Social Service Note Weekly Interdisciplinary Team meeting held today. IDT members present for this meeting: CNO, Social Worker, Director of Rehab, BOM, LNFA, and MD N. Admitting dx: Cervical spine fracture, DM2, ESRD, Hepatitis C, HTN, stroke. PT: for transfers and bed mobility. OT: for transfers and bed mobility. In a record review of Resident #26's discharge summary dated 10/31/23 at 2:49 PM Resident discharged to another facility. Report called to facility. Resident signed discharge paperwork. Advised guest that he will be transported to new facility right after dialysis. Resident verbalized understanding with no further questions or concerns. Copy of discharge papers given to guest. In an interview with Resident #26 on 10/31/23 at 10:30 AM revealed on the day of 10/27/2 3 he was changing his ileostomy bag because the nursing staff don't answer the call light or make rounds and he does not want doo (bowel) on him. He stated that the bag constantly leaks, so he requested extra ileostomy bags to change it himself. He said he put the soiled bag inside the urinal on his bed side table and waited for a nurse or aide to come and discard. He said the nurse gave him the extra bag and he did not know her name. Resident #26 said on 10/27/23 he heard a Resident #7 yelling for help for over 3 hours. After a while he called 911 to ask for help because the crying did not stop. He spoke with EMT but did not know the Resident's room number. He guided them to his hall where they found Resident #7 on the floor. He said the EMT also came to his room to assess. He said the CNA and Nursing had not checked on the residents for over 3 hours. In an interview with EMT on 10/31/23 1:09 PM revealed on 10/27/23 another resident contacted 911 after hearing Resident #7 yelling for help. She stated that dispatch contacted the facility, and no one answered. EMT entered the building searching for the resident. EMT arrived at the nursing station at the top of the hall and observed LVN F sitting at the desk ignoring Resident's yell for help. EMT said she could hear a resident yelling for help. EMT asked LVN F do you hear the resident yelling? LVN F stated that they had another resident with behaviors of yelling. EMT said LVN F was ignoring the resident. EMT proceeded down the hall toward Resident #7's room following the yell for help. While simultaneously reporting to LVN F that a 911 call was received from a resident at the facility, reporting a resident had been lying on the floor yelling for help for hours. EMT entered Resident #7's room and found her on the floor with dried and fresh blood observed on the resident's forehead above the left eye, skin tear right palm, and both knees. Resident's brief was heavily soiled with feces. Resident #7 told EMT that she was sitting on the end of her bed and nose-dived on the floor. EMT then checked on Resident #26 on 10/27/23 after examining and assessing Resident #7 (EMT did not provide a time) and observed him with a heavily soiled ostomy bag that was leaking. EMT stated that both residents had been neglected and nursing failed to meet their needs and respond calls for help. In a telephone interview with LVN F on 10/31/23 at 2:12 PM, she stated when she arrived for work on 10/27/23 at 6:00 PM, she proceeded to prepare passport mediation for her unit a (device used to release resident medications by shift), due to LVN C completing final documentation for the end of shift report. LVN F stated LVN C told her that the Resident #7 was newly admitted and was on isolation. LVN F and LVN C, then completed shift reports. LVN F stated that neither nurse completed rounds to assess baseline conditions, which was the nursing protocol. LVN F said she did not hear any yelling out; however, she referenced knowledge of some residents displaying behaviors of yelling for help frequently. She did not respond to the resident's call for help, because she was reviewing shift medication for Resident administration. LVN F said she does not know why Resident # 14 yells out for help during shift. She said it was her responsibility to assist with call lights and follow up on residents calling out for safety to assist for current need. LVN F reported she did not know that Resident #7 fell , until she received a call from the [company name] dispatcher reporting the incident, resident location, and whereabouts, as a neighboring Resident called 911 for help saying a female resident was yelling for help for hours. LVN F stated shortly after the call, the EMT arrived with the same information, and they went together to Resident #7's room and found her on the floor. LVN F stated the EMT arrived after 7:00 PM and the resident was found on the floor, and soiled herself, and was trying to get up and slid from the floor to the bed She said the floor in Resident # 7 was room was soiled with feces (bowel). Resident reported to LVN F that she slid off the bed from a sitting position to the floor. LVN F observed injuries to her right palm with deep tissue pooling, both knees, and bleeding from a laceration to her forehead above her right eye. LVN F said she notified the MD of the fall and injuries. MD approved order for transfer to ER for treatment. EMT transported resident to hospital. The FM returned resident 10/28/23 at approximately 5:48 AM to the facility MD orders. In a telephone interview on 10/31/23 at 4:36 PM, LVN C stated she arrived at 6:00 PM. LVN C said she and LVN F did not conduct rounds due to end of shift report completion from two admissions. She said once she completed the new admissions assessments and documentation, notified LVN F that all reports were completed, and she left. She said the last time she observed Resident #7 was at 5:45 PM after setting up isolation precaution supplies outside the door, due to an infection to C-Diff. Upon exiting Resident #7's room, she placed call light near to reach. In an interview on 10/31/23 at 4:43 PM with CNA T revealed she was the assigned CNA for Resident #7 on 10/27/23 from 6:00 PM to 6:00 AM. She stated that she arrived at 6:15 PM and conducted rounds with CNA K. She was not aware that Resident #7 had a history and risk of falls, as she was a new admission and proceeded with answering call lights after report and rounds with CNA K. CNA T said she should be checking on Residents every 2 hours and as needed to prevent extensive exposure to the resident's skin that could result in skin damage. CNA T stated she did not hear yelling coming from Resident #7's room, but other residents were calling out and she responded and provided care. The expectation for aides upon arrival to shift, were to conduct rounds together while giving reports, then respond to call lights. She said a negative outcome from not answering call lights could lead to injuries. She said not cleaning resident's bag and discarding properly could result in infection. LVN T stated that call light responses depend on CNA's availability at the time, as she may be providing care to another resident. She said when hearing yelling, she responds as soon as she can. She said on 10/27/23, she had not checked on Resident #7 prior to EMT arriving. In an interview with the DON on 11/01/23 at 4:40 PM, she said she had not reported Resident #7's fall, injuries, and EMT, and ER visit from 10/27/23 to HHS, due to LVN F failing to report all of the details to the fall. LVN F did not report that she was not responding to Resident #7's yell for help, failure to conduct resident rounds, and condition resident was found in by EMT. The DON said LVN F did report that another Resident called 911 after hearing Resident #7 yell for help. The DON said she was not told that the Resident # 7 was lying on the floor yelling for over an hour for help until the EMT arrived and found the resident. She expected all staff to respond immediately to calls lights, resident yelling out to provide assessments, interventions, and care. The DON said that she and ADON's were responsible for overseeing LVN 's patient care as well as monitoring job task and needs for help. She reported that LVN C and LVN F should have conducted rounds at the top of the shift. The phone should have been answered, and more information should have been provided about the incident and it would have been investigated. In an interview on 11/01/23 at 4:45 PM, the Administrator stated she was notified that Resident #7 fell and EMT were present on 10/27/23 after the EMT left aby the DON. There was no additional information about staff not responding to the Resident yelling out for help, and EMT arriving seeking resident location as the nurse were not answering the phone. She stated it was her expectation for staff to answer when they hear yelling, call lights, and provide care immediately to the residents to prevent further injuries, and harm from occurring. The Administrator said that all staff were aware that she was the abuse coordinator. She expects the DON and ADON to monitor the clinical task and care of residents by monitoring and auditing, addressing concerns in IDT meeting to implement interventions. She said that residents should not be yelling for help and not getting immediate care. She said that additional task will be implemented to assure Resident safety and timely response from staff to meet medical needs and prevent accidents and injuries. In an interview with CNA J on 11/02/23 at 11:01 AM revealed she did not hear yelling from any resident's or calling out for help while working on 10/27/23. CNA J said the protocol for assisting residents with call lights and yelling out included an immediate response to assure the resident's safety, try to comfort and calm the resident. She said LVN C was observed counting medication with LVN F when she left at on 10/27/23 at 6:20 PM. She last saw Resident #7 upon her arrival at 4:45 PM. Record review of the facility's CNA and LVN assignments for 10/27/23, reflected CNA K relieved CNA T. LVN F relieved LVN C. Shifts were scheduled 6 AM to 6 PM. In a record review of the facility's in-service dated 11/01/23 revealed on abuse, neglect, call light response priority, and resident's yelling .find the source of the yelling, reporting abuse and neglect resident behaviors and implementing interventions .A resident lying on the floor and not responding is considered abuse. In an interview on 11/02/23 at 10:10 AM, Resident #7's family member, he reported that he followed the hospital transport of Resident #7 to facility for admission on 10/27/23 and the nursing staff educated and orientation him and Resident #7. Resident #7 understood call light usage for safety and waiting for assistance to prevent injuries. The FM said he was notified by LVN F of the fall and hospital location for Resident #7. On 10/27/23 around 8:00 PM. Resident #7 told FM that she should have asked for help, and she was sitting at the end of her bed and fell on the floor. Resident #7 told him that she tried to get up on her own, however, she was not successful. Resident #7 said when she could not get up, she yelled for help, as the call light was not nearby. The FM said the resident sustained injuries to the head requiring sutures and injuries to hand and knees. The FM said he transported the resident back to facility. In an interview with CNA K on 11/02/23 at 11:12 AM revealed she was working on 10/27/23, the date Resident #7 was admitted at 4:20 PM. She assisted Resident #7 by transferring her to bed, assessed her and orienting her on call light and asking for help. CNA K said the resident was not confused and she understood the call light process. She said at approximately 5:45 PM, Resident #7 used the call light for incontinent care. She responded immediately and provided care prior to shift ending at 6:00 AM. She said the resident was on isolation for C-Diff and called via call light frequently (Q 10 minutes) for care, due to the loose stool. She said CNA S and CNA T arrived at approximately 6:15 PM. They completed rounds and reports, then she left. CNA K said she did not hear any resident's yelling when she was leaving her shift. Staff were expected to respond regardless of the resident behaviors. She stated that call lights should be responded to immediately and the failure to respond could lead to a resident getting hurt. In a record review of facility policy titled To provide guidance on use of call light for residents dated 04/2023 reflected in part the following: 1 The call light system is provided as a tool for residents to communicate with staff. 2. Residents will be evaluated for ability to use call light on admission, quarterly and annually. 3. If residents are determined to be physically unable to use call lights, alternative call buttons (touch, whistle, etc.) will be provided. 4. If residents are determined to be cognitively unable to use call lights, residents will be monitored for needs by staff members during rounds and while delivering care. 5. Staff members will ensure that call lights are within reach of a resident who is able to cognitively use a call light each time they leave the room. This was determined to be an Immediate Jeopardy on 11/01/23 at 3:00 PM. The Administrator and the DON were notified. The Administrator and the DON were provided with the Immediate Jeopardy Template on 11/01/23 at 5:34 PM. The following Plan of Removal submitted by the facility was accepted on 11/02/23 at 11:50 AM: F 600 Allegation of Credible Compliance Immediate Interventions: 1. Notification made MD N and MD B, physicians, and Medical Directors, of Immediate Jeopardy on 11/01/2023 at 4:15 PM. 2. Emergent Meeting conducted with action plan developed. This occurred at 4:30 pm on 11/01/2023. Attendance included the following: Administrator DON 3. Direct Care Nursing Staff in-serviced on neglect, expectations in responding timely to calls for assistance. 11/01/2023 by DON and ADON 4. 11/01/2023 and 11/02/2023: Nursing staff educated on timely response to answering the phone. Education provided by DON. And LVN, ADON. 5. Nurse involved in incident with pt #7 has been suspended pending further facility investigation. This Nurse will be referred to the Texas Board of Nursing. This nurse will not return to work at [facility name]. 6. Further education to direct care staff to respond immediately to calls for help to prevent significant injuries, prolonged care, assessments, and treatment. Education provided by ADM, DON, ADON-A on 10/31/23 and 11/1/2023. 7. if EMT notifies facility of a resident call for help, an immediate staff response is required to ensure resident safety. Meeting with the following managers to review Immediate Jeopardy on 11/1/2023: a. Administrator b. Director of Nursing c. Director of Rehabilitation d. Assistant Director of Nursing e. Activities Director f. Dietary Manager g. Social Services h. Social Services i. MDS Nurse Training: 1. An immediate in-service was initiated on 10/31/23 and 11/01/2023, by the Director of Nursing, on Neglect and responding to calls for assistance. 2. 11/01/2023 and on-going: A post-test will be completed by direct care staff to ensure competency on Neglect education. Staff must answer all questions correctly before returning to work. 3. New staff will receive in-servicing prior to orientation on the floor. PRN staff will not be allowed to work in the facility until they have completed in-service training and post-test. 4. A payroll report listing current employees will be used to track in-service completion. Monitoring: 1. Nursing Administration (ADM, DON, and ADON) will review 24-hour report for any change in condition to ensure timely follow up and intervention occurs. The Care plan and the Nurse Aide Kardex will be updated at that time to reflect the intervention. 2 Administrator, or appointed designee, will review this process in the Clinical Meeting scheduled 5 times per week (Monday through Friday) to monitor for compliance, and to make changes based on the interdisciplinary team's (IDT) decision. Monitoring of the POR included the following: Record review of in-service titled Abuse and Neglect, dated 10/31/23, 11/01/23, and 11/02/23, reflected curriculum covered the facility's policy on abuse and neglect, fall response, answering calls, interventions and reporting abuse and behaviors of resident's that yell out or have behaviors. Additional training was conducted online with post testing about Abuse and neglect. Record review of in-service dated 10/31/23 conducted by DON and ADON B reflected Monitoring call lights, assure they are operational .Provide appropriate care/intervention to address behavior issues, and document. Notify ADM and DON as soon as possible when behaviors are exhibited. A total of 31 staff attended the training. Observations and interviews on 11/02/23 from 1:50 PM to 3:00 PM with Residents #7, #14, #21, #26, and #30 revealed no concerns fo [TRUNCATED]

Based on interview, and record review, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there was an accident involving the resident which results in injury and has the potential for requiring physician intervention for one of 16 residents (Resident #50) reviewed for physician notification. 1. The facility failed to notify the physician of Resident #50's fall with acute hip fracture. The failure could place residents at risk for pain, significant injury, and decreased level of functioning and quality of life. Findings included : Record review of face sheet dated 8/24/23 revealed Resident #50 was a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included orthostatic hypotension (low blood pressure when standing), age related physical debility with an admitting diagnosis of fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing. Record review of Resident #50's care plan dated 8/10/23 revealed Resident #50 was at risk for falls related to impaired mobility. Interventions included: anticipate the resident's needs, ensure bed brakes were locked, ensure footwear fit properly, ensure resident's call light was within reach, and ensure resident received prompt response to all requests for assistance. Review of Resident #50's physician orders, dated 08/10/23, revealed Acetaminophen Tablet 650 mg by mouth once every four hours as needed for pain was ordered 08/10/23, prior to the fall. Review of Resident #50's MDS assessment dated , 09/09/23, revealed her BIMS score of 14, which indicated little to no cognitive impairment. The resident's functional status after the fall on 08/18/23 indicated no change to her functional status. Resident remained able to ambulate of self-performance of 1, indicating supervision in walking, transferring, bed mobility, dressing, toilet use, and personal hygiene. Interview with Resident #50 over the phone on 09/18/23 at 9:50 AM revealed she had fractured her left hip due to the fall. She stated she had been in the restroom at about 3:00 AM in the morning (08/18/23) and as she was coming towards the bed, she saw something she wanted to pick up and fell down hard on her hip. She stated she was able to get herself back on the bed and mentioned to the nurse over the weekend. She stated someone came in Monday to take x-rays and a fracture was found. Resident #50 did not recall who was the nurse who assisted her when she fell but pain was immediate when she hit the floor. She stated she was administered pain medication but does not recall if she had pain over the weekend. Review of Resident #50's Provider Investigation Report , dated 08/23/23, from the facility's self-report revealed Resident #50 had a fall. When discovered the resident had a fall, x-rays were ordered but no incident report was completed for the fall. The resident fell on the night of 08/18/23 and x-ray results were sent to the nurse on 08/19/23. Two areas were x-rayed with one x-ray showing possible fracture with osteopenia and the other x-ray did not show a fracture. Both nurses (RN J and LVN R) did not read the x-ray results correctly and they did not see the fracture on the results according to the PIR. Resident was given pain medication and the resident did not complain of pain all weekend. Both nurses were in-serviced and suspended pending investigation. The Provider Investigation report included the resident's face sheet, in-services, safe surveys, and x-ray results showing a left subcapital fracture with mild impaction on left hip. Osteopenia was noted. Acute left hip fracture was noted . Review of Resident #50's x-ray results, dated 08/18/23, revealed pain in left hip with left subcapital fracture with mild impaction with osteopenia and pain in left knee with no fracture. Review of Resident #50's MAR for August 2023 revealed the following: - Acetaminophen Tablet 670 mg, one tablet by mouth every 4 hours as needed for pain. Resident #50 was administered on 08/18/23 at 4:34 AM with a pain level at a 7 by RN L. - Acetaminophen Tablet 670 mg, one tablet by mouth every 4 hours as needed for pain. Resident #50 was administered on 08/18/23 at 10:17 AM with a pain level at a 5 by RN J. - Tramadol HCI Oral Tablet 50 mg two tablets by mouth every 6 hours as needed for pain. Resident #50 was administered on 08/20/23 at 10:04 AM with a pain level at a 6 by RN J. - Tramadol HCI Oral Tablet 50 mg two tablets by mouth every 6 hours as needed for pain. Resident #50 was administered on 08/20/23 at 9:22 PM by LVN R. - There was no documentation of pain level and pain medication administered received for 08/19/23. Review of Resident #50's progress notes for 08/18/23 revealed Resident #50 had notified RN J she had fallen hard on her bottom while trying to get in bed around 2:00 AM. RN J notified NP and x-rays were ordered. Acetaminophen tablet 650 mg (Tylenol) was administered. The nurse followed up later at 11:31 AM on 08/18/23 and pain was unrelieved by Tylenol. RN J notified NP for new pain intervention medication. RN J followed-up again on 08/18/23 in the afternoon and administered another Acetaminophen tablet 650 mg. Follow-up pain level was 1. Review of Resident #50's progress notes for 08/19/23 revealed no documentation of pain medication given or requested. Review of Resident #50's Occupational Therapy notes, dated 08/18/23 (the date of her fall), revealed the resident had informed OT that she had a fall last night (it was 2:00 AM in the morning on 08/18/23) and that she had reported it to staff and nursing. Resident #50 indicated she had gotten herself back into bed by herself. Resident's pain at the time was 8 out of 10 and she did not want to participate in OT. OT notified nursing and would continue to monitor. Review of Resident #50's physician orders, dated 08/18/23, revealed tramadol HCI Oral Tablet 50 mg (Tramadol HCI) was ordered for one tablet by mouth every 6 hours as needed for pain and give two tablets by mouth every 6 hours for pain as needed. Review of Resident #50's progress notes for 08/20/23 revealed tramadol HCI Oral Tablet 50 mg was ordered. Tramadol HCI Oral Tablet 50 mg was given in the morning by RN J. Follow-up revealed Resident #50's pain had decreased to 2. At night, LVN R administered Tramadol HCI Oral Tablet 50 mg. Follow-up pain was 2. Review of Resident #50's Occupational Therapy notes, dated 08/20/23, revealed the resident attended therapy and resident performed shoulder flexion and extension of 10 repetitions of three sets from a seated position. Resident reported a pain level of 5 prior to therapy and a level of 5 after therapy, which indicated no changes to her pain level. Written Statement dated 8/22/23, from ACNO F revealed the ACNO F was not informed by RN J about Resident #50 having a fall nor was she informed that an x-ray was being ordered. ACNO F was informed about Resident #50's fall when the reports were printed for the morning meeting 08/22/2023. She then checked the x-ray lab results and printed them to follow up with a call to the nurse practitioner. ACNO F stated the nurse practitioner was in the building at the time to relay the results to the nurse practitioner. Attempted interview on 8/23/23 at 2:15 PM with LVN R unsuccessful. Attempted to call but didn't get an answer or a call back. Record review of a written statement by LVN R dated and signed 8/22/23 revealed, Friday 8/18/23 at around 1800 (6:00 PM) she endorsed that Resident #50 claims she fell and had pain on her left hip. LVN R contacted the nurse practitioner. Pain medication tramadol was prescribed by the nurse practitioner and faxed to pharmacy. During the shift LVN R stated she followed up with the pain medication with the pharmacy and the provider. LVN R stated no report was given to her that X-rays were done, and the x-rays needed to be followed up on. Review of RN J's email statement, dated 08/22/23, revealed RN J received a report Friday morning (08/18/23) that Resident #50 had slipped and fell . RN J stated Resident #50 denied hitting her head and any other symptoms other than pain on her bottom. RN J assumed LVN R had completed an incident report. RN J checked on the resident and notified the NP for an x-ray to be requested. RN J had checked to see if x-ray results had come in and they had not. RN J passed on the information to look out for the x-ray results to LVN R and that to be expecting results and fax them to the doctor . RN J returned to work on Saturday (08/19/23) and LVN R had informed that she had reviewed the x-ray and it showed no fracture, only osteoarthritis. RN J handed the resident the x-ray results to inform [Resident #50] of the results but when RN J read the results, she had failed to notice there were two separate results on the same page initially. The order for tramadol was received by RN J, however Resident #50 did not request pain medication throughout the shift RJ J worked and stated her leg only hurt when she put weight on it. Interview on 8/23/23 at 10:00AM with the Administrator revealed, we put in every preventable measure for falls, and it depends on what the needs are. If we must use fall mats, we will and take them to the bathroom often. Medication reviews. Making sure things are in reach. We don't get too many people with dementia here, but we do see that was where many of our falls come from. I think the surgery was the case with Resident #50 (a prior surgery had contributed to Resident #50's falls). She was brittle and old. Very pleasant. I think it was one of those cases that she was used to doing things on her own and forgot she needed to use the walker and just wasn't thinking about it. She fell and got back in bed. She was very independent. She didn't think anything of it. The Administrator stated we have guardian rounds and that's one of the things we look for are fall risk. Administrator stated the facility usually does rounds every day sometimes twice a day to make sure staff are doing what they are supposed to do. Interview on 8/23/23 at 2:00 PM with RN J revealed Resident #50 fell Thursday morning 8/18/23 before her morning shift. She came in Friday morning and received a report from LVN R that Resident #50 had gone to the bathroom by herself, without calling for assistance, and fell hard in her room. She got up got herself back in bed and she informed the night staff of what happened some hours later, stating it happened around 2:00 AM. RN J called the nurse practitioner and ordered x-rays and notified the ACNO. RN J stated Resident #50 was more worried about her left knee and it was just a small abrasio n. RN J stated she got orders from the nurse practitioner for tramadol. The x-ray came out sometime later. She stated she failed to review the second results of the x-ray when coming on to night shift but did give the x-ray results to the resident. RN J stated LVN R, the night nurse, told her it was only osteoarthritis. When RN J read the results, she stated she didn't see there were two separate results and only saw the knee results of osteoarthritis. RN J stated she misread the x-ray. RN J stated LVN J told RN J she got an order from the nurse practitioner for tramadol for pain PRN. RN J stated the resident requested pain medication one time the whole three days RN J cared for her . She assumed since it happened on night shift, on LVN R's shift, that she had done an incident report. RN J stated the nurses were supposed to fax the results from the X-ray to the doctor once the nurses on shift receive them, but she wasn't sure that happened since the results didn't come back on her shift. RN J stated she has been trained on what to do when falls occur but thought LVN R had already done the necessary steps that needed to be taken. RN J was suspended upon investigation completion. Interview on 8/23/23 at 2:30 PM with the Administrator revealed the facility was not aware of the incident with Resident #50 until that following Monday on 8/21/23. The facility received a notification that an x-ray was ordered and upon looking at the results found that Resident #50 fractured her hip. They immediately investigated and got statements from both RN J and LVN R. RN J was suspended until further notice. The facility realized RN J received the x-ray results on her shift but didn't read the results correctly. They also stated RN J didn't notify the doctor of the results. The Administrator stated once the nurse gets the results, the nurses were supposed to notify the physician and inform the resident. The administrator stated an incident report wasn't completed and Resident #50 didn't go to the hospital until Monday on 8/21/23 once the ACNO printed of the reports for the morning meeting. Follow-up interview with the Administrator on 8/23/23 at 3:00 PM revealed she had received more information and the x-ray report that came in on LVN R's shift and not RN J's shift. Administrator stated they (the facility) was currently taking RN J off from being suspended but could not get a hold of LVN R. Administrator stated phone calls and voicemails have been made by the DON, but the DON hasn't received a return phone call. Administrator also revealed the fall occurred on LVN R's shift (date and time) and an incident should have been done, as well as, notifying the nurse practitioner. Review of Resident #50's hospital records dated, 08/24/23, revealed Resident #50 was admitted to the hospital on 08/21/23 at 12:11 PM due to left femur fracture. An x-ray was taken on 08/21/23 at the hospital with findings of a compression screw and plate fixation right femoral neck fracture to her hip, which indicated a compression screw and plate fixation already existed for the resident hip. Resident has had a CVA many years ago but made full recovery. Pain was mild and controlled. On 08/22/23 the resident underwent closed reduction and percutaneous screw fixation (minimally invasive surgery by making small incisions to insert screws with the goal to achieve anatomical reduction and stabilization of the fracture) of left femoral neck fracture a day after hospital admission. Resident did well postoperatively, and resident was already working with PT/OT (physical therapy/occupational therapy). Resident to discharge 08/22/23. Record review dated November 2020 of the facility's policy for fall prevention reflected: Use the temporary care plan and communication tool to identify activities or habits that place the resident at risk for falls Keep walkways clear Keep equipment out of the way so they won't create obstacles to others. Be alert for anything that is in the path of traffic which could create walking hazards. Review of the facility's policy Change in Resident Condition, dated November 2018, revealed, .Should there be a change in the resident's physical, mental or emotional status, the attending physician should be notified .if at any time during this process the resident's condition deteriorates or it is determined a medical emergency exists, then send the resident to the hospital via 911 .

Based on interview, and record review, the facility failed to ensure based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of 16 residents (Resident #50) reviewed for quality of care. The facility failed to notify the physician of Resident #50's fall with acute hip fracture and failed to follow-up on x-ray results which would require physician intervention or timely transport to the hospital. The failure could place residents at risk for pain, significant injury, and decreased level of functioning and quality of life. Findings included : Record review of face sheet dated 8/24/23 revealed Resident #50 was a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included orthostatic hypotension (low blood pressure when standing), age related physical debility with an admitting diagnosis of fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing. Record review of Resident #50's care plan dated 8/10/23 revealed Resident #50 was at risk for falls related to impaired mobility. Interventions included: anticipate the resident's needs, ensure bed brakes were locked, ensure footwear fit properly, ensure resident's call light was within reach, and ensure resident received prompt response to all requests for assistance. Review of Resident #50's physician orders, dated 08/10/23, revealed Acetaminophen Tablet 650 mg by mouth once every four hours as needed for pain was ordered 08/10/23, prior to the fall. Review of Resident #50's MDS assessment dated , 09/09/23, revealed her BIMS score of 14, which indicated little to no cognitive impairment. The resident's functional status after the fall on 08/18/23 indicated no change to her functional status. Resident remained able to ambulate of self-performance of 1, indicating supervision in walking, transferring, bed mobility, dressing, toilet use, and personal hygiene. Interview with Resident #50 over the phone on 09/18/23 at 9:50 AM revealed she had fractured her left hip due to the fall. She stated she had been in the restroom at about 3:00 AM in the morning (08/18/23) and as she was coming towards the bed, she saw something she wanted to pick up and fell down hard on her hip. She stated she was able to get herself back on the bed and mentioned to the nurse over the weekend. She stated someone came in Monday to take x-rays and a fracture was found. Resident #50 did not recall who was the nurse who assisted her when she fell but pain was immediate when she hit the floor. She stated she was administered pain medication but does not recall if she had pain over the weekend. Review of Resident #50's Provider Investigation Report , dated 08/23/23, from the facility's self-report revealed Resident #50 had a fall. When discovered the resident had a fall, x-rays were ordered but no incident report was completed for the fall. The resident fell on the night of 08/18/23 and x-ray results were sent to the nurse on 08/19/23. Two areas were x-rayed with one x-ray showing possible fracture with osteopenia and the other x-ray did not show a fracture. Both nurses (RN J and LVN R) did not read the x-ray results correctly and they did not see the fracture on the results according to the PIR. Resident was given pain medication and the resident did not complain of pain all weekend. Both nurses were in-serviced and suspended pending investigation. The Provider Investigation report included the resident's face sheet, in-services, safe surveys, and x-ray results showing a left subcapital fracture with mild impaction on left hip. Osteopenia was noted. Acute left hip fracture was noted . Review of Resident #50's x-ray results, dated 08/18/23, revealed pain in left hip with left subcapital fracture with mild impaction with osteopenia and pain in left knee with no fracture. Review of Resident #50's MAR for August 2023 revealed the following: - Acetaminophen Tablet 670 mg, one tablet by mouth every 4 hours as needed for pain. Resident #50 was administered on 08/18/23 at 4:34 AM with a pain level at a 7 by RN L. - Acetaminophen Tablet 670 mg, one tablet by mouth every 4 hours as needed for pain. Resident #50 was administered on 08/18/23 at 10:17 AM with a pain level at a 5 by RN J. - Tramadol HCI Oral Tablet 50 mg two tablets by mouth every 6 hours as needed for pain. Resident #50 was administered on 08/20/23 at 10:04 AM with a pain level at a 6 by RN J. - Tramadol HCI Oral Tablet 50 mg two tablets by mouth every 6 hours as needed for pain. Resident #50 was administered on 08/20/23 at 9:22 PM by LVN R. - There was no documentation of pain level and pain medication administered received for 08/19/23. Review of Resident #50's progress notes for 08/18/23 revealed Resident #50 had notified RN J she had fallen hard on her bottom while trying to get in bed around 2:00 AM. RN J notified NP and x-rays were ordered. Acetaminophen tablet 650 mg (Tylenol) was administered. The nurse followed up later at 11:31 AM on 08/18/23 and pain was unrelieved by Tylenol. RN J notified NP for new pain intervention medication. RN J followed-up again on 08/18/23 in the afternoon and administered another Acetaminophen tablet 650 mg. Follow-up pain level was 1. Review of Resident #50's progress notes for 08/19/23 revealed no documentation of pain medication given or requested. Review of Resident #50's Occupational Therapy notes, dated 08/18/23 (the date of her fall), revealed the resident had informed OT that she had a fall last night (it was 2:00 AM in the morning on 08/18/23) and that she had reported it to staff and nursing. Resident #50 indicated she had gotten herself back into bed by herself. Resident's pain at the time was 8 out of 10 and she did not want to participate in OT. OT notified nursing and would continue to monitor. Review of Resident #50's physician orders, dated 08/18/23, revealed tramadol HCI Oral Tablet 50 mg (Tramadol HCI) was ordered for one tablet by mouth every 6 hours as needed for pain and give two tablets by mouth every 6 hours for pain as needed. Review of Resident #50's progress notes for 08/20/23 revealed tramadol HCI Oral Tablet 50 mg was ordered. Tramadol HCI Oral Tablet 50 mg was given in the morning by RN J. Follow-up revealed Resident #50's pain had decreased to 2. At night, LVN R administered Tramadol HCI Oral Tablet 50 mg. Follow-up pain was 2. Review of Resident #50's Occupational Therapy notes, dated 08/20/23, revealed the resident attended therapy and resident performed shoulder flexion and extension of 10 repetitions of three sets from a seated position. Resident reported a pain level of 5 prior to therapy and a level of 5 after therapy, which indicated no changes to her pain level. Written Statement dated 8/22/23, from ACNO F revealed the ACNO F was not informed by RN J about Resident #50 having a fall nor was she informed that an x-ray was being ordered. ACNO F was informed about Resident #50's fall when the reports were printed for the morning meeting 08/22/2023. She then checked the x-ray lab results and printed them to follow up with a call to the nurse practitioner. ACNO F stated the nurse practitioner was in the building at the time to relay the results to the nurse practitioner. Attempted interview on 8/23/23 at 2:15 PM with LVN R unsuccessful. Attempted to call but didn't get an answer or a call back. Record review of a written statement by LVN R dated and signed 8/22/23 revealed, Friday 8/18/23 at around 1800 (6:00 PM) she endorsed that Resident #50 claims she fell and had pain on her left hip. LVN R contacted the nurse practitioner. Pain medication tramadol was prescribed by the nurse practitioner and faxed to pharmacy. During the shift LVN R stated she followed up with the pain medication with the pharmacy and the provider. LVN R stated no report was given to her that X-rays were done, and the x-rays needed to be followed up on. Review of RN J's email statement, dated 08/22/23, revealed RN J received a report Friday morning (08/18/23) that Resident #50 had slipped and fell . RN J stated Resident #50 denied hitting her head and any other symptoms other than pain on her bottom. RN J assumed LVN R had completed an incident report. RN J checked on the resident and notified the NP for an x-ray to be requested. RN J had checked to see if x-ray results had come in and they had not. RN J passed on the information to look out for the x-ray results to LVN R and that to be expecting results and fax them to the doctor . RN J returned to work on Saturday (08/19/23) and LVN R had informed that she had reviewed the x-ray and it showed no fracture, only osteoarthritis. RN J handed the resident the x-ray results to inform [Resident #50] of the results but when RN J read the results, she had failed to notice there were two separate results on the same page initially. The order for tramadol was received by RN J, however Resident #50 did not request pain medication throughout the shift RJ J worked and stated her leg only hurt when she put weight on it. Interview on 8/23/23 at 10:00AM with the Administrator revealed, we put in every preventable measure for falls, and it depends on what the needs are. If we must use fall mats, we will and take them to the bathroom often. Medication reviews. Making sure things are in reach. We don't get too many people with dementia here, but we do see that was where many of our falls come from. I think the surgery was the case with Resident #50 (a prior surgery had contributed to Resident #50's falls). She was brittle and old. Very pleasant. I think it was one of those cases that she was used to doing things on her own and forgot she needed to use the walker and just wasn't thinking about it. She fell and got back in bed. She was very independent. She didn't think anything of it. The Administrator stated we have guardian rounds and that's one of the things we look for are fall risk. Administrator stated the facility usually does rounds every day sometimes twice a day to make sure staff are doing what they are supposed to do. Interview on 8/23/23 at 2:00 PM with RN J revealed Resident #50 fell Thursday morning 8/18/23 before her morning shift. She came in Friday morning and received a report from LVN R that Resident #50 had gone to the bathroom by herself, without calling for assistance, and fell hard in her room. She got up got herself back in bed and she informed the night staff of what happened some hours later, stating it happened around 2:00 AM. RN J called the nurse practitioner and ordered x-rays and notified the ACNO. RN J stated Resident #50 was more worried about her left knee and it was just a small abrasio n. RN J stated she got orders from the nurse practitioner for tramadol. The x-ray came out sometime later. She stated she failed to review the second results of the x-ray when coming on to night shift but did give the x-ray results to the resident. RN J stated LVN R, the night nurse, told her it was only osteoarthritis. When RN J read the results, she stated she didn't see there were two separate results and only saw the knee results of osteoarthritis. RN J stated she misread the x-ray. RN J stated LVN J told RN J she got an order from the nurse practitioner for tramadol for pain PRN. RN J stated the resident requested pain medication one time the whole three days RN J cared for her . She assumed since it happened on night shift, on LVN R's shift, that she had done an incident report. RN J stated the nurses were supposed to fax the results from the X-ray to the doctor once the nurses on shift receive them, but she wasn't sure that happened since the results didn't come back on her shift. RN J stated she has been trained on what to do when falls occur but thought LVN R had already done the necessary steps that needed to be taken. RN J was suspended upon investigation completion. Interview on 8/23/23 at 2:30 PM with the Administrator revealed the facility was not aware of the incident with Resident #50 until that following Monday on 8/21/23. The facility received a notification that an x-ray was ordered and upon looking at the results found that Resident #50 fractured her hip. They immediately investigated and got statements from both RN J and LVN R. RN J was suspended until further notice. The facility realized RN J received the x-ray results on her shift but didn't read the results correctly. They also stated RN J didn't notify the doctor of the results. The Administrator stated once the nurse gets the results, the nurses were supposed to notify the physician and inform the resident. The administrator stated an incident report wasn't completed and Resident #50 didn't go to the hospital until Monday on 8/21/23 once the ACNO printed of the reports for the morning meeting. Follow-up interview with the Administrator on 8/23/23 at 3:00 PM revealed she had received more information and the x-ray report that came in on LVN R's shift and not RN J's shift. Administrator stated they (the facility) was currently taking RN J off from being suspended but could not get a hold of LVN R. Administrator stated phone calls and voicemails have been made by the DON, but the DON hasn't received a return phone call. Administrator also revealed the fall occurred on LVN R's shift (date and time) and an incident should have been done, as well as, notifying the nurse practitioner. Review of Resident #50's hospital records dated, 08/24/23, revealed Resident #50 was admitted to the hospital on 08/21/23 at 12:11 PM due to left femur fracture. An x-ray was taken on 08/21/23 at the hospital with findings of a compression screw and plate fixation right femoral neck fracture to her hip, which indicated a compression screw and plate fixation already existed for the resident hip. Resident has had a CVA many years ago but made full recovery. Pain was mild and controlled. On 08/22/23 the resident underwent closed reduction and percutaneous screw fixation (minimally invasive surgery by making small incisions to insert screws with the goal to achieve anatomical reduction and stabilization of the fracture) of left femoral neck fracture a day after hospital admission. Resident did well postoperatively, and resident was already working with PT/OT (physical therapy/occupational therapy). Resident to discharge 08/22/23. Record review dated November 2020 of the facility's policy for fall prevention reflected: Use the temporary care plan and communication tool to identify activities or habits that place the resident at risk for falls Keep walkways clear Keep equipment out of the way so they won't create obstacles to others. Be alert for anything that is in the path of traffic which could create walking hazards. Review of the facility's policy Change in Resident Condition, dated November 2018, revealed, .Should there be a change in the resident's physical, mental or emotional status, the attending physician should be notified .if at any time during this process the resident's condition deteriorates or it is determined a medical emergency exists, then send the resident to the hospital via 911 .

Based on interview, and record review, the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for one of 16 residents (Resident ##50) reviewed for x-ray results. The facility failed to follow-up on x-ray results for Resident #50 which indicated an acute hip fracture, preventing the resident from being sent out timely to the hospital. The failure could place residents at risk for pain, significant injury, and decreased level of functioning and quality of life. Findings included: Record review of face sheet dated 8/24/23 revealed Resident #50 was a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included orthostatic hypotension (low blood pressure when standing), age related physical debility with an admitting diagnosis of fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing. Record review of Resident #50's care plan dated 8/10/23 revealed Resident #50 was at risk for falls related to impaired mobility. Interventions included: anticipate the resident's needs, ensure bed brakes were locked, ensure footwear fit properly, ensure resident's call light was within reach, and ensure resident received prompt response to all requests for assistance. Review of Resident #50's physician orders, dated 08/10/23, revealed Acetaminophen Tablet 650 mg by mouth once every four hours as needed for pain was ordered 08/10/23, prior to the fall. Review of Resident #50's MDS assessment dated , 09/09/23, revealed her BIMS score of 14, which indicated little to no cognitive impairment. The resident's functional status after the fall on 08/18/23 indicated no change to her functional status. Resident remained able to ambulate of self-performance of 1, indicating supervision in walking, transferring, bed mobility, dressing, toilet use, and personal hygiene. Interview with Resident #50 over the phone on 09/18/23 at 9:50 AM revealed she had fractured her left hip due to the fall. She stated she had been in the restroom at about 3:00 AM in the morning (08/18/23) and as she was coming towards the bed, she saw something she wanted to pick up and fell down hard on her hip. She stated she was able to get herself back on the bed and mentioned to the nurse over the weekend. She stated someone came in Monday to take x-rays and a fracture was found. Resident #50 did not recall who was the nurse who assisted her when she fell but pain was immediate when she hit the floor. She stated she was administered pain medication but does not recall if she had pain over the weekend. Review of Resident #50's Provider Investigation Report , dated 08/23/23, from the facility's self-report revealed Resident #50 had a fall. When discovered the resident had a fall, x-rays were ordered but no incident report was completed for the fall. The resident fell on the night of 08/18/23 and x-ray results were sent to the nurse on 08/19/23. Two areas were x-rayed with one x-ray showing possible fracture with osteopenia and the other x-ray did not show a fracture. Both nurses (RN J and LVN R) did not read the x-ray results correctly and they did not see the fracture on the results according to the PIR. Resident was given pain medication and the resident did not complain of pain all weekend. Both nurses were in-serviced and suspended pending investigation. The Provider Investigation report included the resident's face sheet, in-services, safe surveys, and x-ray results showing a left subcapital fracture with mild impaction on left hip. Osteopenia was noted. Acute left hip fracture was noted . Review of Resident #50's x-ray results, dated 08/18/23, revealed pain in left hip with left subcapital fracture with mild impaction with osteopenia and pain in left knee with no fracture. Review of Resident #50's MAR for August 2023 revealed the following: - Acetaminophen Tablet 670 mg, one tablet by mouth every 4 hours as needed for pain. Resident #50 was administered on 08/18/23 at 4:34 AM with a pain level at a 7 by RN L. - Acetaminophen Tablet 670 mg, one tablet by mouth every 4 hours as needed for pain. Resident #50 was administered on 08/18/23 at 10:17 AM with a pain level at a 5 by RN J. - Tramadol HCI Oral Tablet 50 mg two tablets by mouth every 6 hours as needed for pain. Resident #50 was administered on 08/20/23 at 10:04 AM with a pain level at a 6 by RN J. - Tramadol HCI Oral Tablet 50 mg two tablets by mouth every 6 hours as needed for pain. Resident #50 was administered on 08/20/23 at 9:22 PM by LVN R. - There was no documentation of pain level and pain medication administered received for 08/19/23. Review of Resident #50's progress notes for 08/18/23 revealed Resident #50 had notified RN J she had fallen hard on her bottom while trying to get in bed around 2:00 AM. RN J notified NP and x-rays were ordered. Acetaminophen tablet 650 mg (Tylenol) was administered. The nurse followed up later at 11:31 AM on 08/18/23 and pain was unrelieved by Tylenol. RN J notified NP for new pain intervention medication. RN J followed-up again on 08/18/23 in the afternoon and administered another Acetaminophen tablet 650 mg. Follow-up pain level was 1. Review of Resident #50's progress notes for 08/19/23 revealed no documentation of pain medication given or requested. Review of Resident #50's Occupational Therapy notes, dated 08/18/23 (the date of her fall), revealed the resident had informed OT that she had a fall last night (it was 2:00 AM in the morning on 08/18/23) and that she had reported it to staff and nursing. Resident #50 indicated she had gotten herself back into bed by herself. Resident's pain at the time was 8 out of 10 and she did not want to participate in OT. OT notified nursing and would continue to monitor. Review of Resident #50's physician orders, dated 08/18/23, revealed tramadol HCI Oral Tablet 50 mg (Tramadol HCI) was ordered for one tablet by mouth every 6 hours as needed for pain and give two tablets by mouth every 6 hours for pain as needed. Review of Resident #50's progress notes for 08/20/23 revealed tramadol HCI Oral Tablet 50 mg was ordered. Tramadol HCI Oral Tablet 50 mg was given in the morning by RN J. Follow-up revealed Resident #50's pain had decreased to 2. At night, LVN R administered Tramadol HCI Oral Tablet 50 mg. Follow-up pain was 2. Review of Resident #50's Occupational Therapy notes, dated 08/20/23, revealed the resident attended therapy and resident performed shoulder flexion and extension of 10 repetitions of three sets from a seated position. Resident reported a pain level of 5 prior to therapy and a level of 5 after therapy, which indicated no changes to her pain level. Written Statement dated 8/22/23, from ACNO F revealed the ACNO F was not informed by RN J about Resident #50 having a fall nor was she informed that an x-ray was being ordered. ACNO F was informed about Resident #50's fall when the reports were printed for the morning meeting 08/22/2023. She then checked the x-ray lab results and printed them to follow up with a call to the nurse practitioner. ACNO F stated the nurse practitioner was in the building at the time to relay the results to the nurse practitioner. Attempted interview on 8/23/23 at 2:15 PM with LVN R unsuccessful. Attempted to call but didn't get an answer or a call back. Record review of a written statement by LVN R dated and signed 8/22/23 revealed, Friday 8/18/23 at around 1800 (6:00 PM) she endorsed that Resident #50 claims she fell and had pain on her left hip. LVN R contacted the nurse practitioner. Pain medication tramadol was prescribed by the nurse practitioner and faxed to pharmacy. During the shift LVN R stated she followed up with the pain medication with the pharmacy and the provider. LVN R stated no report was given to her that X-rays were done, and the x-rays needed to be followed up on. Review of RN J's email statement, dated 08/22/23, revealed RN J received a report Friday morning (08/18/23) that Resident #50 had slipped and fell . RN J stated Resident #50 denied hitting her head and any other symptoms other than pain on her bottom. RN J assumed LVN R had completed an incident report. RN J checked on the resident and notified the NP for an x-ray to be requested. RN J had checked to see if x-ray results had come in and they had not. RN J passed on the information to look out for the x-ray results to LVN R and that to be expecting results and fax them to the doctor . RN J returned to work on Saturday (08/19/23) and LVN R had informed that she had reviewed the x-ray and it showed no fracture, only osteoarthritis. RN J handed the resident the x-ray results to inform [Resident #50] of the results but when RN J read the results, she had failed to notice there were two separate results on the same page initially. The order for tramadol was received by RN J, however Resident #50 did not request pain medication throughout the shift RJ J worked and stated her leg only hurt when she put weight on it. Interview on 8/23/23 at 10:00AM with the Administrator revealed, we put in every preventable measure for falls, and it depends on what the needs are. If we must use fall mats, we will and take them to the bathroom often. Medication reviews. Making sure things are in reach. We don't get too many people with dementia here, but we do see that was where many of our falls come from. I think the surgery was the case with Resident #50 (a prior surgery had contributed to Resident #50's falls). She was brittle and old. Very pleasant. I think it was one of those cases that she was used to doing things on her own and forgot she needed to use the walker and just wasn't thinking about it. She fell and got back in bed. She was very independent. She didn't think anything of it. The Administrator stated we have guardian rounds and that's one of the things we look for are fall risk. Administrator stated the facility usually does rounds every day sometimes twice a day to make sure staff are doing what they are supposed to do. Interview on 8/23/23 at 2:00 PM with RN J revealed Resident #50 fell Thursday morning 8/18/23 before her morning shift. She came in Friday morning and received a report from LVN R that Resident #50 had gone to the bathroom by herself, without calling for assistance, and fell hard in her room. She got up got herself back in bed and she informed the night staff of what happened some hours later, stating it happened around 2:00 AM. RN J called the nurse practitioner and ordered x-rays and notified the ACNO. RN J stated Resident #50 was more worried about her left knee and it was just a small abrasio n. RN J stated she got orders from the nurse practitioner for tramadol. The x-ray came out sometime later. She stated she failed to review the second results of the x-ray when coming on to night shift but did give the x-ray results to the resident. RN J stated LVN R, the night nurse, told her it was only osteoarthritis. When RN J read the results, she stated she didn't see there were two separate results and only saw the knee results of osteoarthritis. RN J stated she misread the x-ray. RN J stated LVN J told RN J she got an order from the nurse practitioner for tramadol for pain PRN. RN J stated the resident requested pain medication one time the whole three days RN J cared for her . She assumed since it happened on night shift, on LVN R's shift, that she had done an incident report. RN J stated the nurses were supposed to fax the results from the X-ray to the doctor once the nurses on shift receive them, but she wasn't sure that happened since the results didn't come back on her shift. RN J stated she has been trained on what to do when falls occur but thought LVN R had already done the necessary steps that needed to be taken. RN J was suspended upon investigation completion. Interview on 8/23/23 at 2:30 PM with the Administrator revealed the facility was not aware of the incident with Resident #50 until that following Monday on 8/21/23. The facility received a notification that an x-ray was ordered and upon looking at the results found that Resident #50 fractured her hip. They immediately investigated and got statements from both RN J and LVN R. RN J was suspended until further notice. The facility realized RN J received the x-ray results on her shift but didn't read the results correctly. They also stated RN J didn't notify the doctor of the results. The Administrator stated once the nurse gets the results, the nurses were supposed to notify the physician and inform the resident. The administrator stated an incident report wasn't completed and Resident #50 didn't go to the hospital until Monday on 8/21/23 once the ACNO printed of the reports for the morning meeting. Follow-up interview with the Administrator on 8/23/23 at 3:00 PM revealed she had received more information and the x-ray report that came in on LVN R's shift and not RN J's shift. Administrator stated they (the facility) was currently taking RN J off from being suspended but could not get a hold of LVN R. Administrator stated phone calls and voicemails have been made by the DON, but the DON hasn't received a return phone call. Administrator also revealed the fall occurred on LVN R's shift (date and time) and an incident should have been done, as well as, notifying the nurse practitioner. Review of Resident #50's hospital records dated, 08/24/23, revealed Resident #50 was admitted to the hospital on 08/21/23 at 12:11 PM due to left femur fracture. An x-ray was taken on 08/21/23 at the hospital with findings of a compression screw and plate fixation right femoral neck fracture to her hip, which indicated a compression screw and plate fixation already existed for the resident hip. Resident has had a CVA many years ago but made full recovery. Pain was mild and controlled. On 08/22/23 the resident underwent closed reduction and percutaneous screw fixation (minimally invasive surgery by making small incisions to insert screws with the goal to achieve anatomical reduction and stabilization of the fracture) of left femoral neck fracture a day after hospital admission. Resident did well postoperatively, and resident was already working with PT/OT (physical therapy/occupational therapy). Resident to discharge 08/22/23. Record review dated November 2020 of the facility's policy for fall prevention reflected: Use the temporary care plan and communication tool to identify activities or habits that place the resident at risk for falls Keep walkways clear Keep equipment out of the way so they won't create obstacles to others. Be alert for anything that is in the path of traffic which could create walking hazards. Review of the facility's policy Change in Resident Condition, dated November 2018, revealed, .Should there be a change in the resident's physical, mental or emotional status, the attending physician should be notified .if at any time during this process the resident's condition deteriorates or it is determined a medical emergency exists, then send the resident to the hospital via 911 .