Every finding on record at Keller Oaks Healthcare Center

Based on observation, interview and record review the facility failed to ensure the resident has the right to be informed of his or her rights and of all rules and regulations governing resident conduct and responsibilities during his or her stay in the facility for eight (confidential) of eight residents reviewed for resident rights. The facility failed to ensure residents were informed of their rights on an ongoing basis. Specifically, resident council members were uninformed of their resident right of how to contact HHSC to file a complaint and did not know where to find the information This failure could place residents at risk for lack of knowledge of who to contact to file a complaint and being uninformed of their resident rights. Findings included: Record Review of Resident Council Minutes from April to June 2026 revealed no documentation of reviewing any resident rights in resident council meeting. A confidential group interview on 07/15/26 at 1:30 PM with eight residents revealed they did not know how to contact HHSC to file a complaint and were not verbally informed of their resident rights in resident council meetings. They would like to know how to contact HHSC to file a complaint and did not know who to talk to about it. In an interview on 07/16/26 at 11:01 AM at 11:23 AM with the Activity Director revealed she had gone over the resident right to refuse care and showers in a previous resident council meeting. She stated she had been working at the facility for 13 years. She had not gone over the resident right to contact HHSC for complaints and how to contact them with the residents in resident council. She stated in the June 2026 resident council meeting, she did not review any resident rights. She stated she was not aware she should be reviewing resident rights to the residents during resident council meetings. She stated it was important to review resident rights to the residents so they are informed of their rights. She stated in the next resident council meeting, she would print off the resident rights and review them with the residents. Record review on 07/16/26 at 11:23 AM with Activity Director of the October 2025 resident council minutes revealed she reviewed the resident right to refuse care in the resident council meeting, and it was documented. Observation on 07/16/26 at 11:52 AM of hallway leading to dining room revealed there was no HHSC required posting of complaint number to contact in an accessible area. There was a small posting of Adult Protective Services abuse, neglect and financial exploitation [PHONE NUMBER]. An interview with the Administrator on 07/16/26 at 12:10 PM and 1:29 PM revealed she would have to reach out to get the required HHSC posting for complaints. She stated they had the HHSC contact number for complaints, but was not sure about the specific HHSC posting she needed to have posted. She stated they would be changing their process to ensure residents were informed of their resident rights in resident council meetings going forward. Review of Resident Rights policy dated 10/04/16 reflected Information and Communication. You have the right to: be informed of your rights and of all rules and regulations governing resident conduct and responsibilities during your stay in the facility. have access to the names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit.

Based on observation, interview, and record review, the facility failed to post, in a form and manner accessible and understandable to residents, resident representatives: (i) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency and (ii) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, and non-compliance with the advanced directives requirements (42 CFR part 489 subpart I) and requests for information regarding returning to the community reviewed for resident rights. The facility failed to ensure the HHSC's required posting of complaint procedures and phone number was in an accessible place. This failure could place residents at risk of not knowing how to contact HHSC to file a complaint, and abuse, neglect, or exploitation, and feeling voiceless. Findings include: A confidential group interview on 07/15/26 at 1:30 PM with eight residents revealed they did not know how to contact HHSC to file a complaint and were not verbally informed of their resident rights in resident council meetings. They would like to know how to contact HHSC to file a complaint and did not know who to talk to about it. Interview on 07/16/26 at 11:01 AM with Activity Director revealed she had not gone over the resident right to contact HHSC for complaints and how to contact them with the residents in resident council. Observation on 07/16/26 at 11:52 AM of hallway leading to dining room revealed there was no HHSC required posting of complaint number to contact in an accessible area. There was a small posting of Adult Protective Services abuse, neglect and financial exploitation [PHONE NUMBER]. Interview with Administrator on 07/16/26 at 12:10 PM and 1:29 PM revealed she would have to reach out to get the required HHSC posting for complaints. She stated they had the HHSC contact number for complaints but was not sure about the specific HHSC posting she needed to have posted. She stated they would be changing their process to ensure residents are informed of their resident rights in resident council meetings going forward. Review of Resident Rights policy dated 10/04/16 reflected Information and Communication. You have the right to: be informed of your rights and of all rules and regulations governing resident conduct and responsibilities during your stay in the facility. have access to the names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit.

Based on interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 (Medication Cart #5) of 5 carts reviewed for pharmacy services. The facility failed to ensure MA B, LVN C, and LVN D were responsible for Medication Cart #5, counted controlled drugs every shift change. This failure could place residents at risk of not having the medication available due to possible drug diversion.Findings included: Record review and observation on 07/15/26 at 09:23 AM of the narcotic count sheet located in the medication cart #5, with MA B revealed missing signatures for:7/1/26 - Nurse on duty 6a-6p shift7/12/26 - Nurse off duty 6a-7p shift and nurse on duty 6p-6a shift7/13/26 - Nurse off duty 6p-6a shift In an interview on 07/15/2026 at 11:09 AM, LVN C stated she should have signed the narcotic sheet after counting the narcotics on 7/13/26 at the beginning and at the end of the shift. She stated she got busy and did not go back to sign the count sheet. She stated she knew she was supposed to sing immediately after the count was done. She stated the risk would be potential for drug diversion. In an interview on 07/15/26 at 11:18 AM, MA B stated she should have signed the narcotic sheet after counting the narcotics on 7/1/26 at the beginning and at the end of the shift. MA B stated, she counted with the other nurse, but she did not remember why she did not sign the count sheet. MA B stated this failure could potentially cause a drug diversion. In an interview on 07/16/2026 at 10:19 AM, LVN D stated she should have signed the narcotic sheet after counting the narcotics on 7/12/26 at the beginning and at the end of the shift. She stated she forgot to sign the count sheet. She stated she knew that she was supposed to sing immediately after the count was done. She stated the risk would be potential for drug diversion. In an interview on 07/16/26 at 11:10 AM, the DON stated she expected nurses to sign the narcotic count sheet at the beginning, and at the end of their shift after they completed the counts with the incoming and off-going nurse. The DON stated if the staff was not signing the narcotic count sheets, she was unable to prove they were counting. The DON stated it was important to ensure a drug diversion did not occur. The DON stated the ADONs would check the carts daily Review of the facility's policy Pharmacy Services - Narcotic Count revised November 2007, reflected the following: . One RN or one LVN or one CMA going off duty and one RN or one LVN or CMA coming on duty must count and justify narcotics supply for each individual resident at the change of each shift .After the supply is counted and justified, each nurse must record the date and his/her signature verifying that the count is correct .

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's only kitchen in that:1.The facility's dietary staff failed to ensure temperatures were taken of all hot foods before serving them to residents during lunch meal service on 7/14/26.2.The facility's dietary staff failed to practice appropriate hand hygiene and glove changes during lunch services on 7/14/26.3.The facility's dietary staff failed to ensure seasonings used for food preparation were not expired, and tomatoes were not molded on 7/14/26. 4.The facility's dietary staff failed to appropriately date and label food items in the walk-in refrigerator and freezer on 7/14/26. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed and food contamination.Findings included:An observation and interview with the Dietary Manager in the walk-in refrigerator on 7/14/26 at 9:52 a.m. revealed a metal baking sheet with what the Dietary Manager stated was a cake on the shelf with no cover, label or date. The Dietary Manager stated the cake had just been baked and was going to be served that day. However, it should have been covered, dated and labeled. Observed a 44 oz Styrofoam cup with a red and white gas station logo on it, with a straw and lid that appeared to be a personal drink with no identifying information of the liquid in the cup. The Dietary Manager grabbed the cup, and took it out of the refrigerator to discard it. She stated it should not have been there. Observed a tray of 4 loaves of what appeared to be white bread with no date or label of what they were. The Dietary Manager stated they were loaves of white bread and stated the tray they were on should have had a label and date received on but it must have fallen off. Observed a clear plastic bag with 7 tan square like food items the Dietary Manager stated were wheat bread with no label of contents, date received, or date of opening. Observed an opened bag of shredded cheddar cheese with the original label inside a sealed plastic bag with no date opened. The Dietary Manager stated the sealed bag should have been labeled with the date opened. Observed a box that contained 13 tomatoes and 2 potatoes, 5 of the 13 tomatoes had black and white mold on them. The Dietary Manager immediately grabbed the box and discarded it in the trash. An observation and interview with Dietary Manager of the walk-in freezer on 7/14/26 at 10:01 a.m. revealed an opened 10 lb box of fully cooked Flame broiled Rib Shaped Pork Patties with a manufacturer opened plastic bag almost full of patties that was not securely closed and opened to the air. The bag or box of patties did not have an date opened on it. Observed a round yellowish circular object that was about 8 inches with a 1-inch circular whole in the middle that the Dietary Manager identified as Angel food cake with no label of what the item was. A second Angel Food Cake with a two-inch triangular piece missing with no date opened or label of what the item was. Observed half of a banana cream pie in the original packaging with an aluminum bottom and plastic top wrapped in plastic wrap with no date opened. The Dietary Manager stated all food should have been labeled with a received date and a date opened if they were opened. An observation and interview of the dry storage area with the Dietary Manager on 7/14/26 at 10:09 a.m. revealed about 1/8 of a gallon sized light corn syrup with an date opened of 11/21/23. The Dietary Manager stated she did not know the shelf life for the corn syrup, and there was no expiration date on it. The Dietary Manager stated she would call her distributor to find out the shelf life of corn syrup. At 11:15 a.m., the Dietary Manager stated per the food distributer the cornstarch had a shelf life of a year, and she stated she had discarded the corn syrup already. An observation of [NAME] F on 7/14/26 at 11:20 a.m. revealed she wiped the serving area in front of the heating table with a dry paper towel without any cleaning agent and she had gloves on. [NAME] F, with the gloves on, grabbed the thermometer and alcohol pads in preparation of temping the food. [NAME] F proceeded to take the temperature of the foods that were being held on the warming table with the same gloves on. [NAME] F failed to sanitized the thermometer for 4 out of 10 food items she temped. [NAME] F wiped the thermometer with a soiled paper towel after temping the enchilada sauce, the hamburger patties, the green beans and the zucchini. [NAME] F continued with the same gloves and went to the dish sink grabbed a wet towel and She wiped the counter in front of the warming table, she then grabbed some clean serving utensils with the same gloves on. At 11:27 a.m. [NAME] F removed the gloves and threw them in the trash, without washing her hands, she grabbed more serving utensils, put them in the foods on the warming table, and then went to the sink, washed her hands, grabbed new gloves and put them on. An observation of Dietary Aide G during lunch service on 11/14/26 at 11:30 a.m. revealed she was assisting with tray preparation and put her gloves on and had not washed her hands prior to putting the gloves on. Dietary Aide G resident food trays and plates with food on them. At 11:38 am, Dietary Aide G grabbed fries from the frying basket with the same gloves and served them on a plate. Dietary Aide G also grabbed some chicken strips with her from the covered metal pan sitting on the stove with her gloved hands and had not temped the chicken strips. An observation of Dietary Aide H on 7/14/26 at 11:32 a.m. revealed he put frozen fries that he grabbed from the freezer with his gloves and put them in the frying basket to fry. Dietary Aide H, while wearing the same gloves he went to the walk-in refrigerator and returned with sliced cheese that he placed on the stove. Dietary Aide H then picked up the basket of fried from the fryer and let them sit while he went around to the back of the kitchen to get something else with his gloves on. Dietary Aide H returned with the same gloves on, and grabbed the fries with his hands, put them on a plate and did not temp the fries. Dietary Aide H with his gloved hands grabbed some chicken strips that were sitting on the stove in a metal pan covered, and put some on the plate with the fries. Dietary Aide H had not temped the chicken prior to serving them. An interview with the Dietary Manager on 07/14/2026 at 2:51 p.m. revealed her expectation was staff should have temped all foods per the facility policy. The Dietary Manager stated the chicken strips and French fries should have been temped before serving. The Dietary Manager stated staff should change gloves whenever they change tasks or leave the serving area. The Dietary Manager stated the staff were supposed to wash their hands between the changing of their gloves. The Dietary Manager stated when the dietary staff temp food they were supposed to sterilize the thermometer between each food. The Dietary Manager stated paper towels were not an appropriate method for sanitizing the thermometer of any surfaces. The Dietary Manager stated the risk to the resident of not having temped all foods was they could have gotten sick or food poisoning. The Dietary Manager stated the risk to the residents of improper hand hygiene and inappropriate sanitizing of the food thermometer was cross contamination. The Dietary Manager stated the lack of labeling and dates on foods in the freezer and refrigerator could have caused the residents to be served food that was bad or outdated. The Dietary Manager stated if expired or bad food was served to residents it could have caused them to get sick. The Dietary Manager stated food not properly sealed, in the refrigerator or freezer, could have caused the food to go bad due to condensation or freezer burn. Surveyor requested to interview [NAME] F An interview with [NAME] F on 07/15/2026 at 9:08 a.m. revealed she should have changed when she changed stations or left the serving area. [NAME] F stated the expectation was hand must have been washed prior to changing gloves. [NAME] F stated she was very nervous and believed she may have forgotten to change her gloves and wash her hands during lunch service on 7/14/26. [NAME] F stated she typically changed gloves during food service at least 5 times and always washed her hands between glove changes. [NAME] F stated the risk to the residents of not having washed her hands between glove changes was cross contamination. [NAME] F stated when she temped food, she used a glass of water, rinsed the thermometer in the glass, and used alcohol pads to sanitize the thermometer after temping each food item. [NAME] F stated she did not recall wiping the thermometer on a paper towel while she temped the food however, it would be incorrect if she had wiped the thermometer on a paper towel in between food temps. [NAME] F stated the risk to the resident of not having sanitized the thermometer between food temps was they could have been exposed to something they were allergic to or cross contamination. [NAME] F stated she had taken the temperature of the chicken strips when she cooked them, prior to surveyor's observation. [NAME] F was unable to provide proof she had temped the chicken strips. [NAME] F stated the chicken strips should have been temped before serving. [NAME] F stated she had not made the french fries and therefore had not temped them. [NAME] F stated it was the responsibility of Dietary Aide H to temp the fries before he served them. [NAME] F stated the risk to the resident of not having taken the temperature of the chicken strips and fries was it could have made residents sick or could have diminished the food quality. An interview with Dietary Aide G on 07/15/2026 9:43 AM revealed she typically washed her hands 8 to 9 times during lunch service. Dietary Aide G was unable to recall washing her hands during lunch service on 7/14/26. Dietary Aide G stated when gloves were taken off the expectation was to wash hands prior to putting new gloves on. Dietary Aide G stated every time new food was touched, gloves should have been removed, hands should have been and a new set of gloves should have been put on. Dietary Aide G stated the risk to the residents of not washing hands, between glove changes, was cross contamination and food borne illness. Dietary Aide G stated she should have changed her gloves, washed her hands, and then got the fries out of the fryer during lunch service on 7/14/26. Dietary Aide G stated the cook usually temped all food prior to her serving it. Dietary Aide G stated the chicken strips and french fries should have been temped prior to serving. Dietary Aide G stated the risk to the residents of not having temped the food was it could not have been thoroughly cooked or exposure to food borne illnesses. An interview with Dietary Aide H on 07/15/2026 at 9:53 a.m. revealed gloves should have been changed between any tasks or when leaving the serving area. Dietary Aide H stated when dirty gloves were taken off, he would throw them away, wash his hands, and put new gloves on. Dietary Aide H stated he had not washed his hands during lunch service on 7/14/26. Dietary Aide H stated the risk to the residents of not washing his hands and changing gloves was cross contamination, passing germs and allergens to residents. Dietary Aide H stated the main cook was responsible for temping the food. Dietary Aide H stated he did not temp the chicken strips or fries on 7/14/26, and he should have temped the fries, but the cook should have temped the chicken strips. Dietary Aide H stated the risk to the residents of not temping the fries was they could be served undercooked fries, and they could have made them sick. An interview with the Administrator on 07/16/2026 at 1:25 p.m. revealed dietary staff should follow their policies, and temp all foods served to residents. The Administrator stated the expectation was kitchen staff should wash hands based on the facility policy. The Administrator would not elaborate on the expectations for dietary staff regarding temping food and glove-use, and hand washing. The Administrator stated all items in the freezer, the refrigerator, and the dry goods should have been labeled and dated. The Administrator stated they already started in-servicing dietary staff on cross contamination and handwashing. The Administrator stated bad or expired food should not have been served to residents, as it could make them sick. The Administrator stated the risk to the residents of improper handwashing, and not temping all foods would have been foodborne illness or cross contamination. Review of the facility's policy Infection Control Policy/Procedure for dietary staff revised 2/5/25 reflected It is the policy of this facility to prevent contamination of food products and therefore prevent foodborne illness. PROCEDURES:1. DIRECTOR OF FOOD SERVICE RESPONSIBILITIES Provide safe food services for residents and employees. Provide for the proper receipt and storage of all food supplies.Personal Hygiene.Wash hands carefully with soap and water whenever they become soiled, immediately before work in the morning, after using the bathroom, after coughing, sneezing, or blowing the nose, after touching the hair, mouth, or cigarettes, after handling raw unwashed food and dirty dishes; before touching food, clean dishes and silverware .Food Storage. Upon arrival, all food will be inspected for damage, rodent or insect infestation and spoilage.Proper Food Handling. All meats, stuffings and poultry meat are to be heated throughout to a minimum temperature of 165 F; pork 180 F. Served at 135 degrees. Vegetables, Fruits and legumes 135 degrees. Dressing should be baked in separate pans. Foods reheated should be served at 135 degrees Fahrenheit.Leftovers must be dated, labeled, covered, cooled and stored (within 1/2 hour) in a refrigerator, not at room temperature. Fingers are to be kept out of food. Foods that have stood for several hours at room temperature cannot be considered safe and free from contamination and cannot be made so by refrigeration, especially during the summer season. They must be discarded .Review of the Food and Drug Administration Food Code, dated 2022, reflected, . S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: . (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; . (H) Before donning gloves to initiate a task that involves working with FOOD; P and (I) After engaging in other activities that contaminate the hands 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under . 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety .6-404.11 Segregation and Location. Products which are damaged, spoiled, or otherwise unfit for sale or use in a food establishment may become mistaken for safe and wholesome products and/or cause contamination of other foods, equipment, utensils, linens, or single-service or single-use articles. To preclude this, separate and segregated areas must be designated for storing unsalable goods.

Based on observation, interview, and record review, the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #17) of 8 residents reviewed for quality of life. The facility failed to ensure Resident #17 had his fingernails cleaned and trimmed on 07/14/26. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.Findings included:Record review of Resident #17's Quarterly MDS assessment dated [DATE] reflected Resident #17 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses included dementia (a decline in mental ability, reasoning, and communication, severe enough to interfere with daily life) and need for assistance with personal care. Resident #17's BIMS score of 00, indicated Resident #17's cognition was severely impaired. The MDS assessment indicated Resident #17 dependent on staff for personal hygiene. Record review of Resident #17's Care Plan dated 04/23/25, reflected the following: Focus: [Resident #17] had ADL self-care performance deficit. Interventions: . Requires total assist . with personal hygiene and oral cadre (sic). An observation on 07/14/26 at 11:10 AM revealed Resident #17 was lying in his bed. The nails on both hands were discolored, tan and had yellow greenish colored residue underside and on the nails' bed. Resident #17 was confused and his answers were not pertinent to the subject. In an interview on 07/14/26 at 11:38 AM, CNA A stated CNAs and nurses were responsible for cleaning and cutting the residents' nails. CNA A stated she did not notice Resident #17's nails. She stated she would do it right then. She stated the risk would be infection. In an interview on 07/16/26 at 11:10 AM, the DON stated nail care should be completed as needed and every time aides washed the residents' hands. The DON stated nails should be observed daily. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON stated she expected CNAs to offer to cut and clean nails if they were long and dirty. The DON stated the ADON and the DON would do the routine rounds to monitor. The DON stated residents having dirty nails could be an infection control issue. Record review of the facility's policy Nails, Care of revised January 2022, reflected the following: .The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis .Gently clean underneath nails .

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for 1 of 6 residents (Resident #17) reviewed for supervision. The facility failed to ensure Resident #17, who required total assist of 2 staff participation to reposition and turn in bed, was not turned in bed, during incontinent care, by 1 staff. This failure could place residents at risk of accidents, falls, pain, and injury. Findings included: Record review of Resident #17's quarterly MDS assessment dated [DATE] reflected an [AGE] year-old male admitted to the facility initially on 02/07/23 and readmitted on [DATE]. The resident's diagnoses included hypertension (elevated blood pressure), obstructive uropathy (a blockage in the urinary tract that prevents urine from flowing freely), Alzheimer's disease (a progressive, irreversible brain disorder), Non-Alzheimer's dementia (brain disorders that cause cognitive decline but have distinct causes and symptoms), and cancer (a broad group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body). Resident#17 BIMS score was 00/15 indicating severe cognitive impaired. Record review of section GG functional abilities: Roll left and right: substantial/maximal assistance-helper does more than half the effort, helper lift or holds trunk or limbs and provides more than half the effort. Record review of Resident #17's Comprehensive Care Plan updated 07/09/26 reflected Focus: I have ADL self-care performance deficit related to reduced mobility, Alzheimer's, dementia. Focus: Will maintain current level of function in bed mobility, transfers. through the review date. Interventions: bed mobility requires total assist x two staff participation to reposition and turn in bed. Observation on 07/15/26 at 10:17 AM, revealed Resident #17 was getting incontinent care with CNA E in attendance. CNA E was wearing a gown and gloves. Resident#17 was uncovered, turned to his right side. CNA E was holding a folded dirty brief disposed of it in the trash. CNA E changed gloves with hands hygiene, put a clean brief on Resident #17 and finished the incontinent care. CNA E removed gloves, gown, gathered the trash bag, washed hands, and exited the room. In an interview on 07/15/26 at 10:27 AM, CNA E stated that he did not know Resident #17 was a 2-person assist for bed mobility. CNA E stated he normally worked in the memory unit and that his first time taking care of Resident #17. CNA E stated if a resident was new to him, he would ask the nurse if the new resident was a 1- or 2- . CNA E stated he did not know if he had any in-servicing on 1- or 2- person assists, or how to look up the information related to residents' care in the POC/Kardex. CNA E stated if a resident who required a 2-person assist was helped by only 1 person, the resident could fall and sustain injury. In an interview on 07/16/26 at 10:56 PM, the DON stated the charge nurse, and all licensed nurses were responsible for supervising CNAs. She said the CNAs are in-serviced at least monthly on 1- or 2-person assists. The DON stated the Kardex should be checked when providing care. She stated the nurses are notified of changes in residents' condition, and the nurses notified the CNAs. She said if a resident, who was a 2-person assist, had only 1-person assist, the resident could fall or get injured. Record review of the facility's policy Titled Policy/Procedure-Nursing administration. Care and treatment- Subject: Accident intervention dated 05/2025, revealed It is the policy of this facility that the resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent accidents. Follow up - assess resident during each shift - at least once. Document findings for seventy-two (72) hours. 2. Report - 24 Hour Report. Pass information on in shift report.

Based on observation, interview, and record review, the facility failed to ensure residents who are incontinent of bladder receive appropriate treatment and services to prevent urinary tract infections for 1 (Resident #17) of 6 residents reviewed for urinary catheters. CNA D placed Resident #17's Foley catheter (a tube that carries urine from the bladder to the outside of the body and held in place by a balloon inflated inside of the bladder) drainage bag on the bed during repositioning in the bed. This failure placed residents at risk for urinary tract infection, unwanted antibiotic therapy, and decrease in quality of life. Findings included: Record review of Resident #17's quarterly MDS assessment dated [DATE] reflected an [AGE] year-old male admitted to the facility initially on 02/07/23 and readmitted on [DATE]. The resident's diagnoses included hypertension (elevated blood pressure), obstructive uropathy (a blockage in the urinary tract that prevents urine from flowing freely), Alzheimer's disease (a progressive, irreversible brain disorder), Non-Alzheimer's dementia (brain disorders that cause cognitive decline but have distinct causes and symptoms), and cancer (a broad group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body). Resident #17's BIMS score was 00 out of 15 indicating severe cognitive impairment. Record review of section H-Bladder/Bowel reflected the resident had an indwelling Foley catheter. Record review of Resident #17's Comprehensive Care Plan updated 07/09/26 reflected Focus: I have an indwelling catheter related to a diagnosis of obstructive and reflux uropathy. Goal: will show no signs and symptoms of urinary infection through review date. Intervention: Catheter: position catheter bag and tubing bellow the level of the bladder. Observation on 07/15/26 at 10:17 AM revealed CNA J was in the process of getting Resident#17 ready for a mechanical lift transfer from the bed to wheelchair. During the process of putting the Mechanical lift sling under Resident#17, CNA J put the foley catheter drainage bag on the bed above Resident#17 bladder level. There was cloudy urine in the tubing visibly going back toward Resident #17's bladder. In an interview on 07/15/26 at 10:27 AM, CNA D stated he had received an in-service on Foley catheter care. CNA D stated he should not have placed the resident's Foley catheter drainage bag on the bed, during care and repositioning, due to the risk of urine flowing back in the resident's bladder, placing the resident at risk for urinary tract infections. In an interview on 07/16/26 at 10:56 AM, the DON, who was the facility's Infection Control Preventionist, stated when the staff provided Foley catheter care and resident positioning in bed, the Foley catheter drainage bag should not be placed on the resident's bed, but hung below the resident's bladder on the side of the bed to prevent the back flow of urine in the resident's bladder and the development of urinary tract infection. Record review of the facility's policy Titled Infection control policy/procedure. Quality of care. Subject: Indwelling Urinary Catheters dated September 2025, revealed It is the policy of this facility that each resident with an indwelling catheter will receive catheter care to promote hygiene, comfort and decrease the risk of infection.7. The drainage bag will be kept below the level of the bladder to promote drainage.

Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of four residents (Resident #1) reviewed for catheter and incontinence care. The facility failed to ensure staff provided Resident #1 timely perineal care after an incontinent episode when they failed to check and change the resident from 06:00 a.m. to 9:35 a.m. on 06/18/26. This failure could place residents at risk for not receiving appropriate care to address their incontinence and could increase the risk of urinary tract infections.Findings included: Record Review of Resident #1's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female with an admission date of 11/05/25. She had a BIMS score of 7 which indicated she was severely cognitively impaired. She was always incontinent of bowel and bladder and was dependent for toileting assistance. Her diagnoses included chronic obstructive pulmonary disease (lung disease causing obstructive air flow) and diabetes. Record review of Resident #1's care plan with a revision date of 12/05/25 reflected, Has bowel/bladder incontinence related to overactive bladder.Goal-Will remain free from skin breakdown due to incontinence.Interventions-Incontinent: Check as required for incontinence. Wash, rinse and dry perineum. During an interview and observation with Resident #1 on 06/18/2026 at 09:35 a.m. Resident #1, was observed in her room lying in bed. CNA B entered the room and told Resident #1 she was here to provide her with incontinent care. Resident #1 was asked if she consented to the surveyor observing the care and she stated, yes, CNA B then performed hand hygiene and put on gloves and assisted Resident #1 onto her back. CNA B uncovered the resident revealing she had soaked through her brief onto the bed pad. The edges of the urine stain were light brown and had begun to dry. CNA B unfastened the resident's brief revealing her brief was saturated with urine. CNA B wiped from front to back down each groin and then down the middle and assisted the resident onto her side, removed the soiled brief and wiped the resident's buttocks area from front to back. There was no skin breakdown or redness noted. CNA B then placed the clean brief and a clean bed pad under the resident. CNA B then fastened the brief and repositioned the resident. During an interview with CNA B on 06/18/26 at 9:45 p.m. she stated this was the first time she had changed Resident #1 since coming on duty at 06:00 a.m. today (06/18/26). She stated she thought the night shift aide had changed her close to 06:00 a.m. but stated she was not sure since she was so wet. She stated they were expected to check and change any incontinent resident every 2 hours and change them as needed. She stated the risk of not changing them timely was a risk of urinary tract infections and skin problems. During an interview with the DON on 06/18/26 at 11:30 a.m. she stated any resident who was incontinent of bowel and bladder needed to be checked for incontinence every 2 hours and changed as needed. She stated by not providing timely incontinent care it placed residents at risk for urinary tract infections, skin breakdown and overall poor hygiene. She stated they were going to have to increase their monitoring to ensure residents were getting changed timely. During an interview with Resident #1 on 06/18/26 at 3:08 p.m. she stated she could not remember what time she was changed on the night shift. She stated she rarely soaks through her brief. She stated the staff were usually good about changing her timely. During an Interview with Administrator on 06/18/26 at 3:10 p.m. she stated they had recently increased their staffing and had been doing additional training on activities of daily living care and infection control. She stated they had added additional observations and tasks to be done during their Angel rounds with an emphasis on resident hygiene and quality of life. She stated they were going to start doing more one on one observations with the staff, instead of just classroom education. She stated the expectation was all the residents' hygiene needs were provided timely to prompt dignity and comfort. Record review of the facility's policy titled, Perineal Care, revised May 2025, reflected, It is the policy of this facility to: Cleanse the perineum, Eliminate odor, Prevent irritation or infection, Enhance resident's self-esteem.

Based on observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 Residents (Resident #1 and Resident #2) observed for infection control. 1. The facility failed to ensure CNA B performed hand hygiene during incontinent care on Resident #1 on 06/18/26. 2.The facility failed to ensure CNA B utilized Enhanced Barrier Precautions and performed hand hygiene during incontinent care Resident #2 on 06/18/26. These failures could place the residents at risk of cross-contamination and development of infection.Findings included: 1. Record Review of Resident #1's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female with an admission date of 11/05/25. She had a BIMS score of 7 which indicated she was severely cognitively impaired. She was always incontinent of bowel and bladder and was dependent for toileting assistance. Her diagnoses included chronic obstructive pulmonary disease (lung disease causing obstructive air flow) and diabetes. During an interview and observation with Resident #1 on 06/18/2026 at 09:35 a.m. Resident #1, was observed in her room lying in bed. CNA B entered the room and told Resident #1 she was there to provide her with incontinent care. Resident #1 was asked if she consented to the surveyor observing the care and she stated, yes, CNA B then performed hand hygiene and put on gloves and assisted Resident #1 onto her back. CNA B unfastened the resident's brief revealing her brief was saturated with urine with had soaked through to the bed pad. CNA B wiped from front to back down each groin and then down the middle and assisted the resident onto her side, removed the soiled brief and wiped the resident's buttocks area from front to back. CNA B then changed her gloves but did not perform hand hygiene and placed the clean brief under the resident. CNA B then fastened the brief, repositioned the resident and removed her gloves and then performed hand hygiene. During an interview with CNA B on 06/18/26 at 9:45 p.m. she stated she was supposed to do hand hygiene before and after incontinent care but then stated she should have done it after she finished cleaning the resident and changed her gloves. She stated the risk of not doing hand hygiene was the spread of germs and infection. 2. Record Review of Resident #2's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old male with an admission date of 11/29/25. He had a BIMS score of 12 which indicated he was moderately cognitively impaired. He was occasionally incontinent of bowel and bladder and was dependent for toileting assistance. His diagnoses included chronic obstructive pulmonary disease (lung disease causing obstructive air flow) cerebral vascular accident (stroke), dementia and venous ulcers (slow healing open wounds caused by damaged vein valves). During an observation and interview on 06/18/26 at 09:50 a.m. with Resident #2 revealed an Enhanced Barrier sign posted outside of Resident #2's room which indicated he was on Enhanced Barrier precautions for high contact care. Resident #2 was observed lying in bed. He had a gauze wrap around the lower portion of his right leg and a large fluid filled blister on his left leg. Resident stated he had dealt with the wounds on his legs for long time. He stated the blisters would pop up and once they popped they would drain until they closed up. He stated this was a chronic condition. He stated he also had areas on the back of both of thighs the facility had been treating and they were improving. He stated he took fluid pills and was a heavy wetter right after breakfast and after he took his medications. During an observation on 06/18/26 at 9:55 a.m. revealed CNA B entered Resident #2's room to perform incontinence care and get him up for the day. CNA B performed hand hygiene and put on gloves but no gown. CNA B unfastened the resident's brief and provided peri care, changing the wipes with each wipe. Resident rolled onto his side and CNA B wiped from the front to back, cleaning the resident's buttocks and upper thighs. There was a dressing in place on both the resident's upper thighs. CNA B then changed her gloves without performing hand hygiene and picked up the clean brief. She then stated, I forgot to wash my hands, and removed her gloves and performed hand hygiene. CNA B then placed the brief on the resident and fastened the brief. CNA B then pumped lotion onto her gloved hands and rubbed lotion on the resident's lower legs, around the dressing on his right leg and around the blister on his left lower leg. CNA B then removed her gloves and put on clean gloves without performing hand hygiene and dressed the resident and assisted him into his wheelchair. CNA B then removed her gloves and performed hand hygiene. During an interview on 06/18/26 at 10:00 a.m. with CNA B she stated she remembered she was supposed to perform hand hygiene after she had cleaned the resident but stated she did not realize she had not performed hand hygiene after she put on the lotion and changed her gloves. She then realized she had forgotten to wear a gown during Resident #2's care. She stated she had received training on enhanced barrier precautions and stated any resident who had a wound required enhanced barrier precautions. She stated the risk was the spread of infection and acknowledged she should have had a gown on during Resident #2's care since it was considered high contact care. During an interview with the DON on 06/18/26 at 11:25 a.m. she stated staff were to change their gloves and perform hand hygiene before going from dirty to clean, before entering a resident's room and before leaving a resident's room. She stated all residents who were on Enhanced Barrier Precautions had signs posted on their doors and the staff were expected to follow those protocols. She stated they train and do in-services constantly on infection control. She stated the sign clearly tells the staff what is considered high contact care if they don't remember. She stated she was really disappointed since they had done so much training. She stated she would be doing skills checks and re-education with the staff on overall infection control. Record review of the facility's policy titled, IPCP Standard and Transmission-Based Precautions, revised October 2022, reflected, .It is the policy of this facility to implement infection control measure to prevent the spread of communicable disease and conditions. Enhanced Barrier Precautions (EBP) expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDRO's to staff hands and clothing then indirectly transferred to residents or from resident-to- resident. (e.g., residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs) .Examples of high-contact resident care activities requiring gown and glove use.transferring.changing briefs. Record review of the facility's policy titled, Hand Washing , revised July 2025, reflected, It is the policy of this facility to cleanse hands to prevent transmission of possible infectious material and to provide clean, healthy environment for resident's and staff. Hand washing/hand hygiene is generally considered the most important single procedure for preventing nosocomial infections.Some situations require hand washing in areas where sinks are not readily available. In these circumstance, waterless hand-washing products may be used.

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident#1) of 4 residents reviewed for ADLs. The facility failed to ensure Resident#1 had her fingernail cleaned and trimmed on 05/19/26.This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. A record review of Resident #1's quarter MDS assessment dated [DATE] reflected Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis of: Muscle Weakness (Generalized) and Need For Assistance With Personal Care. The review further reflected the resident was dependent with ADL's (activity of daily living). A record review of Resident #1's Comprehensive Care Plan dated 05/08/26 reflected Focus: I have a potential ADL Self Care Performance Deficit r/t impaired thought process. Goal: Will safely perform.Personal Hygiene with limited assistance x1 person through the review date. Interventions: Encourage to discuss feelings about self-care deficit. An observation and interview on 05/19/26 at 09:50 AM revealed Resident #1 was up in wheelchair in the TV area. Resident#1 both hands were severely contracted with supportive devices (Contracted hands sponge pads). Resident#1 had a long fingernail approximately 0.6 cm on both hands, with a brown matter underneath the left-hand thump. Resident#1 was asked if she want her fingernail trimmed and cleaned, she nodded with her head yes gesture with a smile. In an observation and interview on 05/19/26 at 09:55 AM CNA A physically assessed Resident#1's fingernails and stated needed trimming and the left thump needed to be cleaning due to brown matter underneath. CNA A stated that nail care for the resident was performed by CNAs on shower days and it was the responsibility of the nurses and CNAs to ensure resident's nails kept clean and trimmed to prevent infection, and skin injury through scratching. CNA A stated the risk to Resident#1 could be infection development, skin integrity, and dignity issue. An interview on 05/19/26 10:25 AM RN B stated CNAs and Nurses were responsible for nail care. He stated nail care should be performed for all residents on their shower schedule days, and as needed. He stated the risk of not cutting and cleaning nails was lapses in infection control and loss of quality of life. Interview and observation on 05/19/26 at 1:22 PM the DON stated, she expected resident nails care to be provided during the shower days, and if the resident is diabetic the nurses had to trim the nails. The DON stated that residents was at risk of infection development and skin break down if she scratched herself. Record review of facility's undated policy titled, Policy/Procedure, section: [Quality of care] subject: [ADL, Services to carry out] revealed It is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities.Residents who are unable to carry out activities of daily living (ADL) will receive necessary services to maintain: Grooming. Personal hygiene .

Based on observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 Residents (Resident #1, Resident #2, Resident #3) observed for infection control. 1.The facility failed to ensure PTA B, CNA C and RN A utilized enhanced barrier precautions during incontinent care and gait belt transfer on Resident #1 on 03/31/26. 2. The facility failed to ensure CNA C performed hand hygiene during incontinent care on Resident #2 on 03/31/26. 3. The facility failed to ensure CNA D performed glove changes and hand hygiene during incontinent care on Resident #3 and Staffing Coordinator failed to prevent cross contamination of Resident #3 oxygen cannula, and CNA D and Staffing Coordinator to perform hand hygiene after incontinent care before leaving Resident #3's room on 03/31/26. These failures could place the residents at risk of cross-contamination and development of infection.Findings included: 1. Record Review of Resident #1's Face Sheet dated 03/31/26 reflected a [AGE] year-old female with an admission date of 01/22/25. Her diagnoses included pressure ulcer of sacral (buttocks) region, cereberal infarction (stroke), dysphagia (difficulty swallowing) and gastrostomy status (artificial opening into the abdomen for a feeding tube). During an observation on 03/31/26 at 10:35 a.m. with Resident #1 in her room, the resident was observed on a low air loss mattress. Resident #1 was observed to have a G-tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach) and a PICC (a line inserted into an arm vein threaded to a large vein near the heart) line in her upper left arm. The resident was non-verbal but smiled in response to questions. There was an enhanced barrier precautions sign posted outside of Resident #1's room which indicated she was in enhanced barrier precautions for high contact care. During an observation on 02/21/2026 at 1:25 p.m. revealed PTA B and CNA C completing incontinent care on Resident #1 and preparing the resident to get up for physical therapy. PTA B and CNA C had on gloves but no gown. RN A entered the room, performed hand hygiene and put on gloves but no gown and disconnected the feeding tube from the resident so PTA B could transfer Resident #1 to her wheelchair. PTA B, with assistance of CNA C, sat the resident on the side of the bed and PTA B placed a gait belt around the resident and performed a one-person gait belt transfer from her bed to the wheelchair. During an interview on 03/31/26 at 1:40 p.m. with RN A, PTA B and CNA C, they all stated they had received training on enhanced barrier precautions and stated any resident who had a wound, g-tube or any other medically inserted device required enhanced barrier precautions. They all stated the risk was the spread of drug-resistant organisms and acknowledged they should have had a gown on during Resident #1's care since it was considered high contact care. 2. Record review of Resident #2's face sheet, dated 03/31/26, reflected a [AGE] year-old female admitted [DATE], diagnosis included type 2 diabetes mellitus (chronic condition where high blood sugar results from insufficient insulin production), chronic obstructive pulmonary disease (lung disease causing obstructive air flow) and overactive bladder (causes a sudden, uncontrollable urge to urinate). During an interview and observation with Resident #2 on 03/31/26 at 1:50 p.m. Resident #2 was observed in her room lying in bed. CNA C entered the room and told Resident #2 she was there to provide her incontinent care. Resident #2 was asked if she consented to the surveyor observing the care and she stated, Yes that was okay. CNA C then performed hand hygiene and put on gloves and assisted Resident #2 onto her back. CNA C unfastened the resident's brief revealing she was wet but not saturated with urine. CNA C wiped from the front to back, down each groin, and then down the middle and assisted the resident onto her side, removed the soiled brief and wiped the resident's buttocks area from front to back. CNA C then changed her gloves but did not perform hand hygiene and placed the clean brief under the resident. CNA C then fastened the brief, repositioned the resident and removed her gloves and then performed hand hygiene. During an interview with CNA C on 3/21/26 at 01:55 p.m. she stated she was supposed to do hand hygiene before and after incontinent care but then stated she should have done it after she finished cleaning the resident and changed her gloves. She stated the risk of not doing hand hygiene was the spread of germs and infection. 3. Record review of Resident #3's face sheet, dated 03/31/26, reflected a [AGE] year-old female admitted [DATE], diagnosis included dementia (a progressive decline in memory) and chronic obstructive pulmonary disease (lung disease causing obstructive air flow). During an interview and observation with Resident #3 on 03/31/26 at 2:10 p.m. Resident #3 was observed in her room lying in bed. CNA D entered the room and told Resident #3 she was there to provide her incontinent care. Resident #3 was asked if she consented to the surveyor observing the care and she stated, Okay. The oxygen concentrator was observed to be on, but the resident's oxygen cannula was observed on the floor. CNA C performed hand hygiene and put on gloves. The Staffing Coordinator entered the room and stated she was there to assist with turning Resident #3. The Staffing Coordinator performed hand hygiene and put on gloves and both staff assisted Resident #3 onto her back. CNA D unfastened the resident's brief, placed a clean brief beside the resident and wiped the resident down the middle from front to back, and then down each groin. Both staff rolled the resident onto her back and CNA D removed the soiled brief and then placed the clean brief under the resident before cleaning her buttocks. CNA D then wiped the resident's buttocks area from front to back. CNA D was about to roll the resident back onto her back when the Staffing Coordinator told her she needed to apply barrier cream. CNA D then reached for a tube of barrier cream on Resident #3's bedside chest of drawers and while wearing the same gloves used to clean the resident, she applied barrier cream to her buttocks. Still wearing the soiled gloves, CNA D and the Staffing Coordinator rolled the resident onto her back, fastened the brief and repositioned the resident and pulled her up in the bed. The Staffing Coordinator then picked up the oxygen cannula off the floor and placed it on the resident's nose. Both staff removed their gloves, gathered the trash and left the room without performing hand hygiene. Both staff walked down the hall, deposited the trash in the dirty linen room and then went to the sink behind the nurse's station and washed their hands. During an interview with the Staffing Coordinator on 03/31/26 at 2:15 p.m. she stated they were required to perform hand hygiene before and after care and stated she realized she had not done that before she left Resident #3's room. She stated she was not sure what she should have done with the oxygen cannula but stated being on the floor she should have attempted to clean it before placing it back on the resident. She stated the risk of not following the infection control protocol was spread of germs and infections. During an interview with CNA D on 03/31/26 at 2:20 p.m. she stated she was supposed to perform hand hygiene before and after care but was not certain about during care. She stated she should have changed her gloves when she went from dirty to clean and should not have placed the clean brief under the resident before she had cleaned her, because she had cross-contaminated the brief. She stated she also realized she had not washed her hands before she left, which was why she went to the nurse's station sink to wash her hands. She stated the risk of not performing hand hygiene and glove changes was the spread of germ, cross-contamination and increased infections. During an interview with the DON on 3/31/26 at 3:40 p.m. she stated staff were to change their gloves and perform hand hygiene before going form dirty to clean, before entering a resident's room and before leaving a resident's room. She stated all residents who were on enhanced barrier precautions had signs posted on their doors and the staff was expected to follow those protocols. She stated they trained and did in-services constantly on infection control. She stated she had tried to teach enhanced barrier precautions in the simplest to understand way, and stated the sign clearly tells the staff what is considered high-contact care if they don't remember. She stated anytime oxygen cannula was found on the floor the staff was to discard it and replace it with a new cannula. She stated she would be doing skills checks and re-education with the staff on overall infection control. Record review of the facility's policy titled, IPCP Standard and Transmission-Based Precautions, revised October 2022, reflected, .It is the policy of this facility to implement infection control measure to prevent the spread of communicable disease and conditions. Enhanced Barrier Precautions (EBP) expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDRO's to staff hands and clothing then indirectly transferred to residents or from resident-to- resident. (e.g., residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs) .Examples of high-contact resident care activities requiring gown and glove use.transferring.changing briefs.Device care or use.feeding tubes. Record review of the facility's policy titled, Hand Washing reflected, It is the policy of this facility to cleanse hands to prevent transmission of possible infectious material and to provide clean, healthy environment for resident's and staff. Hand washing/hand hygiene is generally considered the most important single procedure for preventing nosocomial infections.Some situations require hand washing in areas where sinks are not readily available. In these circumstance, waterless hand-washing products may be used.

Based on observations , interviews, and record review, the facility failed to ensure that residents who are incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for one of nine residents (Resident #277) reviewed for incontinence and indwelling urinary catheter care in that: The facility did not obtain physician orders for indwelling catheter care and peri care for Resident #277 for March and April 2025. This deficient practice could place residents with indwelling catheters at risk of developing or worsening urinary infection and skin breakdown. The findings included: Record review of Resident #277's admission record reviewed a [AGE] year-old female with an initial admission of 09/13/24 and readmitted on [DATE]. Her primary diagnosis was infection and inflammatory reaction due to indwelling urethral catheter subsequent encounter (this is an infection and swelling while having an indwelling Catheter. An indwelling catheter is a medical device used to drain urine from the bladder into a bag). Her secondary diagnoses were acute cystitis without hematuria (kidney stone without blood in urine), chronic obstructive pulmonary diseases (a lung disease that blocks airflow and makes it difficult to breathe), cognitive communication deficit, unspecified dementia (this is a brain disease that alters brain function causes cognitive decline), Unspecified stage pressure ulcer of the sacral region (bed sores on her lower back bone/tail bone area) and need for assistance with care. Review of Resident # 277's quarterly MDS assessment dated [DATE] revealed Resident #277 had a BIMS score of 15 indicating her cognition was intact. Resident #277 required extensive assistance for ADLs and was always incontinent of bowel and she had an indwelling catheter. Review of Resident #277's care plan initiated 09/13/24 revealed, Resident #277 had an indwelling catheter related to obstructive uropathy (urine flow obstructed). The goal was for the resident not to show signs and symptoms of urinary infection through review date 06/03/25. The interventions were to change catheter bag and tubing as ordered, Monitor and document intake and output as per facility policy, Monitor/record/report to MD for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns and use Enhanced Barrier Precautions. The care plan did not reflect catheter care and peri care for interventions. Record review of Resident #277's May 2025 physician order, reflected: - Catheter care every shift. Monitor urethral site for s/s of skin breakdown, pain/discomforts, unusual odor, urine characteristic or secretions, catheter pulling causing tension. . Review of Resident #277 MAR for March 2025 did not reflect Catheter and peri care ordered. Review of Resident #277 MAR for April 2025 did not reflect Catheter and peri care ordered. In an observation and interview on 05/07/25 at 10:50 AM, it was revealed Resident #277 was with family at the bedside. Resident #277 was interviewable but she said she could not recall all the details. Resident #277's family stated on many occasions that she had visited Resident #277, and the resident was dirty with BM and her catheter was covered with BM. She said Resident #277 just returned to the facility on [DATE] after being in the hospital for a urinary infection. She said this was caused by not receiving incontinence care timely and not getting catheter care daily. Resident #277 family said she had pictures of the different times she came to the facility and found Resident #277 soiled with BM or her catheter would be leaking, and the resident would be wet. The family said they sent pictures to CII. Observation of pictures dated 1/27/25, 2/3/25, 2/26/25, 3/9/25, 3/18/25, 4/11/25 revealed Resident #277 had BM and BM was covering her catheter. Family stated on those days she would clean up Resident #277 by herself and cover her wound if the dressing was soiled. Resident #277 family moved the covers and revealed Resident #277 was clean, dry and catheter was clean. An interview with CNA C on 05/07/25 at 1:35 PM, revealed she emptied the catheter bag every two hours and made sure that it was not touching the floor and that it was not on top of the bed. She stated the nurses were responsible for making sure that catheter care was done and checking it off on the computer. She stated she had not completed catheter care for any resident since she had been employed for a month because her understanding was that the nurses did it. An interview with CNA D on 05/07/25 at 2:00 PM, revealed she completed catheter care daily on residents and if a resident had a BM, then she would complete catheter care, and during showers. She said peri care and catheter care was completed daily and sometimes multiple times on incontinence residents. She said foley care was important to prevent infections. Interview with LVN E on 05/08/25 at 9:00 AM, she stated the CNA were expected to complete catheter care, but it was the responsibility of the nurses to make sure that it was done. She said she always did her own catheter care so that she made sure that it was done. She said all catheters were changed every 15th of the month unless directed by the physician or urologist not to change them. She said it was important to complete catheter care to prevent catheter associated infection. In an interview with NP on 07/05/25 at 11:43 AM, it was revealed that all residents with a catheter had batch orders which included catheter care. She said she was not sure why some residents might have missing orders for catheter care. However, the expectation was that all residents who had a catheter received catheter care orders. She said orders drove care, and catheter care was important to help prevent infection. She said she was not sure if Resident #277 had been missing catheter care orders before she went to the hospital. She said she would verify and make sure that all orders related to the catheter were in place. In an interview with DON on 05/08/25 at 02:57 PM, it was revealed that catheter care was the responsibility of the nurses, and they needed to make sure that it was done on their shift. She said CNA were expected to provide catheter care when doing incontinence care and baths, and the nurses should follow up to make sure it was done. DON said the expectation was that there was an order for catheter care, and if there was none, to call the physician and obtain one. DON said she and the ADON's did random monitoring on orders, she was tracking UTI patterns, and there were no concerns at that time. She said catheter care was necessary to prevent infection control. In an interview with ADM on 05/08/25 at 04:25 PM, she said expected for staff to follow the catheter policy , and if catheter care was not done risk of infection. Review of the facility policy and procedure titled Infection Control/Procedure: Resident Care; Catheter Care, Foley revision date July 2022 revealed It is the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and PRN when soiling. Purpose: To promote hygiene, comfort, and decrease risk of infection for catheterized residents.17. Document.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for safety in the facility's only kitchen. 1. The facility failed to label and date three 1- gallon pitchers of liquid. 2. The facility failed to remove three dented cans from the dry food storage area. 3. The facility DA failed to wear a beard net while in the kitchen. The failures could place all residents at risk for food-borne illness. Findings included: In an observation on 05/06/25 at 6:47 AM, the kitchen reflected 1 of 1 refrigerator with a 1-gallon pitcher, with a red liquid that was not labeled or dated, a 1-gallon pitcher of dark colored liquid was not labeled, and a 1- gallon pitcher of a yellow liquid was not labeled. In an observation on 05/06/25 at 6:55 AM, the kitchen reflected 1 of 1 dry food storage with one dented can labeled apple slices on the second wired rack of the shelf, one dented can labeled baked beans on the third rack, and one dented can labeled spaghetti sauce on the fifth wired rack. In an observation on 05/06/25 at 7:05 AM of the kitchen reflected one DA without a beard net. In an observation on 05/06/25 at 12:41 PM of the dining area reflected the same DA without a beard net while serving trays from the kitchen. In an observation on 05/07/25 at 2:14 PM revealed DA was observed still in the kitchen with no beard net. In an interview on 05/07/25 at 7:05 AM, DA stated he was unaware he was supposed to wear a beard net. DA stated the risk of not wearing a beard net was that hair could fall into a resident's food. In an interview on 05/07/25 at 6:47 AM, DS stated the first pitcher of red liquid that contained no date or label was fruit punch, the second pitcher that was dark in color that contained no label was tea, and the last pitcher that contained no label was lemonade. DS stated all items must be labeled and dated. DS stated the risk of not labeling and dating items could cause a risk of sending out old food that can potentially harm the residents. At 7:00 AM, DS stated the dented cans were normally stored on the top rack of the shelf. DS stated the risk of serving food from the dented cans, could cause a food-borne illness. At 7:07 AM, DS stated all staff are required to wear hair nets and beard nets and the risk of them not wearing hair restraints is that hair can fall into a resident's food causing contamination. On 05/07/25 at 10:45 AM, ADM stated all kitchen staff should be wearing hair nets and beard nets. ADM stated it is the responsibility of the ADM and the employee to put hair nets and beard nets on. ADM stated the risk of not wearing beard nets could cause hair to contaminate the resident's food. ADM stated all items in the kitchen must be labeled and dated. ADM stated the canned food items that had dents in them should be stored in their own area. ADM stated failing to label, date, or removing dented items could place residents at risk for food-borne illnesses. Record Review of the facility policy Infection Control Policy/Procedure revised 02/05/24 reflected: A: Proper attire for food handlers should include a hair covering (hair nets or caps), freshly laundered uniform and work shoes and short, clean fingernails. Moustaches and sideburns must be kept trimmed. Beards must be covered. B: Foods coming from broken packages or swollen cans or food with an abnormal appearance or odor will not be served. M: Leftovers must be dated, labeled, covered .

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 2 of 2 Residents (Resident #16 and Resident #84) observed for infection control. The ABOM failed to perform hand hygiene while assisting Resident #16 and Resident #84 during the lunch meal on 05/06/2025. These failures could place residents at risk for cross contamination and infections. Findings included: Observation on 05/06/25 at 12:17 pm and at 12:30 pm revealed the ABOM sitting in between Resident #16 and Resident #84 during the lunch meal. The ABOM was observed feeding both residents at the same time without using hand sanitizer in between. Interview on 05/06/25 at 12:43 pm, the Administrator revealed the ABOM was also a CNA. She stated there was a potential risk for infection if staff did not perform hand hygiene while feeding residents. Interview on 05/06/25 at 12:43 pm, the DON stated her expectation was for staff to feed one resident and use hand sanitizer. She stated she expected staff to use hand sanitizer, and make sure not to cross contaminate as long as it did not impede the care. Interview on 05/06/25 at 1:09 pm, the ABOM stated she was a CNA and had not worked on the floor for about 6 months since switching positions to ABOM. She stated she thought she used hand sanitizer in between feeding Resident #16 and Resident #84. She said there could be a risk of cross contamination between residents, and she should have used hand sanitizer between each resident. Record review of facility policy titled Hand Washing revised 07/2021, revealed the procedure for hand washing, but did not indicate when hand hygiene was to be performed.

Based on observations, interviews, and record review, the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for one of four hallways (A hallway) medications carts in hallways that were reviewed for security and storage of drugs and biologicals. The facility did not ensure A hallway medication cart was locked and medications were not left on top of the medication cart unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. Findings included: Record review of Resident #44 active physician Order summary dated 05/06/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included cerebral palsy (a congenital disorder of movement, muscle tone and posture), gastrostomy status (this is a feeding tube that is placed through the abdominal cavity area into the stomach for nutritional purpose and medication for individual who have a difficulty swallowing), seizures, and other genetic related intellectual disabilities. Further review of the order summary reflected: - Keppra Oral Solution (Levetiracetam). Give 10 ml by mouth two times a day for seizures Keppra 100mg/ml. - Gabapentin Oral Solution 300 MG/6ML (Gabapentin). Give 6 ml via G-Tube three times a day for Neuropathy [nerve pain]. - Trileptal Oral Suspension 300 MG/5ML (Oxcarbazepine). Give 2.5 ml via PEG-Tube two times a day for seizures. Observation on 05/07/25 at 07:04 AM revealed the medication cart parked on A hallway between room [ROOM NUMBER] and 112, had the lock mechanism in the open (unlocked) position, and Resident #44's Keppra Oral Solution, Gabapentin Oral Solution and Trileptal Oral Suspension medications were left unattended on top of the medication cart . There were no staff next to the unlocked cart. Interview with LVN A on 05/07/25 at 07:07 AM revealed LVN A forgot to lock the medication cart. He said he was too focused on getting everything ready to be observed for G-tube medication observation and when he realized he had no wipes, walked away, and forgot to lock the medication cart to get a new bottle of wipes. LVN A said the expectation was that the medication cart was locked, and all medication was secured and not left on top of the cart which can be accessed. He said the potential risk was someone can come and get the medication and get into the cart. An interview with CMA F on 05/08/25 at 2:18 PM, revealed she was trained to make sure that the medication cart was locked and secured when not in use. She said all medications carts were the responsibility of the authorized person, and when not in attendance, the cart should be locked. She said it was important to lock the cart because anyone can get into it, and if a resident was confused, they could get into something that they were allergic to, or a resident who could not swallow whole pills could choke and have adverse issues. She said she always made sure that her medication cart was locked, and the computer screen was hidden before she walked away from the medication cart. An interview on 05/08/25 at 2:57 PM with DON revealed, the expectation was the medication cart should be locked, and no medication left on top of the medication cart when staff was not directly working with the cart. She said LVN A should have locked the medications [for Resident #44] inside the cart or taken with him when he walked away from his cart. She said all nursing staff were responsible for securing medications when not in use. She stated an in-service would be completed with the nursing staff. She said the risk was anyone could have access to the medications. An interview on 05/08/25 at 4:39 PM with the Administrator revealed, the medication cart should be locked if it was out of site, and staff were not actively working in the cart so that unauthorized persons did not have access to it. Review of facility policy Storage of Medication revised in April 2019 reflected The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 9. Unlocked medication carts are not left unattended.

Based on interview and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices for 1 resident (Resident #1) of 6 residents reviewed for clinical records. -The facility failed to completely and accurately document Resident #1's weekly skin assessments and any follow-up assessments relating to new bruises documented on the shower sheets, which would indicate details of the bruises and care as necessary. This failure could place all residents at risk of having skin conditions that are untreated and having incomplete and inaccurate records, which could lead to harm. Findings include: Record review of Resident #1's face sheet, dated 09/23/24, revealed she was an [AGE] year-old female who admitted to the facility on [DATE] and discharged on [DATE] with diagnoses that included: metabolic encephalopathy (change in brain function), dementia (loss of memory and thinking abilities), muscle weakness, lack of coordination, and abnormalities of gait and mobility. Record review of Resident #1's Admission MDS Assessment, dated 08/09/24, revealed the resident had BIMS score of 3 which indicated her cognition was severely impacted. Resident #1 required partial/moderate assistance with most ADLs. Record review of Resident #1's care plan, revised on 08/15/24, revealed the resident was at risk for falls r/t poor balance with interventions that included therapy evaluation, keeping call light within reach, determining causation of falls, monitoring/documenting/reporting to MD s/x of pain, bruises, change in mental status, and providing activities that promote exercise and strength building where possible. Record review of Resident #1's weekly skin assessments, from 08/15/24-09/12/24, revealed the following: -08/08/24 (admission) - Bruising to BUE (Bilateral (both sides) upper extremities) -08/15/24 - No open skin areas -08/22/24 - No skin issues -08/29/24 - No skin issues -09/05/24 - No skin issues -09/12/24 - Scattered bruises to upper and lower extremities, no open areas; [Resident #1] was doing group activity when this nurse [LVN B] notice a bruise to right arm. Question [Resident #1] and she stated that she didn't know, or she may have bump it somewhere. This nurse [LVN B] notified [family] and the [family] stated that she seen that, and it was ok but [Resident #1] c/o shoulder pain. This nurse [LVN B] examine arm but [Resident #1] refused and got agitated and stated she is fine (leave me alone). Notified [NP] and she told me to monitor it. Record review of Resident #1's incident report for injury of unknown origin, dated 09/12/24, completed by LVN B revealed the following: Resident: [Resident #1] Incident location: Unknown Person preparing report: [LVN B] Nursing description: [Resident #1] has a bruise to right upper arm, no pain voiced when examine. Resident description: [Resident #1] stated she do not know how it got their [sic]. [Resident #1 stated she may have hit her arm somewhere. Was this incident witnessed: No Description: head to toe assessment, pain, loc, skin . Predisposing physiological factors: none Predisposing situation factors: none Persons notified: 1) [NP]- stated to monitor it. 2) [Family]-stated she knew and was concern about pain to right shoulder. 3) [LVN E]-monitor the area Record review of Resident #1's shower sheets, from 09/2024, reflected the following: -09/02/24 - no skin issues documented -09/06/24 - bruise to back of upper right arm documented -09/11/24 - bruises to front of both thighs -09/13/24 - shower refused; skin observation not completed Record review of Resident #1's nurses progress notes reflected there was no documentation on 09/11/24 about an assessment or notification to appropriate parties regarding the bruises found on the Resident #1's thighs by CNA C during the resident's shower on this date. Record review of Resident #1's nurses progress notes, dated 09/12/24 at 1:18 PM by LVN B, reflected: [Resident #1] has a bruise to right upper arm, no pain or distress noted, [Resident #1] stated she don't know how this happen and she may have it [sic] it on something. Notified doctor, rp, [LVN D] Record review of Resident #1's nurses progress notes reflected there was no documentation on 09/12/24 by LVN B about an assessment or notification to appropriate parties regarding bruises found on the Resident #1's thighs. Record review of Resident #1's physician orders reflected the following: -Aspirin 81mg oral tablet chewable-give 1 tablet by mouth one time a day for analgesic (for pain). Start date: 08/0924; End date: 09/15/24. -Clopidogrel Bisulfate Oral tablet 75mg-give 1 tablet by mouth one time a day for hematologic disorder (blood disorder). Start date: 08/0924; End date: 09/15/24. Record review of in-service titled Skin, dated 09/15/24, reflected all staff were educated on notifying the MD and family of anu skin issues and change of condition, monitoring orders, and documentation. Record review of in-service titled Shower sheets, dated 09/17/24, reflected all staff were educated on how to properly complete shower sheets regarding legibility and appropriate documentation, including identifying any bruises or other skin issues. In an interview on 09/20/24 at 12:38 PM, CNA C stated she worked at the facility for 1.5 years. CNA C stated she worked with Resident #1 on 09/11/24. She stated she gave the resident a shower on that day and completed a shower sheet. CNA C stated Resident #1 always had scattered bruises on her body because she was always moving around and was sometimes combative towards other residents. CNA C stated she cold vaguely recall Resident #1 having a more significant bruise on her upper right arm and a yellow bruise on one of her thighs. CNA C could not recall if she reported the bruises to the nurse. In an interview on 09/20/24 at 01:03 PM, LVN A stated she worked at the facility since 03/2024. LVN A stated she worked with Resident #1 on 09/14/24, the day she discharged from the facility. LVN A stated she completed a head-to-toe assessment of Resident #1 before she left the facility and found a large bruise on the middle part of the resident's rights arm, a lot of age spots, scattered small red dots, a yellowish bruise on abdomen, and large bruises on the front of both thighs. LVN A stated when the aides give the residents showers, they are supposed to document any new skin issues and immediately report it to the nurse. LVN A stated she did not know where the bruises came from and denied receiving reports of Resident #1 having any incidents or new skin issues. LVN A stated the large bruises on Resident #1 caught her by surprise as she was unaware of them. In an interview on 09/23/24 at 09:18 AM, LVN B stated she worked at facility since 06/2024. LVN B stated she worked with Resident #1 on 09/12/24 and completed a head-to-toe assessment on the resident after a therapist reported seeing a bruise on her right arm. LVN B stated during the assessment she found a large bruise on Resident #1's upper right arm, scattered bruising, and brown spots on Resident #1's skin. LVN B stated she completed an incident report for the bruise on Resident #1's arm because it was significant, and no one knew how it happened. LVN B denied seeing significant or large bruises on Resident #1's thighs, only small, scattered ones, which was normal for the resident because she wandered a lot, bumping and hitting walls. In an interview on 09/23/24 at 11:30 AM, the NP stated she was not aware of any concerns for abuse of Resident #1. The NP stated she was aware that Resident #1 admitted to the facility with multiple bruises on her body and the resident had a history of bruising easily due to the use of blood thinners. The NP stated she was notified on 09/12/24 by LVN B that Resident #1 had a large bruise on her right arm, and she ordered an X-ray that was negative for injury. The NP stated on 09/14/24, LVN A completed a discharge skin assessment on Resident #1 and found scattered bruises to abdomen, back, arm, and thighs. The NP stated LVN A notified her and sent pictures. The NP stated Resident #1 discharged on the same day and she did not get a chance to assess her; however, if the resident remained at the facility, she would have ordered labs and an ultrasound to check for hematomas due to the resident's use of blood thinners. The NP stated it was possible for the blood thinners to cause smaller bruises to spread and become larger. The NP could not recall being made aware of any bruises on other dates. In an interview on 09/23/24 at 02:44 PM, the DON stated all residents received skin assessments each week and as needed. The DON stated the importance of head-to toe skin assessments was for the nurses to identify any wounds, rashes, discoloration, bruises, or anything potentially going on with the residents. The DON stated it was also important for the aides and nurses to accurately document the skin assessments, shower sheet, incident reports, and progress notes to reflect exactly when and what was found on the residents so that appropriate treatment can be provided. In an interview on 09/23/24 at 03:33 PM, the Administrator stated it was the expectation for complete and accurate documentation to be done for all residents, and for it to be objective and timely. The Administrator stated the risk of not having complete and accurate clinical records could be the residents not receiving appropriate continuum of care. In an interview on 10/07/24 at 12:45 PM with the DON and the Administrator, the Administrator stated the expectation was for the CNAs to document on the shower sheet and report and changes/skin issues to the charge nurse, then for the charge nurse to assess and see if further investigation or care was needed. The Administrator stated if the nurse did not see anything suspicious in nature after the assessment, they would sign-off on the CNA's shower sheets to indicate that follow-up was completed with no concerns. The DON stated after a nurse signed off on a shower sheet, there was no need to document a separate clinical note or skin assessment unless there were concerns, then the documentation needed to be accurate and thorough. The DON stated there had been issues with the nurses' documentation and there had already been education provided to all staff. Review of the facility's policy titled Nursing Clinical: Charting and Documentation, revised 05/2024, revealed in part the following: Definition of record: The resident's clinical record is a concise account of treatment, care, response to care, signs, symptoms and progress of the resident's condition. Is also necessary to include data needed for identification and communication with family and friends. Complete history of resident and present illness is required under current law and regulations at the time of admission. . Rules for charting: 1. Notes are to be written on all long-term residents by day, evening, and night shifts; frequency is determined by the individual nursing service. 2. Daily notes are required as the necessary arises. 3. The admitting nurse to complete an admission assessment.

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 that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Residents #1) of 7 residents reviewed for dignity. The facility failed to ensure Residents #1's rights to a dignified existence when there were flies on him, his g-tube was exposed, and his room had a strong foul odor. This failure could affect the residents by placing them at risk for a loss of dignity, decreased self-worth and decreased self-esteem. Findings included: Record review of Resident #1's face sheet dated 09/05/2024, revealed a [AGE] year-old male that was admitted to the facility on [DATE]. His diagnoses included down syndrome (this is a genetic chromosome 21 disorder causing developmental and intellectual delay), aphasia (this is a language disorder that affects ability to communicate), metabolic encephalopathy (this is a brain disease that alters brain function or structure), gastrostomy status (this is a feeding tube that is placed through the abdominal cavity area into the stomach for nutritional purpose and medication for individual who have a difficulty swallowing), type 2 diabetes mellitus (uncontrolled blood sugars), lack of coordination, severe protein calorie malnutrition, other symptoms and signs concerning food and fluid intake, cognitive communication deficit, and need for assistance with personal care. Face sheet further revealed Resident #1's parent was his RP, and he had a full code status. Review of Resident #1's quarterly MDS dated [DATE] reflected, Resident #1 had a BIMS score of zero, indicating severe cognitive impairment. He had no indicators of delirium, depression, or behaviors. Resident #1 had no impaired range of motion on his upper and lower body and was completely dependent on staff to set up and clean up following activity. Resident #1 was always incontinent of bowel and bladder. The document reflected Resident #1 had a feeding tube while a resident of the facility and received 51% or more of his nutrition through the feeding tube. Review of Resident #1's care plan dated 09/05/2024 reflected Resident #1 had Date Initiated 06/26/2024. Care plan also reflected Resident #1 was at risk for falls related to cognitive impairment/down syndrome. His goals were to be free of falls through the review date and to no sustain serious injury through the review date 07/09/2024. His interventions included: To anticipate and meet his needs, to follow facility fall protocol, needs a safe environment: floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Side rails as ordered, handrails on walls, personal items within reach. Date initiated 03/06/2024. In an observation on 09/05/2024 at 12:15 pm, revealed Resident #1's door was closed. Signage on Resident #1's room read Enhanced Barrier Precaution on a second signage it listed that the resident was non-verbal and that he required max support to complete ADLs. Upon entry to Resident #1's room he was lying on a mattress on the floor. Resident #1 was lying on his left side and his g-tube was exposed, connected to a feeding pump. Resident #1's room had a strong foul odor of unknown substance. He had one black fly on his forehead, another fly on his g-tube, another fly on his stomach, two flies on his right leg, one fly on his feeding pump, and one fly floating and buzzing around Resident #1. Resident #1 reached his forehead to swish/remove the fly and two gnats were observed floating by his head. Resident #1 could not speak, nor could he express his thoughts on the flies in his room and him. In an interview with LVN A on 09/05/2024 at 12:20 pm, she stated Resident #1 preferred lying on the floor mat and after 6 weeks trying, he agreed to be transitioned to a mattress on the floor. She stated Resident #1's room smelled of bowel movement. She stated some of the smell was most likely coming from the tiles on the floor. She stated she had seen the flies in Resident #1's room and had reported it to housekeeping and maintenance two weeks ago. She stated management were aware of the flies. She stated the gnats could possibly be from Resident #1 spilling his milk. She stated Resident #1 refused assistance eating and on multiple occasions he spilled his milk. She stated she had used some peppermint oils to help with the flies. LVN A did not know who had brought the peppermint oil but was told to use it to keep flies away. She stated the risk to Resident #1 having flies on him and in his room was a dignity issue and flies carry germs that could cause illness. In an interview with the Housekeeping Supervisor on 09/05/2024 at 1:18 pm, she stated Housekeeper C had informed her about the flies in Resident #1's room. The Housekeeping Supervisor stated herself and Housekeeper C deep cleaned Resident #1's room including his mattress and curtains. She also instructed housekeeping staff to clean Resident #1's room two times a day in the morning and afternoon. She stated it was the responsibility of the nursing staff to make sure that trash with bowel movement diapers were removed out of the room to prevent flies. She stated that if the housekeeping staff were cleaning Resident #1's room in the afternoon and they found trash, she had instructed them to remove the trash even those diapers with bowel movement in the trash. The Housekeeping Supervisor stated she informed the Maintenance Director, and he called pest control. The Housekeeping supervisor stated it was not good having flies on Resident #1 because it was unhygienic. In an interview with Housekeeper C on 09/06/2024 at 1:41 PM, she stated LVN A had alerted her about the flies in Resident #1's room. She stated that she had noticed them two weeks ago and she notified her supervisor. She stated she had been instructed to start cleaning Resident #1's room two times a day and her supervisor wrote in the pest control book for Resident #1's room. She stated she had been in-serviced that if she sees anything bad to report it. She stated the risk to residents having pests in their room can cause them to be unwell and their stay was not better. She stated the risk to Resident #1 was it was not hygienic, and it was unhealthy to have pests in your room and on you. In an interview with the Maintenance Director on 09/05/2024 at 1:59 PM, he stated he did not see any flies when he went to Resident #1's room when housekeeping staff were cleaning the room. He stated he could not remember exactly when he had been informed of one of the resident's rooms had one fly in it, and he instructed housekeeping staff to increase cleaning to two times a day. He stated this was the first time he had learned of the flies and gnats in Resident #1's room since they started cleaning his room twice a day. He stated the flies in Resident #1's room could be entering from the exit door because his room was close to the exit. He sated he had gone in Resident #1's room and checked his windows and screens which were in place. He stated pest control came two times a month to spray the main stations outside and if any rooms have any pest concerns. He stated housekeeping was responsible for deep cleaning rooms as needed and he got pest control within 24 hours of report of pests. In an interview with LVN B on 09/05/2024 at 3:17 PM, she stated she treated Resident#1 on 08/23/24 due to having moisture associated skin damage on his back. She said Resident#1 was on a mattress on the floor. She said he does not stay on the bed. She stated she did not notice any flies or gnats in the room. She stated Resident#1 does not really communicate. She said he makes noises but does eye gestures and hand motions. LVN B stated flies should not be on a resident, just like she would not like them on her. She stated some flies can bite and can cause infection for Residents #1 with his with G-tube. Attempted phone interview with RP on 09/05/2024 at 3:45PM, RP could not be reached. In an interview with the DON on 09/05/2024 at 5:09 PM she stated she was not aware of the flies in Resident #1's room until today. She stated a head-to-toe assessment was completed on Resident #1. She stated there were no bite marks or any skin conditions found on Resident #1. The DON stated herself, the nursing staff, and housekeeping had deep cleaned Resident #1's room, including his walls, curtains, mattress switched to a new one, the equipment was wiped down with disinfectant, and a new order to clean Resident #1's room three times a day. The DON stated family may have brought in the peppermint oils because the RP had reported they liked to bring soothing natural oils. The DON stated it was likely the sweet oils were attracting flies and gnats. The DON stated she would monitor and follow-up with the ADON, CNAs, and housekeeping to make sure interventions were effective. The DON stated the floors were also the issue with smell and the facility was getting new floors which would help with the smell. She stated the risk to Resident #1 was potential discomfort. In an interview with the ADM on 09/10/2024 at 11:57 AM, she stated that the Maintenance Director was responsible for ensuring effective pest control for the facility which he did for Resident #1. She stated she expected the facility to have pest control twice a month and they can also be reached within 24 hours as needed. She sated the DON had in-serviced on pest control and potential hazards for cleanliness and a homelike environment. Record review of a service inspection invoice by [Pest Control Service] on 07/30/2024, general comments twice a month, treated bait stations on exterior, cleared out debris from bait stations, and treated general pests. Treatment on 07/10/2024 treated for ants and rodents. Invoice for 08/29/2024 reflected treatment twice a month, treated exterior bait stations for rodent activity, treated for general pest, cleared out debris from bait stations, and removed ant piles around the outside. The pest control service did not reflect treatment for flies and/or gnats. Residenst Right policy was requesed on 09/05/2024 at 09:43 AM, email was sent to both ADM and DON. Resident Right policy was not provided by exit date 09/10/2024. Record review of the facility's pest control service agreement, with an initial service date of 11-07-2019, stated Pest Services . Service Provider shall provide Services in accordance with all applicable federal and state laws and within the established policies of Facility . Record review of the facility policy titled, Nursing Services: Quality of Care, ADL, Services to Carry Out, revised 07/2020, reflected, it is the policy of this facility that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident in accordance with a written plan of care. Policy read in part 2. If a resident is unable to carry out activities of daily living, the necessary services to maintain good nutrition, grooming, and personal oral hygiene, it will be provide by qualified staff .

Based on observation, interview and record review, the facility failed to ensure the residents received services in the facility with reasonable accommodation of each resident's needs for 4 of 7 (Residents #1, #2, #3, and #4) reviewed for accommodation of needs in that: The facility failed to ensure Resident #1, #2, #3, and #4's call lights were within reach of the Resident. This failure could affect all residents who needed assistance and could result in their needs not being met. Findings included: Record review of Resident #1's face sheet, dated 4-23-2024, indicated an [AGE] year-old-female admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of psychotic disturbance, mood disturbance, and anxiety and secondary diagnosis of muscle weakness, abnormalities of gait and mobility, and need for assistance with personal care. Record review of Resident #1's MDS assessment, dated 10-1-2023, revealed a BIMS score of 7 indicating severe cognitive impairment. Resident #1's MDS further revealed Resident #1 had Urinary incontinence occasionally and bowel incontinence frequently. Record review of Resident #1's care plan, dated 7-24-2023, indicated Resident #1 is at risk for falls with a history for falling stating Be sure the call light is within reach and encourage to use it to call for assistance as needed. In an observation/interview on 4-23-2024, at 1:00 PM, Resident #1's call light was on the floor against the wall the headboard was against, out of reach of the resident. Resident #1 was observed sitting on her bed. Resident #1 stated she did not know where her call light was and needed help showering. Record review of Resident #2's face sheet, dated 4-23-2024, indicated a [AGE] year-old-female admitted to the facility on [DATE]. Resident #2 had a primary diagnosis of chronic atrial fibrillation (type of heart arrhythmia, lasting more than one week, that causes the top chambers of your heart, the atria, to quiver and beat irregularly) with secondary diagnosis of difficulty walking, abnormalities of gait and mobility, and bed confinement status. Record Review of Resident #2's MDS, dated [DATE], revealed a BIMS score of 12, indicating moderate cognitive impairment. Resident #2's MDS further revealed Resident #2 had total dependence with bathing, occasional urinary incontinence, and frequent bowel incontinence. Record review of Resident #2's care plan, dated 4-10-2023, indicated Resident #2 had an ADL self-care deficit in bed mobility, transfers, eating, dressing, grooming, and hygiene stating Encourage to use bell to call for assistance. Resident #2's care plan further stated Resident #2 had an actual fall on 7-28-2023 and stated 7/28/23 educated on using call light Date Initiated: 07/31/2023. In an observation/interview on 4-23-2024, at 1:10 PM, revealed Resident #2 laying in her bed with her call light out of reach, hanging 1 inch above the floor, next to the wall. Resident #2 spoke in a very soft voice to the point; that one needed to get within 2 feet of the Resident's mouth to hear her. Resident #2 stated she did not know where her call light was, and she used it. Record review of Resident #3's face sheet, dated 4-23-2024, indicated a [AGE] year-old female admitted to the facility on [DATE]. Resident #3 had a primary diagnosis of Alzheimer's disease, history of falling, chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), and orthopedic joint implants. Record review of Resident #3's MDS, dated [DATE], indicated a BIMS score of 00 indicating severe cognitive impairment. Resident #3's MDS further indicated Resident #3 ambulated in a wheelchair and was always urinary incontinent and always bowel incontinent. In an observation/interview on 4-23-2024, at 1:50 PM, revealed Resident #3 lying on her bed with her call light out of reach, underneath her bed. Resident #3 had a communication challenge but stated she needed her call light. Record review of Resident #4's face sheet, dated 4-23-2024, indicated an [AGE] year-old female admitted to the facility on [DATE]. Resident #4 had a primary diagnosis of dementia without behavioral disturbance, congestive heart failure, osteoarthritis of hip, and lack of coordination. Record review of Resident #4's MDS, dated [DATE], indicated a BIMS score of 02, indicating severe cognitive impairment. Resident #4's MDS further indicated the need for extensive assistance for bed mobility, movement in her bedroom, dressing, personal hygiene, and toilet use. Record review of Resident #4's care plan, dated 8-13-2023, revealed Resident #4 had an injury of an unknown origin related to osteoarthritis (degeneration of joint cartilage and the underlying bone) and osteopenia (lower than normal bone mass) with fracture to left fifth digit stating that facility staff need to Be sure call light is within reach and respond promptly to all requests for assistance. Resident #4's care plan further stated Resident #4 is bilingual and at times is at risk for a communication barrier as her dementia will cause her to speak in Spanish and staff should ensure/provide a safe environment, call light in reach, adequate low glare light, bed in lowest position, wheels locked, and avoid isolation. In an observation/interview on 4-23-2024, at 1:55 PM, revealed Resident #4 did not speak English and did not respond to my questions. Resident #4 was lying in her bed and her call light was not in reach touching the floor. In an interview with CNA/CMA A, on 4-23-2024, at 2:05 PM, it was revealed that when call lights were not within reach of residents, there was a risk they could fall and get hurt. In an interview with LVN A, on 4-23-2024, at 2:48 PM, it was disclosed that she worked the 200-hall area and expected her CNAs to make rounds every two hours; making sure call lights were within reach. LVN A stated the risk to residents who could not reach their call light was a high risk and they may not get the care they need. In an interview with the DON, on 4-23-2024, at 4:20 PM, it was revealed that the risk to residents not having their call lights within reach was the residents might not get the help or care they needed. The DON stated that the facility needed to anticipate the needs of residents who unclipped their call lights and let them drop to the ground. In an interview with the Administrator, on 4-23-2024, at 5:22 PM, revealed that her expectations were for call lights to be within reach and for staff to make rounds ensuring they are in place. The Administrator stated the nurses were responsible to ensure the CNAs placed the call lights within reach of the residents. The Administrator stated the risk, to the residents, of call lights not being within reach, was their needs might not be met. Record review of the facility's call light policy, dated August 2020, stated: It is the policy of this facility to provide the resident a means of communication with nursing staff by .Place the call device within resident's reach before leaving room .

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure food items in the facility's only dry storage were dated and sealed appropriately. 2. The facility failed to ensure food items in the facility's only walk in refrigerator were dated and sealed appropriately. 3. The facility failed to ensure cleaning chemicals were not near prepared food. 4. The facility failed to ensure drinks and food for personal use were properly stored. 5. The facility failed to ensure the kitchen door opening to the outside was closed. These failures could place residents at risk for food-borne illness, and food contamination. Findings include: Observations of the facility kitchen's only walk-in refrigerator and dry storage on at [DATE] at 9:04 AM revealed the following items were not sealed or dated: - In the walk-in refrigerator a metal container with sliced cheese, onions, tomatoes, pickles, and lettuce covered with plastic wrap not labeled or dated. - In the walk-in refrigerator in a zip lock bag contain sliced ham not labeled or dated. - In the walk-in refrigerator in a small plastic bowl covered with plastic wrap leftover puree lemon pudding not labeled or dated. - In the walk-in refrigerator a small container of watermelon spears for personal use. - In the walk-in refrigerator a zip lock bag contained a tomato not labeled or dated. - In the walk-in refrigerator an uncovered box of dried mushroom and a whole tomato not labeled or dated. - In the walk-in refrigerator a zip lock bag contained lettuce not labeled or dated. - In the walk-in refrigerator a zip lock bag contained sliced cheese not labeled or dated. - In the walk-in refrigerator stored on the top shelf personal use lunch bag. - In the dry goods storage, a zip lock bag contained crumbled cookies not labeled or date. Observation on [DATE] at 11:05 AM revealed the kitchen backdoor held open with a rock. Observation on [DATE] at 9:04 am revealed a container labeled spray cleaner with bleach next to a plastic bin container of individually wrapped slices of bread. Observation on [DATE] at 11:22 am revealed two personal use cups on the counter while food was being prepared. Interview on [DATE] at 1:34 PM with Cook A reflected that food stored should be labeled with the name of item and dated with day and year because it is only good for 3 days. The risk of not labeling or dating food can result in cross-contamination. She stated that the pink lunch bag belonged to her. She stated that she should have placed it in the staff refrigerator in the staff room. The risk of storing personal items in the facility refrigerator is cross contamination. Interview on [DATE] at 1:47 PM with Cook B reflected each food item should be placed in a separate container labeled and dated to prevent cross contamination and the residents could get sick. Food is only supposed to be used with in 2 days and then thrown away. The backdoor should not be propped open because insects can come in and get on the food. Interview on [DATE] at 2:00 PM with Cook C and Cook D reflected unable to interview staff, staff members was unable to remain after shift for interview. Interview on [DATE] at 4:14 PM with Dietary Manager reflected all items that are opened and placed in storage should be labeled and dated. The risk is infection control, giving the residents old or spoiled food, and food borne illness. All foods must be separated to prevent cross contamination. She stated that the mushroom and whole tomato in the uncovered box should have been thrown away. She stated that the chemical should have been stored in the chemical room and not next to food. The risk is that it could poison a resident. The back door should not be propped open because bugs could come into the kitchen. Interview on [DATE] at 5:24 PM with DON reflected the risk of kitchen items not being labeled or dated is food poisoning if things are expired. Interview on [DATE] at 5:38 PM with ADM reflected staff should follow policy and procedure for proper storage of food. The risk is food borne illness. Record review of facility policy dated revised ,d+[DATE] revealed 4a Foods should be covered, labeled, and dated. Foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. 5. Pesticides or other toxic substances and drugs are not to be stored in the kitchen area or in storerooms for food or food preparation equipment and utensils. 6. Soaps, detergents, cleaning compounds or similar substances are stored in separate storage areas. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed ,d+[DATE].17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, ,d+[DATE].11, revealed: Preventing Contamination from the Premises - Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, Paragraph ,d+[DATE].11 stated . Personal belongings can contaminate food, food equipment, and food-contact surfaces. Proper storage facilities are required for articles .

Based on observation, interview, and record review the facility failed to provide services to residents with reasonable accommodation of resident needs and preferences by not providing a call light system within reach for 2 of 31 (Residents # 1 & #2) observed for call lights. The facility failed to ensure Residents #1 and #2 had a call light within reach to communicate to staff they needed assistance. This failure affected residents by placing them at risk for not getting their needs met and diminishing their quality of life. Findings include: Record review of Resident #1's Face Sheet, dated 3-26-2024, revealed an [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of calculus of gallbladder and bile duct with acute cholecystitis with obstruction (gallstone blockage) and secondary diagnosis of enterocolitis (intestines inflammation) due to clostridium difficile (a germ (bacterium) that causes diarrhea and colitis (an inflammation of the colon) recurrent, gait/mobility abnormality (the pattern one walks), and dementia (loss of brain function). Record review of Resident #1's MDS (a standardized assessment tool that measures health status in nursing home residents), dated 11-22-2023, indicated a BIMS Score of 12, indicating Resident #1 had a moderate cognitive impairment. The MDS indicated Resident #1 needed Substantial/maximal assistance - (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for toileting hygiene, shower/bathe self, putting on/take off footwear, and personal hygiene. In an observation/interview, of Resident #1, on 3-26-2024, at 10:30 AM, revealed Resident #1 was in pain distress and needing assistance. Resident #1 stated she did not know where her call light was. Resident #1 stated she knows how to use the call light and does. Observation revealed Resident #1's call light was drooped down, on the right side of Resident #1's bed, touching the floor. Resident #1 stated not being able to reach her call light caused her to feel worried she could not get help. Record review of Resident #1's, doctor surgical note, revealed Resident #1 had surgery on her (left foot/left 2nd toe) to drain an abscess on 3-25-2024. In an interview with CNA-E, on 3-26-2024, at 10:35 AM, revealed the concern for Resident #1 not having her call light within reach as Resident #1 could not call the nursing staff for help as she was in pain. In an observation/interview with ADON-D, on 3-26-2024, at 10:40 AM, ADON-D was informed of Resident #1 being in pain and not having her call light within reach. ADON-D revealed the nurses are responsible to ensure call lights of residents are within reach. ADON-D stated this was important because it is the main way residents can let staff know they need help. ADON-D was observed giving pain medicine to Resident #1. Record review of Resident #1's care plan, dated 3-10-2024, indicated Resident #1 is at risk for falls and stated, be sure the call light is within reach and encourage to use it to call for assistance as needed. Record review of Resident #1's nursing notes, dated 3-26-2024, revealed Resident #1 fell just 10 hours prior to this observation, while getting into/out of bed. Record review of Resident #2's face sheet, dated 3-27-2024, indicated a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had a primary diagnosis of dementia, and secondary diagnosis of right artificial hip joint, abnormalities of gait and mobility, need of assistance with personal care, and anxiety disorder. Record review of Resident #2's MDS, dated [DATE], revealed a BIMS score of 03, indicating significant cognitive impairment with a functional impairment rating of 3 (Extensive assistance - resident involved in activity, staff provide weight-bearing support) for transfers, toileting, bed mobility, and dressing. Record review of Resident #2's care plan dated, 03-15-2023, indicated Resident #2 had ADL self-care deficit due to right shoulder/right hip fractures requiring extensive assistance bathing, personal hygiene, and dressing. Record review of Resident #2's care plan revealed she was at risk for falls stating, Be sure the call light is within reach and encourage to use it to call for assistance as needed. In an observation/interview, on 3-27-2024, at 12:15 PM, revealed Resident #2 did not know where her call light was and that she uses her call light. Observation showed Resident #2's call light was dangling, on the left side of Resident #2's bed on the floor, while Resident #2 was sitting in a wheelchair, on the right side of her bed. Resident #2 said not being able to find her call light made her feel alone. In an interview with RN-A, on 3-27-2024, at 12:20 PM, it was revealed the concern for Resident #2, not being able to reach her call light, was Resident #2 could have been in distress and not be able to contact the nursing staff for help. In an interview with the DON, on 3-27-20245, at 3:00 PM, it was disclosed that the concern for residents, not having their call lights within reach, was they will not be able to get help when needed. The DON stated every direct care staff is responsible for ensuring call lights are within reach for each resident. The DON said the facility ensures call lights are within reach of each resident by teamwork and communication between staff members. The DON stated the facility provides education to ensure staff understand the importance of call lights being within reach of residents. In an interview with the Administrator, on 3-28-2024, at 5:40 PM, it was revealed that her expectation, concerning call lights being within reach, was to follow the facility's call light policy and for the call lights to be within reach of the resident, before the staff member leave the resident's room. The Administrator stated that the CNAs work under the license of the nurses, so the nurses are responsible to follow up behind the CNAs ensuring call lights are placed within reach of residents. Record review of the facility's call light policy, dated 8-2020, stated it is the policy of this facility to provide the resident a means of communication with nursing staff by 1 - Answering the light/bell within a reasonable time frame 2 - Turn off the call light/bell 3 - Listen to the residents need 4 - Respond to the request . 5 - Leave the resident comfortable. Place the call device within resident's reach before leaving room .

Based on observation, interview and record review, the facility failed to consult with the resident's physician and notify the resident's representative when there was a significant change in the resident's physical status for one (Resident #1) of three residents reviewed for notification of changes. LVN A failed to consult with Resident #1's attending physician or notify the resident's representative when the condition of the wound on Resident #1's left foot deteriorated significantly. The wound was identified on [DATE] and five days later, on [DATE], Resident #1 required hospitalization due [MEDICAL CONDITION], gangrene and osteo[DIAGNOSES REDACTED] related to the wound on her left foot. Resident #1's left leg was amputated below the knee, but she died from complications on [DATE]. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility Administrator received and signed the IJ template on [DATE] at 6:10 PM. These failures could place residents at risk for a delay in treatment or [DIAGNOSES REDACTED]. Findings included: Review of Resident #1's Minimum Data Set (MDS) Quarterly Resident Assessment, dated [DATE], reflected she was an [AGE] year old female admitted to the facility on [DATE]. Her active [DIAGNOSES REDACTED]. She had severe cognitive impairment and required extensive assistance of one person for her activities of daily living. She was identified as a high risk for skin alteration but did not have any skin injuries noted at the time of the assessment. Review of Resident #1's comprehensive care plan, dated [DATE], reflected she was at risk for skin breakdown or pressure ulcers related to impaired mobility and unable to reposition self. The interventions included weekly skin checks and prevent of friction or sheering. Review of Resident #1's Skin Assessment, dated [DATE], revealed the assessment did not identify any wounds or injuries to Resident #1's left foot. Review of Resident #1's Skin Altercation Report, dated [DATE] and revised [DATE] by LVN A, reflected LVN A documented Resident #1's family member noticed a skin tear to the resident's left great toe. The report indicated Resident #1's great toe, second toe and lower extremity was purple. LVN A documented she would perform wound care to the skin tear and call the physician. The report did not reflect actual contact with the physician. Review of Resident #1's Skin Assessment, dated [DATE] and completed by LVN A, reflected the wound on Resident #1's left was described as a skin tear to the right (error) toe and the dimensions were identified as 1.2 centimeters (cm) in length, 1 cm in width and 0.1 cm in depth. Review of Resident #1's nurses' note, dated [DATE] and entered by LVN T, who was the charge nurse for the oncoming shift, revealed x-rays to the resident's left foot were done and the results were pending. The entry revealed the resident's great toe was slightly tender and Resident #1 withdrew her foot when touched, but refused pain medication and vitals. There was no documentation in the nurses' notes on [DATE] of the resident's physician or physician's assistant (PA) being notified of the new skin injury . Review of physician's orders [REDACTED]. The order was not signed by the physician. Review of Resident #1's nurses' note, dated [DATE] and entered by LVN T during the 2 PM to 10 PM shift, revealed Resident #1's left big toe was swollen, x-rays were done and the results were negative for fracture (verified by review of x-ray results). The note revealed the resident's vitals were within normal limits and her foot was slightly elevated . The note did not reflect any evidence of the family or physician being notified. Review of physician's orders [REDACTED]. The order was not signed by the physician. Review of Resident #1's nurses' note, dated [DATE] and entered by LVN C, revealed Resident #1's foot was described as swollen with black spots and a foul odor. The note indicated Resident #1's PA was notified and orders were received to send Resident #1 to the hospital for further evaluation. According to the note the DON and the family were notified and the family member was present when Resident #1 was transported to the hospital. The note reflected no treatment orders for the wound on (Resident #1's) left foot. Review of Resident #1's nurses' notes conducted prior to [DATE] revealed there were no nurses' notes on [DATE], [DATE], and [DATE] related to Resident #1's left foot. On [DATE] LVN A made two late entries into the nurses' notes. LVN A documented on [DATE] wound care was performed and a uric acid level was ordered and on [DATE] Resident #1's PA was notified of the x-ray results. Review of Resident #1's clinical record, including physician's orders [REDACTED].#1's left foot from [DATE] through [DATE]. LVN A made a late entry on [DATE], to reflect wound care orders given by Resident #1's attending physician to cleanse left foot 2nd digit with normal saline, pat dry, apply steri-strips and monitor daily until heal. Since this was a late entry, there was no corresponding record of this treatment when/if it was rendered. Review of the facility's 24-hour Report for [DATE] through [DATE], reflected the following entries related to Resident #1: [DATE] - x-ray to left foot, pending results. [DATE] - x-ray to left foot, pending results. [DATE] - x-ray to left foot negative for fracture. See MAR/TAR for new medications. [DATE] - monitor for [MEDICAL CONDITION]. [DATE] - monitor for [MEDICAL CONDITION]. [DATE] - sent out to hospital. Review of Resident #1's Medication/Treatment Administration Record, dated [DATE], reflected no evidence of orders for wound care to Resident #1's left foot or of any wound care treatment rendered to her left foot. General [MEDICAL CONDITION] (did not specify lower extremities) was monitored and signed off on every shift however there was no documentation of if [MEDICAL CONDITION] was present and if so, how much [MEDICAL CONDITION] was noted. Review of Resident #1's hospital records, dated [DATE] through [DATE], reflected the following: On [DATE] the emergency room doctor assessed the resident's left foot and noted a stasis ulcer (a breakdown of the skin caused by fluid build-up from poor circulation) on her lower left extremity. The great toe was described as black, foul smelling and appeared to be in various stages of necrosis (dead tissue). The hospital record indicated Resident #1 was diagnosed with [REDACTED]. According to the medical records, Resident #1 was transferred to a different hospital for advanced vascular care. On [DATE] Resident #1 received an additional [DIAGNOSES REDACTED]. On [DATE] Resident #1 presented with post-operative [MEDICAL CONDITION] and was transferred to the Intensive Care Unit on ventilator. In an interview with Resident #1's family member on [DATE] at 11:45 AM, she said she discovered Resident #1's left foot/toe wound on [DATE] as she helped the resident put her shoes on. She said she immediately informed LVN A, who was the wound care nurse. The family member said Resident #1's entire left foot was swollen, the great toe had an open area, and four toenails and the surrounding areas were light purple and light black. The family member said LVN A told her this was the first report/sighting of the wound and she (LVN A) would follow-up on it. Resident #1's family member said LVN A called the next day or the day after and told her the x-rays were negative for a fracture and the resident wound be tested for gout. The family member said she was not contacted again regarding Resident #1's condition, the state of the wound, or any test results. She said she visited Resident #1 on [DATE] and noticed the resident's left foot/toe had severely worsened. She said there was a foul, pungent odor and the black/purple colors had turned much darker. She described the appearance of the wound and surroundig skin as similar to burnt skin. She said Resident #1 was immediately transported to the hospital for further evaluation. She said the hospital physicians diagnosed Resident #1 with gangrene on her left foot. She said amputation was discussed however other treatments were going to be attempted first since the likelihood of Resident #1 surviving a major surgery was low. An interview with LVN A on [DATE] at 1:10 PM revealed she was Resident #1's charge nurse and also the wound care nurse as of about one month ago. She said she was notified of Resident #1's wound on her left foot by their family member during the week of [DATE]. She said she assessed the area and the resident's entire left foot was swollen, discolored (red and purple tones), and an open area was noted on the side of her great toe. LVN A said x-rays were done but the results were negative for a fracture. She said Physician's Assistant (PA) B then ordered a uric acid lab for possible gout, but the resident was sent out to the hospital before those results were available. She said prior to Resident #1's hospitalization , she provided wound care to the affected area for about two days, which involved applying skin prep and a steri-strip on the open area . LVN A alleged she received wound care orders from PA B and she performed the care at least two times during the week. She later said she must have just forgot to document the order and therefore also failed to document the days/times the treatments were rendered. LVN A said she communicated with oncoming staff about the Resident#'1's condition through the 24-hour reports. She said Resident #1 was eventually sent out to the hospital on [DATE], due to further discoloration noted to her left foot. LVN A said she did not have too much information about Resident #1's status on [DATE] as she only worked Monday through Friday and did not receive direct report about the situation. Interview with CNA D on [DATE] at 3:15 PM revealed she first saw Resident #1's left foot wound on [DATE]. She said LVN A told her and LVN T and LVN U, not to worry about it because she had already gotten x-rays of it and had it taken care of. CNA D said Resident #1's left foot looked swollen and red in color on [DATE]. She said by the next day ([DATE]) the color started to turn into a purple and black hue. She said there as an open area on one of Resident #1's toes and a few scabs noted on the front and side of the foot. She said LVN A insisted she had it under control and even mentioned she told the family member it was not necessary for Resident #1 to be seen by the wound care doctor when they requested it. CNA D said she never saw any wound care treatment being performed on Resident #1's left foot nor did she see any steri-strips applied to it either. CNA D stated over the weekend, [DATE] night going into the [DATE] morning shift, LVN C started to ask questions about Resident #1's wound and called the PA. CNA D said Resident #1's family member arrived shortly after the PA was contacted and the resident was transported to the hospital. Attempts to interview LVN U were unsuccessful on [DATE] 5:00 PM and [DATE] at 1:00 PM. Attempts interview LVN T were unsuccessful on [DATE] at 4:45 PM and [DATE] and 4:00 PM. Interview with LVN C on [DATE] at 3:07 PM revealed she was Resident #1's charge nurse over the weekends. LVN C said she previously saw Resident #1 on [DATE] and there were no issues noted to her left foot at that time. She said, on [DATE] , she was prompted by Resident #1 family member to check her left foot. She said she noticed Resident #1 had a wound to her left foot with a foul yeast-like odor, swelling and severe discoloration, including red and black hues. She said the great toe and second digit were completely black in color and there were scattered black areas on the rest of the toes and the front of the foot. She said she checked Resident #1's nurses' notes and saw documentation about a skin tear on the resident's left foot but did not see any physician's orders [REDACTED]. She said she only saw evidence of an x-ray done a few days prior. She said this prompted her to call PA B and describe the wound/foot to her. LVN C stated she received orders to send Resident #1 out to the hospital for further evaluation. LVN C said she notified the family and DON of the situation. She said Resident #1 was not known to have frequent swelling/[MEDICAL CONDITION] or discoloration to her extremities. LVN C said she worked the day prior, [DATE], but was not prompted to check Resident #1's foot since there were no orders and the resident did not have any signs/symptoms of discomfort or pain to her lower extremities. Interview with LVN A on [DATE] at 4:15 PM revealed she realized she had not adequately documented the change of condition regarding Resident #1's foot wound. She said she added some late entry nurses notes today and revised the skin assessments/reports to be more detailed. She said she must have forgotten to document the telephone orders for the wound care treatment, but she insisted that PA B verbally gave her the orders to apply skin prep daily and a one-time application of steri-strips to the left great toe. LVN A said she could not recall the date these orders were given. LVN A acknowledged that these alleged wound care orders were not listed on the treatment administration record (TAR) since she did not enter the order in the electronic system and therefore weekend staff did not know to render treatment. She said the last time she saw Resident #1's left foot wound was on [DATE] and there were no signs of necrotic tissue or foul odors at that time. She said she recalled documenting on the facility's 24-hour report and verbally reporting to the oncoming nurse, LVN T, about the condition of the resident's foot. LVN A denied refusing Resident #1's family member's request for a wound care consult/referral. Interview with PA B on [DATE] at 9:15 AM revealed she was Resident #1's Attending Physician's representative and routinely saw Resident #1 and provided medical care to her. PA B said she was in the facility on [DATE] however she was not told about Resident #1 having a newly identified wound and therefore did not see her on that day. PA B said the first report of the area to Resident #1 left foot was on [DATE] by LVN A. She said LVN A reported to her that Resident #1 had a swollen left foot and that x-rays had been performed and were negative for a fracture. PA B said she did not order those x-rays or any wound care treatment. (It was never determined who gave these orders) PA B stated she was not made aware of any open areas to Resident #1's foot or any discoloration - only swelling. PA B said she gave orders (on [DATE]) for a uric acid level test to eliminate gout as the cause for the swelling and also ordered two oral medications to treat the symptoms. PA B said LVN A did not communicate with her any time after [DATE] related to Resident #1's wound. PA B said on [DATE], she received a call from the weekend nurse, LVN C, and this was the first time she became aware of an open area and discoloration to Resident #1's toe. She said LVN C reported black narcotic tissue on Resident #1's left foot and a foul odor on [DATE]. PA B said she immediately gave orders to send Resident #1 to the hospital for further evaluation. PA B said had she known about an open area or any discoloration prior to [DATE], she would have had a different course of treatment for [REDACTED]. She said LVNs/RNs do not have the ability to give orders for x-rays or wound care treatment and she expected a detailed report of wounds and changes in conditions. PA B said Resident #1 did not have a significant history of non-healing/worsening wounds and did not have an issue of frequent [MEDICAL CONDITION]/swelling. Interview with Resident #1's Attending Physician on [DATE] at 3:28 PM revealed he was not made aware of Resident #1's wound or worsening condition until [DATE] after PA B informed him of the narcotic tissue and hospitalization . He denied having any standing orders for x-rays or wound treatment or giving LVN A such orders for Resident #1's left foot. Interview with the Wound Care Physician on [DATE] at 1:15 PM revealed she never had Resident #1 on her case load nor was she ever asked to see her. She said she was in the facility on [DATE] but LVN A, who was the facility's wound care nurse, did not mention anything regarding a wound identified on Resident #1. The Wound Care Physician said she was open to see/assess any resident if a referral was made by their attending physician. She denied having standing orders for wound care in the facility or giving LVN A such orders for Resident #1's left foot. Interview with the DON on [DATE] at 5:00 PM revealed she did not know LVN A left out pertinent details about Resident #1's wound when reporting to PA B or her failure to document adequately on the situation. She said she was appalled by LVN A's actions and LVN A was currently suspended and would likely be terminated as a result of this matter. The DON said she was informed of a skin tear, orders for x-ray, and [MEDICAL CONDITION] days before Resident #1's hospitalization but did not know the severity of it until LVN C reported black necrotic tissue on [DATE] . The DON said since she did not know the severity, she did not assess Resident #1's left foot leading up to her hospitalization . She said she expected her nursing staff to report all wounds/skin integrity issues to the resident's physician in detail, obtain and transcribe orders as given by the physician, and continue to monitor/follow-up until the identified issue was resolved. The DON said she initiated a facility wide skin sweep to determine any other potentially affected residents. Interview with Resident #1's family member on [DATE] at 12:20 PM, revealed Resident #1 underwent vascular surgery and was in ICU because of complications that arose during surgery. She stated Resident #1 almost choked on blood from being ventilated. The family member said amputation of Resident #1's left foot was not totally ruled out yet and would depend on the healing process/effectiveness of the vascular surgery. The family member said she recalled asking LVN A about a wound doctor referral when the wound was first identified and was told by LVN A the area was not bad enough to be seen by the wound doctor. Observation of Resident #1 on [DATE] at 12:20 PM revealed she was in the intensive care unit (ICU) of the hospital following a vascular surgery. At that time, Resident #1 was awake and alert however not available for an interview due to cognitive impairments. Resident #1's left foot was swollen and appeared red in color from the ankle down. The top of the left foot and the outer ankle had half-dollar sized black scabs. All toes had black colored skin in between and behind the toes. Further interviews with the family members between [DATE] and [DATE] revealed Resident #1 did receive an amputation of her left leg, but suffered complications related to kidney failure. The family member reported that Resident #1 expired in the hospital on [DATE] due to lung failure. Further review of Resident #1's hospital records from [DATE] through [DATE] revealed on [DATE] Resident #1 underwent above the knee amputation to the left leg for a [DIAGNOSES REDACTED]. On [DATE], Resident #1 was removed from intubation but was minimally responsive. On [DATE], Resident #1 was placed on hospice services and Do Not Resuscitate forms were initiated. On [DATE], Resident #1 was lethargic with a weak cough and reacted minimally to voice. On [DATE], Resident #1 expired in hospital. Review of a Disciplinary Action Form, dated [DATE], reflected LVN A was terminated due to failure to document. Review of the facility's Change in Condition Policy, revised [DATE], reflected It is the policy of this facility that all changes in resident condition will be communicated to the physician .Any sudden or serious change in resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation .All nursing actions will be documented in the licensed progress notes as soon as possible after resident needs have been met .The licensed nurse responsible for the resident will continue assessment and documentation every shift for at least [AGE] hours or until condition has stabilized .and have needs clearly communicated to each shift . Review of the facility's Wound Care & Treatment Guideline, revised [DATE], reflected It is the policy of this facility to provide excellent wound care to promote healing .a weekly assessment should be done all wounds requirement treatment, will should include description .there must be a specific order for the treatment. Documentation of the treatment should be done immediately after the treatment . Review of the facility's Abuse policy, revised [DATE], reflected It is the policy of this facility that each resident has the right to be free from abuse .The facility will provide oversight and monitoring to ensure that it's staff, who are agents of the facility, deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse . An IJ was identified on [DATE], the Administrator and DON were notified of the IJ and a plan of removal to remove the immediacy was requested at that time. Interview with the Administrator (ADM) on [DATE] at 4:30 PM revealed she believed the IJ occurred due to oversight issues from nursing department. She said she oversaw the nursing department by means of daily rounds and clinical meetings. The ADM said to prevent such further occurrences the entire nursing department had been educated on change of condition, assessments, and documentation. The Quality Assessment and Performance Improvement (QAPI) team would meet weekly with attendance of the Medical Director. She said the nursing department and systems would be monitored more closely as well. Review of the facility's Plan of Removal, dated [DATE], reflected the following: Immediate Action Medical Director notified of IJ on [DATE] at 7:29 p.m. Treatment Nurse suspended on [DATE] and terminated on [DATE]. Skin sweep of total census completed. Skin Integrity Risk Assessment Braden on all residents completed. Review of all treatment orders completed Identification of Others Affected Currently there are 134 residents at risk for alterations in skin integrity. Pressure Wound: 9 Skin Tear: 5 Rash: 19 Vascular Ulcers: 2 Systemic Change to Prevent Re-occurrence 1. RN clinical resource started in-service on [DATE] and completed on [DATE] with DON and ADONs, on documentation of Change of Condition process, monitoring of change of condition, skin integrity and monitoring skin integrity system to include: a. Braden risk assessment to be documented by Licensed Nurse on admission for 4 weeks, quarterly, and with any change of condition. b. Shower sheets implemented [DATE] for CNA to document and communicate any new skin changes (notification of, not limited to: coloration, measurement, type, swelling, temperature, and/or [MEDICAL CONDITION]), to Licensed Nurse who will communicate to ADON/designee for monitoring and follow up. c. Weekly head to toe skin assessments documented for total census started on [DATE] and completed on [DATE]. i. In-services with CNAs on shower sheet documentation and notification to licensed nurse started on [DATE] and to be completed prior to accepting assignment. 2. ADM, DON, ADON, MDS, and treatment nurse/designees to attend weekly systems meeting to include the Skin integrity system to review weekly assessment, status and progression of current pressure injuries and wounds, review and update of care plan interventions, notifications of Resident Responsible Parties, and Physicians. 3. Clinical Resource will In-service nursing staff on documentation of head to toe assessment and timely follow up and notifications started on [DATE] and to be completed prior to accepting assignment. 4. Clinical Resource will in-service on documentation of change of condition notification to responsible party and physician (notification of, not limited to: coloration, measurement, type, swelling, temperature, and/or [MEDICAL CONDITION]), with nursing staff including documentation of Stop and Watch, Change of Condition assessment, notifications, and monitoring after a change of condition occurs. In-services started on [DATE] and to be completed prior to accepting assignment. 5. Providers: a. Podiatry - licensed nurse will accompany podiatrist during scheduled visits. b. Wound Care - review any skin condition referred by facility physician, including skin tears, rashes, discoloration, swelling, vascular ulcers, pressure ulcers, and/or surgical wounds. Monitoring Daily review of documented Change of Condition, Stop & Watch, Change of Condition assessment in leadership start up meeting (ADM, Interim DON, ADON, MDS/designees). Daily review of documented head to toe skin assessments completed and documented shower sheets (CNA communication sheets.) by DON or designee. DON/designee will ensure notifications and physician orders [REDACTED]. In-services not limited to, documenting skin assessments, timely follow up and notification to Responsible Party and Medical Doctor (notification of, not limited to: coloration, measurement, type, swelling, temperature, and/or [MEDICAL CONDITION]), Stop and Watch, E-interact Change of Condition assessment, and monitoring after a change of condition occurs, notification of change of condition (notification of, not limited to: coloration, measurement, type, swelling, temperature, and/or [MEDICAL CONDITION]), wound treatments, until all applicable personnel educated, in-services will be completed prior to accepting assignments. Summary of IJ and corrective action to be reviewed by QAPI weekly until substantial compliance established and monthly for 90 days to ensure ongoing compliance. Monthly QAPI meeting will include skin related conditions, not limited to, skin tears, rashes, vascular ulcers, pressure ulcers, and/or surgical wounds. Review of a facility in-services, dated [DATE] through [DATE], reflected nursing department staff were trained regarding the following topics: Skin assessments - weekly head to toe assessments, identify areas, who to notify, what/where to document. Changes of condition - who to report to, things to mention, who to notify, how to document. Wounds - notify physician, obtain orders, and document. Resident care - signs and symptoms and prognosis Documentation on electronic healthcare system On [DATE], 16 individual staff interviews were conducted from 8:00 AM to 6:00 PM. Staff represented all three shifts and also worked weekends. Staff were asked to describe the training they had received. Staff were asked about what to do when skin integrity issues and changes of condition were noted on residents. This included who to report to, what information to report, what/where to document and the follow-up/monitoring. All employees interviewed were able to correctly answer questions and described all changes of conditions would be reported to charge nurse. Charge nurses said they would assess the change of condition, document actions, notify residents' physician, family, and DON, obtain/transcribe orders as indicated, follow course of treatment, and monitor until resolved or notify physician, family and DON if condition worsens or does not resolve. The employees were as follows: Day Shift (6:00 AM to 2:00 PM or 8:00 AM to 5:00 PM) LVN E, LVN F, LVN G, CNA H, CNA I, CNA J and CNA K. Evening Shift (2:00 PM to 10:00 PM): LVN L, RN M, CNA N, CNA O, CNA P, and CNA Q. Night Shift (10:00 PM to 6:00 AM): LVN R, LVN S, and CNA T. On [DATE] from 8:00 AM to 6:00 PM, 10 individual residents (Resident #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11) were reviewed for skin integrity issues . This review included a head-to-toe skin assessment, review of their physician orders [REDACTED]. The residents represented varying skin integrity issues and resided in different halls. All residents reviewed had a thorough skin assessment and were receiving adequate care/treatment to any identified skin integrity issues. On [DATE] the Administrator was informed the IJ was removed. While the IJ was removed the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor to ensure the implementation and effectiveness of their plan of removal.

Based on observation, interview and record review, the facility failed to ensure residents were free from abuse for one (Resident #1) of three residents reviewed for abuse. LVN A failed to ensure Resident #1's left foot wound was continuously and accurately assessed, monitored, and treated and the condition of the wound was documented. The wound was identified on [DATE] and five days later, on [DATE], Resident #1 required hospitalization due [MEDICAL CONDITION], gangrene, and osteo[DIAGNOSES REDACTED] related to the wound on her left foot. Resident #1's left leg was amputated below the knee, but she died from complications on [DATE]. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility Administrator received and signed the IJ template on [DATE] at 6:10 PM. These failures could place residents at risk for a delay in treatment or [DIAGNOSES REDACTED]. Findings included: Review of Resident #1's Minimum Data Set (MDS) Quarterly Resident Assessment, dated [DATE], reflected she was an [AGE] year old female admitted to the facility on [DATE]. Her active [DIAGNOSES REDACTED]. She had severe cognitive impairment and required extensive assistance of one person for her activities of daily living. She was identified as a high risk for skin alteration but did not have any skin injuries noted at the time of the assessment. Review of Resident #1's comprehensive care plan, dated [DATE], reflected she was at risk for skin breakdown or pressure ulcers related to impaired mobility and unable to reposition self. The interventions included weekly skin checks and prevent of friction or sheering. Review of Resident #1's Skin Assessment, dated [DATE], revealed the assessment did not identify any wounds or injuries to Resident #1's left foot. Review of Resident #1's Skin Altercation Report, dated [DATE] and revised [DATE] by LVN A, reflected LVN A documented Resident #1's family member noticed a skin tear to the resident's left great toe. The report indicated Resident #1's great toe, second toe and lower extremity was purple. LVN A documented she would perform wound care to the skin tear and call the physician. The report did not reflect actual contact with the physician. Review of Resident #1's Skin Assessment, dated [DATE] and completed by LVN A, reflected the wound on Resident #1's left was described as a skin tear to the right (error) toe and the dimensions were identified as 1.2 centimeters (cm) in length, 1 cm in width and 0.1 cm in depth. Review of Resident #1's nurses' note, dated [DATE] and entered by LVN T, who was the charge nurse for the oncoming shift, revealed x-rays to the resident's left foot were done and the results were pending. The entry revealed the resident's great toe was slightly tender and Resident #1 withdrew her foot when touched, but refused pain medication and vitals. There was no documentation in the nurses' notes on [DATE] of the resident's physician or physician's assistant (PA) being notified of the new skin injury . Review of physician's orders [REDACTED]. The order was not signed by the physician. Review of Resident #1's nurses' note, dated [DATE] and entered by LVN T during the 2 PM to 10 PM shift, revealed Resident #1's left big toe was swollen, x-rays were done and the results were negative for fracture (verified by review of x-ray results). The note revealed the resident's vitals were within normal limits and her foot was slightly elevated . The note did not reflect any evidence of the family or physician being notified. Review of physician's orders [REDACTED]. The order was not signed by the physician. Review of Resident #1's nurses' note, dated [DATE] and entered by LVN C, revealed Resident #1's foot was described as swollen with black spots and a foul odor. The note indicated Resident #1's PA was notified and orders were received to send Resident #1 to the hospital for further evaluation. According to the note the DON and the family were notified and the family member was present when Resident #1 was transported to the hospital. The note reflected no treatment orders for the wound on (Resident #1's) left foot. Review of Resident #1's nurses' notes conducted prior to [DATE] revealed there were no nurses' notes on [DATE], [DATE], and [DATE] related to Resident #1's left foot. On [DATE] LVN A made two late entries into the nurses' notes. LVN A documented on [DATE] wound care was performed and a uric acid level was ordered and on [DATE] Resident #1's PA was notified of the x-ray results. Review of Resident #1's clinical record, including physician's orders [REDACTED].#1's left foot from [DATE] through [DATE]. LVN A made a late entry on [DATE], to reflect wound care orders given by Resident #1's attending physician to cleanse left foot 2nd digit with normal saline, pat dry, apply steri-strips and monitor daily until heal. Since this was a late entry, there was no corresponding record of this treatment when/if it was rendered. Review of the facility's 24-hour Report for [DATE] through [DATE], reflected the following entries related to Resident #1: [DATE] - x-ray to left foot, pending results. [DATE] - x-ray to left foot, pending results. [DATE] - x-ray to left foot negative for fracture. See MAR/TAR for new medications. [DATE] - monitor for [MEDICAL CONDITION]. [DATE] - monitor for [MEDICAL CONDITION]. [DATE] - sent out to hospital. Review of Resident #1's Medication/Treatment Administration Record, dated [DATE], reflected no evidence of orders for wound care to Resident #1's left foot or of any wound care treatment rendered to her left foot. General [MEDICAL CONDITION] (did not specify lower extremities) was monitored and signed off on every shift however there was no documentation of if [MEDICAL CONDITION] was present and if so, how much [MEDICAL CONDITION] was noted. Review of Resident #1's hospital records, dated [DATE] through [DATE], reflected the following: On [DATE] the emergency room doctor assessed the resident's left foot and noted a stasis ulcer (a breakdown of the skin caused by fluid build-up from poor circulation) on her lower left extremity. The great toe was described as black, foul smelling and appeared to be in various stages of necrosis (dead tissue). The hospital record indicated Resident #1 was diagnosed with [REDACTED]. According to the medical records, Resident #1 was transferred to a different hospital for advanced vascular care. On [DATE] Resident #1 received an additional [DIAGNOSES REDACTED]. On [DATE] Resident #1 presented with post-operative [MEDICAL CONDITION] and was transferred to the Intensive Care Unit on ventilator. In an interview with Resident #1's family member on [DATE] at 11:45 AM, she said she discovered Resident #1's left foot/toe wound on [DATE] as she helped the resident put her shoes on. She said she immediately informed LVN A, who was the wound care nurse. The family member said Resident #1's entire left foot was swollen, the great toe had an open area, and four toenails and the surrounding areas were light purple and light black. The family member said LVN A told her this was the first report/sighting of the wound and she (LVN A) would follow-up on it. Resident #1's family member said LVN A called the next day or the day after and told her the x-rays were negative for a fracture and the resident wound be tested for gout. The family member said she was not contacted again regarding Resident #1's condition, the state of the wound, or any test results. She said she visited Resident #1 on [DATE] and noticed the resident's left foot/toe had severely worsened. She said there was a foul, pungent odor and the black/purple colors had turned much darker. She described the appearance of the wound and surroundig skin as similar to burnt skin. She said Resident #1 was immediately transported to the hospital for further evaluation. She said the hospital physicians diagnosed Resident #1 with gangrene on her left foot. She said amputation was discussed however other treatments were going to be attempted first since the likelihood of Resident #1 surviving a major surgery was low. An interview with LVN A on [DATE] at 1:10 PM revealed she was Resident #1's charge nurse and also the wound care nurse as of about one month ago. She said she was notified of Resident #1's wound on her left foot by their family member during the week of [DATE]. She said she assessed the area and the resident's entire left foot was swollen, discolored (red and purple tones), and an open area was noted on the side of her great toe. LVN A said x-rays were done but the results were negative for a fracture. She said Physician's Assistant (PA) B then ordered a uric acid lab for possible gout, but the resident was sent out to the hospital before those results were available. She said prior to Resident #1's hospitalization , she provided wound care to the affected area for about two days, which involved applying skin prep and a steri-strip on the open area . LVN A alleged she received wound care orders from PA B and she performed the care at least two times during the week. She later said she must have just forgot to document the order and therefore also failed to document the days/times the treatments were rendered. LVN A said she communicated with oncoming staff about the Resident#'1's condition through the 24-hour reports. She said Resident #1 was eventually sent out to the hospital on [DATE], due to further discoloration noted to her left foot. LVN A said she did not have too much information about Resident #1's status on [DATE] as she only worked Monday through Friday and did not receive direct report about the situation. Interview with CNA D on [DATE] at 3:15 PM revealed she first saw Resident #1's left foot wound on [DATE]. She said LVN A told her and LVN T and LVN U, not to worry about it because she had already gotten x-rays of it and had it taken care of. CNA D said Resident #1's left foot looked swollen and red in color on [DATE]. She said by the next day ([DATE]) the color started to turn into a purple and black hue. She said there as an open area on one of Resident #1's toes and a few scabs noted on the front and side of the foot. She said LVN A insisted she had it under control and even mentioned she told the family member it was not necessary for Resident #1 to be seen by the wound care doctor when they requested it. CNA D said she never saw any wound care treatment being performed on Resident #1's left foot nor did she see any steri-strips applied to it either. CNA D stated over the weekend, [DATE] night going into the [DATE] morning shift, LVN C started to ask questions about Resident #1's wound and called the PA. CNA D said Resident #1's family member arrived shortly after the PA was contacted and the resident was transported to the hospital. Attempts to interview LVN U were unsuccessful on [DATE] 5:00 PM and [DATE] at 1:00 PM. Attempts interview LVN T were unsuccessful on [DATE] at 4:45 PM and [DATE] and 4:00 PM. Interview with LVN C on [DATE] at 3:07 PM revealed she was Resident #1's charge nurse over the weekends. LVN C said she previously saw Resident #1 on [DATE] and there were no issues noted to her left foot at that time. She said, on [DATE] , she was prompted by Resident #1 family member to check her left foot. She said she noticed Resident #1 had a wound to her left foot with a foul yeast-like odor, swelling and severe discoloration, including red and black hues. She said the great toe and second digit were completely black in color and there were scattered black areas on the rest of the toes and the front of the foot. She said she checked Resident #1's nurses' notes and saw documentation about a skin tear on the resident's left foot but did not see any physician's orders [REDACTED]. She said she only saw evidence of an x-ray done a few days prior. She said this prompted her to call PA B and describe the wound/foot to her. LVN C stated she received orders to send Resident #1 out to the hospital for further evaluation. LVN C said she notified the family and DON of the situation. She said Resident #1 was not known to have frequent swelling/[MEDICAL CONDITION] or discoloration to her extremities. LVN C said she worked the day prior, [DATE], but was not prompted to check Resident #1's foot since there were no orders and the resident did not have any signs/symptoms of discomfort or pain to her lower extremities. Interview with LVN A on [DATE] at 4:15 PM revealed she realized she had not adequately documented the change of condition regarding Resident #1's foot wound. She said she added some late entry nurses notes today and revised the skin assessments/reports to be more detailed. She said she must have forgotten to document the telephone orders for the wound care treatment, but she insisted that PA B verbally gave her the orders to apply skin prep daily and a one-time application of steri-strips to the left great toe. LVN A said she could not recall the date these orders were given. LVN A acknowledged that these alleged wound care orders were not listed on the treatment administration record (TAR) since she did not enter the order in the electronic system and therefore weekend staff did not know to render treatment. She said the last time she saw Resident #1's left foot wound was on [DATE] and there were no signs of necrotic tissue or foul odors at that time. She said she recalled documenting on the facility's 24-hour report and verbally reporting to the oncoming nurse, LVN T, about the condition of the resident's foot. LVN A denied refusing Resident #1's family member's request for a wound care consult/referral. Interview with PA B on [DATE] at 9:15 AM revealed she was Resident #1's Attending Physician's representative and routinely saw Resident #1 and provided medical care to her. PA B said she was in the facility on [DATE] however she was not told about Resident #1 having a newly identified wound and therefore did not see her on that day. PA B said the first report of the area to Resident #1 left foot was on [DATE] by LVN A. She said LVN A reported to her that Resident #1 had a swollen left foot and that x-rays had been performed and were negative for a fracture. PA B said she did not order those x-rays or any wound care treatment. (It was never determined who gave these orders) PA B stated she was not made aware of any open areas to Resident #1's foot or any discoloration - only swelling. PA B said she gave orders (on [DATE]) for a uric acid level test to eliminate gout as the cause for the swelling and also ordered two oral medications to treat the symptoms. PA B said LVN A did not communicate with her any time after [DATE] related to Resident #1's wound. PA B said on [DATE], she received a call from the weekend nurse, LVN C, and this was the first time she became aware of an open area and discoloration to Resident #1's toe. She said LVN C reported black narcotic tissue on Resident #1's left foot and a foul odor on [DATE]. PA B said she immediately gave orders to send Resident #1 to the hospital for further evaluation. PA B said had she known about an open area or any discoloration prior to [DATE], she would have had a different course of treatment for [REDACTED]. She said LVNs/RNs do not have the ability to give orders for x-rays or wound care treatment and she expected a detailed report of wounds and changes in conditions. PA B said Resident #1 did not have a significant history of non-healing/worsening wounds and did not have an issue of frequent [MEDICAL CONDITION]/swelling. Interview with Resident #1's Attending Physician on [DATE] at 3:28 PM revealed he was not made aware of Resident #1's wound or worsening condition until [DATE] after PA B informed him of the narcotic tissue and hospitalization . He denied having any standing orders for x-rays or wound treatment or giving LVN A such orders for Resident #1's left foot. Interview with the Wound Care Physician on [DATE] at 1:15 PM revealed she never had Resident #1 on her case load nor was she ever asked to see her. She said she was in the facility on [DATE] but LVN A, who was the facility's wound care nurse, did not mention anything regarding a wound identified on Resident #1. The Wound Care Physician said she was open to see/assess any resident if a referral was made by their attending physician. She denied having standing orders for wound care in the facility or giving LVN A such orders for Resident #1's left foot. Interview with the DON on [DATE] at 5:00 PM revealed she did not know LVN A left out pertinent details about Resident #1's wound when reporting to PA B or her failure to document adequately on the situation. She said she was appalled by LVN A's actions and LVN A was currently suspended and would likely be terminated as a result of this matter. The DON said she was informed of a skin tear, orders for x-ray, and [MEDICAL CONDITION] days before Resident #1's hospitalization but did not know the severity of it until LVN C reported black necrotic tissue on [DATE] . The DON said since she did not know the severity, she did not assess Resident #1's left foot leading up to her hospitalization . She said she expected her nursing staff to report all wounds/skin integrity issues to the resident's physician in detail, obtain and transcribe orders as given by the physician, and continue to monitor/follow-up until the identified issue was resolved. The DON said she initiated a facility wide skin sweep to determine any other potentially affected residents. Interview with Resident #1's family member on [DATE] at 12:20 PM, revealed Resident #1 underwent vascular surgery and was in ICU because of complications that arose during surgery. She stated Resident #1 almost choked on blood from being ventilated. The family member said amputation of Resident #1's left foot was not totally ruled out yet and would depend on the healing process/effectiveness of the vascular surgery. The family member said she recalled asking LVN A about a wound doctor referral when the wound was first identified and was told by LVN A the area was not bad enough to be seen by the wound doctor. Observation of Resident #1 on [DATE] at 12:20 PM revealed she was in the intensive care unit (ICU) of the hospital following a vascular surgery. At that time, Resident #1 was awake and alert however not available for an interview due to cognitive impairments. Resident #1's left foot was swollen and appeared red in color from the ankle down. The top of the left foot and the outer ankle had half-dollar sized black scabs. All toes had black colored skin in between and behind the toes. Further interviews with the family members between [DATE] and [DATE] revealed Resident #1 did receive an amputation of her left leg, but suffered complications related to kidney failure. The family member reported that Resident #1 expired in the hospital on [DATE] due to lung failure. Further review of Resident #1's hospital records from [DATE] through [DATE] revealed on [DATE] Resident #1 underwent above the knee amputation to the left leg for a [DIAGNOSES REDACTED]. On [DATE], Resident #1 was removed from intubation but was minimally responsive. On [DATE], Resident #1 was placed on hospice services and Do Not Resuscitate forms were initiated. On [DATE], Resident #1 was lethargic with a weak cough and reacted minimally to voice. On [DATE], Resident #1 expired in hospital. Review of a Disciplinary Action Form, dated [DATE], reflected LVN A was terminated due to failure to document. Review of the facility's Change in Condition Policy, revised [DATE], reflected It is the policy of this facility that all changes in resident condition will be communicated to the physician .Any sudden or serious change in resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation .All nursing actions will be documented in the licensed progress notes as soon as possible after resident needs have been met .The licensed nurse responsible for the resident will continue assessment and documentation every shift for at least [AGE] hours or until condition has stabilized .and have needs clearly communicated to each shift . Review of the facility's Wound Care & Treatment Guideline, revised [DATE], reflected It is the policy of this facility to provide excellent wound care to promote healing .a weekly assessment should be done all wounds requirement treatment, will should include description .there must be a specific order for the treatment. Documentation of the treatment should be done immediately after the treatment . Review of the facility's Abuse policy, revised [DATE], reflected It is the policy of this facility that each resident has the right to be free from abuse .The facility will provide oversight and monitoring to ensure that it's staff, who are agents of the facility, deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse . An IJ was identified on [DATE], the Administrator and DON were notified of the IJ and a plan of removal to remove the immediacy was requested at that time. Interview with the Administrator (ADM) on [DATE] at 4:30 PM revealed she believed the IJ occurred due to oversight issues from nursing department. She said she oversaw the nursing department by means of daily rounds and clinical meetings. The ADM said to prevent such further occurrences the entire nursing department had been educated on change of condition, assessments, and documentation. The Quality Assessment and Performance Improvement (QAPI) team would meet weekly with attendance of the Medical Director. She said the nursing department and systems would be monitored more closely as well. Review of the facility's Plan of Removal, dated [DATE], reflected the following: Immediate Action Medical Director notified of IJ on [DATE] at 7:29 p.m. Treatment Nurse suspended on [DATE] and terminated on [DATE]. Skin sweep of total census completed. Skin Integrity Risk Assessment Braden on all residents completed. Review of all treatment orders completed Identification of Others Affected Currently there are 134 residents at risk for alterations in skin integrity. Pressure Wound: 9 Skin Tear: 5 Rash: 19 Vascular Ulcers: 2 Systemic Change to Prevent Re-occurrence 1. RN clinical resource started in-service on [DATE] and completed on [DATE] with DON and ADONs, on documentation of Change of Condition process, monitoring of change of condition, skin integrity and monitoring skin integrity system to include: a. Braden risk assessment to be documented by Licensed Nurse on admission for 4 weeks, quarterly, and with any change of condition. b. Shower sheets implemented [DATE] for CNA to document and communicate any new skin changes (notification of, not limited to: coloration, measurement, type, swelling, temperature, and/or [MEDICAL CONDITION]), to Licensed Nurse who will communicate to ADON/designee for monitoring and follow up. c. Weekly head to toe skin assessments documented for total census started on [DATE] and completed on [DATE]. i. In-services with CNAs on shower sheet documentation and notification to licensed nurse started on [DATE] and to be completed prior to accepting assignment. 2. ADM, DON, ADON, MDS, and treatment nurse/designees to attend weekly systems meeting to include the Skin integrity system to review weekly assessment, status and progression of current pressure injuries and wounds, review and update of care plan interventions, notifications of Resident Responsible Parties, and Physicians. 3. Clinical Resource will In-service nursing staff on documentation of head to toe assessment and timely follow up and notifications started on [DATE] and to be completed prior to accepting assignment. 4. Clinical Resource will in-service on documentation of change of condition notification to responsible party and physician (notification of, not limited to: coloration, measurement, type, swelling, temperature, and/or [MEDICAL CONDITION]), with nursing staff including documentation of Stop and Watch, Change of Condition assessment, notifications, and monitoring after a change of condition occurs. In-services started on [DATE] and to be completed prior to accepting assignment. 5. Providers: a. Podiatry - licensed nurse will accompany podiatrist during scheduled visits. b. Wound Care - review any skin condition referred by facility physician, including skin tears, rashes, discoloration, swelling, vascular ulcers, pressure ulcers, and/or surgical wounds. Monitoring Daily review of documented Change of Condition, Stop & Watch, Change of Condition assessment in leadership start up meeting (ADM, Interim DON, ADON, MDS/designees). Daily review of documented head to toe skin assessments completed and documented shower sheets (CNA communication sheets.) by DON or designee. DON/designee will ensure notifications and physician orders [REDACTED]. In-services not limited to, documenting skin assessments, timely follow up and notification to Responsible Party and Medical Doctor (notification of, not limited to: coloration, measurement, type, swelling, temperature, and/or [MEDICAL CONDITION]), Stop and Watch, E-interact Change of Condition assessment, and monitoring after a change of condition occurs, notification of change of condition (notification of, not limited to: coloration, measurement, type, swelling, temperature, and/or [MEDICAL CONDITION]), wound treatments, until all applicable personnel educated, in-services will be completed prior to accepting assignments. Summary of IJ and corrective action to be reviewed by QAPI weekly until substantial compliance established and monthly for 90 days to ensure ongoing compliance. Monthly QAPI meeting will include skin related conditions, not limited to, skin tears, rashes, vascular ulcers, pressure ulcers, and/or surgical wounds. Review of a facility in-services, dated [DATE] through [DATE], reflected nursing department staff were trained regarding the following topics: Skin assessments - weekly head to toe assessments, identify areas, who to notify, what/where to document. Changes of condition - who to report to, things to mention, who to notify, how to document. Wounds - notify physician, obtain orders, and document. Resident care - signs and symptoms and prognosis Documentation on electronic healthcare system On [DATE], 16 individual staff interviews were conducted from 8:00 AM to 6:00 PM. Staff represented all three shifts and also worked weekends. Staff were asked to describe the training they had received. Staff were asked about what to do when skin integrity issues and changes of condition were noted on residents. This included who to report to, what information to report, what/where to document and the follow-up/monitoring. All employees interviewed were able to correctly answer questions and described all changes of conditions would be reported to charge nurse. Charge nurses said they would assess the change of condition, document actions, notify residents' physician, family, and DON, obtain/transcribe orders as indicated, follow course of treatment, and monitor until resolved or notify physician, family and DON if condition worsens or does not resolve. The employees were as follows: Day Shift (6:00 AM to 2:00 PM or 8:00 AM to 5:00 PM) LVN E, LVN F, LVN G, CNA H, CNA I, CNA J and CNA K. Evening Shift (2:00 PM to 10:00 PM): LVN L, RN M, CNA N, CNA O, CNA P, and CNA Q. Night Shift (10:00 PM to 6:00 AM): LVN R, LVN S, and CNA T. On [DATE] from 8:00 AM to 6:00 PM, 10 individual residents (Resident #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11) were reviewed for skin integrity issues . This review included a head-to-toe skin assessment, review of their physician orders [REDACTED]. The residents represented varying skin integrity issues and resided in different halls. All residents reviewed had a thorough skin assessment and were receiving adequate care/treatment to any identified skin integrity issues. On [DATE] the Administrator was informed the IJ was removed. While the IJ was removed the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor to ensure the implementation and effectiveness of their plan of removal.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest, practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one (Resident #1) of three residents reviewed for quality of care related to change of condition and assessment. LVN A failed to ensure Resident #1's left foot wound was continuously and accurately assessed, monitored, and treated and the condition of the wound was documented. The wound was identified on [DATE] and five days later, on [DATE], Resident #1 required hospitalization due [MEDICAL CONDITION], gangrene, and osteo[DIAGNOSES REDACTED] related to the wound on her left foot. Resident #1's left leg was amputated below the knee, but she died from complications on [DATE]. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility Administrator received and signed the IJ template on [DATE] at 6:10 PM. These failures could place residents at risk for a delay in treatment or [DIAGNOSES REDACTED]. Findings included: Review of Resident #1's Minimum Data Set (MDS) Quarterly Resident Assessment, dated [DATE], reflected she was an [AGE] year old female admitted to the facility on [DATE]. Her active [DIAGNOSES REDACTED]. She had severe cognitive impairment and required extensive assistance of one person for her activities of daily living. She was identified as a high risk for skin alteration but did not have any skin injuries noted at the time of the assessment. Review of Resident #1's comprehensive care plan, dated [DATE], reflected she was at risk for skin breakdown or pressure ulcers related to impaired mobility and unable to reposition self. The interventions included weekly skin checks and prevent of friction or sheering. Review of Resident #1's Skin Assessment, dated [DATE], revealed the assessment did not identify any wounds or injuries to Resident #1's left foot. Review of Resident #1's Skin Altercation Report, dated [DATE] and revised [DATE] by LVN A, reflected LVN A documented Resident #1's family member noticed a skin tear to the resident's left great toe. The report indicated Resident #1's great toe, second toe and lower extremity was purple. LVN A documented she would perform wound care to the skin tear and call the physician. The report did not reflect actual contact with the physician. Review of Resident #1's Skin Assessment, dated [DATE] and completed by LVN A, reflected the wound on Resident #1's left was described as a skin tear to the right (error) toe and the dimensions were identified as 1.2 centimeters (cm) in length, 1 cm in width and 0.1 cm in depth. Review of Resident #1's nurses' note, dated [DATE] and entered by LVN T, who was the charge nurse for the oncoming shift, revealed x-rays to the resident's left foot were done and the results were pending. The entry revealed the resident's great toe was slightly tender and Resident #1 withdrew her foot when touched, but refused pain medication and vitals. There was no documentation in the nurses' notes on [DATE] of the resident's physician or physician's assistant (PA) being notified of the new skin injury . Review of physician's orders [REDACTED]. The order was not signed by the physician. Review of Resident #1's nurses' note, dated [DATE] and entered by LVN T during the 2 PM to 10 PM shift, revealed Resident #1's left big toe was swollen, x-rays were done and the results were negative for fracture (verified by review of x-ray results). The note revealed the resident's vitals were within normal limits and her foot was slightly elevated . The note did not reflect any evidence of the family or physician being notified. Review of physician's orders [REDACTED]. The order was not signed by the physician. Review of Resident #1's nurses' note, dated [DATE] and entered by LVN C, revealed Resident #1's foot was described as swollen with black spots and a foul odor. The note indicated Resident #1's PA was notified and orders were received to send Resident #1 to the hospital for further evaluation. According to the note the DON and the family were notified and the family member was present when Resident #1 was transported to the hospital. The note reflected no treatment orders for the wound on (Resident #1's) left foot. Review of Resident #1's nurses' notes conducted prior to [DATE] revealed there were no nurses' notes on [DATE], [DATE], and [DATE] related to Resident #1's left foot. On [DATE] LVN A made two late entries into the nurses' notes. LVN A documented on [DATE] wound care was performed and a uric acid level was ordered and on [DATE] Resident #1's PA was notified of the x-ray results. Review of Resident #1's clinical record, including physician's orders [REDACTED].#1's left foot from [DATE] through [DATE]. LVN A made a late entry on [DATE], to reflect wound care orders given by Resident #1's attending physician to cleanse left foot 2nd digit with normal saline, pat dry, apply steri-strips and monitor daily until heal. Since this was a late entry, there was no corresponding record of this treatment when/if it was rendered. Review of the facility's 24-hour Report for [DATE] through [DATE], reflected the following entries related to Resident #1: [DATE] - x-ray to left foot, pending results. [DATE] - x-ray to left foot, pending results. [DATE] - x-ray to left foot negative for fracture. See MAR/TAR for new medications. [DATE] - monitor for [MEDICAL CONDITION]. [DATE] - monitor for [MEDICAL CONDITION]. [DATE] - sent out to hospital. Review of Resident #1's Medication/Treatment Administration Record, dated [DATE], reflected no evidence of orders for wound care to Resident #1's left foot or of any wound care treatment rendered to her left foot. General [MEDICAL CONDITION] (did not specify lower extremities) was monitored and signed off on every shift however there was no documentation of if [MEDICAL CONDITION] was present and if so, how much [MEDICAL CONDITION] was noted. Review of Resident #1's hospital records, dated [DATE] through [DATE], reflected the following: On [DATE] the emergency room doctor assessed the resident's left foot and noted a stasis ulcer (a breakdown of the skin caused by fluid build-up from poor circulation) on her lower left extremity. The great toe was described as black, foul smelling and appeared to be in various stages of necrosis (dead tissue). The hospital record indicated Resident #1 was diagnosed with [REDACTED]. According to the medical records, Resident #1 was transferred to a different hospital for advanced vascular care. On [DATE] Resident #1 received an additional [DIAGNOSES REDACTED]. On [DATE] Resident #1 presented with post-operative [MEDICAL CONDITION] and was transferred to the Intensive Care Unit on ventilator. In an interview with Resident #1's family member on [DATE] at 11:45 AM, she said she discovered Resident #1's left foot/toe wound on [DATE] as she helped the resident put her shoes on. She said she immediately informed LVN A, who was the wound care nurse. The family member said Resident #1's entire left foot was swollen, the great toe had an open area, and four toenails and the surrounding areas were light purple and light black. The family member said LVN A told her this was the first report/sighting of the wound and she (LVN A) would follow-up on it. Resident #1's family member said LVN A called the next day or the day after and told her the x-rays were negative for a fracture and the resident wound be tested for gout. The family member said she was not contacted again regarding Resident #1's condition, the state of the wound, or any test results. She said she visited Resident #1 on [DATE] and noticed the resident's left foot/toe had severely worsened. She said there was a foul, pungent odor and the black/purple colors had turned much darker. She described the appearance of the wound and surroundig skin as similar to burnt skin. She said Resident #1 was immediately transported to the hospital for further evaluation. She said the hospital physicians diagnosed Resident #1 with gangrene on her left foot. She said amputation was discussed however other treatments were going to be attempted first since the likelihood of Resident #1 surviving a major surgery was low. An interview with LVN A on [DATE] at 1:10 PM revealed she was Resident #1's charge nurse and also the wound care nurse as of about one month ago. She said she was notified of Resident #1's wound on her left foot by their family member during the week of [DATE]. She said she assessed the area and the resident's entire left foot was swollen, discolored (red and purple tones), and an open area was noted on the side of her great toe. LVN A said x-rays were done but the results were negative for a fracture. She said Physician's Assistant (PA) B then ordered a uric acid lab for possible gout, but the resident was sent out to the hospital before those results were available. She said prior to Resident #1's hospitalization , she provided wound care to the affected area for about two days, which involved applying skin prep and a steri-strip on the open area . LVN A alleged she received wound care orders from PA B and she performed the care at least two times during the week. She later said she must have just forgot to document the order and therefore also failed to document the days/times the treatments were rendered. LVN A said she communicated with oncoming staff about the Resident#'1's condition through the 24-hour reports. She said Resident #1 was eventually sent out to the hospital on [DATE], due to further discoloration noted to her left foot. LVN A said she did not have too much information about Resident #1's status on [DATE] as she only worked Monday through Friday and did not receive direct report about the situation. Interview with CNA D on [DATE] at 3:15 PM revealed she first saw Resident #1's left foot wound on [DATE]. She said LVN A told her and LVN T and LVN U, not to worry about it because she had already gotten x-rays of it and had it taken care of. CNA D said Resident #1's left foot looked swollen and red in color on [DATE]. She said by the next day ([DATE]) the color started to turn into a purple and black hue. She said there as an open area on one of Resident #1's toes and a few scabs noted on the front and side of the foot. She said LVN A insisted she had it under control and even mentioned she told the family member it was not necessary for Resident #1 to be seen by the wound care doctor when they requested it. CNA D said she never saw any wound care treatment being performed on Resident #1's left foot nor did she see any steri-strips applied to it either. CNA D stated over the weekend, [DATE] night going into the [DATE] morning shift, LVN C started to ask questions about Resident #1's wound and called the PA. CNA D said Resident #1's family member arrived shortly after the PA was contacted and the resident was transported to the hospital. Attempts to interview LVN U were unsuccessful on [DATE] 5:00 PM and [DATE] at 1:00 PM. Attempts interview LVN T were unsuccessful on [DATE] at 4:45 PM and [DATE] and 4:00 PM. Interview with LVN C on [DATE] at 3:07 PM revealed she was Resident #1's charge nurse over the weekends. LVN C said she previously saw Resident #1 on [DATE] and there were no issues noted to her left foot at that time. She said, on [DATE] , she was prompted by Resident #1 family member to check her left foot. She said she noticed Resident #1 had a wound to her left foot with a foul yeast-like odor, swelling and severe discoloration, including red and black hues. She said the great toe and second digit were completely black in color and there were scattered black areas on the rest of the toes and the front of the foot. She said she checked Resident #1's nurses' notes and saw documentation about a skin tear on the resident's left foot but did not see any physician's orders [REDACTED]. She said she only saw evidence of an x-ray done a few days prior. She said this prompted her to call PA B and describe the wound/foot to her. LVN C stated she received orders to send Resident #1 out to the hospital for further evaluation. LVN C said she notified the family and DON of the situation. She said Resident #1 was not known to have frequent swelling/[MEDICAL CONDITION] or discoloration to her extremities. LVN C said she worked the day prior, [DATE], but was not prompted to check Resident #1's foot since there were no orders and the resident did not have any signs/symptoms of discomfort or pain to her lower extremities. Interview with LVN A on [DATE] at 4:15 PM revealed she realized she had not adequately documented the change of condition regarding Resident #1's foot wound. She said she added some late entry nurses notes today and revised the skin assessments/reports to be more detailed. She said she must have forgotten to document the telephone orders for the wound care treatment, but she insisted that PA B verbally gave her the orders to apply skin prep daily and a one-time application of steri-strips to the left great toe. LVN A said she could not recall the date these orders were given. LVN A acknowledged that these alleged wound care orders were not listed on the treatment administration record (TAR) since she did not enter the order in the electronic system and therefore weekend staff did not know to render treatment. She said the last time she saw Resident #1's left foot wound was on [DATE] and there were no signs of necrotic tissue or foul odors at that time. She said she recalled documenting on the facility's 24-hour report and verbally reporting to the oncoming nurse, LVN T, about the condition of the resident's foot. LVN A denied refusing Resident #1's family member's request for a wound care consult/referral. Interview with PA B on [DATE] at 9:15 AM revealed she was Resident #1's Attending Physician's representative and routinely saw Resident #1 and provided medical care to her. PA B said she was in the facility on [DATE] however she was not told about Resident #1 having a newly identified wound and therefore did not see her on that day. PA B said the first report of the area to Resident #1 left foot was on [DATE] by LVN A. She said LVN A reported to her that Resident #1 had a swollen left foot and that x-rays had been performed and were negative for a fracture. PA B said she did not order those x-rays or any wound care treatment. (It was never determined who gave these orders) PA B stated she was not made aware of any open areas to Resident #1's foot or any discoloration - only swelling. PA B said she gave orders (on [DATE]) for a uric acid level test to eliminate gout as the cause for the swelling and also ordered two oral medications to treat the symptoms. PA B said LVN A did not communicate with her any time after [DATE] related to Resident #1's wound. PA B said on [DATE], she received a call from the weekend nurse, LVN C, and this was the first time she became aware of an open area and discoloration to Resident #1's toe. She said LVN C reported black narcotic tissue on Resident #1's left foot and a foul odor on [DATE]. PA B said she immediately gave orders to send Resident #1 to the hospital for further evaluation. PA B said had she known about an open area or any discoloration prior to [DATE], she would have had a different course of treatment for [REDACTED]. She said LVNs/RNs do not have the ability to give orders for x-rays or wound care treatment and she expected a detailed report of wounds and changes in conditions. PA B said Resident #1 did not have a significant history of non-healing/worsening wounds and did not have an issue of frequent [MEDICAL CONDITION]/swelling. Interview with Resident #1's Attending Physician on [DATE] at 3:28 PM revealed he was not made aware of Resident #1's wound or worsening condition until [DATE] after PA B informed him of the narcotic tissue and hospitalization . He denied having any standing orders for x-rays or wound treatment or giving LVN A such orders for Resident #1's left foot. Interview with the Wound Care Physician on [DATE] at 1:15 PM revealed she never had Resident #1 on her case load nor was she ever asked to see her. She said she was in the facility on [DATE] but LVN A, who was the facility's wound care nurse, did not mention anything regarding a wound identified on Resident #1. The Wound Care Physician said she was open to see/assess any resident if a referral was made by their attending physician. She denied having standing orders for wound care in the facility or giving LVN A such orders for Resident #1's left foot. Interview with the DON on [DATE] at 5:00 PM revealed she did not know LVN A left out pertinent details about Resident #1's wound when reporting to PA B or her failure to document adequately on the situation. She said she was appalled by LVN A's actions and LVN A was currently suspended and would likely be terminated as a result of this matter. The DON said she was informed of a skin tear, orders for x-ray, and [MEDICAL CONDITION] days before Resident #1's hospitalization but did not know the severity of it until LVN C reported black necrotic tissue on [DATE] . The DON said since she did not know the severity, she did not assess Resident #1's left foot leading up to her hospitalization . She said she expected her nursing staff to report all wounds/skin integrity issues to the resident's physician in detail, obtain and transcribe orders as given by the physician, and continue to monitor/follow-up until the identified issue was resolved. The DON said she initiated a facility wide skin sweep to determine any other potentially affected residents. Interview with Resident #1's family member on [DATE] at 12:20 PM, revealed Resident #1 underwent vascular surgery and was in ICU because of complications that arose during surgery. She stated Resident #1 almost choked on blood from being ventilated. The family member said amputation of Resident #1's left foot was not totally ruled out yet and would depend on the healing process/effectiveness of the vascular surgery. The family member said she recalled asking LVN A about a wound doctor referral when the wound was first identified and was told by LVN A the area was not bad enough to be seen by the wound doctor. Observation of Resident #1 on [DATE] at 12:20 PM revealed she was in the intensive care unit (ICU) of the hospital following a vascular surgery. At that time, Resident #1 was awake and alert however not available for an interview due to cognitive impairments. Resident #1's left foot was swollen and appeared red in color from the ankle down. The top of the left foot and the outer ankle had half-dollar sized black scabs. All toes had black colored skin in between and behind the toes. Further interviews with the family members between [DATE] and [DATE] revealed Resident #1 did receive an amputation of her left leg, but suffered complications related to kidney failure. The family member reported that Resident #1 expired in the hospital on [DATE] due to lung failure. Further review of Resident #1's hospital records from [DATE] through [DATE] revealed on [DATE] Resident #1 underwent above the knee amputation to the left leg for a [DIAGNOSES REDACTED]. On [DATE], Resident #1 was removed from intubation but was minimally responsive. On [DATE], Resident #1 was placed on hospice services and Do Not Resuscitate forms were initiated. On [DATE], Resident #1 was lethargic with a weak cough and reacted minimally to voice. On [DATE], Resident #1 expired in hospital. Review of a Disciplinary Action Form, dated [DATE], reflected LVN A was terminated due to failure to document. Review of the facility's Change in Condition Policy, revised [DATE], reflected It is the policy of this facility that all changes in resident condition will be communicated to the physician .Any sudden or serious change in resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation .All nursing actions will be documented in the licensed progress notes as soon as possible after resident needs have been met .The licensed nurse responsible for the resident will continue assessment and documentation every shift for at least [AGE] hours or until condition has stabilized .and have needs clearly communicated to each shift . Review of the facility's Wound Care & Treatment Guideline, revised [DATE], reflected It is the policy of this facility to provide excellent wound care to promote healing .a weekly assessment should be done all wounds requirement treatment, will should include description .there must be a specific order for the treatment. Documentation of the treatment should be done immediately after the treatment . Review of the facility's Abuse policy, revised [DATE], reflected It is the policy of this facility that each resident has the right to be free from abuse .The facility will provide oversight and monitoring to ensure that it's staff, who are agents of the facility, deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse . An IJ was identified on [DATE], the Administrator and DON were notified of the IJ and a plan of removal to remove the immediacy was requested at that time. Interview with the Administrator (ADM) on [DATE] at 4:30 PM revealed she believed the IJ occurred due to oversight issues from nursing department. She said she oversaw the nursing department by means of daily rounds and clinical meetings. The ADM said to prevent such further occurrences the entire nursing department had been educated on change of condition, assessments, and documentation. The Quality Assessment and Performance Improvement (QAPI) team would meet weekly with attendance of the Medical Director. She said the nursing department and systems would be monitored more closely as well. Review of the facility's Plan of Removal, dated [DATE], reflected the following: Immediate Action Medical Director notified of IJ on [DATE] at 7:29 p.m. Treatment Nurse suspended on [DATE] and terminated on [DATE]. Skin sweep of total census completed. Skin Integrity Risk Assessment Braden on all residents completed. Review of all treatment orders completed Identification of Others Affected Currently there are 134 residents at risk for alterations in skin integrity. Pressure Wound: 9 Skin Tear: 5 Rash: 19 Vascular Ulcers: 2 Systemic Change to Prevent Re-occurrence 1. RN clinical resource started in-service on [DATE] and completed on [DATE] with DON and ADONs, on documentation of Change of Condition process, monitoring of change of condition, skin integrity and monitoring skin integrity system to include: a. Braden risk assessment to be documented by Licensed Nurse on admission for 4 weeks, quarterly, and with any change of condition. b. Shower sheets implemented [DATE] for CNA to document and communicate any new skin changes (notification of, not limited to: coloration, measurement, type, swelling, temperature, and/or [MEDICAL CONDITION]), to Licensed Nurse who will communicate to ADON/designee for monitoring and follow up. c. Weekly head to toe skin assessments documented for total census started on [DATE] and completed on [DATE]. i. In-services with CNAs on shower sheet documentation and notification to licensed nurse started on [DATE] and to be completed prior to accepting assignment. 2. ADM, DON, ADON, MDS, and treatment nurse/designees to attend weekly systems meeting to include the Skin integrity system to review weekly assessment, status and progression of current pressure injuries and wounds, review and update of care plan interventions, notifications of Resident Responsible Parties, and Physicians. 3. Clinical Resource will In-service nursing staff on documentation of head to toe assessment and timely follow up and notifications started on [DATE] and to be completed prior to accepting assignment. 4. Clinical Resource will in-service on documentation of change of condition notification to responsible party and physician (notification of, not limited to: coloration, measurement, type, swelling, temperature, and/or [MEDICAL CONDITION]), with nursing staff including documentation of Stop and Watch, Change of Condition assessment, notifications, and monitoring after a change of condition occurs. In-services started on [DATE] and to be completed prior to accepting assignment. 5. Providers: a. Podiatry - licensed nurse will accompany podiatrist during scheduled visits. b. Wound Care - review any skin condition referred by facility physician, including skin tears, rashes, discoloration, swelling, vascular ulcers, pressure ulcers, and/or surgical wounds. Monitoring Daily review of documented Change of Condition, Stop & Watch, Change of Condition assessment in leadership start up meeting (ADM, Interim DON, ADON, MDS/designees). Daily review of documented head to toe skin assessments completed and documented shower sheets (CNA communication sheets.) by DON or designee. DON/designee will ensure notifications and physician orders [REDACTED]. In-services not limited to, documenting skin assessments, timely follow up and notification to Responsible Party and Medical Doctor (notification of, not limited to: coloration, measurement, type, swelling, temperature, and/or [MEDICAL CONDITION]), Stop and Watch, E-interact Change of Condition assessment, and monitoring after a change of condition occurs, notification of change of condition (notification of, not limited to: coloration, measurement, type, swelling, temperature, and/or [MEDICAL CONDITION]), wound treatments, until all applicable personnel educated, in-services will be completed prior to accepting assignments. Summary of IJ and corrective action to be reviewed by QAPI weekly until substantial compliance established and monthly for 90 days to ensure ongoing compliance. Monthly QAPI meeting will include skin related conditions, not limited to, skin tears, rashes, vascular ulcers, pressure ulcers, and/or surgical wounds. Review of a facility in-services, dated [DATE] through [DATE], reflected nursing department staff were trained regarding the following topics: Skin assessments - weekly head to toe assessments, identify areas, who to notify, what/where to document. Changes of condition - who to report to, things to mention, who to notify, how to document. Wounds - notify physician, obtain orders, and document. Resident care - signs and symptoms and prognosis Documentation on electronic healthcare system On [DATE], 16 individual staff interviews were conducted from 8:00 AM to 6:00 PM. Staff represented all three shifts and also worked weekends. Staff were asked to describe the training they had received. Staff were asked about what to do when skin integrity issues and changes of condition were noted on residents. This included who to report to, what information to report, what/where to document and the follow-up/monitoring. All employees interviewed were able to correctly answer questions and described all changes of conditions would be reported to charge nurse. Charge nurses said they would assess the change of condition, document actions, notify residents' physician, family, and DON, obtain/transcribe orders as indicated, follow course of treatment, and monitor until resolved or notify physician, family and DON if condition worsens or does not resolve. The employees were as follows: Day Shift (6:00 AM to 2:00 PM or 8:00 AM to 5:00 PM) LVN E, LVN F, LVN G, CNA H, CNA I, CNA J and CNA K. Evening Shift (2:00 PM to 10:00 PM): LVN L, RN M, CNA N, CNA O, CNA P, and CNA Q. Night Shift (10:00 PM to 6:00 AM): LVN R, LVN S, and CNA T. On [DATE] from 8:00 AM to 6:00 PM, 10 individual residents (Resident #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11) were reviewed for skin integrity issues . This review included a head-to-toe skin assessment, review of their physician orders [REDACTED]. The residents represented varying skin integrity issues and resided in different halls. All residents reviewed had a thorough skin assessment and were receiving adequate care/treatment to any identified skin integrity issues. On [DATE] the Administrator was informed the IJ was removed. While the IJ was removed the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor to ensure the implementation and effectiveness of their plan of removal.