Every finding on record at Las Palomas Center

Based on observation and interviews, the facility failed to ensure kitchen appliances (storage equipment) were maintained and food was stored properly, when the facility failed to:Ensure the South unit's nourishment room freezer seal was in good condition, and the freezer was free from excessive ice and frost buildup.This deficient practice is likely to affect all 52 residents on the South units identified on the resident census list provided by the Administrator on 07/15/26. If food is not stored properly and kitchen appliances are not maintained, residents are at increased risk of contracting foodborne illnesses.The findings are:A. On 07/15/26 at 3:15 pm, during an observation of the South unit's nourishment room, the following was identified: The nourishment room freezer door was cracked along the inside seal, preventing the door from sealing properly.The inside of the freezer was covered in thick ice and frost buildup. Items inside included two ice cream containers frozen with frost around the containers and lids, an unidentifiable piece of fabric, one frozen salad dressing bottle, water bottles, and one milkshake. B. On 07/15/26 at 3:25 pm, during an interview, Certified Nursing Assistant (CNA) #1 stated he was unaware the South unit's nourishment room freezer seal was broken and the freezer had ice and frost buildup. C. On 07/15/26 at 3:29 pm, during an interview, the Licensed Practical Nurse (LPN) #2 stated she was unaware the South unit's nourishment room freezer seal was broken. D. On 07/16/26 at 8:15 am, during an interview, the Administrator stated she had not been made aware of the condition of the South unit's nourishment room freezer. She stated the freezer door should seal properly and should not have ice and frost buildup covering items stored inside.

Based on record review and interview, the facility failed to make prompt (done without delay; immediate) efforts to resolve resident's grievances for 1 (R # 6) of 1 (R # 6) resident reviewed by not responding/following up on grievances that involved resident to resident altercation after the grievance was reported to staff. If the facility is not ensuring that grievances are responded to and without delay, then residents are likely at risk of continued/repeaedt concerns and feeling as though their concerns are unimportant to the facility.The findings are: A. Record review of R #6 Minimum Data Set (MDS)- Section C- Cognitive Patterns dated 02/22/26 revealed that R #6 received a Brief Interview of Mental Status (BIMS) score of 15.B. Record review of a grievance form dated 1/25/26 revealed that R #6 reported an altercation with R #5. An attached loose notebook note to the grievance form contained a statement from R #6 stated, R #5 has been messing with me all morning. He almost hit me for no reason. C. Record review of R#6 Progress notes dated 1/27/26 at 11:38 am, revealed that R #6 was visited by Social Services Director (SSD) and Social Service Assistant (SSA) regarding a resident to resident altercation on 1/25/26. SSA and SSD offered R #6 a room move and educated on room move policy.D. On 3/31/26 at 9:45 am during an interview with R #6, R #6 stated he has gotten into verbal altercations with R #5 and R #5 has attempted to punch R #6 in the past. R #6 stated Everybody (staff and resident) knows and sees what he does. R #6 asked if they could park him anywhere else. R #6 stated that he asked SSD if they could move R #5 but SSD said they could not. E. Record Review of R #6 and R #5 revealed that there is no Change of condition (CIC) or progress notes documenting the altercation between both residents on 1/25/26. F. On 3/31/26 at 10:25 am during an interview with SSD , SSD stated that when there is a resident-to-resident altercation both residents are placed on a 1-1 until they are cleared. Psychological services clear them and SSD conducts a wellness check within 72 hours of the incident. A risk management service and change in condition (CIC) is completed on both residents. SSD confirmed that there is no change of condition for i R #5 or for R #6 for their altercation on 1/25/26. SSD stated CIC should have been in both resident's file alongside with a follow up progress note documenting the resolution.G. On 03/31/26 at 12:05 pm during an interview with Registered Nurse (RN) #1, RN #1 stated after a resident-to-resident altercation an investigation should be conducted, make sure no one was harmed. Physical altercations require residents to be placed on a one to one with a staff member until the provider lifts it. RN #1I confirmed that there is no documentation for the incident/follow up between in R #5's chart for the incident that occurred on 01/25/26.

Based on record review and interviews, the facility failed to appropriately discharge 1 (R #1) of 1 (R #1) resident when the facility failed to re-admit R #1 from the hospital and ensure coordination with an appropriate receiving facility so R #1's needs could be met after discharge from the hospital. This deficient practice resulted in R #1 being discharged to the hospital without a plan for her return to the facility and without appropriate coordination to ensure R #1's wellbeing and continuity of care following the hospital stay. The findings are:A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] and was discharged to the hospital on [DATE] with the following medical diagnoses (including but not limited to): 1. Cerebral infarction (occurs when blood flow to a part of the brain is obstructed). 2. Unspecified cerebrovascular disease. (various conditions that disrupt blood flow to the brain) 3. Dysphagia (difficulty swallowing) following unspecified cerebrovascular disease. 4. Generalized anxiety (a feeling of worry, nervousness or unease) disorder. 5. Dementia (loss of cognitive functioning that interferes with daily life and activities) in other diseases classified elsewhere, severe, with other behavior disturbance. 6. Age-related cognitive decline. 7. Other symptoms and signs involving appearance and behavior. 8. Major depressive disorder (a persistent feeling of sadness and loss of interest), recurrent, moderate. 9. Unspecified symptoms and signs involving cognitive functions following cerebral infarction. 10. Personal history of traumatic brain injury (brain injury that is caused by an outside force). 11. Aphasia (disorder that affects language abilities due to brain damage) following unspecified cerebrovascular disease. 12. Cognitive communication deficit.B. Record review of R #1's nursing progress notes revealed the following: 1. On 09/07/25 at 7:01am: Change in condition: Behavior symptoms. Monitor resident for signs and symptoms of aggression toward others and notify physician for any new incident. 2. On 09/07/25 at 2:05pm: Called (Name of local police department(APD) to report R #1 having homicidal ideations. 3. On 09/07/25 at 4:40 pm: R #1 was sent to hospital to be evaluated for homicide idealization against three residents. Guardian contacted.4. On 09/08/25 at 9:36 am: R #1 was placed on 1 to 1 supervision (supervision by one staff member within close proximity). Care plan reviewed and updated.5. On 09/08/25 at 5:10 pm: R #1 came back from the hospital to the facility at 3:10 pm. 6. On 09/10/25 at 4:04 pm: Mood is pleasant, no unwanted behaviors witnessed. 7. On 09/10/25 at 12:45 am: Mood is pleasant, no unwanted behaviors witnessed. 8. On 09/11/25 at 9:26 am: Change in condition: Behavioral symptoms. Send out for eval and treatment 9. On 09/11/25 at 5:49 am: R #1 was received sleeping comfortably in bed. Woke up twice to use the bathroom and went back to sleep. R #1 was accompanied to join the smoke break at 5:10 am. Nil (no) behavior seen throughout the night.10. On 09/11/25 at 1:00 am: R #1 is a threat to herself and others. Despite being on 1 to 1 supervision, R #1 continues to have verbal and physical aggression towards staff and others. R #1 care cannot safely be managed at this level of care. 11. On 09/11/25 at 9:33 am: R #1 placed on a 1 to 1 supervision. When R #1 returned from the hospital on [DATE] at approximately 3:30 pm, due to the recent escalation (when a situation gets bigger, worse or more intense) of threatening behaviors which led to her being sent out on 09/07/25, the nurses and Certified Nurse Aide (CNA)'s have provided the 1 to 1 supervision since her return. R #1 was evaluated by two Psych providers since R #1's return, both agreed that a 1 on 1 supervision was appropriate, and new medication orders were also placed. At approximately 8:30 am on 09/11/25, R #1 approached the Administrator, Director of Nursing (DON) and supervising staff member and expressed frustration with having 1 to 1 supervision and began demonstrating aggressive behavior and cussing at the Administrator. R #1 proceeded to hit the Administrator and then threw a vase of flowers at the Activities Director hitting her. Due to R #1 being a present danger to herself or others, 911 was activated. 1 to 1 remained in place while waiting for APD/EMS to arrive. 12. On 09/11/25 at 11:38 am: R #1 was discharged and exited the facility with EMS (emergency medical service) and APD to local hospital. D. Record review of the facility's change in condition form for R #1 revealed the following: 1. On 09/07/25 at 7:01 am: Resident still verbalizing anger and frustration toward other. Resident became verbally abuse toward other resident in the dining room at breakfast time. She did not get physical. One on one care per protocol initiated. Message left to the guardian at 10:50 am. 2. On 09/11/25 at 9:26 am: police notified of incident (aggressive behaviors),1 to 1 supervision continues to be at resident's side. Increased aggression noted verbal and physical behaviors noted. R #1 threw a vase with flowers at Activity director and slapped the administrator. Guardian notified at 9am.E. Record review of R #1's care plan dated 09/05/25 revealed the following: 1. R #1 has the potential to demonstrate verbal and/or physical behaviors. 2. R #1 is at risk for elopement (to leave secretly). 3. R #1 exhibits and has the potential to exhibit physical behavior. Interventions: Monitor medications and body language for aggressive intent of verbal behaviors. Evaluate the nature and circumstances (i.e., triggers) of the verbal aggression with resident/patient and/or resident representative. Evaluate need/provide for Psych/Behavioral Health consultation. Remove [name of R #1] from the environment if needed. Gently guide her from the environment while speaking in a calm, reassuring voice. Allow time for expression of feelings; provide empathy, encouragement, and reassurance. Remind [Name of R #1] that she should ignore the other resident and seek assistance from staff if approached by another resident.F. On 01/14/26 at 11:12am during an interview with the guardian, she stated R #1 was discharged to the hospital on a Thursday (09/11/25) and she was abandoned by the facility because they would not re-admit R #1 once she was ready for discharge from the hospital on [DATE]. R #1 has documented behaviors since her admission to the facility. R #1 has been sent to the hospital for evaluation and treatment in the past. The facility dumped R #1 in the hospital with no proper discharge plan and that is unsafe. R #1 stayed in the emergency room holding area while the guardian and hospital case managers find her a safe place to live. R #1 has nowhere to go, and she showed no aggressive behavior in the hospital and was denied re-admission to the facility. The guardian confirmed R #1 cannot take care of herself and would be in danger if she was discharged from the hospital to the streets. R #1's guardian also confirmed R #1 was eventually discharged from the hospital to an out-of-town assisted living facility.G. On 01/15/26 at 1:33pm during an interview with the social services director (SSD), she stated R #1 expressed frustration and confronted the administrator on 09/11/25 regarding the 1 to 1 supervision that was placed since 09/07/25. R #1 then hit the administrator and threw a vase to the activity director. This prompted the facility to call the police and R #1 was taken to the hospital for evaluation and treatment. SSD believed the facility did everything they could to de-escalate the situation and follow protocol (communicate with R #1 calmly, remove from situation, demonstrate understanding) for this situation. SSD stated that she doesn't believe it was a safe discharge, but it was the administrator's decision not re-admit R #1 to the facility.H. On 01/15/26 at 3:55pm during an interview with the hospital case manager director (CM), she stated that when they reached out to the facility social services representative (can't recall the name of the person they spoke with), the facility claimed that they did an immediate eviction (not allow to return to facility) due to her son being aggressive and the facility felt that the son wis a danger to R #1 and staff. CM stated that R #1 had no aggressive behavior and was ready to be discharged only a few hours after arriving to the hospital and R #1 did not meet the criteria to be admitted to the hospital, due to the information brought to them by the facility (sons aggressive behavior and R #1's eviction), Hospital held R #1 in the emergency room holding area for seven days until R #1 was able to be safely transferred to an out-of-town assisted living facility.

Based on observation, record review and interview, the facility failed to properly intervene and prevent a Certified Nurse's Aide (CNA) from touching and interacting inappropriately with multiple residents over multiple times for 4 (R #17, 46, 96, and 120) of 4 (R #17, 46, 96, and 120) residents who were reviewed for possible abuse. If staff do intervene and take steps to prevent abuse, then other residents are at risk of abuse which may cause physical, emotional, and psychological harm. The findings are: R #96A. Record review of R #96's face sheet, dated 09/04/25, revealed an admission date of 09/07/24 with the following diagnoses: Cerebral (brain) Infarction (stroke),Monoplegia (paralysis of one limb) of lower limb left side,Dysphagia (difficulty swallowing),Dysphonia (difficulty speaking). B. Record review of R #96's Minimum Data Set (MDS; a collection of assessments of a resident's abilities and care needs), dated 06/27/25, revealed a Brief Interview of Mental Status (BIMS; a simple test of mental/Memory abilities) score of 13, cognitively intact. C. Record review of R #96's daily care notes, dated 08/06/25 at 1:49 pm and entered by Social Services Director (SSD) revealed the SSD was informed of a report of sexual abuse from a night CNA. R #96 told the SSD, When he was putting cream on my private parts, I felt him put his finger up there [anus]. The SSD reported the incident to the facility Administrator (ADM) and the facility Abuse Officer. D. Record review of the facility's provided Incident Report, dated 08/13/25, revealed R #96 stated CNA #1 performed peri care (care provided to maintain cleanliness at the area of the body between the genitals and anus) on 08/06/25. During peri care, R #96 reported CNA #1 touched her anus (the opening at the end of the large intestine where waste is excreted) with his finger. R #96 stated the interaction made her feel uncomfortable. R #96 stated she felt the touching was intentional. The report indicated CNA #1 was placed on leave on the morning of 08/06/25, pending the outcome of the investigation. The report stated an abuse questionnaire was conducted with other residents in the facility. Per the report, the abuse questionnaire did not reveal any abuse of other residents. Staff were educated to inform residents of their actions while providing care. CNA #1 was allowed to return to work on 08/06/25 for his next scheduled shift at 6:00 pm, with the requirement that he did not have further contact with R #96. E. On 08/26/25 at 3:30 pm during interview, R #96 stated CNA #1 tried to hug her on multiple occasions (she could not recall specific dates). R #96 stated CNA #1 used inappropriate language with her on several occasions, but she could not provide the specific statements. She stated she felt the communication was inappropriate. R #96 stated CNA #1 touched her anus while conducting peri care on one occasion (08/06/25). R #96 reported the incident to the Social Services Assistant (SSA). R #96 stated she became very uncomfortable with CNA #1 assisting her, and she asked that CNA #1 not be assigned to her again. R #96 stated CNA #1 was moved to another area since her complaint, and she did not receive care from him again. R #46F. Record review of R #46's face sheet dated 09/08/25 revealed she had been admitted to the facility on [DATE] with multiple diagnoses including:Acute cystitis (sudden onset inflammation of the bladder),Heart failure (a condition when the heart fails to efficiently pump blood). G. Record review of R #46's MDS, dated [DATE], revealed a BIMS score of 12, cognitively intact. H. Record review of R #46's daily nursing note, dated 08/21/25 at 11:38 am and written by the Social Services Assistant (SSA), stated, This writer received report that resident [R #46] claimed her night CNA attempted to sexually abuse her. When resident was interviewed, she stated, 'I kicked him away and told him I am not that pendeja (asshole) cabron! (bastard) I am going to report you. CNA then stated, 'I don't give a fuck. He turned off all the lights and used the light on his phone to see. He put his hand under [R #120; roommate] blanket, and I heard him say 'Do you like that?' This writer [SSA] and SSD performed abuse questionnaires on whole building and filed police report on accused CNA [not identified]. I. Record review of R #46's daily nursing note, dated 08/22/25 at 8:54 am, revealed a change of condition in which R #46 reported the night shift CNA (CNA #1) engaged in sexual harassment toward both her and her roommate R #120. J. On 08/25/25 at 1:00 pm during phone interview, R #46 stated CNA #1 entered her room during the early morning hours of 08/21/25, and CNA #1 attempted to touch her body. R #46 stated she became angry and yelled at him. R #46 stated CNA #1 left her and went to her roommate (R #120). R #46 stated she could see CNA #1 as he placed his hand under R #120's blanket and touched her body. R #46 stated she could hear CNA #1 ask R #120 if she liked what he was doing. R #46 could not hear any response from R #120. R #120K. Record review of R #120's face sheet dated 08/25/25 revealed she was admitted to the facility on [DATE] with multiple diagnoses including: Wernicke's encephalopathy (a serious brain disorder associated with alcohol abuse and malnutrition with symptoms of confusion),Cognitive communication deficit (difficulty understanding words and communicating with others),Adult sexual abuse confirmed. L. Record review R #120's MDS, dated [DATE], revealed a BIMS score of 9, moderately impaired. M. Record review of R #120's daily nursing notes revealed the following:- Dated 08/22/25 at 1:05 am, R #120 was on the floor of her room. She was confused, fearful, and talking about an event she believed happened. R #120 reported she was afraid of someone. - Dated 08/22/25 at 2:28 am, a change of condition for behavioral symptoms of agitation (angry or threatening behavior) and psychosis (a mental condition in which thoughts are distorted and unrealistic). [Name of resident] seems different than usual.- Dated 08/22/25 at 6:33 am, police arrived after a resident (unknown) called 911. Police spoke with R #120 and night staff, and they left the facility. The note did not include any further information regarding any police report or investigation.- Dated 08/22/25 at 2:25 pm, a note by SSD that Sexual Assault Nurse Examiner (SANE) nurse arrived at 2:13 pm to evaluate and treat the resident for sexual assault. The note did not include any further information regarding the SANE report. N. On 08/25/25 at 11:00 am, during interview, R #120 was unable to recall any events during her stay at the facility. She was unable to recall any care provided by CNA #1. She was unable to recall CNA #1. Throughout the interview, R #120 seemed fearful and confused, and she had difficulty participating in the conversation. O. On 08/25/25 at 11:20 am, during phone interview, R #120's husband stated he was informed by an unknown facility staff that his wife had been accosted (to touch or communicate a threat) by a CNA who was assigned to work with his wife during the night of 08/21/22 to 08/22/25. The husband stated he came to the facility late in the afternoon to be with his wife. He stated when he arrived his wife began crying and apologizing for cheating. The husband stated he tried to reassure R #120 that she did nothing wrong. He stated he was concerned, because his wife seemed to be declining in her mental and physical abilities. He stated he was concerned the incident would set her back even more. R #17P. Record review of R #17's face sheet, dated 09/04/25, revealed an admission date of 07/24/25 with the following diagnoses: Sepsis (a severe life-threatening infection),Urinary tract infection (UTI; an infection in any part of the urinary system, which includes the kidneys, ureters, bladder, and urethra),Low back pain. Q. Record review of R #17's BIMS, dated 08/18/25, revealed a BIMS score of 14, cognitively intact. R. On 08/26/25 at 1:30 pm, during interview, R #17 stated she was frequently assisted with peri care and other personal care by CNA #1 since she was admitted to the facility. R #17 stated CNA #1 would make inappropriate comments such as Will you miss me? and Do you think of me? R #17 stated she found the comments to be creepy, and she felt CNA #1 was trying to groom her. She denied CNA #1 attempted to touch her inappropriately. R #17 stated she did not report this to any facility staff, because CNA #1 was a night shift worker, and he had less contact with her on a day-to-day basis. She stated that is why she did not make any complaints. S. On 08/27/25 at 11:00 am during interview, the Administrator stated CNA #1 was an Agency CNA (an employee who works by contract through another agency). He stated the Agency documented CNA #1 completed training for abuse and neglect with them (Agency). He stated CNA #1 worked by a contract with the facility for several months. The Administrator stated he was informed of the allegations made by R #96 on 08/06/25, and he immediately began an investigation of the abuse concerning R #96. The Administrator stated CNA #1 was suspended pending the outcome of the investigation on 08/06/25 (time unknown). The Administrator stated other residents were interviewed regarding any sexual abuse by staff on 08/06/25. The Administrator stated they utilized a questionnaire that included a question asking if the resident had been sexually abused. The Administrator stated all other residents answered no to the question. The Administrator stated R #96 was interviewed about the incident, and the Administrator believed R #96's main concern was to have no further contact with CNA #1. The Administrator stated he did not confirm the allegation of abuse occurred. The Administrator stated since he did not substantiate the allegation of abuse, he contacted CNA #1, informed CNA #1 he was clear to return to work that night (08/06/25), and instructed CNA #1 not to have any further contact with R #96. The Administrator stated he immediately contacted CNA #1's agency on 08/22/25 when he learned of new allegations and informed them CNA #1 was not to return to the facility. T. On 09/02/25 at 4:11 pm during interview, the SSD stated R #96 told her there were a couple of instances that made her (R #96) uncomfortable. She stated R #96 reported CNA #1 would hug her when she did not want to be hugged, and he told R#96 that she looked ashy (a pale gray/white skin tone) and needed lotion. She stated R #96 reported CNA #1 changed R #96's brief and applied lotion, and his finger slipped into her rectum. The SSD stated she conducted an investigation of the report and informed the Administrator. The SSD stated there were not any other residents who reported any issues with CNA #1. The SSD stated the Administrator determined the allegations were unsubstantiated. The SSD stated she then told the Administrator she believed abuse occurred based on her interview with R #96, and the report should be substantiated. On 08/27/25 at 12:20 pm, the Administrator was notified of a finding of Immediate Jeopardy (IJ).On 08/28/25 at 12:01 pm, the facility provided an acceptable Plan of Removal (POR) which included the following: Corrective ActionAll residents have the potential to be affected by this alleged deficient practice. The following measures and monitoring will be completed by 08/27/25. Reportable sent for the initial resident 08/21/25. Two extra reportable were sent in late after new allegations of abuse on 08/26/25 and 08/27/25. CNA in question was terminated 08/21/25. Center has implemented a new abuse questionnaire that allows for a more thorough investigation starting 08/27/25. Whole house abuse questionnaire completed with residents 08/27/25. Systemic Measures Starting 08/27/25 the Center Nursing staff will be re-educated on the following areas by the Nurse Educator/Designee: If abuse or behavioral issues are occurring (combative/physical behavior, threatening behavior, or anything that could be harmful to oneself or any other person), the victim should be separated from the aggressor immediately. The aggressor should be placed on 1:1 supervision immediately and remain on this type of monitoring until they have been sent to the ER, a behavioral unit, or the provider has cleared them of all potential to harm themselves or others. Documentation needs to occur to reflect this monitoring and clear discontinuation of the 1:1 and reasoning by a provider. If a staff member is accused of abuse, they should be replaced on their shift and removed from the building until police arrive (if necessary), removed from the schedule, and not put back on the schedule until an investigation is completed and they have been cleared by the Administrator or DON (Director of nursing) to return. The provider, nurse manager and family have to be notified immediately. The eInteract change in condition assessment needs to be completed filled out with all the details of what happened. Monitoring and interventions need to continue to happen and be documented if the residents remain in the building, until we know they have stabilized per the provider or have left the center. Administrator and DON were educated on the need for individual reports for each resident regarding abuse. Center has implemented a new abuse questionnaire that allows for a more thorough investigation. When an allegation of abuse is identified, the center will report to the state agency. On 08/29/25 at 12:53 pm, the scope and severity was reduced from a K to an E. Implementation of the POR was verified by the following: - Record review of the facility's Abuse and Neglect training, dated 08/27/25, revealed all nursing staff were trained to recognize and report any abuse, including involuntary seclusion, unwanted physical contact, misappropriation, verbal abuse, or mental abuse. - On 08/29/25 at 10:54 am during interview, the facility Nurse Practice Educator stated she personally met with all nursing staff and provided each with the required re-education and re-training to recognize and report abuse.- On 08/28/25 at 10:00 am multiple nursing staff were contacted and interviewed. Each confirmed they had been provided re-education regarding abuse and neglect. Each confirmed they had been provided this training individually by the Nurse Practice Educator on 08/27/25. Each nursing staff interviewed was able to give a description of the training content and what was expected of them to recognize and report abuse. - On 09/01/25 at 9:30 am during observation of all areas of the facility, staff interacted with residents, provided care and assistance to residents and provided meals to residents. All staff were observed to interact in a respectful and dignified manner.

Based on record review and interview, the facility failed to thoroughly investigate multiple allegations of abuse. The facility then failed to take steps to prevent any future abuse of 4 (R #17, 46, 96 and 120) out of 4 (R #17, 46, 96 and 120) residents reviewed for abuse. If staff do not investigate allegations of abuse and take steps to prevent abuse, then other residents are at risk of abuse which may cause physical, emotional, and psychological harm. The findings are:R #96 A. Record review of R #96 face sheet, dated 09/04/25, revealed she had been admitted to the facility on [DATE] with multiple diagnoses including: -Cerebral (brain) Infarction (stroke), -Monoplegia (paralysis of one limb) of lower limb left side, -Dysphagia (difficulty swallowing), -Dysphonia (difficulty speaking). B. Record review of R #96's Minimum Data Set (MDS; a collection of assessments of a resident's abilities and care needs) Brief Interview of Mental Status (BIMS; a simple test of mental/memory abilities), dated 06/27/25, revealed a score of 13, cognitively intact. C. Record review of a facility provided Incident Report number 2584078, dated 08/13/25, revealed a report by R #96 in which she accused Certified Nurse's Aide (CNA) #1 of performing pericare (care provided to maintain cleanliness at the area of the body between the genitals and anus) on 08/06/25. During pericare, R #96 reported CNA #1 touched her anus with his finger. The report indicated CNA #1 was placed on leave pending the outcome of the investigation. The report further stated an abuse questionnaire was conducted with other residents in the facility. Per the report, the abuse questionnaire revealed no other abuse of other residents. Staff were educated to inform residents of their actions while providing care. CNA #1 was allowed to return provided he had no further contact with R #96. D. Record review of R #96's daily care notes, dated 08/06/25 at 1:49 pm and entered by the Social Services Director (SSD), revealed she was informed of a report of sexual abuse from a night CNA. The SSD was told by R #96, When he was putting cream on my private parts, I felt him put his finger up there [anus]. The SSD reported the incident to the facility Administrator (the facility Abuse Officer). E. On 08/26/25 at 3:30 pm during an interview with R #96, she stated CNA #1 had tried to hug her on 08/08/25 on multiple occasions. She stated CNA #1 used inappropriate language with her on other occasions, and CNA #1 touched her anus while conducting pericare on another occasion. R #96 reported these multiple events made her feel very uncomfortable and caused her to ask that CNA #1 not be allowed to provide care to her. R #46 F. Record review of R #46's face sheet, dated 09/08/25, revealed she was admitted to the facility on [DATE] with multiple diagnoses including: -Acute cystitis (sudden onset inflammation of the bladder), -Heart failure. G. Record review of R #46's MDS BIMS, dated 08/09/25, revealed a score of 12, moderately impaired. H. Record review of R #46's daily nursing notes revealed the following: - Dated 08/21/25 at 11:38 am and written by Social Services Assistant (SSA), stated, This writer received report that resident [R #46] claimed her night CNA attempted to sexually abuse her. When resident was interviewed, she stated 'I kicked him away and told him I am not that pendeja [asshole] cabron [bastard]! I am going to report you. CNA then stated, 'I don't give a fuck. He turned off all the lights and used the light on his phone to see. He put his hand under her [R #120's] blanket, and I heard him say 'Do you like that?' This writer (SSA) and SSD performed abuse questionnaires on whole building and filed police report on accused CNA. - Dated 08/22/25 at 8:54 am, revealed a change of condition in which R #46 reported the night shift CNA (CNA #1) had engaged in sexual harassment toward both her and her roommate R #120. I. On 08/25/25 at 1:00 pm during a phone interview with R #46, she stated CNA #1 entered her room during the early morning hours of 08/21/25, and CNA #1 attempted to touch her body. R #46 stated she became angry and began to yell at him. R #46 stated CNA #1 then left her and went to her roommate (R #120). R #46 stated she could see CNA #1 as he placed his hand under R #120's blanket and touched her body. R #46 stated she could hear CNA #1 as he asked R #120 if she liked what he was doing to her. R #120 J. Record review of R #120's face sheet, dated 08/25/24, revealed she was admitted to the facility on [DATE] with multiple diagnoses including: -Wernicke's encephalopathy (a serious brain disorder associated with alcohol abuse and malnutrition with symptoms of confusion), -Cognitive communication deficit (difficulty understanding words and communicating with others), -Adult sexual abuse confirmed. K. Record review R #120's MDS BIMS, dated 08/25/25, revealed a score of 9, moderately impaired. L. Record review of R #120's daily nursing notes revealed the following: - Dated 08/22/25 at 1:05 am, R #120 was found on the floor of her room. She was confused, fearful, and talked about an event she believed had happened. R #120 reported she was afraid of someone. - Dated 08/22/25 at 2:28 am, a change of condition for behavioral symptoms-agitation, psychosis (a condition of the mind causing illogical and irrational thoughts). R #120 seemed different than usual. - Dated 08/22/25 at 6:33 am, police arrived after a resident (unknown) called 911. Police spoke with R #120, then with the night staff, and then left the facility. - Dated 08/22/25 at 2:25 pm, a note by SSD that a Sexual Assault Nurse Examiner (SANE) nurse arrived at 2:13 pm to evaluate and treat resident for sexual assault. (No results of the SANE exam were available). M. On 08/25/25 at 11:00 am during an interview with R #120, she was unable to recall any events during her stay at the facility. She was unable to recall any care provided by CNA #1. She was unable to recall CNA #1. Throughout the interview, R #120 seemed fearful and confused. N. On 08/25/25 at 11:20 am during a phone interview with R #120's husband, he stated the facility staff informed him that his wife had been assaulted by a CNA working with his wife during the night on 08/21/25 to 08/22/25. The husband stated he was not told of any details of his wife's assault. The husband stated he came to the facility late in the afternoon to be with his wife. He stated that when he arrived, his wife began crying and apologizing for cheating. The husband stated he tried to reassure his wife that she was not to blame. The husband stated that his wife was becoming more confused since her admission to the facility. R #17 O. Record review of R #17's face sheet, dated 09/04/25, revealed she was admitted to the facility on [DATE] with multiple diagnoses including: -Sepsis (a several general infection), -Urinary tract infection (UTI; an infection in any part of the urinary system, which includes the kidneys, ureters, bladder, and urethra), -Low back pain. P. Record review of R #17's MDS BIMS, dated 08/18/25, revealed a score of 14, cognitively intact. Q. Record review of R #17's daily nursing notes revealed staff did not document any complaints from R #17 regarding care from CNA #1 or any other staff member. R. On 08/26/25 at 1:30 pm during an interview, R #17 stated she was assisted on multiple occasions by CNA #1 with general daily care such as repositioning, transferring from bed to wheelchair, and peri-care. R #17 stated CNA #1 would make inappropriate comments such as Will you miss me? and Do you think of me? R #17 stated she found these comments to be creepy, and she felt CNA #1 was trying to groom her. She denied CNA #1 attempted to touch her inappropriately. R #17 could not provide specific dates or times when these comments occurred. R #17 stated she never reported any of this information to any staff. She stated she did not like his care. She stated CNA #1 was a night shift worker, and he had less contact with her on a day-to-day basis. She stated that is why she did not make any complaints. S. On 08/27/25 at 11:00 am during an interview, the Administrator stated CNA #1 was an agency CNA (an employee who works by contract through another agency). The Administrator stated he was informed of the allegations made by R #96 on 08/06/25 regarding CNA #1, and he immediately began an investigation of abuse. The Administrator stated CNA #1 worked the night shift ending 08/06/25, and CNA #1 was assigned to give care to R #96 on the night shift ending 08/06/25. The Administrator stated CNA #1 was scheduled to return for his next assigned shift on 08/06/25 at 6:00 pm, but he contacted CNA #1 and informed him he was suspended from work pending the outcome of an abuse investigation. The ADM stated he began his investigation with the help of the SSD. The Administrator stated they interviewed other residents regarding any sexual abuse, and they utilized a questionnaire that included a question asking if the resident had been sexually abused. The Administrator stated all other residents answered no to the question. The Administrator stated R #96 was interviewed about the incident, and the Administrator believed her main concern was to have no further contact with CNA #1. The Administrator stated R #96's allegations regarding CNA #1 could not be confirmed. The Administrator stated he did not substantiate the allegation of abuse. He stated he contacted CNA #1 and said he was clear to return to work that night provided he did not have any further contact with R #96. The Administrator stated CNA #1 was assigned to another hall in another part of the building following the incident. The Administrator stated he was informed of new allegations of abuse on 08/22/25 in which CNA #1 was accused of abusing R # 46 and R #120. The Administrator stated he immediately contacted CNA #1's agency when he learned of these new allegations of abuse on 08/22/25, and he informed them CNA #1 was not to return to the facility. He stated he told the agency he would not be hired for future contract work. T. On 09/02/2025 at 4:11 pm during interview, the SSD stated she was told by R #96 that there were a couple of incidents that made her (R #96) uncomfortable. She stated R #96 reported CNA #1 would hug her when she did not want to be hugged, CNA #1 would say she looked ashy and needed lotion, and CNA #1's finger slipped into her rectum when he changed her brief. The SSD stated she spoke with R #96 as well as presenting a sex abuse questionnaire to multiple residents (no residents were identified specifically by SSD). The SSD stated she provided the Administrator her investigation, and she informed the Administrator that other residents did not have any issues regarding staff care. The SSD stated the Administrator determined the allegations were unsubstantiated. The SSD stated she told the Administrator she believed the abuse occurred and the report should be substantiated. On 08/27/25 at 12:29 pm, the Administrator was notified of a finding of Immediate Jeopardy (IJ). On 08/29/25 at 10:40 am, the facility provided a Plan of Removal (POR) which included the following: Corrective Action All residents have the potential to be affected by this alleged deficient practice. The following measures and monitoring will be completed by 08/27/25. Facility sent in late reportable for the second and third identified residents on 08/26/25 and 08/27/25. Change in Condition with provider and responsible parties notified 08/21/25. Whole house abuse questionnaire completed with residents 08/27/25. Skin check for residents involved as appropriate 08/21/25. Psychiatric service referral for residents involved as appropriate 08/21/25. CNA in question was terminated 08/21/25. Systemic Measures Starting 08/27/25 the Center leadership staff will be re-educated on the following areas by Market Resource Nurse. Investigations start with removal of staff member and protection of resident. Abuse questionnaires to be completed by those who have the potential to be affected by the staff member or resident. Individual self-reports to follow for any other residents who are identified during the questionnaires. Change in condition with provider and responsible party notification for those affected or impacted. Skin checks for residents involved as appropriate Social services to complete wellness checks and offer psychosocial support as appropriate. Psychiatric services referral for residents involved as appropriate. The scope and severity were reduced from a K to an E. Implementation of the POR was verified by the following: - Record review of the facility's Abuse and Neglect training, dated 08/27/25, revealed all nursing staff were trained to recognize and report any abuse including involuntary seclusion, unwanted physical contact, misappropriation, verbal abuse, or mental abuse. - On 08/28/25 at 10:00 am multiple nursing staff were contacted and interviewed. Each confirmed they had been provided re-education regarding abuse and neglect. Each confirmed they had been provided this training individually by the Nurse Practice Educator on 08/27/25. Each nursing staff interviewed was able to give a description of the training content and what was expected of them to recognize and report abuse. - On 08/29/25 at 10:54 am during interview with the Nurse Practice Educator, she stated she personally met with all nursing staff and provided each with the required re-education and re-training to recognize and report abuse. - On 09/01/25 at 9:30 am during observation of all areas of the facility, staff were observed as they interacted with residents, provided care and assistance to residents and provided meals to residents. All staff were observed to interact in a respectful and dignified manner.

Based on record review and interviews, the facility failed to follow provider orders for 2 (R #3 and R#121) of 2 (R #3 and R#121) residents when staff failed:-Complete, relay and document weekly Prothrombin Time and International Normalized Ratio (PT/INR) (a test administered to monitor and manage blood levels of Warfarin-a blood thinning medication) laboratory results for R #3. -Follow physician order for oxygen use for R#121. These deficient practices are likely to result in residents not maintaining their optimal health as planned by their medical provider. The findings are:R#3 A) On 9/3/25, record review of R 33's Physician's Orders revealed an order to check INR every Monday, call result to provider and enter nursing note with result, provider you spoke with, and any new orders received. B) Record review of R #3's daily nursing notes failed to show any documentation on 07/07/25, 07/14/25, 08/04/25, 08/11/25, 08/18/25, and 09/01/25 that INR was completed, recorded, provider notified and new orders. C) On 09/03/25 at 9:31 AM during an interview with the Director of Nursing (DON), she stated the in house INR is done every Monday per order and nursing staff is to document all results in the progress notes including conversations with the assigned provider. DON confirmed the documentation was incomplete and verified that there was no documentation regarding INR results before 07/07/25. R#121 D) Record review of R #121's physician order revealed #121 is on continuous oxygen to keep oxygen saturation level greater than 88%. E) On 09/05/25 at 10:32 AM, during a telephone interview with the Hospice Registered (HR) nurse, assigned to R #121 stated on one of his visits, he witnessed a staff walking the resident in the hallway with no oxygen on. He quickly checked her oxygen saturation level, and it was 82%. He notified all visible staff at the nurse's station to get an oxygen tank and return the resident back to her room where she has her own oxygen concentrator.

Based on observation, record review, and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) for 3 (R #'s 5, 15, and 9) of 3 (R #'s 5, 15, and 9) residents reviewed for ADL care by staff failing to: Providing assistance for baths and showers.This deficient practice is likely to affect the dignity and health of the residents. The findings are: R #5: A. Record review of R #5's face sheet revealed R #5 was admitted into the facility on [DATE]. B. Record review of R #5's care plan dated 07/18/25 revealed R #5 required ADL assistance for bathing due to R #5 having limited mobility and being legally blind. C. Record review of the facility's shower schedule revealed R #5's bath/showers were scheduled for Tuesdays and Fridays. D. Record review of R #5's documentation survey report (Activities of Daily Living - ADL tracking form), dated 06/01/25 through 06/30/25 revealed R #5 was offered/given 3 showers out of 8 opportunities. E. Record review of R #5's shower sheets dated 06/01/25 through 06/30/25 revealed R #5 was offered/given 3 showers out of 8 opportunities. F. Record review of R #5's documentation survey report dated 07/01/25 through 07/31/25 revealed R #5 was offered/given 1 shower out of 6 opportunities. G. Record review of R #5's shower sheets dated 07/01/25 through 07/31/25 revealed R #5 was offered/given 3 showers out of 6 opportunities. H. Record review of R #5's documentation survey report dated 08/01/25 through 08/31/25 revealed R #5 was offered/given 2 showers out of 9 opportunities. I. Record review of R #5's shower sheets dated 08/01/25 through 08/31/25 revealed R #5 was offered/given 5 showers out of 9 opportunities. J. On 08/26/2025 at 10:23 am during an interview and observation with R #5, he stated that he does not always get showered per his shower schedule. R #5 was observed to be unkempt (messy and without sings of a recent bath/shower) and have dirty nails. K. On 09/02/25 at 5:27 pm during an interview with Nursing Assistant (NA) #1, she stated that R #5 enjoys showers, and he does not refuse them often. L. On 09/03/25 at 12:16 pm during an interview with Certified Nursing Assistant (CNA) #3, she stated that showers/baths are documented in the electronic health record (documentation survey report) and shower sheets. CNA #3 also stated that she did not recall R #5 refusing baths/showers and he liked them. M. On 09/03/25 at 12:43 pm during an interview with Registered Nurse (RN) 31, she stated that she was not aware of R #5 refusing baths/showers. RN #1 also stated that baths/showers should be offered to residents per their shower schedule. N. On 09/04/25 at 4:35 pm during an interview with the Director of Nursing (DON), she stated residents should be offered baths/showers per the shower schedule and at least twice a week. The DON confirmed all baths/showers should be documented when completed or a resident refused, and R #5 was not offered/given enough showers and should have been. R #15: O. Record review of R #15's face sheet revealed R #15 was admitted into the facility on [DATE]. P. Record review of R #15's care plan dated 07/10/25 revealed R #15 required ADL assistance for bathing due to cognitive impairments (problems with mental functions). Q. Record review of the facility's shower schedule revealed R #15's bath/showers were scheduled for Wednesday and Saturday. R. Record review of R #15's documentation survey report dated 06/01/25 through 06/30/25 revealed R #15 was offered/given 1 shower out of 8 opportunities. S. Record review of R #15's shower sheets dated 06/01/25 through 06/30/25 revealed R #15 was offered/given 3 showers out of 8 opportunities. T. Record review of R #15's documentation survey report dated 07/01/25 through 07/31/25 revealed R #15 was offered/given 4 showers out of 9 opportunities. U. Record review of R #15's shower sheets dated 07/01/25 through 07/31/25 revealed R #15 was offered/given 7 showers out of 9 opportunities. V. Record review of R #15's documentation survey report dated 08/01/25 through 08/31/25 revealed R #15 was offered/given 4 showers out of 9 opportunities. W. Record review of R #15's shower sheets dated 08/01/25 through 08/31/25 revealed R #15 was offered/given 5 showers out of 9 opportunities. X. On 08/26/2025 at 2:18 pm during an interview with R #15, she stated that she would like at least two showers a week, but she does not get that often. R #15 also stated that she becomes frustrated when she is not given at least two showers a week. Y. On 09/02/25 at 5:25 pm during an interview with NA #1, she stated that R #15 likes to receive showers and does not refuse them. Z. On 09/02/25 at 5:37 pm during an interview with CNA #2, she stated R #15 likes showers, but she does not always get one because of staffing. AA. On 09/03/25 at 11:54 am during an interview with LPN #1, she confirmed R #15 likes to receive showers and R #15 does not refuse them. BB. On 09/04/25 at 4:36 pm during an interview with the DON, she confirmed R #15 was not offered enough baths/showers and should have been. R # 9 CC. Record review of R #9's face sheet revealed R #9 was admitted into the facility on [DATE]. DD. Record review of R #9's care plan dated 06/04/25 revealed R #9 requires ADL assistance for bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion (ability to get from one place to another in wheelchair or on foot), and toileting related to: Paralysis/Weakness, and limited mobility. EE. Record review of the facility's shower schedule revealed R #9's bath/showers were scheduled for Mondays and Thursdays. FF. Record review of R #9's shower sheets dated 06/01/25 through 06/30/25 revealed R #9 was given 4 showers out of 8 opportunities. GG. Record review of R #9's documentation survey report (DSR), dated 07/01/25 through 07/31/25, revealed R #9 was given a shower 6 out of 10 opportunities. HH. Record review of R #9's documentation survey report dated 08/01/25 through 08/31/25 revealed R #9 was offered/given 5 showers out of 10 opportunities. II. On 08/26/25 at 3:47 pm during an interview with the Resident Representative (RR), she stated there was an issue with showers, and R #9 did not get showers regularly, and was soiled on some visit occasions. R #9 complains to me at every visit that she is not getting bathed enough. JJ. On 09/03/25 at 9:30 am during an interview with the Director of Nursing (DON), she stated the expectation for shower sheet completion is the sheets will be reviewed by staff then given to Medical records for upload the same day. The DON stated there have been issues with the charting program, but there has been an increase in documentation across the board since the implementation of the shower sheet requirement for staff. KK. On 09/03/25 at 5:02 pm during an interview with the DON, she stated staff should document if it was refused for bed baths or showers regardless of the outcome. She stated showers should always be offered two times per week, and she could not explain blank spaces or missing documentation.

Based on observation and interview, the facility failed to ensure residents were treated with respect and dignity for 1(R #1) of 1 (R #1) resident when the facility failed to ensure the resident was not soiled while in the common areas for extended periods of time. This deficient practice is likely to result in residents feeling as if they were unimportant and not having privacy. The findings are: A. On 08/25/25 at 10:00 am observation revealed R #1 seated in her wheelchair visibly wet from her lower shirt to knees, located at the south nursing station. Further observation revealed R #1 remained soiled in the common area for 15 minutes.B. On 08/25/25 at 10:15 am during an interview with R #1, she stated they do not care, I have to wear two briefs because the other ones do not hold enough, and they will not change me unless I ask.C. On 08/25/25 at 10:15 am during an interview with Certified Nursing Assistant (CNA) #4, he stated he would just take care of it, after R #1 asked him who was her assigned CNA. He stated he could see R #1 was wet. D. On 08/26/25 at 2:10 pm during an interview with R #1's Power of Attorney (POA), she stated the bathing schedule seems off, and R #1 always complains to me about not being clean, staff need to be more aware of her. She also stated she took R #1 to a Urologist (A doctor who specializes in diagnosing and treating problems of the urinary tract), and they did not see a reason for the incontinence ( Loss of control over urination or bowel movements), so R #1 previously had a foley catheter (a thin plastic tube used for continuous urine drainage) placed but it was removed three months ago.E. On 08/29/25 at 12:40 pm observation revealed the following:R #1 was located in the dining room after lunch service while seated in her wheelchair.Resident had a strong odor of urine. F. On 08/29/25 at 2:00 pm observation revealed R#1 was still wet with urine after she traveled the hallways between the dining room and the south nursing station common areas. R #1 self-propelled in her wheelchair past Licensed Practical Nurse (LPN) # 4 and the Nurse Practice Educator (NPE) on the two hallways to the south nursing station. R #1 then asked the NPE to assist with calling her POA at the nurse's station phone. The NPE pushed R # 1's wheelchair to the phone from the west hallway to the south nurse's station and after four minutes of unsuccessful phone call attempts, the NPE took R #1 to the Social Services office to use the phone. R #1 spoke with the POA and then asked The NPE to assist with a brief change, and the NPE asked CNA #8 to change the resident's brief.G. On 09/02/25 at 3:15 pm during an interview with CNA #11, he stated to ensure resident's dignity while incontinent he monitors each incontinent resident continually. He stated I make sure they're clothed and clean, covered up if necessary. Only a few residents need monitoring, but staff are familiar with those who need extra support. CNA #11 stated if he saw a resident soiled in the hallway or common areas he would address it even if it wasn't his assignment. He stated anyone with a clinical certification should be able to help change a brief.H. On 09/02/2025 at 4:30 pm observation revealed R #1 had a foley catheter placed after an appointment with the Urologist on 09/02/25 at 2:00 pm.I. On 09/02/25 at 4:30 pm during an interview with R #1, she stated she requested for a foley catheter to be reinserted at the Urologist today due to not being changed often enough. She stated the POA had to purchase a new outfit for her since she was soiled upon arrival at the Dr.'s office, which included a bowel movement. R #1 stated through clenched jaws that she was embarrassed at the office and just feels wet when she is not changed and wearing clean clothes.J. On 09/03/25 at 9:30 am during an interview with the Director of nursing (DON) she stated the expectation for facility staff to ensure the dignity of incontinence residents, is staff completes rounding but they cannot force residents to get cleaned, sometimes they will refuse when we ask them to receive care.

Based on record review and interview, the facility failed to provide the highest level of care for 1 (R #1) of 8 (R #1, 2, 3, 4, 5, 6, 7, 8) residents. The facility failed to provide consistent and adequate wound care (observation and care that promotes healing of wounds) to promote the healing of R #1's wounds. This deficient practice is likely to result in residents not receiving care that would promote the healing of resident's wounds. The findings are:A. Record review of R #1's face sheet dated 10/30/25 revealed he was admitted to the facility on [DATE] with multiple diagnoses including:Acute (sudden onset) Osteomyelitis (an infection of the bone) of the left ankle and foot.Cutaneous (skin) Abscess (infectious material that has accumulated in tissues of the body) of Left Foot.Diabetes (a chronic disease caused by failure of the body to control blood sugars) with Chronic Kidney Disease.End Stage Renal Disease (chronic, progressive disease of the kidneys).Further review revealed R #1 was discharged from the facility on [DATE] when he was discharged to hospital care.B. Record review of R #1's hospital discharge orders dated 09/29/25 revealed the following:Admit to Skilled Nursing Facility: Diagnosis Foot Ulcer (an open sore).Nursing Orders: Multiple wound care orders with instructions and directions to continue until discontinued. Wound Care team Eval (evaluate) and treat starting 09/29/25. C. Record review of R #1's physician orders dated 10/30/25 revealed:10/09/25 An appointment to visit the provider of a local Podiatrist (a doctor who specializes in the care of feet and ankles) on 10/15/25.10/15/25 An order to provide wound care to bilateral (both) heels-cleanse with Vashe (a wound cleaning solution), pat dry, apply Calcium Aliginate (a solution that promotes healing of wounds), cover with Optifoam (a soft protective wound covering) every day shift.There were no orders to monitor or provide wound care to any existing wounds entered before the date of 10/15/25. D. Record review of daily nursing care notes revealed the following:09/29/25 but dated 09/28/25 at 11:00pm stated:After hours telehealth (a visit with provider that occurs over the internet) consult. Medication list (with all medications and doses listed). Notation of Chief Complaints which includes Osteomyelitis of bilateral heels and skin notes that stated Bilateral heel ulcers with osteomyelitis noted. Management plan includes direction to follow specific wound care orders for bilateral heel ulcers.09/30/25 at 1:22 am a skilled nursing note that states Skin-skin warm & dry, skin color WNL (within normal limits). No other skin condition is described.09/30/25 at 5:58 pm a skilled nursing note that contains no comments of R #1's skin condition, wounds or wound care.10/02/25 at 5:57 pm a skilled nursing note that contains no comments of R #1's skin condition, wounds or wound care.10/03/25 at 1:00 am provider encounter note that includes information of hospital care for left heel diabetic ulcer complicated by osteomyelitis which was treated by antibiotics (medications prescribed to treat infections) and debridement (a treatment that cuts dead skin from a wound area) on 09/21/25. The note indicates the provider met with resident at his bedside. The note contains no orders or plans for the treatment of left heel wounds and is signed by Physician Assistant (PA).10/03/25 at 1:51 pm a nursing note for Skin Issues that revealed a description of the left heel wound-no exudate (a fluid that seeps from an open wound), No odor, no Eschar (dead tissue) with measurement: Length-4.47 cm (centimeters) Width 2.82 cm Depth 0 area 8.41 cm2 (square centimeters). The note further describes wound care provided 10/03/25 at 1:52 pm a skilled nursing note that stated-left heel diabetic foot ulcer. Wound present on admission. No special care is noted.10/04/25 at 7:02 pm a skilled nursing note that stated-left heel diabetic foot ulcer. Wound present on admission. No special care is noted.10/05/25 at 4:11 pm a skilled nursing note that stated-left heel diabetic foot ulcer. Wound present on admission. No special care is noted.10/06/25 at 12:25 pm a skin check that stated-left heel diabetic foot ulcer. Wound present on admission. No completed clinical suggestions are provided.10/07/25 at 11:25 am a skilled nursing note that stated-left heel diabetic foot ulcer. Wound present on admission. No special care is noted.10/08/25 at 1:00 am a provider encounter note which included medication review, skin-+ foot wounds and bilateral feet in clean and dry dressings/bandages. the note contains no orders to monitor or provide wound care.10/10/25 at 1:00 am a provider encounter note which included medication review, bilateral feet wrapped in kerlix (a stretchable soft bandage strip)-Left heel with minimal soaked through.10/10/25 at 1:53 pm a note for skin issues that revealed a description of the left heel wound-no exudate (a fluid that seeps from an open wound), No odor, no Eschar (dead tissue) with measurement: Length-4.87 cm (centimeters) Width 4.11 cm Depth 0 area 14.58 cm2. The note further describes wound care provided. 10/10/25 at 4:43 pm a skilled nursing note that stated left heel diabetic foot ulcer. Wound present on admission. No special care is noted.10/12/25 at 1:24 pm a skilled nursing note that stated left heel diabetic foot ulcer. Wound present on admission. No special care is noted.10/13/25 at 10:22 am a skin check note that stated-Progress improving, wound present on admission, signs or symptoms of infection none, measurements not documented. 10/15/25 at 1:00 am a provider encounter note revealed he (R #1) was evaluated ay a podiatrist today who reportedly advised immediate transfer to the emergency department for potential amputation due to exposed bone.10/15/25 at 9:57 am a nursing note that stated-(name of R #1) returned from his appointment at (name of podiatrist clinic and Doctor of Podiatry Medicine). It was recommended R #1 go to hospital emergency department for his foot wounds.A late note dated 09/30/25 at 2:13 pm but entered sometime 10/15/25 which states resident (R #1) refused skin check by this writer. E. Record review of Doctor of Podiatry (DPM) visit dated 10/15/25 revealed provider notes to transfer R #1 to local hospital today and signed by the DPM.F. Record review of R #1's Treatment Administration Record (TAR) dated September 2025 contained no documentation of any wound care order or any wound care provided on 09/30/25. G. Record review of R #1's TAR dated October 2025 contained no documentation of any wound care order or any wound care provided until 10/15/25. Further review of the TAR revealed that Licensed Practical Nurse (LPN) #1 had documented care to R #1 on 10/02/25, 10/03/25, 10/04/25, 10/05/25, 10/10/25, 10/11/25, and 10/12/25.H. On 10/30/25 at 11:35 am during interview with R #1's sister, she stated she often visited R #1 while he was in the facility. She stated she did not see R #1's dressings to his left foot being changed until 10/03/25 when she was with a nurse who removed and replaced the dressing. She stated she had visited and believed R #1's dressings had not been changed and she asked nursing staff to perform dressing changes. She stated her brother R #1 had told her that he had also asked nursing staff on several times to change dressings on his feet. She stated when she would ask nursing staff to do dressing changes they would tell her they would do changes later. Sister stated that she had been notified on this day-10/30/25-that R #1's left foot was to be amputated today.I. On 10/30/25 at 1:32 pm during interview with the facility Skin Treatment Nurse (STN) she stated she was present when R #1 was admitted on [DATE]. She stated she went to R #1 and asked to remove the dressings from his feet. She stated R #1 refused. She stated several days later-on 10/03/25-while family was present, she went to R #1 and asked and was given permission to remove and measure his wound to his left heel. STN stated she removed the old dressing and measured the wounds then replaced the dressings with what she thought was appropriate to meet his needs. STN stated she went to R #1 on 10/10/25 and performed the same wound care to his left foot. STN stated that on 10/15/25, R #1 went to a scheduled podiatrist appointment and when he returned, he had notes from the podiatrist to be transferred to the hospital emergency room to have his left heel assessed. STN stated she entered an order on 10/15/25 to do wound care and she marked his TAR stating she had done wound care. STN reviewed R #1's provider notes and confirmed there were no orders to provide wound care. She stated she assessed the wound both times but did not check for and did not enter orders to provide wound care to R #1's left heel. STN further stated there was no documentation of R #1's TAR that she had completed wound care on 10/03/25 or on 10/10/25. J. On 10/30/25 at 1:54 pm during interview with LPN #1 he stated he was an LPN and had provided care to R #1 on multiple days when R #1 was a resident. He stated that he provided wound care to residents as ordered and as indicated by resident's TAR. LPN #1 stated that if there was no provider order and if there was no indication in the TAR, then he would not provide wound care. LPN #1 then reviewed R #1's provider orders and TAR for the month of October 2025. He acknowledged there was no provider order to complete wound care and there was no TAR notation to document wound care being done. LPN #1 stated he was aware of R #1's wounds and was sure that he had provided wound care but could not explain how and could not provide documentation that he had completed wound care. K. On 11/03/25 at 10:30 am during interview with DPM he stated he recalled R #1 and his visit. He stated he saw R #1 to review wounds to his right and left heels. DPM stated that when he removed the dressing from R #1's left foot he saw a wound that in his opinion was neglected, untreated and required greater care than he could provide in his office. DPM stated he contacted the facility and directed that R #1 should be transferred to a local hospital emergency room immediately for his left foot to be evaluated and treated. He stated he later learned that R #1's left foot had been amputated. L. Record review of R #1's hospital record dated 10/31/25 revealed documentation that on 10/30/25 R #1's left foot leg was amputated below the knee. On 11/03/25 at 5:03 pm the facility was notified of a finding of Immediate Jeopardy (IJ). On 11/04/25 at 3:28 pm an acceptable plan of removal was submitted with the following evidence of Past Non-compliance:Corrective Action/IdentificationAll residents have the potential to be affected by this alleged deficient practice. The following measures and monitoring will be completed by 10/22/2025. On 10/22/2025 the center initiated a new admit audit to ensure all tasks and admissions items and will confirm any outstanding items as complete during the stand down process. 10/22/2025 QAPI was performed as an education piece and update to wound care order verification process. In attendance were the reviewer of all new admit orders [NAME] LPN unit manager. [NAME] unit manager, [NAME] director of nursing, [NAME] treatment nurse, [NAME] SHTL, [NAME] admissions director, [NAME] Administrator to educate the team on the new clinical review protocol. admission is to notify the IDT team that a resident is admitting with wounds. Unit manager and or designee will review the orders with the provider. If the wound is to be thought that an admitting wound is considered complex or needs additional oversight the NExcell provider will be contacted. Weekly wound care meeting will be held by the IDT team to ensure genesis process is followed and all orders are entered timely, appropriately, updated care plan, accurate care plan, pictures taken with the swift phone.This is to ensure that all individuals involved have an awareness of the resident that is being admitted and what is needed before and during their stay in the center. On 10/22/2025 and 10/30/25, a whole house skin sweep audit was conducted to identify any undocumented wounds, On 10/22/25 and 10/29/2025, all treatment orders were confirmed to be in place and accurate 10/22/2025, 10/29/25 all care plans were audited and accurate per wound orders Starting on 10/31/2025 direct care staff were re-educated on Wound Documentation and inputting orders upon admission.Systemic Measures Starting 10/30/2025 the Center Nurses will be re-educated on the following areas by the Nurse Educator/Designee. Nurses will be re-educated on completion of skin assessments weekly per schedule. Nurses will be educated on their responsibility with communication with management and provider for the change in condition process/documentation when a resident is having a change in condition (including new or worsening wounds). On 10/30/2025 Nurses will start to be educated on Genesis wound processes which include the DIMES, timely and accurate identification and documentation for wounds/wound changes, change in condition process, and appropriate treatment/intervention implementation upon identification of new or worsening wounds. CNA's will be educated on the change in condition process for CNA's (including skin changes) and stop and watch.As of 10/31/2025 100% of available staff have been educated on these processes. Any staff member that has not been scheduled, on leave of absence (FMLA), vacation, or PRN staff will be educated prior to returning to their next shift. Quality Assurance & MonitoringThe Director of Nursing/Designee will audit education sign-off sheets to ensure that all nursing staff receive the education mentioned above. The Director of Nursing/Designee will conduct 5 random audits of Residents that have wounds for skin assessment, order accuracy and for wound care process abidance. This will be audited weekly for 12 weeks.An Ad Hoc QAPI Meeting was held on 10/22/2025 to approve the above plan.The DON/designee and the Administrator/designee will bring the results of the audits to the QAPI committee for tracking, trending and further recommendations to ensure compliance with the plan. The audits will be brought to the QAPI committee for 3 months. The Administrator will oversee the QAPI committee.The Plan of Removal was approved on 11/04/25. The Immediate Jeopardy was removed as of 10/31/25 and the scope and severity was reduced from J to D.The POR was verified as follows:Record review confirmed full house audit of all residents to identify any wounds. On 11/05/25 at 11:00 am the Plan of Removal was verified when LPN #1, 2, 3 and Registered Nurse (RN) #1 each interviewed and stated they had been provided training on 10/31/25 which included reviewing all admitting orders for all residents, verifying the admitting orders with the facility provider and entering the admitting orders in each resident's EMR. All four nurses confirmed their training included monitoring all residents for daily wound care orders completing wound care orders and then documenting wound care. The STN reported she had been provided training on 10/31/25 to monitor all residents with wounds review all resident's wound care orders and document all wound care provided. Certified Nurse's Aides #1 and 2 were interviewed and each confirmed they had been trained on 10/31/25 to observe all residents and note any new or old wounds and to document in each resident's EMR their observations and report to the assigned nurse, their observations of any changes in resident skin conditions. The facility nurse educator was interviewed and confirmed she had met with all nursing staff and trained them on 10/31/25 as to the requirements of the Plan of Removal.The facility administrator was interviewed and confirmed that the plan of removal had been reviewed by the facility Quality Assurance and Performance Improvement (QAPI) (a group of facility leaders who review the performance of the facility and staff and determine areas that could be improved) team on 10/22/25 and the changes were now included in the QAPI review.

Based on record review and interview the facility failed to assure that the physician/provider reviewed and entered all orders for 1 (R #1) of 1 (R #1) resident when the provider failed to review and enter an order upon admission to provide wound care. This deficient practice is likely to result in residents not having adequate review and submission of treatment and medication orders resulting in less-than-optimal care. The findings are: A. Record review of R #1's face sheet dated 10/30/25 revealed he was admitted to the facility on [DATE] with multiple diagnoses including:Acute (sudden onset) Osteomyelitis (an infection of the bone) of the left ankle and foot.Cutaneous (skin) Abscess (infectious material that has accumulated in tissues of the body) of Left Foot.Diabetes (a chronic disease caused by failure of the body to control blood sugars) with Chronic Kidney Disease.End Stage Renal Disease (chronic, progressive disease of the kidneys).Further review revealed R #1 was discharged from the facility on [DATE] when he was discharged to hospital care.B. Record review of R #1's hospital discharge orders dated 09/29/25 revealed the following:Admit to Skilled Nursing Facility: Diagnosis Foot Ulcer (an open sore).Nursing Orders: Multiple wound care orders with instructions and directions to continue until discontinued. Wound Care team Eval (evaluate) and treat starting 09/29/25. C. Record review of R #1's physician orders dated 10/30/25 revealed there were no orders to monitor or provide wound care to any existing wounds until [DATE]. D. On 11/04/25 at 9:40 am during interview with Physician Assistant (PA) she stated she could recall R #1 and could recall that he had multiple medical problems. PA could recall that R #1 had wounds to his heels that required treatment. PA stated she was unaware that R #1 had no orders to provide wound care from the day of his admission on [DATE] until [DATE] when he was discharged . PA stated that normally the facility nurses would contact her with a new admission and review all admitting orders and then place orders as approved by her. PA stated that she could not recall if she was contacted about R #1's admission. PA further stated that between 09/30/25 and 10/15/25 she had visited and assessed R #1 several times. She could not recall reviewing his orders but she believed that R #1 did receive wound care and dressing changes to his heels during his stay. On 11/03/25 at 5:03 pm the facility was notified of a finding of Immediate Jeopardy (IJ). On 11/04/25 at 3:28 pm an acceptable plan of removal was submitted with the following evidence of Past Non-compliance:Corrective Action/IdentificationAll residents have the potential to be affected by this alleged deficient practice. The following measures and monitoring will be completed by 10/22/2025. On 10/22/2025 the center initiated a new admit audit to ensure all tasks and admissions items and will confirm any outstanding items as complete during the stand down process. 10/22/2025 QAPI was performed as an education piece and update to wound care order verification process. In attendance were the reviewer of all new admit orders [NAME] LPN unit manager. [NAME] unit manager, [NAME] director of nursing, [NAME] treatment nurse, [NAME] SHTL, [NAME] admissions director, [NAME] Administrator to educate the team on the new clinical review protocol. admission is to notify the IDT team that a resident is admitting with wounds. Unit manager and or designee will review the orders with the provider. If the wound is to be thought that an admitting wound is considered complex or needs additional oversight the NExcell provider will be contacted. Weekly wound care meeting will be held by the IDT team to ensure genesis process is followed and all orders are entered timely, appropriately, updated care plan, accurate care plan, pictures taken with the swift phone.This is to ensure that all individuals involved have an awareness of the resident that is being admitted and what is needed before and during their stay in the center. On 10/22/2025 and 10/30/25, a whole house skin sweep audit was conducted to identify any undocumented wounds, On 10/22/25 and 10/29/2025, all treatment orders were confirmed to be in place and accurate 10/22/2025, 10/29/25 all care plans were audited and accurate per wound orders Starting on 10/31/2025 direct care staff were re-educated on Wound Documentation and inputting orders upon admission.Systemic Measures Starting 10/30/2025 the Center Nurses will be re-educated on the following areas by the Nurse Educator/Designee. Nurses will be re-educated on completion of skin assessments weekly per schedule. Nurses will be educated on their responsibility with communication with management and provider for the change in condition process/documentation when a resident is having a change in condition (including new or worsening wounds). On 10/30/2025 Nurses will start to be educated on Genesis wound processes which include the DIMES, timely and accurate identification and documentation for wounds/wound changes, change in condition process, and appropriate treatment/intervention implementation upon identification of new or worsening wounds. CNA's will be educated on the change in condition process for CNA's (including skin changes) and stop and watch.As of 10/31/2025 100% of available staff have been educated on these processes. Any staff member that has not been scheduled, on leave of absence (FMLA), vacation, or PRN staff will be educated prior to returning to their next shift. Quality Assurance & MonitoringThe Director of Nursing/Designee will audit education sign-off sheets to ensure that all nursing staff receive the education mentioned above. The Director of Nursing/Designee will conduct 5 random audits of Residents that have wounds for skin assessment, order accuracy and for wound care process abidance. This will be audited weekly for 12 weeks.An Ad Hoc QAPI Meeting was held on 10/22/2025 to approve the above plan.The DON/designee and the Administrator/designee will bring the results of the audits to the QAPI committee for tracking, trending and further recommendations to ensure compliance with the plan. The audits will be brought to the QAPI committee for 3 months. The Administrator will oversee the QAPI committee.The Plan of Removal was approved on 11/04/25. The Immediate Jeopardy was removed as of 10/31/25 and the scope and severity was reduced from J to D.The POR was verified as follows:Record review confirmed full house audit of all residents to identify any wounds. On 11/05/25 at 11:00 am the Plan of Removal was verified when LPN #1, 2, 3 and Registered Nurse (RN) #1 each interviewed and stated they had been provided training on 10/31/25 which included reviewing all admitting orders for all residents, verifying the admitting orders with the facility provider and entering the admitting orders in each resident's EMR. All four nurses confirmed their training included monitoring all residents for daily wound care orders completing wound care orders and then documenting wound care. The STN reported she had been provided training on 10/31/25 to monitor all residents with wounds review all resident's wound care orders and document all wound care provided. Certified Nurse's Aides #1 and 2 were interviewed and each confirmed they had been trained on 10/31/25 to observe all residents and note any new or old wounds and to document in each resident's EMR their observations and report to the assigned nurse, their observations of any changes in resident skin conditions. The facility nurse educator was interviewed and confirmed she had met with all nursing staff and trained them on 10/31/25 as to the requirements of the Plan of Removal.The facility administrator was interviewed and confirmed that the plan of removal had been reviewed by the facility Quality Assurance and Performance Improvement (QAPI) (a group of facility leaders who review the performance of the facility and staff and determine areas that could be improved) team on 10/22/25 and the changes were now included in the QAPI review.

Based on observation, record review and interview, the facility failed to properly intervene and prevent a Certified Nurse's Aide (CNA) from touching and interacting inappropriately with multiple residents over multiple times for 4 (R #17, 46, 96, and 120) of 4 (R #17, 46, 96, and 120) residents who were reviewed for possible abuse. If staff do intervene and take steps to prevent abuse, then other residents are at risk of abuse which may cause physical, emotional, and psychological harm. The findings are: R #96A. Record review of R #96's face sheet, dated 09/04/25, revealed an admission date of 09/07/24 with the following diagnoses: Cerebral (brain) Infarction (stroke),Monoplegia (paralysis of one limb) of lower limb left side,Dysphagia (difficulty swallowing),Dysphonia (difficulty speaking). B. Record review of R #96's Minimum Data Set (MDS; a collection of assessments of a resident's abilities and care needs), dated 06/27/25, revealed a Brief Interview of Mental Status (BIMS; a simple test of mental/Memory abilities) score of 13, cognitively intact. C. Record review of R #96's daily care notes, dated 08/06/25 at 1:49 pm and entered by Social Services Director (SSD) revealed the SSD was informed of a report of sexual abuse from a night CNA. R #96 told the SSD, When he was putting cream on my private parts, I felt him put his finger up there [anus]. The SSD reported the incident to the facility Administrator (ADM) and the facility Abuse Officer. D. Record review of the facility's provided Incident Report, dated 08/13/25, revealed R #96 stated CNA #1 performed peri care (care provided to maintain cleanliness at the area of the body between the genitals and anus) on 08/06/25. During peri care, R #96 reported CNA #1 touched her anus (the opening at the end of the large intestine where waste is excreted) with his finger. R #96 stated the interaction made her feel uncomfortable. R #96 stated she felt the touching was intentional. The report indicated CNA #1 was placed on leave on the morning of 08/06/25, pending the outcome of the investigation. The report stated an abuse questionnaire was conducted with other residents in the facility. Per the report, the abuse questionnaire did not reveal any abuse of other residents. Staff were educated to inform residents of their actions while providing care. CNA #1 was allowed to return to work on 08/06/25 for his next scheduled shift at 6:00 pm, with the requirement that he did not have further contact with R #96. E. On 08/26/25 at 3:30 pm during interview, R #96 stated CNA #1 tried to hug her on multiple occasions (she could not recall specific dates). R #96 stated CNA #1 used inappropriate language with her on several occasions, but she could not provide the specific statements. She stated she felt the communication was inappropriate. R #96 stated CNA #1 touched her anus while conducting peri care on one occasion (08/06/25). R #96 reported the incident to the Social Services Assistant (SSA). R #96 stated she became very uncomfortable with CNA #1 assisting her, and she asked that CNA #1 not be assigned to her again. R #96 stated CNA #1 was moved to another area since her complaint, and she did not receive care from him again. R #46F. Record review of R #46's face sheet dated 09/08/25 revealed she had been admitted to the facility on [DATE] with multiple diagnoses including:Acute cystitis (sudden onset inflammation of the bladder),Heart failure (a condition when the heart fails to efficiently pump blood). G. Record review of R #46's MDS, dated [DATE], revealed a BIMS score of 12, cognitively intact. H. Record review of R #46's daily nursing note, dated 08/21/25 at 11:38 am and written by the Social Services Assistant (SSA), stated, This writer received report that resident [R #46] claimed her night CNA attempted to sexually abuse her. When resident was interviewed, she stated, 'I kicked him away and told him I am not that pendeja (asshole) cabron! (bastard) I am going to report you. CNA then stated, 'I don't give a fuck. He turned off all the lights and used the light on his phone to see. He put his hand under [R #120; roommate] blanket, and I heard him say 'Do you like that?' This writer [SSA] and SSD performed abuse questionnaires on whole building and filed police report on accused CNA [not identified]. I. Record review of R #46's daily nursing note, dated 08/22/25 at 8:54 am, revealed a change of condition in which R #46 reported the night shift CNA (CNA #1) engaged in sexual harassment toward both her and her roommate R #120. J. On 08/25/25 at 1:00 pm during phone interview, R #46 stated CNA #1 entered her room during the early morning hours of 08/21/25, and CNA #1 attempted to touch her body. R #46 stated she became angry and yelled at him. R #46 stated CNA #1 left her and went to her roommate (R #120). R #46 stated she could see CNA #1 as he placed his hand under R #120's blanket and touched her body. R #46 stated she could hear CNA #1 ask R #120 if she liked what he was doing. R #46 could not hear any response from R #120. R #120K. Record review of R #120's face sheet dated 08/25/25 revealed she was admitted to the facility on [DATE] with multiple diagnoses including: Wernicke's encephalopathy (a serious brain disorder associated with alcohol abuse and malnutrition with symptoms of confusion),Cognitive communication deficit (difficulty understanding words and communicating with others),Adult sexual abuse confirmed. L. Record review R #120's MDS, dated [DATE], revealed a BIMS score of 9, moderately impaired. M. Record review of R #120's daily nursing notes revealed the following:- Dated 08/22/25 at 1:05 am, R #120 was on the floor of her room. She was confused, fearful, and talking about an event she believed happened. R #120 reported she was afraid of someone. - Dated 08/22/25 at 2:28 am, a change of condition for behavioral symptoms of agitation (angry or threatening behavior) and psychosis (a mental condition in which thoughts are distorted and unrealistic). [Name of resident] seems different than usual.- Dated 08/22/25 at 6:33 am, police arrived after a resident (unknown) called 911. Police spoke with R #120 and night staff, and they left the facility. The note did not include any further information regarding any police report or investigation.- Dated 08/22/25 at 2:25 pm, a note by SSD that Sexual Assault Nurse Examiner (SANE) nurse arrived at 2:13 pm to evaluate and treat the resident for sexual assault. The note did not include any further information regarding the SANE report. N. On 08/25/25 at 11:00 am, during interview, R #120 was unable to recall any events during her stay at the facility. She was unable to recall any care provided by CNA #1. She was unable to recall CNA #1. Throughout the interview, R #120 seemed fearful and confused, and she had difficulty participating in the conversation. O. On 08/25/25 at 11:20 am, during phone interview, R #120's husband stated he was informed by an unknown facility staff that his wife had been accosted (to touch or communicate a threat) by a CNA who was assigned to work with his wife during the night of 08/21/22 to 08/22/25. The husband stated he came to the facility late in the afternoon to be with his wife. He stated when he arrived his wife began crying and apologizing for cheating. The husband stated he tried to reassure R #120 that she did nothing wrong. He stated he was concerned, because his wife seemed to be declining in her mental and physical abilities. He stated he was concerned the incident would set her back even more. R #17P. Record review of R #17's face sheet, dated 09/04/25, revealed an admission date of 07/24/25 with the following diagnoses: Sepsis (a severe life-threatening infection),Urinary tract infection (UTI; an infection in any part of the urinary system, which includes the kidneys, ureters, bladder, and urethra),Low back pain. Q. Record review of R #17's BIMS, dated 08/18/25, revealed a BIMS score of 14, cognitively intact. R. On 08/26/25 at 1:30 pm, during interview, R #17 stated she was frequently assisted with peri care and other personal care by CNA #1 since she was admitted to the facility. R #17 stated CNA #1 would make inappropriate comments such as Will you miss me? and Do you think of me? R #17 stated she found the comments to be creepy, and she felt CNA #1 was trying to groom her. She denied CNA #1 attempted to touch her inappropriately. R #17 stated she did not report this to any facility staff, because CNA #1 was a night shift worker, and he had less contact with her on a day-to-day basis. She stated that is why she did not make any complaints. S. On 08/27/25 at 11:00 am during interview, the Administrator stated CNA #1 was an Agency CNA (an employee who works by contract through another agency). He stated the Agency documented CNA #1 completed training for abuse and neglect with them (Agency). He stated CNA #1 worked by a contract with the facility for several months. The Administrator stated he was informed of the allegations made by R #96 on 08/06/25, and he immediately began an investigation of the abuse concerning R #96. The Administrator stated CNA #1 was suspended pending the outcome of the investigation on 08/06/25 (time unknown). The Administrator stated other residents were interviewed regarding any sexual abuse by staff on 08/06/25. The Administrator stated they utilized a questionnaire that included a question asking if the resident had been sexually abused. The Administrator stated all other residents answered no to the question. The Administrator stated R #96 was interviewed about the incident, and the Administrator believed R #96's main concern was to have no further contact with CNA #1. The Administrator stated he did not confirm the allegation of abuse occurred. The Administrator stated since he did not substantiate the allegation of abuse, he contacted CNA #1, informed CNA #1 he was clear to return to work that night (08/06/25), and instructed CNA #1 not to have any further contact with R #96. The Administrator stated he immediately contacted CNA #1's agency on 08/22/25 when he learned of new allegations and informed them CNA #1 was not to return to the facility. T. On 09/02/25 at 4:11 pm during interview, the SSD stated R #96 told her there were a couple of instances that made her (R #96) uncomfortable. She stated R #96 reported CNA #1 would hug her when she did not want to be hugged, and he told R#96 that she looked ashy (a pale gray/white skin tone) and needed lotion. She stated R #96 reported CNA #1 changed R #96's brief and applied lotion, and his finger slipped into her rectum. The SSD stated she conducted an investigation of the report and informed the Administrator. The SSD stated there were not any other residents who reported any issues with CNA #1. The SSD stated the Administrator determined the allegations were unsubstantiated. The SSD stated she then told the Administrator she believed abuse occurred based on her interview with R #96, and the report should be substantiated. On 08/27/25 at 12:20 pm, the Administrator was notified of a finding of Immediate Jeopardy (IJ).On 08/28/25 at 12:01 pm, the facility provided an acceptable Plan of Removal (POR) which included the following: Corrective ActionAll residents have the potential to be affected by this alleged deficient practice. The following measures and monitoring will be completed by 08/27/25. Reportable sent for the initial resident 08/21/25. Two extra reportable were sent in late after new allegations of abuse on 08/26/25 and 08/27/25. CNA in question was terminated 08/21/25. Center has implemented a new abuse questionnaire that allows for a more thorough investigation starting 08/27/25. Whole house abuse questionnaire completed with residents 08/27/25. Systemic Measures Starting 08/27/25 the Center Nursing staff will be re-educated on the following areas by the Nurse Educator/Designee: If abuse or behavioral issues are occurring (combative/physical behavior, threatening behavior, or anything that could be harmful to oneself or any other person), the victim should be separated from the aggressor immediately. The aggressor should be placed on 1:1 supervision immediately and remain on this type of monitoring until they have been sent to the ER, a behavioral unit, or the provider has cleared them of all potential to harm themselves or others. Documentation needs to occur to reflect this monitoring and clear discontinuation of the 1:1 and reasoning by a provider. If a staff member is accused of abuse, they should be replaced on their shift and removed from the building until police arrive (if necessary), removed from the schedule, and not put back on the schedule until an investigation is completed and they have been cleared by the Administrator or DON (Director of nursing) to return. The provider, nurse manager and family have to be notified immediately. The eInteract change in condition assessment needs to be completed filled out with all the details of what happened. Monitoring and interventions need to continue to happen and be documented if the residents remain in the building, until we know they have stabilized per the provider or have left the center. Administrator and DON were educated on the need for individual reports for each resident regarding abuse. Center has implemented a new abuse questionnaire that allows for a more thorough investigation. When an allegation of abuse is identified, the center will report to the state agency. On 08/29/25 at 12:53 pm, the scope and severity was reduced from a K to an E. Implementation of the POR was verified by the following: - Record review of the facility's Abuse and Neglect training, dated 08/27/25, revealed all nursing staff were trained to recognize and report any abuse, including involuntary seclusion, unwanted physical contact, misappropriation, verbal abuse, or mental abuse. - On 08/29/25 at 10:54 am during interview, the facility Nurse Practice Educator stated she personally met with all nursing staff and provided each with the required re-education and re-training to recognize and report abuse.- On 08/28/25 at 10:00 am multiple nursing staff were contacted and interviewed. Each confirmed they had been provided re-education regarding abuse and neglect. Each confirmed they had been provided this training individually by the Nurse Practice Educator on 08/27/25. Each nursing staff interviewed was able to give a description of the training content and what was expected of them to recognize and report abuse. - On 09/01/25 at 9:30 am during observation of all areas of the facility, staff interacted with residents, provided care and assistance to residents and provided meals to residents. All staff were observed to interact in a respectful and dignified manner.

Based on record review and interview, the facility failed to thoroughly investigate multiple allegations of abuse. The facility then failed to take steps to prevent any future abuse of 4 (R #17, 46, 96 and 120) out of 4 (R #17, 46, 96 and 120) residents reviewed for abuse. If staff do not investigate allegations of abuse and take steps to prevent abuse, then other residents are at risk of abuse which may cause physical, emotional, and psychological harm. The findings are:R #96 A. Record review of R #96 face sheet, dated 09/04/25, revealed she had been admitted to the facility on [DATE] with multiple diagnoses including: -Cerebral (brain) Infarction (stroke), -Monoplegia (paralysis of one limb) of lower limb left side, -Dysphagia (difficulty swallowing), -Dysphonia (difficulty speaking). B. Record review of R #96's Minimum Data Set (MDS; a collection of assessments of a resident's abilities and care needs) Brief Interview of Mental Status (BIMS; a simple test of mental/memory abilities), dated 06/27/25, revealed a score of 13, cognitively intact. C. Record review of a facility provided Incident Report number 2584078, dated 08/13/25, revealed a report by R #96 in which she accused Certified Nurse's Aide (CNA) #1 of performing pericare (care provided to maintain cleanliness at the area of the body between the genitals and anus) on 08/06/25. During pericare, R #96 reported CNA #1 touched her anus with his finger. The report indicated CNA #1 was placed on leave pending the outcome of the investigation. The report further stated an abuse questionnaire was conducted with other residents in the facility. Per the report, the abuse questionnaire revealed no other abuse of other residents. Staff were educated to inform residents of their actions while providing care. CNA #1 was allowed to return provided he had no further contact with R #96. D. Record review of R #96's daily care notes, dated 08/06/25 at 1:49 pm and entered by the Social Services Director (SSD), revealed she was informed of a report of sexual abuse from a night CNA. The SSD was told by R #96, When he was putting cream on my private parts, I felt him put his finger up there [anus]. The SSD reported the incident to the facility Administrator (the facility Abuse Officer). E. On 08/26/25 at 3:30 pm during an interview with R #96, she stated CNA #1 had tried to hug her on 08/08/25 on multiple occasions. She stated CNA #1 used inappropriate language with her on other occasions, and CNA #1 touched her anus while conducting pericare on another occasion. R #96 reported these multiple events made her feel very uncomfortable and caused her to ask that CNA #1 not be allowed to provide care to her. R #46 F. Record review of R #46's face sheet, dated 09/08/25, revealed she was admitted to the facility on [DATE] with multiple diagnoses including: -Acute cystitis (sudden onset inflammation of the bladder), -Heart failure. G. Record review of R #46's MDS BIMS, dated 08/09/25, revealed a score of 12, moderately impaired. H. Record review of R #46's daily nursing notes revealed the following: - Dated 08/21/25 at 11:38 am and written by Social Services Assistant (SSA), stated, This writer received report that resident [R #46] claimed her night CNA attempted to sexually abuse her. When resident was interviewed, she stated 'I kicked him away and told him I am not that pendeja [asshole] cabron [bastard]! I am going to report you. CNA then stated, 'I don't give a fuck. He turned off all the lights and used the light on his phone to see. He put his hand under her [R #120's] blanket, and I heard him say 'Do you like that?' This writer (SSA) and SSD performed abuse questionnaires on whole building and filed police report on accused CNA. - Dated 08/22/25 at 8:54 am, revealed a change of condition in which R #46 reported the night shift CNA (CNA #1) had engaged in sexual harassment toward both her and her roommate R #120. I. On 08/25/25 at 1:00 pm during a phone interview with R #46, she stated CNA #1 entered her room during the early morning hours of 08/21/25, and CNA #1 attempted to touch her body. R #46 stated she became angry and began to yell at him. R #46 stated CNA #1 then left her and went to her roommate (R #120). R #46 stated she could see CNA #1 as he placed his hand under R #120's blanket and touched her body. R #46 stated she could hear CNA #1 as he asked R #120 if she liked what he was doing to her. R #120 J. Record review of R #120's face sheet, dated 08/25/24, revealed she was admitted to the facility on [DATE] with multiple diagnoses including: -Wernicke's encephalopathy (a serious brain disorder associated with alcohol abuse and malnutrition with symptoms of confusion), -Cognitive communication deficit (difficulty understanding words and communicating with others), -Adult sexual abuse confirmed. K. Record review R #120's MDS BIMS, dated 08/25/25, revealed a score of 9, moderately impaired. L. Record review of R #120's daily nursing notes revealed the following: - Dated 08/22/25 at 1:05 am, R #120 was found on the floor of her room. She was confused, fearful, and talked about an event she believed had happened. R #120 reported she was afraid of someone. - Dated 08/22/25 at 2:28 am, a change of condition for behavioral symptoms-agitation, psychosis (a condition of the mind causing illogical and irrational thoughts). R #120 seemed different than usual. - Dated 08/22/25 at 6:33 am, police arrived after a resident (unknown) called 911. Police spoke with R #120, then with the night staff, and then left the facility. - Dated 08/22/25 at 2:25 pm, a note by SSD that a Sexual Assault Nurse Examiner (SANE) nurse arrived at 2:13 pm to evaluate and treat resident for sexual assault. (No results of the SANE exam were available). M. On 08/25/25 at 11:00 am during an interview with R #120, she was unable to recall any events during her stay at the facility. She was unable to recall any care provided by CNA #1. She was unable to recall CNA #1. Throughout the interview, R #120 seemed fearful and confused. N. On 08/25/25 at 11:20 am during a phone interview with R #120's husband, he stated the facility staff informed him that his wife had been assaulted by a CNA working with his wife during the night on 08/21/25 to 08/22/25. The husband stated he was not told of any details of his wife's assault. The husband stated he came to the facility late in the afternoon to be with his wife. He stated that when he arrived, his wife began crying and apologizing for cheating. The husband stated he tried to reassure his wife that she was not to blame. The husband stated that his wife was becoming more confused since her admission to the facility. R #17 O. Record review of R #17's face sheet, dated 09/04/25, revealed she was admitted to the facility on [DATE] with multiple diagnoses including: -Sepsis (a several general infection), -Urinary tract infection (UTI; an infection in any part of the urinary system, which includes the kidneys, ureters, bladder, and urethra), -Low back pain. P. Record review of R #17's MDS BIMS, dated 08/18/25, revealed a score of 14, cognitively intact. Q. Record review of R #17's daily nursing notes revealed staff did not document any complaints from R #17 regarding care from CNA #1 or any other staff member. R. On 08/26/25 at 1:30 pm during an interview, R #17 stated she was assisted on multiple occasions by CNA #1 with general daily care such as repositioning, transferring from bed to wheelchair, and peri-care. R #17 stated CNA #1 would make inappropriate comments such as Will you miss me? and Do you think of me? R #17 stated she found these comments to be creepy, and she felt CNA #1 was trying to groom her. She denied CNA #1 attempted to touch her inappropriately. R #17 could not provide specific dates or times when these comments occurred. R #17 stated she never reported any of this information to any staff. She stated she did not like his care. She stated CNA #1 was a night shift worker, and he had less contact with her on a day-to-day basis. She stated that is why she did not make any complaints. S. On 08/27/25 at 11:00 am during an interview, the Administrator stated CNA #1 was an agency CNA (an employee who works by contract through another agency). The Administrator stated he was informed of the allegations made by R #96 on 08/06/25 regarding CNA #1, and he immediately began an investigation of abuse. The Administrator stated CNA #1 worked the night shift ending 08/06/25, and CNA #1 was assigned to give care to R #96 on the night shift ending 08/06/25. The Administrator stated CNA #1 was scheduled to return for his next assigned shift on 08/06/25 at 6:00 pm, but he contacted CNA #1 and informed him he was suspended from work pending the outcome of an abuse investigation. The ADM stated he began his investigation with the help of the SSD. The Administrator stated they interviewed other residents regarding any sexual abuse, and they utilized a questionnaire that included a question asking if the resident had been sexually abused. The Administrator stated all other residents answered no to the question. The Administrator stated R #96 was interviewed about the incident, and the Administrator believed her main concern was to have no further contact with CNA #1. The Administrator stated R #96's allegations regarding CNA #1 could not be confirmed. The Administrator stated he did not substantiate the allegation of abuse. He stated he contacted CNA #1 and said he was clear to return to work that night provided he did not have any further contact with R #96. The Administrator stated CNA #1 was assigned to another hall in another part of the building following the incident. The Administrator stated he was informed of new allegations of abuse on 08/22/25 in which CNA #1 was accused of abusing R # 46 and R #120. The Administrator stated he immediately contacted CNA #1's agency when he learned of these new allegations of abuse on 08/22/25, and he informed them CNA #1 was not to return to the facility. He stated he told the agency he would not be hired for future contract work. T. On 09/02/2025 at 4:11 pm during interview, the SSD stated she was told by R #96 that there were a couple of incidents that made her (R #96) uncomfortable. She stated R #96 reported CNA #1 would hug her when she did not want to be hugged, CNA #1 would say she looked ashy and needed lotion, and CNA #1's finger slipped into her rectum when he changed her brief. The SSD stated she spoke with R #96 as well as presenting a sex abuse questionnaire to multiple residents (no residents were identified specifically by SSD). The SSD stated she provided the Administrator her investigation, and she informed the Administrator that other residents did not have any issues regarding staff care. The SSD stated the Administrator determined the allegations were unsubstantiated. The SSD stated she told the Administrator she believed the abuse occurred and the report should be substantiated. On 08/27/25 at 12:29 pm, the Administrator was notified of a finding of Immediate Jeopardy (IJ). On 08/29/25 at 10:40 am, the facility provided a Plan of Removal (POR) which included the following: Corrective Action All residents have the potential to be affected by this alleged deficient practice. The following measures and monitoring will be completed by 08/27/25. Facility sent in late reportable for the second and third identified residents on 08/26/25 and 08/27/25. Change in Condition with provider and responsible parties notified 08/21/25. Whole house abuse questionnaire completed with residents 08/27/25. Skin check for residents involved as appropriate 08/21/25. Psychiatric service referral for residents involved as appropriate 08/21/25. CNA in question was terminated 08/21/25. Systemic Measures Starting 08/27/25 the Center leadership staff will be re-educated on the following areas by Market Resource Nurse. Investigations start with removal of staff member and protection of resident. Abuse questionnaires to be completed by those who have the potential to be affected by the staff member or resident. Individual self-reports to follow for any other residents who are identified during the questionnaires. Change in condition with provider and responsible party notification for those affected or impacted. Skin checks for residents involved as appropriate Social services to complete wellness checks and offer psychosocial support as appropriate. Psychiatric services referral for residents involved as appropriate. The scope and severity were reduced from a K to an E. Implementation of the POR was verified by the following: - Record review of the facility's Abuse and Neglect training, dated 08/27/25, revealed all nursing staff were trained to recognize and report any abuse including involuntary seclusion, unwanted physical contact, misappropriation, verbal abuse, or mental abuse. - On 08/28/25 at 10:00 am multiple nursing staff were contacted and interviewed. Each confirmed they had been provided re-education regarding abuse and neglect. Each confirmed they had been provided this training individually by the Nurse Practice Educator on 08/27/25. Each nursing staff interviewed was able to give a description of the training content and what was expected of them to recognize and report abuse. - On 08/29/25 at 10:54 am during interview with the Nurse Practice Educator, she stated she personally met with all nursing staff and provided each with the required re-education and re-training to recognize and report abuse. - On 09/01/25 at 9:30 am during observation of all areas of the facility, staff were observed as they interacted with residents, provided care and assistance to residents and provided meals to residents. All staff were observed to interact in a respectful and dignified manner.

Based on record review and interviews, the facility failed to follow provider orders for 2 (R #3 and R#121) of 2 (R #3 and R#121) residents when staff failed:-Complete, relay and document weekly Prothrombin Time and International Normalized Ratio (PT/INR) (a test administered to monitor and manage blood levels of Warfarin-a blood thinning medication) laboratory results for R #3. -Follow physician order for oxygen use for R#121. These deficient practices are likely to result in residents not maintaining their optimal health as planned by their medical provider. The findings are:R#3 A) On 9/3/25, record review of R 33's Physician's Orders revealed an order to check INR every Monday, call result to provider and enter nursing note with result, provider you spoke with, and any new orders received. B) Record review of R #3's daily nursing notes failed to show any documentation on 07/07/25, 07/14/25, 08/04/25, 08/11/25, 08/18/25, and 09/01/25 that INR was completed, recorded, provider notified and new orders. C) On 09/03/25 at 9:31 AM during an interview with the Director of Nursing (DON), she stated the in house INR is done every Monday per order and nursing staff is to document all results in the progress notes including conversations with the assigned provider. DON confirmed the documentation was incomplete and verified that there was no documentation regarding INR results before 07/07/25. R#121 D) Record review of R #121's physician order revealed #121 is on continuous oxygen to keep oxygen saturation level greater than 88%. E) On 09/05/25 at 10:32 AM, during a telephone interview with the Hospice Registered (HR) nurse, assigned to R #121 stated on one of his visits, he witnessed a staff walking the resident in the hallway with no oxygen on. He quickly checked her oxygen saturation level, and it was 82%. He notified all visible staff at the nurse's station to get an oxygen tank and return the resident back to her room where she has her own oxygen concentrator.

Based on observation, record review, and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) for 3 (R #'s 5, 15, and 9) of 3 (R #'s 5, 15, and 9) residents reviewed for ADL care by staff failing to: Providing assistance for baths and showers.This deficient practice is likely to affect the dignity and health of the residents. The findings are: R #5: A. Record review of R #5's face sheet revealed R #5 was admitted into the facility on [DATE]. B. Record review of R #5's care plan dated 07/18/25 revealed R #5 required ADL assistance for bathing due to R #5 having limited mobility and being legally blind. C. Record review of the facility's shower schedule revealed R #5's bath/showers were scheduled for Tuesdays and Fridays. D. Record review of R #5's documentation survey report (Activities of Daily Living - ADL tracking form), dated 06/01/25 through 06/30/25 revealed R #5 was offered/given 3 showers out of 8 opportunities. E. Record review of R #5's shower sheets dated 06/01/25 through 06/30/25 revealed R #5 was offered/given 3 showers out of 8 opportunities. F. Record review of R #5's documentation survey report dated 07/01/25 through 07/31/25 revealed R #5 was offered/given 1 shower out of 6 opportunities. G. Record review of R #5's shower sheets dated 07/01/25 through 07/31/25 revealed R #5 was offered/given 3 showers out of 6 opportunities. H. Record review of R #5's documentation survey report dated 08/01/25 through 08/31/25 revealed R #5 was offered/given 2 showers out of 9 opportunities. I. Record review of R #5's shower sheets dated 08/01/25 through 08/31/25 revealed R #5 was offered/given 5 showers out of 9 opportunities. J. On 08/26/2025 at 10:23 am during an interview and observation with R #5, he stated that he does not always get showered per his shower schedule. R #5 was observed to be unkempt (messy and without sings of a recent bath/shower) and have dirty nails. K. On 09/02/25 at 5:27 pm during an interview with Nursing Assistant (NA) #1, she stated that R #5 enjoys showers, and he does not refuse them often. L. On 09/03/25 at 12:16 pm during an interview with Certified Nursing Assistant (CNA) #3, she stated that showers/baths are documented in the electronic health record (documentation survey report) and shower sheets. CNA #3 also stated that she did not recall R #5 refusing baths/showers and he liked them. M. On 09/03/25 at 12:43 pm during an interview with Registered Nurse (RN) 31, she stated that she was not aware of R #5 refusing baths/showers. RN #1 also stated that baths/showers should be offered to residents per their shower schedule. N. On 09/04/25 at 4:35 pm during an interview with the Director of Nursing (DON), she stated residents should be offered baths/showers per the shower schedule and at least twice a week. The DON confirmed all baths/showers should be documented when completed or a resident refused, and R #5 was not offered/given enough showers and should have been. R #15: O. Record review of R #15's face sheet revealed R #15 was admitted into the facility on [DATE]. P. Record review of R #15's care plan dated 07/10/25 revealed R #15 required ADL assistance for bathing due to cognitive impairments (problems with mental functions). Q. Record review of the facility's shower schedule revealed R #15's bath/showers were scheduled for Wednesday and Saturday. R. Record review of R #15's documentation survey report dated 06/01/25 through 06/30/25 revealed R #15 was offered/given 1 shower out of 8 opportunities. S. Record review of R #15's shower sheets dated 06/01/25 through 06/30/25 revealed R #15 was offered/given 3 showers out of 8 opportunities. T. Record review of R #15's documentation survey report dated 07/01/25 through 07/31/25 revealed R #15 was offered/given 4 showers out of 9 opportunities. U. Record review of R #15's shower sheets dated 07/01/25 through 07/31/25 revealed R #15 was offered/given 7 showers out of 9 opportunities. V. Record review of R #15's documentation survey report dated 08/01/25 through 08/31/25 revealed R #15 was offered/given 4 showers out of 9 opportunities. W. Record review of R #15's shower sheets dated 08/01/25 through 08/31/25 revealed R #15 was offered/given 5 showers out of 9 opportunities. X. On 08/26/2025 at 2:18 pm during an interview with R #15, she stated that she would like at least two showers a week, but she does not get that often. R #15 also stated that she becomes frustrated when she is not given at least two showers a week. Y. On 09/02/25 at 5:25 pm during an interview with NA #1, she stated that R #15 likes to receive showers and does not refuse them. Z. On 09/02/25 at 5:37 pm during an interview with CNA #2, she stated R #15 likes showers, but she does not always get one because of staffing. AA. On 09/03/25 at 11:54 am during an interview with LPN #1, she confirmed R #15 likes to receive showers and R #15 does not refuse them. BB. On 09/04/25 at 4:36 pm during an interview with the DON, she confirmed R #15 was not offered enough baths/showers and should have been. R # 9 CC. Record review of R #9's face sheet revealed R #9 was admitted into the facility on [DATE]. DD. Record review of R #9's care plan dated 06/04/25 revealed R #9 requires ADL assistance for bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion (ability to get from one place to another in wheelchair or on foot), and toileting related to: Paralysis/Weakness, and limited mobility. EE. Record review of the facility's shower schedule revealed R #9's bath/showers were scheduled for Mondays and Thursdays. FF. Record review of R #9's shower sheets dated 06/01/25 through 06/30/25 revealed R #9 was given 4 showers out of 8 opportunities. GG. Record review of R #9's documentation survey report (DSR), dated 07/01/25 through 07/31/25, revealed R #9 was given a shower 6 out of 10 opportunities. HH. Record review of R #9's documentation survey report dated 08/01/25 through 08/31/25 revealed R #9 was offered/given 5 showers out of 10 opportunities. II. On 08/26/25 at 3:47 pm during an interview with the Resident Representative (RR), she stated there was an issue with showers, and R #9 did not get showers regularly, and was soiled on some visit occasions. R #9 complains to me at every visit that she is not getting bathed enough. JJ. On 09/03/25 at 9:30 am during an interview with the Director of Nursing (DON), she stated the expectation for shower sheet completion is the sheets will be reviewed by staff then given to Medical records for upload the same day. The DON stated there have been issues with the charting program, but there has been an increase in documentation across the board since the implementation of the shower sheet requirement for staff. KK. On 09/03/25 at 5:02 pm during an interview with the DON, she stated staff should document if it was refused for bed baths or showers regardless of the outcome. She stated showers should always be offered two times per week, and she could not explain blank spaces or missing documentation.

Based on observation and interview, the facility failed to ensure residents were treated with respect and dignity for 1(R #1) of 1 (R #1) resident when the facility failed to ensure the resident was not soiled while in the common areas for extended periods of time. This deficient practice is likely to result in residents feeling as if they were unimportant and not having privacy. The findings are: A. On 08/25/25 at 10:00 am observation revealed R #1 seated in her wheelchair visibly wet from her lower shirt to knees, located at the south nursing station. Further observation revealed R #1 remained soiled in the common area for 15 minutes.B. On 08/25/25 at 10:15 am during an interview with R #1, she stated they do not care, I have to wear two briefs because the other ones do not hold enough, and they will not change me unless I ask.C. On 08/25/25 at 10:15 am during an interview with Certified Nursing Assistant (CNA) #4, he stated he would just take care of it, after R #1 asked him who was her assigned CNA. He stated he could see R #1 was wet. D. On 08/26/25 at 2:10 pm during an interview with R #1's Power of Attorney (POA), she stated the bathing schedule seems off, and R #1 always complains to me about not being clean, staff need to be more aware of her. She also stated she took R #1 to a Urologist (A doctor who specializes in diagnosing and treating problems of the urinary tract), and they did not see a reason for the incontinence ( Loss of control over urination or bowel movements), so R #1 previously had a foley catheter (a thin plastic tube used for continuous urine drainage) placed but it was removed three months ago.E. On 08/29/25 at 12:40 pm observation revealed the following:R #1 was located in the dining room after lunch service while seated in her wheelchair.Resident had a strong odor of urine. F. On 08/29/25 at 2:00 pm observation revealed R#1 was still wet with urine after she traveled the hallways between the dining room and the south nursing station common areas. R #1 self-propelled in her wheelchair past Licensed Practical Nurse (LPN) # 4 and the Nurse Practice Educator (NPE) on the two hallways to the south nursing station. R #1 then asked the NPE to assist with calling her POA at the nurse's station phone. The NPE pushed R # 1's wheelchair to the phone from the west hallway to the south nurse's station and after four minutes of unsuccessful phone call attempts, the NPE took R #1 to the Social Services office to use the phone. R #1 spoke with the POA and then asked The NPE to assist with a brief change, and the NPE asked CNA #8 to change the resident's brief.G. On 09/02/25 at 3:15 pm during an interview with CNA #11, he stated to ensure resident's dignity while incontinent he monitors each incontinent resident continually. He stated I make sure they're clothed and clean, covered up if necessary. Only a few residents need monitoring, but staff are familiar with those who need extra support. CNA #11 stated if he saw a resident soiled in the hallway or common areas he would address it even if it wasn't his assignment. He stated anyone with a clinical certification should be able to help change a brief.H. On 09/02/2025 at 4:30 pm observation revealed R #1 had a foley catheter placed after an appointment with the Urologist on 09/02/25 at 2:00 pm.I. On 09/02/25 at 4:30 pm during an interview with R #1, she stated she requested for a foley catheter to be reinserted at the Urologist today due to not being changed often enough. She stated the POA had to purchase a new outfit for her since she was soiled upon arrival at the Dr.'s office, which included a bowel movement. R #1 stated through clenched jaws that she was embarrassed at the office and just feels wet when she is not changed and wearing clean clothes.J. On 09/03/25 at 9:30 am during an interview with the Director of nursing (DON) she stated the expectation for facility staff to ensure the dignity of incontinence residents, is staff completes rounding but they cannot force residents to get cleaned, sometimes they will refuse when we ask them to receive care.

Based on observation and interview, the facility failed to store and serve food under sanitary conditions when staff failed to ensure: 1. Food items were labeled and dated in the kitchen refrigerator and freezer. 2. Eggs should be refrigerated, kept cold or on ice when out of the refrigerator. 3. Floor in the facility freezer was clean (spilled milk) and free of debris (paper) These deficient practices are likely to affect all 95 residents listed on the resident census list provided by the Administrator on 06/02/25 and are likely lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to. The findings are: A. On 06/02/25 at 9:15 am during a walk through of the facility's kitchen revealed the following: 1. 2 large serving trays with what appeared to be pieces of cake were unlabeled and undated. 2. 3 bags of whipped topping were undated 3. 1 container of what appeared to be sugar was on the shelf unlabeled and undated 4. Pitcher of juice in the refrigerator was unlabeled and undated 5. A tray of what appeared to be thickened juice was unlabeled and undated in the refrigerator. 6. 1 tray of eggs was out and was not sitting on ice, was under the food warmer then staff removed the tray of eggs and placed back in the refrigerator. (Eggs were warm to the touch) 7. Floor in the freezer had spilled milk and paper and plastic wrappers were on the floor . B. On 06/02/25 at 9:20 am during an interview with the Dietary Manager (DM), he confirmed the findings listed above, and stated foods should be labeled and dated, eggs should be on ice or refrigerated and freezers should be kept free of debris.

Based on record review and interview, the facility failed to provide care that met professional standards for 1 (R #2) of 1 (R #2) resident when medications were administered which were contraindicated (medications that counteract each other) resulting in the resident experiencing diarrhea (a condition characterized by excessive and loose, watery bowel movements). This deficient practice is likely to result in residents being uncomfortable, developing skin damage and becoming dehydrated (a condition where the body loses more fluids than it takes in). The findings are: A. Record review of R #2 face sheet dated 06/05/25 revealed he was admitted to the facility on [DATE] with the following diagnoses: -Aneurysm (a weak spot of the wall of an artery) of Iliac Artery (a major artery in the lower body that supplies oxygenated blood to the lower limbs). -Hemiplegia (paralysis or severe weakness of one side of the body) Left side B. Record review of R #2's provider orders revealed the following medication orders: -Started 04/01/25, Sennosides-Docusate (medication prescribed to treat and reduce constipation (infrequent and hard to pass bowel movements) 8.6 -50 MG (milligrams) give 1 tablet twice daily for constipation. Discontinued and replaced on 06/04/25 to give 1 tablet every 12 hours as needed for constipation. -Started 04/25/25 Loperamide (medication prescribed to treat and reduce diarrhea) 2 MG give 1 tablet every 4 hours as needed for diarrhea. -Started 04/01/25 Morphine (narcotic medication that treats pain) 20 mg/ml give 0.25 mil every 4 hours as needed for pain. C. Record review of R #2's Medication Administration Record (MAR) revealed the following medication administrations: Loperamide -05/08/25 Loperamide 1 tablet given at 10:03 am and listed as E (effective). -05/18/25 Loperamide 1 tablet given at 9:57 pm and listed as E. -05/19/25 Loperamide 1 tablet given at 7:29 am and listed as E. -05/22/25 Loperamide 1 tablet given at 5:22 am and listed as I (ineffective). -05/28/25 Loperamide 1 tablet given at 4:35 am and listed as U (ineffective). -05/29/25 Loperamide 1 tablet given at 9:21 am and listed as E. -05/31/25 Loperamide 1 tablet given at 5:28 am and listed as E. -06/02/25 Loperamide 1 tablet given at 2:18 am. -06/03/25 Loperamide 1 tablet given at 8:29 am. -06/03/25 Loperamide 1 tablet given at 12:36 pm. -Sennoside-Docusate 1 tablet was given at 8:00 am and 8:00 pm on all of the days during the month of May except: 05/09/25 at 8:00 am. D. Record review of R #2's daily care notes revealed the following: -05/18/25 at 10:14 pm nurse note: writer was called to R #2's room because he had diarrhea for the past month. Writer did not know about ongoing diarrhea. The oncall provider was notified and was told to give Loperamide and if no relief contact the PCP (Primary Care Provider). -05/19/25 at 12:30 am On-Call provider note: Assessment-Diarrhea, give Imodium (trade name for Loperamide) and hold Senna (Sennosides-Docusate) for the morning. -05/19/25 at 5:31 am nurse note: Resident (R #2) had two more episodes of diarrhea after medication (Loperamide) was given. Will pass on to oncoming nurse. -05/22/25 at 5:40 am nurse note: resident had two episodes of loose stools this shift Loperamide given. E. On 06/02/25 at 10:30 am during an interview with R #2, he stated, that he feels dirty and smells horrible, he does not want to get out of bed or go out of his room because of his diarrhea. He is not able to control when he goes to the bathroom. He further stated that he needs to be changed several times a day and the staff is not always available to change him and he is left dirty for long periods of time. He has requested that he be showered instead of bed baths because he would feel much cleaner, but they have not honored that request. F. On 06/03/25 at 11:50 am during interview with Certified Nurse Aide (CNA) #1, she stated that she was usually assigned to the unit where R #2 was a resident. She stated she was very familiar with him and his care. She stated that she was aware during her days on the unit that R #2 was complaining of diarrhea almost daily. She stated she had completed brief changes for R #2 several times each day that she had worked. She stated with each brief change, she noted that his bowels were very loose and watery, had a foul smell and was sometimes green in color. She stated she had passed this information on to R #2's assigned nurse with each shift she worked. She stated that from her observations, R #2 was having frequent daily bouts of diarrhea for at least the last two weeks. G. On 06/03/25 at 12:10 pm during interview with Licensed Practical Nurse (LPN #2), she stated that she was the nurse assigned to R #2 today, 06/03/25. She stated that she was also assigned to his care the past two days on 06/01/25 and 06/02/25. She stated she was aware that R #1 has had diarrhea on each of the past two days. She stated she had given him Loperamide today 06/03/25 and yesterday 06/02/25. She stated she had held R #1's morning dose of Sennosides-Docusate each day since 06/01/25. She stated the two medications should not be given together. H. On 06/03/25 at 1:00 pm during phone interview with the facility assigned Nurse Practitioner (NP), she stated that common medical practice would be to order the Sennosides-Ducosate daily for a resident who is prescribed narcotic pain medications. She stated that if a resident receiving Sennosides-Ducosate started having diarrhea then common medical practice would be to hold or discontinue the Sennosides-Ducosate and administer Loperamide as needed until the diarrhea ends. She stated that administering both medications at the same time on a daily basis over an extended period of time would be contraindicated as one medication would counteract the other. I. On 06/03/25 at 1:47 pm during interview with Director of Nursing (DON), she reviewed R #2's medical record and his record of medication administration. DON stated that R #2 had an order to administer Sennosides-Ducosate daily. She stated this was a common order for any resident who was receiving narcotic medications to prevent a resident from becoming constipated. She also acknowledged that R #2 had received multiple doses of Loperamide. She stated a resident should not receive both medications at the same time and that a resident who is having diarrhea should not be administered Sennosides-Ducosate at the same time. DON stated that the nurses should have held his Sennosides-Ducosate until the diarrhea had cleared or contacted the provider to notify them of the diarrhea and the contraindicated medications.

Based on record review, and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths and showers for 1 (R #2) of 1 (R #2) resident reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents. The findings are: A. Record review of R #2's face sheet revealed R #2 was admitted into the facility on [DATE]. B. On 06/02/25 at 10:30 AM during an interview with R #2, he stated that he was not receiving showers which he prefers and has requested showers. Instead, he has been given bed baths, and those are inconsistent. He further stated that he had not received a bed bath in about two weeks and that he cannot stand his own stench, which makes him feel like a pig. C. Record review of R #2's care plan dated 10/03/22 revealed, Focus: [Name of R #2] requires assistance for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to CVA (Cerebrovascular accident-medical term for a stroke or brain attack) with limited mobility. Focus: [Name of R #2] is at risk for falls R/T (related to) debility (physical weakness), sedating medications and history of CVA . Interventions: Assistance of two staff members for all transfers. D. Record review of the Shower Schedule revealed R #2 is scheduled to shower on Wednesdays and Saturdays. E. Record review of R #2's Documentation Survey Report (used to chart on resident care) dated April 2025 revealed the report did not contain any documented showers or refusals for the month of April. F. Record review of R #2's Documentation Survey Report dated May 2025 revealed the report did not contain any documented showers or refusals for the month of May. G. Record review of R #2's Shower Sheets revealed R #2 was given four bed baths in the month of May 2025 and for the month of April 2025 shower sheets were not available to review. H. On 06/03/25 at 11:52 AM, during an interview with Certified Nurse Aid (CNA) #1, she stated that hospice is responsible for R #2's showers. She further stated that R #2 had informed her that he would like showers instead of bed baths and she let the floor nurse know of R #2's preference, CNA was unsure of the date she let the floor nurse know. I. On 06/03/25 at 12:09 PM, during an interview with Licensed Practical Nurse (LPN) #2, she stated that she has called hospice multiple times because no one has come here to give R #2 a shower, that is (giving R #2 a shower) part of his hospice care. She further stated facility CNA's will give him a bed bath when hospice does not come in. LPN #2 then confirmed R #2 has not had a shower and I do not know why. J. On 06/03/25 at 1:40 PM during an interview with the Director of Nursing (DON), she stated residents should be getting showers if that is their preference and he should be offered showers on the day he is scheduled to have a shower. She further stated that even if hospice is providing showers the facility should still be offering showers to hospice residents.

Based on observation and interview the facility failed to safeguard clinical record information by leaving Private Health Information (PHI) where unauthorized persons had access to it for the residents of Unit 1 and Unit 2 during random observations. If the resident's clinical information is not sufficiently safe guarded, resident's PHI is likely to be viewed by unauthorized residents, visitors, and staff. The findings are: A. On 06/02/25 at 8:50 AM, during a routine observation of Unit 1 nurses' station, a vital sign sheet was face-up on the counter, displayed the vital signs and names of all the residents in Unit 1. This information was visible to any unauthorized persons approaching the nurses' station. B. On 06/02/25 at 8:53 AM, during an interview with Licensed Practical Nurse (LPN) #1, he confirmed that the vital sign sheet had been left face-up on the counter, making the information visible to all. He stated that it should have been placed face-down. C. On 06/02/25 at 9:17 AM, during a routine observation of Unit 2 nurses' station, a daily resident census sheet was face-up on the counter, displaying the names and room numbers of all residents in the facility. This information was visible to any unauthorized persons approaching the nurses' station. D. On 06/02/25 at 9:19 AM, during an interview with LPN #2, she confirmed that the daily census sheet had been left face-up on the counter, making it visible to all. She stated that it should not have been left face-down. E. On 06/02/25 at 9:23 AM, during a routine observation of Unit 1, a weight list containing the weights of all residents in the facility was found on a clipboard hanging outside room [ROOM NUMBER], facing outward, where it was visible to anyone passing by. F. On 06/02/25 at 9:25 AM, during an interview with LPN #1, he confirmed that the weight list sheet had been left hanging facing outward and should not have been.

Based on observation and interview, the facility failed to serve food at a safe and appetizing temperature for 1 (R #2) of 1(R #2) resident reviewed for food preference. This deficient practice is likely to result in residents consuming less food causing weight loss and malnutrition. The findings are: A. On 06/03/25 during observation of the meal service in the 120 hallway, meal trays arrived at the unit at 12:36 pm for the midday meal service. Meals were on trays that were being held in a tray cart that was closed. Staff began to serve the meals at 12:39 pm. The cart doors were opened and closed as meals were removed from the cart and taken to the assigned room. Each tray removed had a main plate that was covered by a warming cover. All trays were passed out by 12:41 pm. The last tray was held to serve as a test tray. B. On 06/03/25 at 12:44 pm during observation of the the 120 hallway, the Dietary Manager (DM) arrived to the area and he took the test tray from the cart and took the temperatures of the food contained on the test tray. The tray contained a hamburger, broccoli, tater tots (a form of French-fried potatoes), a cookie and several cold drinks. C. On 06/03/25 at 12:45 pm during interview with the DM, he stated that the temperature of the hamburger was 96.8 degrees Fahrenheit and the temperature of the broccoli was measured at 94.7 degrees Fahrenheit. He stated he could not measure the temperature of the tater tots. DM acknowledged that these temperatures were too cool, and the temperatures of the last tray served should be about 130 degrees Fahrenheit. D. On 06/03/25 at 1:00 pm during interview with R #2, she stated that she had just received her meal and that most days her tray arrived with food that was cool to the taste and touch.

Based on record review and interview, the facility failed to provide quality of care for 4 (R #1, 6, 7 and 10) of 4 (R #1, 6, 7 and 10) residents reviewed for change in condition by: 1. Not treating R #1, 7 and 10 when a change in condition was identified 2. Not reporting new wound to physician, delaying in initiating treatment, Physician Assistant (PA) not evaluating the wound before intimating treatment orders for R #6 3. Discharging resident to an assisted living facility instead of the hospital despite the resident showing significant signs of a change in condition. These deficient practices likely resulted in worsening condition and unnecessary discomfort for the residents. The findings are: R #1 A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE]. B. Record review of R #1's nursing progress notes dated 01/1725 through 01/31/25 revealed the following: 1. 01/17/25 at 10:00 am: R #1 complained of cough and rhonchi (continuous, low-pitched lung sounds that resemble snoring or gurgling) to upper part of lungs. Tylenol and chest x-ray ordered. 2. 01/21/25 at 8:49 pm: R #1 is confused. 3. 01/22/25 at 12:00 am: Provider Encounter- R #1 reports having a cough and congestion. R #1 is wearing oxygen (O2) and feels slightly short of breath. 4. 01/25/25 at 1:00 am: New onset of confusion. Labs ordered. 5. 01/25/25: at 3:28 pm: At approximately 1:00 pm R #1 experienced a sudden onset of confusion. R #1 stated she should walk out of the facility and she was seeing her pet cat walk around the room. Monitor until lab results received. 6. 01/27/25 at 11:42 pm: R #1 was experiencing disorientation, disorganized thinking, and confusion. R #1 has been sick and has also been confused as of late. 7. 01/28/25 at 10:35 pm: R #1 is confused. 8. 01/29/25 at 12:00 am: Provider Encounter- R #1 is sleeping in bed and is difficult to wake. R #1 is wearing O2 and has a mild increased work of breathing. R #1 awakens and stated that she has been very tired recently and has had a cough since 01/15/25. Labs reviewed and R #1 has an elevated white blood cell count (which indicates various conditions, including infections, inflammation, or bone marrow disorders). Chest x-ray ordered to rule out Pneumonia. Continue medications and may need to start antibiotics. 9. 01/29/25 at 6:53 pm: R #1 is lethargic and incoherent. 10. 01/30/25 at 10:16 am: R #1 is confused. 11. 01/31/25 at 12:00 am: Provider Encounter- Nurse called to report R #1 is physically declining. R #1's blood pressure is 74/42 and repeated it was 89/40. R #1 is wheezing and lethargic, and stated she has been sick with a respiratory illness. She had a chest x-ray, but the results have not come in yet. Requesting to send R #1 to the hospital because R #1 has significantly declined. R #1 is lethargic, difficult to arouse when name is being called, pale, and clammy. Send R #1 to the hospital for evaluation and treatment. 12. 01/31/25 at 8:16 am: Late Entry- 911 called and R #1 was sent to the ER at 8:45 am on 01/31/25. C. Record review of R #1's ER documentation dated 01/31/25 revealed, R #1 was diagnosed with Pneumonia, UTI, Kidney Inflammation, and Sepsis (a life-threatening complication of an infection). D. On 02/14/25 at 11:34 am during an interview with R #1's friend, she stated R #1 got progressively worse during the dates of 01/15/25 through 01/31/25. R #1's friend stated that the facility delayed sending R #1 to the ER. E. On 02/19/25 at 2:45 pm during an interview with Licensed Practical Nurse (LPN) #4, she stated she worked with R #1 on 01/25/25 when R #1 was confused wanting to leave the facility and seeing her pet cat in her room. LPN #4 stated the Certified Nursing Assistant (CNA) told her that R #1 was experiencing a lot of confusion, so she went to assess R #1. LPN #4 also stated that because R #1 was so confused, she contacted the provider, but the provider did not tell her to send R #1 to the ER. LPN #4 confirmed she believed R #1 should have been sent to the ER sooner than 01/31/25. F. On 02/19/25 at 3:38 pm during an interview with LPN #2, she stated that R #1 was experiencing confusion on 01/29/25, so the provider came to see R #1 and ordered a chest x-ray. G. On 02/19/25 at 4:30 pm during an interview with LPN #3, she stated R #1 was complaining of a cough on 01/17/25, so she contacted the provider to get medication to treat R #1's cough. LPN #3 stated R #1 was not getting better over time, so she requested to send R #1 to theER on [DATE]. LPN #3 also stated that she tried to send R #1 to the ER before, but she was told she could not do that by the former Unit Manager. LPN #3 confirmed R #1 significantly declined to the point where she called 911 to send R #1 to the ER. LPN #3 also confirmed that R #1 should have been sent to the ER sooner than she was sent out. H. On 02/19/25 at 5:30 pm during an interview with R #1, she stated that she became really sick (from 01/15/25 through 01/31/25) and she was not in her right state of mind. R #1 stated the hospital diagnosed her with Pneumonia, a UTI, Sepsis, and Kidney Stones. R #1 also stated that her friends and roommate had concerns that the facility delayed sending her to the ER. I. On 02/20/25 at 11:43 am during an interview with the Physician's Assistant (PA), she stated that she initially evaluated R #1 due to R #1 experiencing a cough, but she was unaware of R #1's confusion due to her not being familiar with R #1. The PA stated that R #1 was not alert when she assessed her and she had diminished lung sounds, which is why she ordered a chest x-ray and antibiotics. The PA confirmed R #1 should have been sent to the ER sooner than she was and she did not know why R #1 was not sent to the ER sooner. J. On 02/20/25 at 2:35 pm during an interview with Registered Nurse (RN) #1, she stated R #1 began to decline prior to being sent to theER on [DATE]. RN #1 also stated that R #1 was not doing well, but she did not remember why R #1 was not sent to the ER. RN #1 confirmed R #1 should have been sent to the ER sooner than 01/31/25. K. On 02/20/25 at 3:13 pm during an interview with the Director of Nursing (DON), she stated that two of the providers that assessed R #1 during 01/17/25 through 01/31/25 were in-house providers and two were on-call providers, which might have delayed sending R #1 out to the ER sooner than 01/31/25. The DON also stated that she would expect there facility nurses to send a declining resident to the ER if needed, and not wait to do so. The DON confirmed R #1 should have been sent to the ER sooner than 01/31/25 and she was not. 33768 Findings related to R #7 L. Record review of the complaint allegation received by the State Agency on 01/09/25 revealed that during the holiday (Christmas), three different family members visited R #7 either in person of via Zoom and all three mentioned that her eyes were red, irritated and making R #7 uncomfortable. The cousin who visited in person alerted staff to this and they brought some eye drops. The complainant stated that she specifically requested care for R #7's eyes via email on 12/24/24 and 12/31/24 however there was no response until 01/07/25. M. On 02/15/25 at 12:33 pm during interview with R #7 when asked about her eyes being irritated, she stated Only thing I remember was they were cutting grass and the window was open. She confirmed that her eyes were itchy but it wasn't painful. R #7 remembered the symptoms only lasting one day. N. On 03/05/25 during interview with R #7's daughter, she stated that she her mother has stroke damage and struggles with short term memory loss. She reported that her cousin and niece had visited her mother in December and noticed that her eye was red and bothering her. R #7's daughter stated that she made outreach to the Director of Nursing during Christmas week and she [DON] didn't get back to her. She stated that R #7 looks forward to her hair appointments and was told she was not allowed to go to her hair appointment she had pink eye. This was on 01/07/25. She stated that she came to visit in January and everyone including the executive Director (Administrator) apologized. She stated that when she came to the facility [on 01/07/25], the issue was finally addressed. O. Record review of email provided by R #7's daughter dated 12/26/24 identified that R #7's other daughter had informed her sister that R #7 had itchy runny eyes that was assumed to be attributed to allergies. Another email identified that R #7's daughter had emailed the Unit Manager on 12/31/24 regarding R #7's eyes and received no response until 01/07/25. P. Record review of the Change in Condition Evaluation for R #7 dated 01/07/25 revealed Eye are red along the upper and lower lids. Inside her eyes they are full of mucus. Dr. (Doctor) seen her today and prescribed medicine for 10 days. Date and time of of clinician notification was identified as 01/07/25. Q. Record review of the Medication Administration Record for R #7 dated January 2025 identified an order Pataday Ophithalmic Solution 0.1 % (antihistamine) one drop in both eye s two times a day for allergic conjunctivitis (pink eye) for 10 days started on 01/07/25. R. On 03/05/25 at 12:33 pm during interview with the Administrator regarding R #7, he stated the issue with her eyes was brought up in the morning clinical meeting as a change in condition (01/07/25) and that the provider saw R #7 and then prescribed an ointment. When asked if the family had brought concerns to his attention prior to 01/07/25, he stated that no one had told him about it but that the Activities Director did received an email on 12/26/24 and should have informed the nurse to tell the doctor. The Administrator confirmed that it would be his expectation that staff should have immediately informed the nurse of a change in condition to the resident however there was no evidence that this was done for R #7. 39509 R #10 S. Record review of R #10 face sheet dated 04/01/25 revealed she was admitted to the facility on [DATE] with multiple diagnoses including: -Cerebral (brain) Infarction (death of tissue due to lack of oxygen-stroke) -Acute Kidney Failure -Alzheimer's Disease (a chronic progressive disease that causes loss of memory and thought) The face sheet also revealed that primary care provider (PCP) was a doctor of a senior service agency, not a provider connected to the facility. T. Record review of R #10 daily care notes revealed: -11/03/24 she was confused, she refused her medications and was not sleeping. A Urinary Tract Infection (UTI) was suspected, and the nurse placed an order to gather and test urine for a urinalysis to test for possible UTI. -11/04/24 R #10's provider called the facility, canceled the urinalysis and reported that R #10 had already had a urinalysis at their facility, the test had returned positive for a UTI and that orders would be entered for an antibiotic for treatment. -11/05/24 R #10 was noted to be confused, had had multiple falls, and required one-to-one monitoring. -11/05/24 After a fall, R #10 was sent to the local hospital for assessment due to her altered mental status. Per the note, she returned later that night after receiving an intravenous (within the veins) antibiotic. U. Record review of R #10 provider order dated 11/08/24 revealed an order to begin Amoxicillin-Clavulanate (an antibiotic medication that treats infections) 875-125 mg (Milligrams) once daily for 7 days for a UTI. V. Record review of R #10 daily care note revealed -12/05/24 R #10's Primary Care Provider (PCP) was notified of R #10's change of condition-she was yelling, wandering about the hall, refusing to comply with directions and could not be redirected. The PCP stated that Risperidone (a psychiatric medication used to treat agitation) would be prescribed. -12/13/24 R #10 is screaming, attempting to throw herself on the floor. The provider was called and ordered R #10 be sent to the hospital for evaluation. -12/13/25 R #10 returned to the facility from the hospital. W. Record review of R #10 provider order dated 12/19/24 revealed an order to administer Risperidone 0.5 mg (milligrams) twice daily for agitation. X. On 04/02/25 at 12:10 pm during interview with the Director of Nursing (DON), stated that R #10 is one of several residents who are managed by a PCP who is not connected with the facility. DON confirmed that R #10's care was delayed. She stated that R #10's senior service PCP should have informed the facility on or before 11/03/24 that the suspected R #10 had a UTI and that they had tested R #10 to confirm this. She stated that R #10's was also delayed when the PCP failed to enter an order for the administration of an antibiotic for 5 days. She also confirmed that R #10's care was delayed when the PCP failed to enter an order for Risperidone for 14 days. 38450 R #6 Cross reference to F580, F641, F658, F686, and F880. Z. Record review of R #6's admission Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 11/19/24, revealed the following: - admitted [DATE] from hospital. - Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) score of 15, cognitively intact. - Always incontinent of bladder and bowels. - Diagnoses of end stage renal disease (ESRD; chronic irreversible kidney failure), dependence on renal dialysis renal dialysis (the process of removing extra fluid and waste products from the blood when the kidneys are not able to function properly), and depression. - The resident was at risk of developing pressure ulcers (PU; an injury to skin and underlying tissue resulting from prolonged pressure on the skin.) - The resident had two Stage 1 pressure ulcers (intact skin over a bony prominence with a reddened, painful area of skin that does not turn white when pressed.) - The resident had one Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) present on admission. - The resident had a skin tear (a type of injury where the skin is torn from the body.) - Staff did not document any other skin issues, ulcers, or wounds. AA. Record review of R #6's Wound Evaluation, dated 11/28/24, revealed the following: - Burn, third degree. - Staged by in-house nursing. - Location: Sacrum (a large flat bone in the lower part of the spine.) - Minutes old and acquired in-house (at the facility.) - Measurements: length 6.64 centimeters (cm), width 4.2 cm, depth 0.2 cm, area 15.95 cm^2 (square centimeters.) - Wound bed: Epithelial tissue (a thin, continuous layer of cells) present, granulation tissue (new connective tissue and blood vessels, a sign of wound healing) present. - Moderate serosanguineous (clear or light pink, thin, watery fluid) exudate (body fluid discharged by the body in response to tissue damage and wound healing.) - Edges attached, surrounding tissue erythema (redness.) - Temperature was hot, localized. - Resident reported pain at a 7 out of 10 during dressing. - Treatment: Generic wound cleanser, composite dressing, and Xeroform bordered gauze. - Notes: Resident's skin was hot to touch with a heating pad under her. The resident's skin was thin and fragile. Removed the heating pad. - Education: The resident was educated about the risk factors involved in using a heating pad. Resident was strongly advised to discontinue use of the heating pad and to shift weight in bed frequently. - Notification: None documented. - Electronically signed by the facility's Skin Health Team Lead (SHTL) on 11/29/24 at 12:33 pm. BB. Record review of R #6's Physician Orders, dated November 2024, revealed the following: - Order dated 11/13/24, pressure redistribution cushion to chair. - Order dated 11/13/24, pressure redistribution mattress to bed. - Order dated 11/29/24, wound care for sacrum lower back. Cleans with generic wound cleanser, pad dry, apply small amount of xeroform, and apply bordered gauze. CC. Record review of R #6's Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated November 2024, the record did not contain wound care orders or documentation staff administered the orders, dated 11/28/25, for the resident's third degree burn to the sacrum. DD. Record review of R #6's medical record revealed the record did not contain any documentation staff administered wound treatments, dated 11/28/25, for the resident's third degree burn to sacrum. EE. Record review of R #6's care plan revealed the following: - Dated 11/13/24, last updated 11/19/24. - The resident was at risk for skin breakdown related to advanced age, decreased activity, frail fragile skin, and limited mobility. - The resident would not show signs of skin breakdown for 90 days. - Interventions: Pressure redistribution surface to chair and bed, weekly skin check by licensed nurse, offload heels while in bed, observe skin condition daily with ADL care and report abnormalities, apply barrier cream with each cleansing. - The record did not document the resident's third degree burn on her sacrum. FF. Record review of R #6's Nursing Skilled Evaluation, dated 11/29/24, revealed the following: - Pain: Indicators of pain: None. - The record did not contain any information in the following areas: skin, special care, safety, completed clinical suggestions, comments. - The record did not address the resident's third degree burn on her sacrum and her wound treatments. - Electronically signed by an agency licensed nurse. GG. Record review of R #6's Progress Note, dated 12/02/25, revealed the following: - Visit type was acute follow-up. - Chief complaint and nature of the presenting problem: Follow-up of admitting medical diagnoses, including depression. - Resident was a fairly inconsistent historian but at time of encounter denied complaint or concern. - Nursing staff denied new or worsening behaviors, recent fall or injury, unstable vital signs, or other complaint or concern. - The record did not address the resident's third degree burn on her sacrum and her wound treatments. - Electronically signed by the Nurse Practitioner on 12/03/24 at 4:55 pm. HH. Record review of R #6's nutrition progress note, dated 12/03/24, revealed the following: - Resident had multiple pressure wounds. - The record did not address the resident's sacrum wound. II. Record review of R #6's Wound Evaluation, dated 12/04/24, revealed the following: - Burn, third degree. - Staged by in-house nursing. - Located on sacrum. - Six days old and acquired in-house. - Measurements: length 6.24 cm, width 3.9 cm, depth 0.2 cm, area 18.24 cm^2. - Wound bed 70 percent (%) epithelial, 70% granulation, 20% slough (yellow stringy tissue adhered to wound bed.) - Evidence of infection: increased drainage, increased pain. - Bleeding. - Moderate serosanguineous exudate with faint odor after cleaning. - Edges attached, surrounding tissue erythema. - Resident reported pain at a 7 out of 10 during dressing. - Dressing appeared saturated. - Treatment: Vashe (wound cleanser), Medihoney (wound and burn gel), foam, incontinence management. - Healable. - Stable. - Notification: None documented. - Electronically signed by the facility's SHTL on 11/04/24 at 1:05 pm. JJ. Record review of R #6's Physiatry (related to physical medicine and rehabilitation) progress notes, date 12/05/24, revealed the following: - The resident's plan and progress was discussed with nursing staff and therapy. Resident was sitting up in bed and she reported pain at right leg. Resident stated she slept on and off throughout the night. No complaints of fever, chills, nausea, vomiting. - Pain: Resident reported pain at right lower extremity at hip region. Continue lidocaine patch to affected area once daily. - Electronically signed by the Consultant. KK. Record review of R #6's Physician Orders, dated December 2024, revealed the following: - Order dated 12/04/24, for lower back sacrum wound. Cleanse wound with Vashe, soak gauze in Vashe. Lace on wound and allow to soak area for 20 minutes. Pat dry. Apply Medihoney and cover with bordered gauze. Every day and night shift, and as needed for when soiled or dressing is removed. - Order dated 12/05/24, silver sulfadiazine cream 1%. Apply to burn on sacrum topically every day and night shift for wound care. Cleanse with generic wound cleanser, pat dry. Apply thin layer of silver sulfadiazine cream, cover with border gauze. - Order dated 12/05/24, lidocaine external patch. Apply to right hip topically in the morning for pain. End date 12/12/24. - Order dated 12/05/24, remove lidocaine patch from right hip at bed time for pain. End date 12/12/24. LL. Record review of R #6's MAR and TAR, dated December 2024, revealed the following: - Silver Sulfadiazine cream 1%. Staff did not document they applied the cream on the night of 12/06/25. - Lidocaine external patch. Apply to right hip topically in the morning for pain. Staff documented they applied the patch 12/06/24, 12/07/24, 12/08/24, and 12/09/24. - Remove lidocaine patch from right hip at bedtime for pain. Staff documented they removed the patch on 12/05/24, 12/06/24, 12/07/24, 12/08/24, and 12/09/24. - The record did not contain the wound care orders or documentation staff administered the orders, dated 12/04/24, for the resident's third degree burn to sacrum. MM. Record review of R #6's medical record revealed it did not contain any documentation staff administered the wound treatments, dated 12/04/24, for the resident's third degree burn to sacrum. NN. Record review of R #6's Progress Note, dated 12/06/25, revealed the following: - Visit type: Discharge. - Chief complaint and nature of the presenting problem: Discharge summary and plan. - The resident was initially to be seen today for discharge summary and plan. The NP was contacted by the wound care nurse and notified the resident had a burn to her back. The burn reported had an odor and greenish discharge. The resident was asymptomatic without indication of sepsis or systemic infection. Patient lay in bed, and did not appear to be in acute distress. Resident was a poor historian secondary to dementia, and the NP was unable to reposition the resident at the time of the encounter in order to examine the resident's back. Order to apply silver sulfadiazine cream (antibiotic cream for serious skin infections and burns) 1% placed with wound care nurse. No other concerns noted at time of encounter. - Discharge home. - Discharge condition stable. - Diagnosis: Superficial burn. - Plan for superficial burn: No signs of systemic infection. Continue silver sulfadiazine 1% cream twice daily. Follow-up with primary care physician for further management. - Electronically signed by the NP on 12/09/24 at 8:24 pm. OO. Record review of R #6's Nursing Skilled Evaluation, dated 12/07/24, revealed the following: - Pain: Indicators of pain: None. - The record did not contain any information in the following areas: skin, special care, safety, completed clinical suggestions, and comments. - The record did not address the resident's third degree burn on her sacrum and her wound treatments. - Electronically signed by an agency licensed nurse. PP. Record review of R #6's discharge progress note, dated 12/09/24, revealed the following: - Wound care: redness on buttock bilaterally. - Medications were given to daughter at discharge. - Resident was transferred by wheelchair and two nurse aides assisted. - Resident remained stable. - Resident was discharged to assisted living with family support. QQ. Record review of R #6's Discharge Plan Documentation, dated 12/09/24, revealed the following: - Discharge time 12:00 pm. - Next doctor appointment with primary care doctor on 12/23/24. - No other doctor appointments were documented. - Skin intact. - Infections: Not applicable. - Resident was stable at time of discharge. - Electronically signed by facility nurse on 12/10/24. RR. Record review of R #6's discharge MDS, dated [DATE], revealed staff documented the following: - Discharge, return not anticipated. - discharge date [DATE]. - discharged home under care of organized home health service organization. - Staff did not mark the resident was discharged to Home/Community to include assisted living facility. - Did not receive scheduled pain medication regimen. - Staff did not document the resident received schedule lidocaine external patch. - The resident had one unstageable pressure ulcers, noted at the time of admission. - The resident had one Stage 4 pressure ulcer, noted at the time of admission. - The resident had one unstageable pressure ulcer that was not present at admission. - Staff did not document the resident's sacrum wound. SS. On 03/05/25 at 2:17 pm, during an interview, R #6's daughter her mother was admitted to the hospital on 11/02/24 for peritonitis (inflammation of the tissue that lines the abdomen), which made her blood pressure drop. She stated her mother was in the hospital from 11/03/24 through 11/12/24. The daughter stated her mother was admitted to the facility on [DATE] for rehabilitation to get her strength up. She stated she was not aware of any of her mother's wounds when her mother arrived at the facility. The daughter stated there was a care plan meeting on 11/18/24, and the staff told her about her mother's pressure ulcers. The daughter stated she visited her mother almost every day, sometimes in the morning and sometimes in the afternoon. She stated she visited her mother early in the day on 12/04/24, and the wound nurse stated she did not like the way her mother's sacrum wound looked because it was turning green. The daughter stated the wound nurse took a picture and sent it to her and told her she would send the picture to the doctor. The daughter stated it had been four days since she saw her mother and it looked a lot worse than the last time she saw the wound. She stated she asked the wound nurse what she was looking at in the picture, and the wound nurse told her it was slough, which could lead to infection. The daughter stated she spoke to a Certified Nursing Assistant (CNA) on 12/07/25, and the CNA stated her mother was not feeling well and did not go to dialysis. The daughter stated the CNA reported she applied a salve to her mother's wound twice a day, and her mother's wound had a smell to it. The daughter stated over the next couple days her mother did not look well. She stated by the day she discharged (12/09/24) her mother looked horrible and was sweating. She stated the CNAs did not know why her mom was sweating. The daughter stated they tried to move her mother into a chair, but her mother begged to get back into bed. The daughter stated her mother was supposed to discharge at noon on 12/09/24, but she was not ready on time. She stated her mother was in an unusual amount of pain when the two CNAs transferred her into a wheelchair, and her mother was confused and agitated. She stated her mother was not mentally herself, and her back was covered with sweat. The daughter stated the facility did not have transportation to take her mother to the Assisted Living Facility (ALF) which was right down the street from the facility. She stated two CNAs from the facility were not able to transfer her mother into her car, because her mother was in a lot of pain. She stated her mother was propelled in a wheelchair up the street to the ALF. She stated when her mother got to the ALF, staff put her right to bed, and her mother calmed down. The daughter stated her mother was in too much pain to sit up. The daughter stated her mother was scheduled for dialysis on 12/10/24, but the dialysis center sent her mother to the emergency room , because her heart rate was very low. The daughter stated her mother was admitted to the hospital with a diagnosis of septic shock. They told her that her mother had a racing heart rhythm, low blood pressure, and was incoherent. The daughter stated her mother was too weak for a full session of dialysis, and she passed away in the hospital eight days later. The daughter stated while her mother was at the facility, she brought a heating pad for her mother to use. She stated her mother used it for a little while, but then the heating pad disappeared. She stated that was around the beginning of December. The daughter stated she did not remember staff telling her that her mother was burned by the heating pad. She stated her mother used it all the time at home and was responsible with it. TT. On 03/06/25 at 11:26 am, during a record review and interview, the Physician Assistant (PA) stated she began working at the facility in January 2025, and she was not present when R #6 was at the facility. The PA stated she worked at the facility Monday through Fridays, and she conducted resident visits every day. She stated her responsibilities included evaluating the residents, following up on diagnosis, and prescribing treatments. She stated staff update her on resident conditions while she is at the facility or they call her on the on-call number. She stated she would expect staff to notify her of any changes in condition, medication issues, and physical conditions. The PA reviewed R #6's wound documentation dated 11/28/24. She stated she would not have said the wound was a burn, because it looked like skin breakdown to her. She stated if it was a burn due to a wet brief on a heating pad then it would be a bigger area. She stated all the areas in contact with the heating pad should have burn marks. She stated she would have expected staff to notify her of that wound. She stated she would have prescribed a barrier treatment for the wound. The PA reviewed R #6's wound documentation dated 12/04/24, and stated she saw necrosis (dead tissue), an enlarging of the wound, and she thought the tissue looked different. She stated the wound looked deeper, but it was hard to tell if there was depth with that type of ulcer. She stated the wound was getting worse, and it was not a burn wound at that point. She stated she would have wanted to see the wound, and she would have sent the resident out to the ER if she had seen it. The PA stated a prescription for burn cream would not have hurt the resident's wound, but it would not have helped it either. She stated a wound like that could result in osteomyelitis (inflammation of bone and bone marrow) and sepsis. She stated the signs of sepsis was tachycardia, fever, confusion, and sweating. She stated R #6 should not have been discharged to an ALF with that wound. She stated the resident should have went to the hospital. UU. On 03/07/25 at 11:38 am, during a record review and interview, the Medical Director (MD) stated she has been the facility's MD for several years. She stated she was not familiar with R #6, but she reviewed the resident's discharge summary. The MD reviewed the R #6's wound documentation dated 11/28/25. She stated she agreed with the wound assessment of a burn. She stated she would expect the staff to report the wound to her, but she did not recall staff notifying her. She stated she did not provide treatment orders. She stated the wound care nurse decided and implemented treatments for wounds. She stated she expected the treatment for the wound to begin at this stage. The MD reviewed R #6's wound documentation dated 12/4/24. She stated the wound was getting worse and bigger. She stated the wound should have been reported to her before it got to that state. She stated treatments should have been implemented before the wound got to that state. The MD stated the wound was not reported to her. She stated the measurements in the record did not appear to be accurate. She stated the wound needed to be debrided. She stated she needed to see and smell the wound to determine the best course of act

Based on observation, record review, and interview, the facility failed to notify the resident's physician for 2 (R #2 and #6) of 2 (R #2 and #6) residents reviewed when: 1. R #2 began having difficulty feeding herself with low meal intake percentages 2. R #6 developed a sacrum wound These deficient practices likely resulted in R #2 not getting the assistance she needed resulting in a decrease in meal intake and a delay in treatment and deterioration in R #6's wound likely resulting in the wound becoming septic. The findings are: Findings for R #2 A. Record review of R #2's face sheet revealed R #2 was admitted into the facility on [DATE]. B. Record review of R #2's care plan dated 01/27/25 revealed the following: 1. R #2 exhibits impaired swallowing related to dementia; Provide assistance during meals and provide supervision during meals. 2. R #2 is a nutritional risk related to skin breakdown; Weigh per policy and as needed, and alert dietitian and physician to any significant weight loss or gain. C. Record review of the facility meal consumption percentage (%) tracking form dated 02/03/25 through 02/20/25 (breakfast), revealed the following: - 02/03/25: R #2 ate 25% of her breakfast, 50% of her lunch, and 25% of her dinner. - 02/04/25: R #2 ate 50% of her breakfast, 75% of her lunch, and 25% of her dinner. - 02/05/24: R #2's meal intake was not recorded. - 02/06/25: R #2 ate 50% of her breakfast, 50% of her lunch, and 75% of her dinner. - 02/07/25: R #2 ate 50% of her breakfast, 25% of her lunch, and 75% of her dinner. - 02/08/25: R #2 ate 100% of her breakfast, 25% of her lunch, and 25% of her dinner. - 02/09/25: R #2 ate 50% of her breakfast, 25% of her lunch, and 75% of her dinner. - 02/10/25: R #2 ate 50% of her breakfast, 50% of her lunch, and 75% of her dinner. - 02/11/25: R #2 ate 50% of her breakfast, 50% of her lunch, and 75% of her dinner. - 02/12/25: R #2 ate 50% of her breakfast, 25% of her lunch, and 50% of her dinner. - 02/13/25: R #2 ate 25% of her breakfast, 25% of her lunch, and 0% of her dinner. - 02/14/25: R #2 ate 25% of her breakfast, 25% of her lunch, and 25% of her dinner. - 02/15/25: R #2 ate 50% of her breakfast, 25% of her lunch, and 100% of her dinner. - 02/16/25: R #2 ate 75% of her breakfast, 25% of her lunch, and 25% of her dinner. - 02/17/25: R #2 ate 25% of her breakfast, 50% of her lunch, and 25% of her dinner. - 02/18/25: R #2 ate 50% of her breakfast, 50% of her lunch, and 50% of her dinner. - 02/19/25: R #2 ate 100% of her breakfast, lunch was not recorded, and 100% of her dinner. - 02/20/25: R #2 ate 75% of her breakfast. R #2's meal consumption percentage was not recorded prior to 02/03/25. D. Record review of R #2's Electronic Health Record (EHR) banner reviewed on 02/19/25 revealed Set-up for all meals and no feeding assistance required. E. On 02/19/25 at 2:08 pm during an interview with R #2's Power of Attorney (POA; authority to act for another person in specified or all legal or financial matters), she stated that on multiple occasions, R #2's meal tray was left in front of her untouched by R #2. R #2's POA also stated that R #2 requires assistance with feeding, but the facility is not helping with that. F. On 02/19/25 at 3:41 pm during an interview with Licensed Practical Nurse (LPN) #2, she stated that R #2 is a set-up help only for meals. LPN #2 confirmed that she was not aware of R #2 experiencing difficulty feeding herself. G. On 02/19/25 at 4:37 pm during an interview with LPN #3, she stated that the majority of the time the facility CNAs (Certified Nursing Assistant's) will only set up R #2's meal and they will not assist her with feeding. LPN #3 also stated that R #2 usually needs help with feeding, and will require supervision when eating as well. LPN #3 confirmed she would help R #2 with feeding as often as she could, but R #2 required feeding assistance and meal supervision on a consistent basis. H. On 02/19/25 at 5:14 pm during a dinner observation, R #2 was observed lying in bed and then being woken up by CNA #3 for dinner. CNA #3 moved R #2's bed up so R #2 could eat. I. On 02/19/25 at 5:15 pm during an interview with CNA #3, she stated that R #2 was a set-up assist only and the CNAs will check on R #2 as often as they can during the meal service. CNA #3 was observed leaving R #2's room shortly after the interview to continue to pass out resident meal trays in the unit. J. On 02/19/25 at 5:19 pm during a dinner observation, R #2 was observed sitting upright in her bed attempting to eat without staff presence. R #2's spoon was in the middle of her plate and she was trying to eat her orange dessert by licking the side of the dessert dish. R #2 was not successful in doing so. K. On 02/19/25 at 5:28 pm during a dinner observation, CNA #3 is observed returning to R #2's room to assist R #2 with her meal. L. On 02/19/25 at 5:30 pm during an interview with CNA #3, she stated that R #2 was just playing with her food and not eating it, which R #2 does a lot. CNA #3 also stated that R #2 is more dependant on staff assisting her with her meals because she can't feed herself that well anymore. M. On 02/20/25 at 11:49 am during an interview with the Physician's Assistant (PA), she stated that she was not made aware of R #2's inability to feed herself and she would expect the facility nursing staff to notify the facility providers, including the DON of this, especially if there is weight loss. N. On 02/20/25 at 12:38 pm during an interview with the RD, she stated that she was unaware of R #2's low meal consumption percentage and she was also unaware of R #2's self feeding limitations. The RD stated that had not reviewed the facility meal consumption percentage tracking form, and would find out about dietary issues from the facility nursing staff. The RD confirmed that she should have been made aware of R #2's inability to consistently feed herself, and R #2 should be reassessed by the speech therapist to get a better understanding of R #2's feeding limitations. O. On 02/20/25 at 1:04 pm during an interview with the Administrator (ADM), he stated that he would expect the RD to be monitoring the facility meal consumption percentage tracking form. The ADM also stated that the CNAs should be notifying the nursing staff, who should be notifying facility providers of a residents decline in self feeding so it can be addressed in the morning clinical meeting. P. On 02/20/25 at 2:41 pm during an interview with Registered Nurse (RN) #1, she stated that R #2 can raise her hand and wipe her mouth, but she does not believe that R #2 could feed herself successfully. RN #1 stated that she does not think the RD has been made aware of this, but she was unsure. Q. On 02/20/25 at 3:07 pm during an interview with the DON, she stated that if CNAs notice R #2 is struggling to feed herself, then they need to notify nursing staff who should then notify her, the RD, and any provider that needs to be informed of that. 38450 Findings related to R #6 Cross reference to F684. R. Record review of R #6's Wound Evaluation, dated 11/28/24, revealed the following: - Burn, third degree. - Staged by in-house nursing. - Located on sacrum (a large flat bone in the lower part of the spine.) - Minutes old and acquired in-house (at the facility.) - Measurements: length 6.64 centimeters (cm), width 4.2 cm, depth 0.2 cm, area 15.95 cm^2. - Wound bed: Epithelial tissue (a thin, continuous layer of cells) present, granulation tissue (new connective tissue and blood vessels, a sign of wound healing) present. - Moderate serosanguineous (clear or light pink, thin, watery fluid) exudate (body fluid discharged by the body in response to tissue damage and wound healing.) - Edges attached, surrounding tissue erythema (redness.) - Temperature was hot, localized. - Resident reported pain at a 7 out of 10 during dressing. - Treatment: Generic wound cleanser, composite dressing, and Xeroform bordered gauze. - Notes: Resident's skin was hot to touch with a heating pad under her. The resident's skin was thin and fragile. Removed the heating pad. - Education: The resident was educated about the risk factors involved in using a heating pad. Resident was strongly advised to discontinue use of the heating pad and to shift weight in bed frequently. - Notification: None documented. - Digitally signed by the facility's Skin Health Team Lead (SHTL) on 11/29/24 at 12:33 pm. S. Record review of R #6's medical record revealed the following the record did not contain documentation staff notified the resident's doctor of the third degree burn on the resident's sacrum. T. Record review of R #6's Progress Note, dated 12/02/25, revealed the following: - Visit type was acute follow-up. - Chief complaint and nature of the presenting problem: Follow-up of admitting medical diagnoses, including depression. - Resident was a fairly inconsistent historian but at time of encounter denied complaint or concern. - Nursing staff denied new or worsening behaviors, recent fall or injury, unstable vital signs, or other complaint or concern. - The record did not mention the resident's sacrum burn or treatment for the burn. - Digitally signed and dated by the Nurse Practitioner on 12/03/24 at 4:55 pm. U. Record review of R #6's Wound Evaluation, dated 12/04/24, revealed the following: - Burn, third degree. - Staged by in-house nursing. - Located on sacrum. - Six days old and acquired in-house. - Measurements: length 6.24 cm, width 3.9 cm, depth 0.2 cm, area 18.24 cm^2. - Wound bed 70 percent (%) epithelial, 70% granulation, 20% slough (yellow stringy tissue adhered to wound bed.) - Evidence of infection: increased drainage, increased pain. - Bleeding. - Moderate serosanguineous exudate with faint odor after cleaning. - Edges attached, surrounding tissue erythema. - Resident reported pain at a 7 out of 10 during dressing. - Dressing appeared saturated. - Treatment: Vashe (wound cleanser), Medihoney (wound and burn gel), foam, incontinence management. - Healable. - Stable. - Notification: None documented. - Digitally signed and dated by the facility's SHTL on 11/4/25 at 1:05 pm. V. Record review of R #6's Progress Note, dated 12/06/25, revealed the following: - Visit type: Discharge. - Chief complaint and nature of the presenting problem: Discharge summary and plan. - The resident was initially to be seen today for discharge summary and plan. The NP was contacted by the wound care nurse and notified the resident had a burn to her back. The burn reported had an odor and greenish discharge. The resident was asymptomatic without indication of sepsis or systemic infection. Patient lay in bed, and did not appear to be in acute distress. Resident was a poor historian secondary to dementia, and the NP was unable to reposition the resident at the time of the encounter in order to examine the resident's back. Order to apply silver sulfadiazine cream (antibiotic cream for serious skin infections and burns) 1% placed with wound care nurse. No other concerns noted at time of encounter. - Discharge home. - Discharge condition stable. - Diagnosis: Superficial burn. - Plan for superficial burn: No signs of systemic infection. Continue silver sulfadiazine 1% cream twice daily. Follow-up with primary care physician for further management. - Digitally signed by the NP on 12/9/25 at 8:24 pm. W. On 03/05/25 at 2:17 pm, during an interview, R #6's daughter stated her mother was admitted to the facility on [DATE] for rehabilitation to get her strength up. She stated she was not aware of any of her mother's wounds when her mother arrived at the facility. The daughter stated there was a care plan meeting on 11/18/24, and the staff told her about her mother's pressure ulcers. The daughter stated she visited her mother almost every day, sometimes in the morning and sometimes in the afternoon. She stated she visited her mother early in the day on 12/04/24, and the wound nurse stated she did not like the way her mother's sacrum wound looked because it was turning green. The daughter stated the wound nurse took a picture and sent it to her and told her she would send the picture to the doctor. The daughter stated it had been four days since she saw her mother and it looked a lot worse than the last time she saw the wound. She stated she asked the wound nurse what she was looking at in the picture, and the wound nurse told her it was slough, which could lead to infection. The daughter stated she spoke to a Certified Nursing Assistant (CNA) on 12/07/25, and the CNA stated her mother was not feeling well and did not go to dialysis. The daughter stated the CNA reported she applied a salve to her mother's wound twice a day, and her mother's wound had a smell to it. The daughter stated over the next couple days her mother did not look well. She stated by the day she discharged (12/09/24) her mother looked horrible and was sweating. She stated the CNAs did not know why her mom was sweating. The daughter stated they tried to move her mother into a chair, but her mother begged to get back into bed. The daughter stated her mother was supposed to discharge from the nursing home at noon on 12/09/24, but she was not ready on time. She stated her mother was in an unusual amount of pain when the two CNAs transferred her into a wheelchair, and her mother was confused and agitated. She stated her mother was not mentally herself, and her back was covered with sweat. The daughter stated the facility did not have transportation to take her mother to the Assisted Living Facility (ALF) which was right down the street from the facility. She stated two CNAs from the facility were not able to transfer her mother into her car, because her mother was in a lot of pain. She stated her mother was propelled in a wheelchair up the street to the ALF. She stated when her mother got to the ALF, staff put her right to bed, and her mother calmed down. The daughter stated her mother was in too much pain to sit up. The daughter stated her mother was scheduled for dialysis on 12/10/24, but the dialysis center sent her mother to the emergency room , because her heart rate was very low. The daughter stated her mother was admitted to the hospital with a diagnosis of septic shock. They told her that her mother had a racing heart rhythm, low blood pressure, and was incoherent. The daughter stated her mother was too weak for a full session of dialysis, and she passed away in the hospital eight days later. X. On 03/06/25 at 11:26 am, during an interview, the Physician Assistant (PA) stated she was at the facility Monday through Friday, every week; and she was responsible for seeing each resident, evaluating new conditions, diagnosing, prescribing treatments, and following-up with the residents. She stated it was expected for staff to notify her if a resident had a change of condition, medication issue, or a physical condition which required her attention. She stated staff could notify her while she was at the facility or call her at the on-call number if she was not at the facility. The PA reviewed R #6's initial wound documentation, dated 11/28/24, and stated she would expect staff to notify her of a wound like that. The PA stated she would have prescribed a barrier cream for the wound. Y. On 03/07/25 at 11:38 am, during an interview, the Medical Director (MD) stated she has been the facility's MD for several years. She stated she was not familiar with R #6, but she reviewed the resident's discharge summary. The MD reviewed R #6's initial wound documentation, dated 11/28/24, and stated she would expect staff to notify her of the wound. She stated she did not recall if staff notified her of the wound. She stated the wound care nurse would decide and implement the treatment for the wound, but she still wanted to be notified of the wound. The MD reviewed R #6's wound documentation, dated 12/03/24, and stated she was not notified of the resident's wound at this point. She stated the wound appeared to be worsening, and the measurements did not appear to be accurate. The MD stated she needed to see and smell the resident's wound in order to make a treatment decision. She stated she expected the NP to give the resident some pain medication and look at the wound. She stated the NP should not have prescribed a treatment without looking at the wound. The MD stated it was not acceptable to treat the wound without looking at it. She stated she would not have discharged the resident with a wound like that, because the resident needed care. Z. On 03/06/25 at 1:27 pm and 03/07/25 at 1:45 pm, during an interview, the Skin Health Team Lead stated a Certified Nursing Assistant (CNA) told her about R #6's sacrum wound. She stated after she looked at the wound, she contacted a wound care company and the facility's Administrator regarding the wound. She stated she tried to text a number the nurse gave her for R #6's doctor. The SHTL stated she did not contact the facility's NP or the Medical Director, because she did not have a number for them. She stated she did not follow-up with the number the nurses gave her for the resident's doctor to ensure she had the right number or information. The SHTL stated she did not contact the resident's family regarding the wound. Based on record reviews and interviews, an Immediate Jeopardy (IJ) was identified. The facility Administrator was notified on 03/05/25 at 3:21 pm. The facility took corrective action by providing an acceptable Plan of Removal (POR). The Plan of Removal was approved on 03/06/25 at 12:10 pm. Plan of Removal All residents have the potential to be affected by this alleged deficient practice. - A whole house audit of heated electrical devices, completed on 02/27/25. - A whole house skin sweep audit to identify any undocumented wounds, completed on 12/30/25. - A second whole house skin sweep was conducted to identify undocumented wounds, completed on 02/03/25. - Direct care staff were educated on wound documentation, starting 01/08/25. - CNAs were educated on the Stop and Watch Process, from 01/21/25 through 01/27/25. - Nurses and CNAs were educated on prohibiting on the use of electrical appliances, completed 02/27/25. - Center Nurses were re-educated on skin assessments weekly per schedule, starting on 03/05/25. - Nurses were educated on their responsibility with communication with management and provider for the change in condition process/documentation, starting on 03/05/25. - Nurses were educated on the facility's wound processes, timely and accurate identification of wounds, documentation for wound/wound changes, change in condition process, and appropriate treatment/intervention implementation upon identification of new or worsening wounds, starting on 03/05/25. - CNAs were educated on change in condition process for CNAs and Stop and Watch, starting on 03/05/25. - The DON/Designee will perform audit education sign-off sheets to ensure all nursing staff receive education as outlined, starting 03/05/25. - The DON/Designee will conduct five random audits on heated electrical devices and skin assessment accuracy weekly for wound care process abidance, starting 03/05/25. - An Ad Hoc QAPI meeting was held on 03/05/25 to approve the POR. - The DON/Designee and the Administrator/Designee will bring the results of the audits to the QAPI committee for three months. - The Administrator will oversee the QAPI committee. Implementation of the POR was verified onsite on 03/07/25 by conducting observations, record reviews, and staff interviews. Scope and Severity was reduced to Level 2, G. Implementation was verified through: Record review of skin sweeps, dated 12/30/25 and 02/03/25. Record review of electrical appliance audits, dated 02/27/25. Record review of skin assessment audits, date 03/05/25. Observations of wound care on 03/06/25 at 1:27 pm for R #4 and on 03/06/25 at 2:40 pm for R #5. Record review for R #4 and R #5 regarding wounds and wound care. Interviews of four CNAs regarding in-services and Stop and Watch process. Interviews of two nurses regarding in-services and wound documentation and communication. Interview with the SHTL regarding in-services and processes regarding wound documentation and orders for treatment. Interview with the Administrator and DON regarding POR, audits, and wound processes.

Based on facility policy review, record review, observation, and interview, the facility failed to develop and implement interventions to reduce accident hazards and risk when the facility failed to ensure safety precautions were taken to decrease the risk of burns or injury while smoking for 5 (Residents (R) 78, R36, R10, R31, and R34) of 21 residents reviewed for smoking out of a total sample of 46 residents. Facility policies and procedures related to the storage of smoking material were not enforced, residents were not appropriately assessed for safe smoking, and the facility's smoking area was not adequately supervised. The facility's failure to develop and implement interventions to reduce accident hazards and risks when facility residents were smoking places residents at risk of burns and/or severe injury. The findings are: Review of the facility's Smoking Policy dated most recently revised on 05/01/24 read, Evidence supports the myriad of health risks associated with tobacco and electronic cigarette (e-cigarette) use, both for the smokers and for those exposed to secondhand smoke and aerosol exposure; and For Centers that allow smoking, smoking (including the use of e-cigarettes) will be permitted in designated areas only. Patients/Residents (hereinafter patient) will be assessed on admission, quarterly, and with change in condition for the ability to smoke safely and, if necessary, will be supervised; and 2. For Centers that allow smoking: 2.1 Smoking (including e-cigarettes) will only be allowed in designated areas. 2.1.1 An area designated as a smoking area will be environmentally separate from all patient care areas (e.g., outdoors or a smoking lounge), will be well ventilated, and, if outdoors, will protect patients from weather conditions. 2.1.2 A primary gathering place for patients will not be designated as a smoking area so that non-smokers are not subjected to secondhand smoke. 2.1.3 Oxygen use is prohibited in smoking areas. Precautionary signage will be posted in the designated smoking areas. 2.1.4 Ashtrays made of non-combustible materials and safe design, and metal containers with self-closing covers into which ashtrays can be emptied, shall be provided in al designated smoking areas as well as at all entrances. 2.1.5 Safety equipment such as a fire blanket and portable fire extinguishers will be available within or near the designated smoking area(s). 2.2 The admissions designee will explain the Center's smoking policy to the patients and their families, and inform them that patients will be assessed to determine if supervision is needed. 2.3 The admitting nurse will perform a Smoking Evaluation on each patient who chooses to smoke. 2.3.1 Patients will be re-evaluated with a change in condition. 2.4 The patient will be allowed to smoke only with direct supervision until the interdisciplinary team has evaluated them. 2.5 A care plan for patients who smoke shall include such elements as the need for supervision or physical assistance while smoking and safety devices that are needed, such as a smoking apron to prevent burns. The care plan will be updated, as necessary. 2.6 Smoking supplies (including but not limited to, tobacco, matches, lighters, lighter fluid, batteries, refill cartridges, etc.) will be labeled with the patient's name, room number, and bed number, maintained by staff, and stored in a suitable cabinet kept at the nursing station. 2.7 Center leadership will consider special circumstances on an individual basis (e.g., the need for a smoking apron). 2.8 Patients will be offered education on the risks of smoking. 2.8.1 Education offered/provided will be documented in the medical record. 3. It may be necessary to counsel patients or patient representatives who violate the smoking policy. 4. If there is a willful disregard for safety to others or the Center is jeopardized by a patient's disregard for the smoking policy, termination of smoking privileges and/or initiation of a discharge plan may occur. 4.1 Such action will be documented in the medical record. Review of the facility's Smoking List, provided by the facility, indicated there were 21 smokers in the facility (identified above). 1. Review of R78's Admission Record, found in the Electronic Medical Record (EMR) under the Admissions tab, indicated the resident was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Review of R78's significant change Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 06/11/24 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact. Review of R78's Social Services Progress Note, dated 07/20/23 and found in the EMR under the Progress Notes tab, read, in pertinent part, Resident was found smoking in her room. Lighters and cigarettes were confiscated by this worker and given to the nurses station for safe keeping. Resident was educated on the dangers of smoking in her room and was educated on building policy on smoking in the building. Review of R78's Physician Order Report, dated 07/19/24 and found in the EMR under the Orders tab, indicated an order for the resident to receive oxygen continuously via nasal cannula 13 liters per minute (lpm) per oxygen concentrator. Review of R78's Smoking Care Plan, dated 06/17/24 and found in the EMR under the Care Plan tab, indicated the following interventions: Patient will smoke safely x [times] 90 days per smoking assessment. Educate patient/health care decision maker on the facility's smoking policy. Ensure that appropriate cigarette/e-cigarette device(s) disposal receptacles are available in smoking areas. Ensure that there is no oxygen use in smoking areas. Inform and remind patient of location of smoking areas and times. Maintain patients smoking materials at nurse's station. Educate patient/health care decision maker on the facility's smoking policy. Inform family and significant others of the patient's inability to smoke. Review of R78's only Smoking Safety Evaluation dated 03/18/24, and found in the EMR under the Assessment tab, revealed the resident was a smoker. The evaluation indicated the resident had a poor memory and had a history of unsafe smoking practices. The assessment indicated supervised smoking was required for the resident. Review of R78's Physician Encounter Note, dated 10/29/23 and found in the EMR under the Progress Notes tab, read, in pertinent part, (R78) is seen sitting up in her wheelchair looking out the window. She states she is not well but does not know why. She denies pain at this time. Patient became upset and refused to answer any more questions. Returned to patient after staff reports patient lit a cigarette in her room. Patient states she lit it to get someone in her room because she has been waiting for assistance hours. She states she called for water since yesterday and is dehydrated. Unable to complete full interview patient upset. Review of R78's Care Plan Meeting Note, dated 01/04/24 and found in the EMR under the Progress Notes tab, read, in pertinent part, Not aloud (sic) to have cigarettes or lighters. has been found smoking in her room to get Certified Nursing Assistant (CNA) attention last month. Review of R78's Care Plan Meeting Note, dated 04/25/24 and found in the EMR under the Progress Notes tab, read, in pertinent part, Discussed residents over all wellbeing, smoking behaviors, weekly activities, and hygiene. Son stated he would talk with his mother about smoking cigarettes in her room is a danger hazard. Review of R78's EMR revealed no evidence that a Behavior Contract had been initiated with R78 related to not following smoking rules. Smoking related incident reports/investigations involving R78 for the previous 12 months were requested of facility Administration on 07/18/24. During an interview with the Director of Nursing (DON) on 07/18/24 at 6:10 PM, she stated she was not aware of any smoking incident occurring in this facility until 07/18/24. Observation of R78 on 07/15/24 at 10:01 AM revealed the resident was in bed sleeping. An unsmoked cigarette was observed in a plastic cup on the resident's overbed table. Smoking related incident reports/investigations involving R78 for the previous 12 months were requested of facility Administration on 07/18/24. During an interview with the Director of Nursing (DON) on 07/18/24 at 6:10 PM, she stated she was not aware of any smoking incident occurring in this facility until 07/18/24. During an interview with R78's family member (FM) 78 on 07/19/24 at 12:55 PM, he stated he had received several calls from the facility related to smoking concerns. He stated staff reported several events, such as when R78 had lit up a cigarette in her room or in her bathroom. He stated the last call he had received related to his mother smoking somewhere other than the designated smoking area had been approximately one month ago (in May or June of 2024). He stated he had been told R78 had been caught smoking in her room, and he was asked to speak to her about it. He stated he told R78 she was going to be in trouble if she continued to smoke in her room. R78's FM stated R78 started a fire at her home prior to being admitted to the facility when she had been smoking with her oxygen on. He stated she had burned the bottom of her foot during the incident and the oxygen tubing had melted during the event. During an interview with CNA 16, Licensed Practical Nurse (LPN)1, and LPN2 on 07/18/24 at 4:34 PM, the staff members were asked if R78 followed the facility's smoking rules, CNA16 stated, I am not going to lie to you. I told them I wouldn't lie. I am not willing to risk my license by not telling the truth. She (R78) gets up at night to smoke and is in bed most of the day. Sometimes, she follows the rules. I have seen cigarettes in her room recently. She usually has them on her person. They are not in the box at the nurse's station. CNA16 removed the metal box used to store resident smoking materials from a drawer at the nurse's station and showed it to the surveyor. The box was empty (no smoking supplies were in the box despite several residents on the unit being active smokers). LPN1 stated all of the residents who smoked on the unit kept their own cigarettes and lighters on their person. LPN2 confirmed R78's oxygen was running in her room continuously all or most of the time due to her order to receive continuous oxygen. LPN2 stated, She has three (oxygen) concentrators there, and she keeps her own lighter and cigarettes in a little black bag in her room. During an interview with the DON on 07/17/24 at 4:07 PM, she stated she did not know what happened with the smokers in the facility because she did not go out there (to the designated smoking area). She confirmed cigarettes had been found in residents' possession, but staff was not allowed to search a resident's room without permission. She stated if smoking materials were found on a resident or in a resident's room and could be confiscated, they would be. She stated, however, an incident report was not generated for any of those events. The DON stated it was not her expectation that staff would tell her or the Administrator when smoking materials were found on a resident or in a resident's room. She stated her expectation was that the nurses would just take the cigarette away from that person. The DON stated she was aware residents were currently not abiding by the facility's smoking rules and that a lot of residents had been found with random cigarettes. The DON stated facility policy was that all resident smoking material was to be kept at the nurse's station. She stated no residents were allowed to keep their own smoking materials. The DON stated residents could be placed on a Behavior Contract related to smoking if they were not following the smoking rules. However, she was unaware of whether R78 had been placed on a behavior contract related to smoking or not. The DON acknowledged residents not following the facility's smoking rules had the potential to lead to fires and/or serious injury/burns. However, she stated, Between you and I, these residents are going to do what they are going to do. During an interview with the Administrator on 07/18/24 at 5:23 PM, he stated he was not aware of any recent incident reports/investigations related to residents not following smoking rules. He confirmed R78 had not been placed on a Behavior Contract related to smoking previously, but that one had been initiated that day (07/18/24). The Administrator stated he was aware smokers had been keeping their own smoking materials on them. He confirmed his expectation was facility policies and procedures would be followed related to smoking. He stated, What is supposed to be happening is we should be monitoring the cigarettes and lighters more closely. 18750 2. Review of the Admission Record for R36 found in the EMR located under the Profile tab indicated R36 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure with Hypoxia (an absence of oxygen in the tissues to sustain bodily function), and Obstructive Sleep Apnea. Review of the admission MDS admission assessment found in the EMR located under the MDS tab revealed an ARD of 04/22/24. The BIMS score was 15 out of 15, revealing intact cognition. Review of the Care Plan for R36 found in the EMR located under the Care Plan tab revealed a care plan for smoking dated 07/10/24 with an intervention of Monitoring patients' compliance to smoking policy. Review of the Smoking Evaluation for R36 found in the EMR located under the Assessment tab dated 07/10/24 indicated R36 could smoke independently and that R36 was made aware of the smoking policies, time, and location. During an interview on 07/17/24 at 9:56 AM, R36 was up in her motorized wheelchair, returning to her room from outside smoking. R36 wore a lanyard around her neck that held a lighter in it. R36 was asked if she kept her own smoking materials. She stated, Yes, I do. I understand keeping them for residents who are not quite all there, but I am, and I can keep them myself. I know I do not comply with the rules. The resident also stated, Sometimes I go out front and smoke because there are too many that will try and bum a cigarette from me. The resident was asked if she wore oxygen. R36 stated, I do, but not when I'm smoking. During an interview on 07/17/24 at 3:2 PM, Licensed Practical Nurse (LPN)6 revealed R36 could smoke independently, and she would go out and smoke at various times. LPN6 was asked how the resident got her smoking materials to smoke. LPN6 stated, I'm not sure because she does not come to the desk to get them. LPN6 was made aware that R36 kept them with her, and she wears the lighter around her neck. LPN6 stated she was not aware the resident had her own smoking materials. During an interview on 07/17/24 at 3:22 PM, the DON revealed, I am sure that they have their own cigarettes. The staff can do their best to get the materials from the residents, but if we do not have permission to look in their room, then we cannot do anything about it. If the materials are laying out in the open, then we can pick them up. The DON stated, I do not expect an incident report to be done for finding someone with cigarettes. All we can do is talk to the resident, and if it continues, place them on a Behavior Contract. The Administrator makes the decision whether a resident stays or not. I only know of one female resident who has been found with smoking materials, and I cannot remember who it was now. The nurse's station should have everybody's smoking materials. There are blatant people who will not follow the policy. During an interview on 07/18/24 at 7:24 PM, the Administrator said he was not aware of residents keeping smoking materials in their rooms or on their person. 20402 3. Review of R10's quarterly MDS located in the EMR under the MDS tab with an ARD of 04/29/24 indicated R10 scored a 15 out of 15 on the BIMS, indicating no cognitive impairment. Review of Physician Orders, dated 07/17/24 and located in R10's EMR under the Orders tab, indicated, Oxygen at 3 lpm via Nasal Cannula continuously. Review of the Smoking Evaluation, dated 07/18/24 and located in R10's EMR under the Assessments tab, indicated, Independent smoking is allowed. It further indicated, Upon observation, R10 is able to light, smoke, and dispose of smoking materials safely. Review of the Care Plan, initiated on 07/18/24 and located in R10's EMR under the Care Plan tab, indicated, Patient may smoke independently per smoking evaluation. Interventions are: Ensure that there is no oxygen use in smoking area(s), monitor patients' compliance to smoking policy, inform and remind patient of location of smoking areas and times. During an interview on 07/18/24 at 5:40 PM, R10 stated he kept two to three cigarettes in his room in his eye glass case. He further revealed staff did not lock up his cigarettes or lighter. 4. Review of R31's admission MDS located in the EMR under the MDS with an ARD date of 06/19/24, indicated R31 scored a 12 out of 15 on the BIMS, indicating no cognitive impairment. Review of the Smoking Evaluation, dated 07/03/24 and located in R31's EMR under the Assessments tab, indicated R31 did not wear oxygen, and independent smoking is allowed. Review of the Care Plan, initiated on 07/03/24 and located in R31's EMR under the Care Plan tab, indicated . Patient may smoke independently per smoking evaluation . educate patient on the facility's smoking policy . monitor patients' compliance to smoking policy. During an observation and interview on 07/18/24 at 7:28 PM, R31 stated he was a smoker. R31 revealed he kept his cigarettes and lighters, and they were not locked up by staff. 5. Review of R34's quarterly MDS located in the EMR under the MDS tab with an ARD date of 07/03/24 indicated R34 scored a 15 out of 15 on the BIMS, which indicated no cognitive impairment. Review of the Smoking Evaluation, dated 07/18/24 and located in R34's EMR under the Assessments tab, indicated R34 did not wear oxygen, and Independent smoking is allowed. The smoking evaluation further indicated R34 is able to safely light, smoke and dispose of smoking materials. Review of the Care Plan, revised on 06/20/24 and located in R34's EMR under the Care Plan tab, indicated, R34 may smoke independently per smoking assessment. Interventions are Educate [name of R34] on the facility's smoking policy, inform and remind patient of location of smoking areas and times, ensure there is no oxygen use in smoking area(s). During an interview on 07/18/24 at 6:00 PM, R34 said he kept his cigarettes and lighter on his person and staff allowed him to do so. Staff has never locked up any of my items for me. During an interview on 07/18/24 at 6:45 PM, CNA15 said R10's cigarettes and lighters are locked up and had never seen them in his room. During an interview on 07/18/24 at 6:53 PM, LPN4 said she thought resident cigarettes and lighters were kept at the desk in a small toolbox. The way it was supposed to work is they would come up to the nurse's desk on the approved smoking time, get a cigarette, and go smoke. During an interview on 07/18/24 at 7:31 PM, CNA14 stated, With R31, he has never kept any of his cigarettes and lighters locked up. He keeps them in his fanny pack. We have never kept them locked up. On 07/19/24 at 9:45 AM, the Administrator and Director of Nursing (DON) were notified that Immediate Jeopardy (IJ) existed due to the failure to ensure safety precautions were taken to decrease the risk of burns and/or serious injury when residents were keeping their smoking materials (i.e., cigarettes and lighters) on their person, and smoking in their room with oxygen. This included R78, R36, R10, R31 and R34. The IJ at F689 also constituted Substandard Quality of Care at 42CFR 483,12. The IJ was determined to first exist on 10/29/23 when the Medical Director noted an incident in which staff reported R78 lit a cigarette in her room. The facility presented an acceptable plan for removal of the IJ on 07/19/24 at 4:27 PM. The survey team validated that the IJ was removed on 07/19/24 at 6:50 PM following verification conducted onsite that the facility implemented the plan of removal. The deficient practice remained at an E (pattern with potential for minimal harm) scope and severity following the removal of the IJ. The Plan of Removal included: Resident #78's smoking assessment was updated 7 /19/24 at to ensure accuracy and has been identified as a supervised smoker. Her care plan was updated to reflect this. Her room and person were observed for smoking material and none was found, as she was compliant in providing her smoking material to the staff when asked. She was re-educated on the smoking policy and agreed to follow the policy. Family was notified of policy as well (highlighted on the list of emails provided). She does have a history of non-compliance and was given a behavioral contract on 7 /18/24. If she does not adhere to the policy, she will be given a 30-day discharge notice. All residents who smoke were assessed by licensed nursing staff on 7/18/2024 with no injury identified related to smoking. The Administrator/designee began individual meetings with smokers on 7/18/2024 and completed meeting on 7 /19/24 by 3:00pm for the identified residents who smoke at the center to review the smoking policy/process, and/or initiate behavioral contract which includes the following (notes will be in chart that indicate the smoking policy review, and behavior contracts will be uploaded in the chart) The Administrator/designee compiled a list of residents who smoke at the center 7/19/2024 to be placed at the nurses station and will be updated as needed. A whole house sweep of resident smoking materials will be completed on 7 /19/24 by 3:30pm by the Administrator/designee to ensure no items are observed in the resident rooms or observed on the resident and will be obtained if found, or a behavioral contract will be initiated if they do not agree to give up items.

Based on interview and record review the facility failed to provide the required supervision for 1 (R #6) of 3 (R #6, 7, and 8) residents reviewed for appropriate diets when R #6 with known behaviors of searching for food, not within his diet was able to grab food from another resident's tray and choke. This deficient practice likely resulted in R #6 needing to be resuscitated (revived from unconsciousness or apparent death) and suctioned (removal of food) and then go into cardiac arrest (loss of heart function, breathing and consciousness) while enroute to the hospital, resulting in multiple strokes (damage to brain from interruption of its blood supply). The findings are: A. Record review of the face sheet for R #6 indicated the following: R #6 was admitted to the facility on [DATE]. He was admitted as a full code (all necessary interventions) and he had a diagnosis of Dysphagia (difficulty swallowing food or liquid), Barrett's Esophagus (an abnormal change of the cells present in the lower portion of the esophagus/food pipe due to acid reflux-a chronic digestive disease where the liquid content of the stomach refluxes into the esophagus, the tube connecting the mouth and stomach-which causes the lining to thicken and become inflamed) with Dysplasia (dysplasia is defined as a precancerous condition in which cells that are very similar to cancer cells can grow). Metabolic Encephalopathy (abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain function). This is not an inclusive list of all diagnoses. B. Record review of R #6's nursing progress notes dated [DATE] indicated the following: resident was found by CNA (Certified Nursing Assistant) o (sic) bed cool clammy drooling code status check and BLS (basic life support) innated (sic) RN (Registered Nurse) from cert (skilled side of facility) called for help supervisor made aware 911 called resident pink ion (sic) color awake at time of arrival of EMS(Emergency Medical Services) took over. C. Record review of R #6's hospital records dated [DATE] and under History of Present Illness indicated the following: Patient was at facility were (sic) faculty noticed the patient was short of breath with a food tray next to them EMS was called, patient went into arrest (stopped breathing) during transport to ED (Emergency Department), received 1 round of CPR (Cardio Pulmonary Resuscitation-an emergency lifesaving procedure performed when the heart stops beating) and EPI (epinephrine-a type of hormone injected whenever a person experiences fear, anxiety, or stress) with ROSC (return of spontaneous circulation, when in cardiac arrest this increases the chances of survival to hospital but doesn't increase neurologically intact survival). Patient was sating in the SO's (sic) upon arrival to the ED and intubated (the process of inserting a tube called an endotracheal tube (ET) into the mouth or nose and then into the airway (trachea) to hold it open). Per nurse/EMS patient somehow got a sandwich, aspirated (occurs when contents such as food, drink, saliva or vomit enters the lungs) was diaphoretic (excessive sweating) and drooling, started BLS (basic life support) and suctioned a good amount of food, 10 minutes until ROSC, was awake for EMS and pink. Oxygen at baseline ,d+[DATE]L (liters) . Dysphagia diet and is unclear how they received a sandwich. D. Record review of R #6's the hospital records; Hospital Course by Diagnosis indicated the following: 68 YO man with history of Ischemic Stroke (the blockage caused by this stroke reduces the blood flow and oxygen to the brain) in [DATE] discharged to skilled nursing facility. Pt presented to ED in cardiac arrest. admitted to the Medical Intensive Care Unit (MICU) for status post cardiac arrest ,d+[DATE] foreign body aspiration (foreign body aspiration occurs when a foreign body enters the airway which can cause difficulty breathing or choking) intubated on [DATE], extubation (is when the doctor takes out a tube that helps you breathe) on [DATE]. Pt was found to be altered with significant left side weakness and MRI brain (an MRI (magnetic resonance imaging) scan, also called a head MRI, is a painless procedure that produces very clear images of the structures inside of your head) showed new stroke . Pt has significant known atherosclerosis (condition where the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall) and stenosis of vessels as well as aortic ulcerated plaques (the plaque wears down the inner lining of the aorta, which is the largest blood vessel in the body and branches off from the heart) that likely embolized (stops blood flow) during resuscitative efforts causing current strokes in multiple territories. He has failed multiple swallow evaluations and PEG (percutaneous endoscopic gastrostomy is the preferred route of feeding and nutritional support) was placed. E. Record review of R #6's diet orders are as follows: [DATE] Regular Dysphagia Puree (smooth and creamy texture) [DATE] Large portions regular Dysphagia Puree [DATE] Regular Dysphagia Advanced (cut up food and avoid tough meats and chewy, sticky breads). F. Record review of R #6's progress note written on [DATE] by the Registered Dietician (RD) indicated the following: Increase portions to double to ensure (name of resident) does not feel the need to get food off trays left in the hall. G. Record review of R #6's Care Plan dated [DATE] (date of initial care plan) revealed that no update to the care plan for a new goal, intervention or behavior monitoring was made to address R #6 taking food off trays in the hall or off of other's plates. H. Record review of the Minimum Data Set (MDS) for R #6 had a BIMS (Brief Assessment of Mental Status) score of 8 on admission, which indicated his cognitive ability (thinking, reasoning and remembering) was moderately impaired. BIMS scoring guide: 13 - 5 cognitively intact; 8 -12 moderately impaired and 0 -7 severely impaired. I. On [DATE] at 11:53 am, during an interview with the Kitchen Manager, he stated that he hasn't been here very long. He stated that the trays being passed out and picked up can be an issue. He stated that the trays for dinner are delivered around 4:30 or 5 pm. He stated that he has seen trays still out on the floors when he leaves for the night around 6:45 pm. He stated that the snacks are locked up in the nourishment rooms and the residents can't get in there to get them, they have to ask a staff member for a snack. J. On [DATE] at 2:00 pm during an interview with the Speech Language Pathologist (SLP), she evaluated R #6 on [DATE] and decided that he was puree initially and then she trialed(tested ) him and he became Dysphagia advanced/mechanical soft puree when he came in, because he was weak and had some problems swallowing. Trialed (tested ) him on mechanical soft on [DATE]. When he was puree, he was getting up and going into patient rooms. He was taking food off other resident's trays. He was hungry. At least one incident that she heard of. Might have been at dinner time. He would eat in his room only. He wasn't totally cognitively intact he had moderate cognitive issues. The SLP stated that she thinks he understood the foods he should or shouldn't eat. He should have been eating sandwiches that were ground or chopped. Soft piece of bread with some moisture like chicken salad, or tuna salad. A whole slice of meat like a ham sandwich and turkey sandwich would not be for a resident who is eating mechanical soft/dysphagia advanced diet. K. On [DATE] at 3:09 pm, during an interview with Certified Nursing Assistant (CNA) #2 he stated that they very seldom see a resident try to take food from other residents trays or off of the food cart that holds trays. He stated that when they (staff) do see this, they always stop the residents. He stated that he just now passed the snacks and that they keep the snacks in the nourishment room, they don't just leave them out. L. On [DATE] at 8:40 am, during an interview with CNA #1 she stated that she did remember R #6 he would wander around in his wheelchair. He always ate in his room. She stated that he was on a puree diet. CNA #1 stated that when the food cart was out she would watch him try to get into it. She would stop him and he would say that he was hungry so she would bring him some snacks like yogurt. She stated that they keep the door to the food cart latched when they walk away from it so residents can't get into it. M. On [DATE] at 9:22 am, during an interview with the Registered Dietician, she stated that R #6 was underweight and Edentulous (no teeth) on puree texture and was on double portions and snacks. The RD stated that he was always hungry. He was mobile in his wheelchair and he would frequently be up and down the halls looking for food. He would take food off others room trays and from the food cart that was parked in the hall if he could. The RD stated that this was common information that he would do this and he would sometimes search all day for food. She stated in a follow up interview that she was aware of the behavior because she saw him try to take something off another tray once and she stated that MDS nurse knew. She was not sure whether or not R #6 understood his food limitations. N. On [DATE] at 12:51 pm, during an interview with the Center Nursing Executive (CNE), she stated that what she knows about R #6 is that he choked on some food, they started CPR, called EMS and he went to the hospital and did not return to the facility. The CNE stated that she was not notified that R #6 would eat off of others trays and would search for food. She stated that this would have been addressed as a behavior if she had known this. She stated that they did a PIP (Program Improvement Plan) for this, but they were looking at residents diets not behaviors. O. On [DATE] at 2:19 pm, during an interview with CNA #5, he stated that he did remember R #6, he stated that he would wander around at night. He was a puree diet. He was aware that he would seek food and would often times just ask him for food. So he would get him a snack.

Based on record review and interview the facility failed to provide quality care for 2 (R # 204 and 28) of 2 (R #'s 204 and 28) residents looked at for quality care issues to include the following: 1. Not receiving prompt wound identification and treatment for [REDACTED]. 2. Missed doses of [MEDICATION NAME] (antibiotic) medication prescribed to R #204 for pneumonia (Infection that inflames air sacs in one or both lungs, which may fill with fluid); 3. Removed R #28 from the facility, late at night to a psychiatric hospital after an outburst that happened early in the day. This deficient practice likely contributed to a re-hospitalization for R #204 and for R #28 the continued pronounced feelings of frustration, anger and not being safe in his home may have been avoided by identifying and proactively managing negative behavioral symptoms prior to a crisis evolving. The findings are: Findings for R #204 Pressure Ulcer Care: A. Record review of R #204's medical chart indicated the resident was admitted [DATE] with 6 pressure ulcers and no wound care or treatments ordered. Three wound care treatments were ordered on [DATE], two of the wound treatments were to start on 04/03/18 and one on 04/04/18. The physician's orders [REDACTED]. 1. Cleanse area to lateral (the outer side) right foot with wound cleanser pat dry and paint with iodine every day shift for wound care. 2. Cleanse wound to buttock with wound cleanser pat dry apply alginate and cover with dry dressing every day shift. 3. Cleanse wound to left trochanter (hip/thigh) with wound cleanser pat dry apply santyl (a sterile enzymatic [MEDICATION NAME] ointment) and cover with opti foam (Adhesive Foam Wound Dressings) every day shift every Monday, Wednesday and Friday. B. Record review of the Skin Integrity Report Sheets indicated that there were 6 wounds documented on six separate Skin Integrity Reports. The reports indicated the following: 1. Pressure wound, buttocks draining wound. The same documentation occurs for dates 04/04/18 and 04/11/18. 3. Pressure wound, left sacral (lower back) crest. This wound was marked as in house acquired wound. The first documentation of the wound is dated 03/28/18 which is the date R #204 was admitted . This wound was marked in size as 8.0 length, 6.0 width and 0 depth. This was a granulating, deep purple/maroon, serosangineous draining wound. The same documentation occurs for dates 04/04/18 and 04/11/18. 4. Pressure wound, right lateral foot. This wound was marked as in house acquired and is a deep tissue injury. The first documentation of the wound is dated 03/28/18 which is the date R #204 was admitted . This wound was marked in size as 0.7 length, 0.5 width and 0 depth. This was an intact, deep purple/maroon wound. The same documentation occurs for dates 04/04/18 and 04/11/18. 5. Pressure wound, right medial (the middle; in or toward the middle; nearer the middle) foot. This wound was marked as present on admission and is a deep tissue injury. The first documentation of the wound is dated 03/28/18 which is the date R #204 was admitted . This wound was marked in size as 2.0 length, 4.0 width and 0 depth. This was an intact, deep purple/maroon wound. The same documentation occurs for dates 04/04/18 and 04/11/18. 6. Pressure wound, left hip trochanter (either of two knobs at the top of the femur). This wound was marked as present on admission and is unstageable (Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed). The first documentation of the wound is dated 03/28/18 which is the date R #204 was admitted . This wound was marked in size as 4.8 cm length, 3.5 cm width and 1.3 cm depth. This was marked as slough (to separate in the form of dead tissue from living tissue) and necrotic (dead) tissue with serosangineous drainage. The same documentation occurs for dates 04/04/18 and 04/11/18. C. On 06/29/18 at 2:30 pm, during an interview with Unit Manager (UM) #2, he stated that because the Skin Integrity Report was not completed until 04/02/18, no wound treatments were completed. UM #2 also stated that he takes responsible for two other wounds and marked them as being in-house acquired wounds because he could not be sure that the resident did or did not come to the facility with those wounds. He stated that because the nursing staff did not fill out a Skin Integrity Report when the resident was admitted he was not aware of the wounds. He stated that no wound treatments were ordered by the physician within 24 hours so no wound treatments were done. The UM #2 stated that there was a communication breakdown between the nursing staff and himself. UM #2 also stated that he dated all the wounds as being seen and measured on 03/28/18, but he had not seen them on that date. He saw and marked them on the 04/04/18 and filled in the 03/28/18 information because that was the date that R #204 arrived at the facility. Findings for R #204 Intravenous (IV) Antibiotics: D. Record review of the physician's orders [REDACTED]. Used to treat certain kinds of bacterial infections in the bowel) HCl Solution Reconstituted, use 945 milligrams (mg) intravenously every 12 hours for hospital acquired pneumonia. Start date 4/11/18 and discontinued on 4/12/18. E. Record review of R #204's Medication Administration Record (MAR) dated (MONTH) (YEAR), indicated that on 04/11/18 resident did not get this dose. It indicates to see the nursing notes. On 04/12/18 it indicated to the see the nursing notes for the 8:00 am dose. The second dose on 04/12/18 was given to R #204. F. Record review of R #204's physician's orders [REDACTED]. Vancomycian 1 gram (gm) ivpb (iv piggy back (The piggy back is a medication that runs in a maintenance line)) every 24 hours vanco (Vancomycian) trough level prior to 4th dose. Start date 4/13/18 and discontinued on 4/18/18. G. Record review of R #204's physician's orders [REDACTED]. Vancomycian 1 gram ivpb every 24 hours vanco (Vancomycian) trough level (the amount of Vanco in the blood rises for a period of time, peaks, and then begins to fall, usually reaching its lowest level, or trough, just before the next dose) prior to 4th dose. Start date 4/13/18 and discontinued on 4/18/18. H. Record review of R #204's MAR indicated that an order for [REDACTED]. Start date 04/10/18 and was discontinued on 04/11/18. There was one dose noted on the MAR and it indicated to see the nursing notes. I. Record review of R #204's Treatment Administration Record dated (MONTH) (YEAR) and the labs in the medical chart did not indicate that a trough level prior to the fourth dose was ever completed. J. Record review of R #204's History and Physical from (name of hospital) dated 04/16/18 indicated that R #204 was admitted to the hospital for [MEDICAL CONDITION] (A life-threatening complication of an infection). In the Assessment and Plan Section it indicated that [MEDICAL CONDITION]ly secondary to hospital acquired pneumonia (HAP) due [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus a type of staph bacteria that is resistant to several antibiotics) /pseudomonas (infection is caused by strains of bacteria found widely in the environment). Patient on Vanc (Vancomycian) and [MEDICATION NAME] (antibiotics) from an outside facility, he was diagnosed with [REDACTED]. K. On 06/29/18 at 2:30 pm, during an interview with Unit Manager #2, he stated that R #204 was started on several antibiotics [MEDICATION NAME] for pneumonia (antibiotic), [MEDICATION NAME] 750 milligram (antibiotic), [MEDICATION NAME] (an antibiotic) and the Vancomycian was also ordered. UM #2 stated that he did not get some of the Vancomycian doses because they were fighting with the pharmacy to get the medication here. He also stated that he did not see that a Vancomycian trough level was ever checked. Findings for R #28: L. Record review of R #28's face sheet revealed the resident's initial admission to the facility was on 12/30/15. His [DIAGNOSES REDACTED]. M. Record review of R #28's face sheet updates revealed: [DIAGNOSES REDACTED].) N. Record review of R #28's care plan dated 01/15/2018 revealed (Name of resident) is at risk for complications related to the use of [MEDICAL CONDITION] drugs Medication: antidepressant with an intervention of, Complete behavior monitoring flow sheet (a way to track and trend behaviors). An updated care plan dated 05/14/18 revealed (Name of resident) gets very anxious when he perceives that staff are not responding fast enough to what he perceives as an emergency with other residents and himself especially his oxygen .(Name of resident) becomes upset when provider will not see him when he demands as he does not realize he was seen and feels his situation is more important than what providers are taking care of. O. Record review of R #28's Electronic Health Record (EHR) revealed no Behavior- Interventions-Side Effects Monitoring form with documentation for resident. P. On 06/29/18 at 2:30 pm, during an interview, the Regional Nurse Consultant confirmed there is no Behavior-Interventions-Side Effects Monitoring Form for R #28 and that, the information will be in the progress notes. Q. Record review of Change in Condition note from LPN #1 dated 05/18/18 at 3:57 pm, revealed, Resident stated he's gonna have a hunger strike if (name of Physician Assistant, Certified, (PA-C)) is still working in the facility. Resident offered alternate meal choices, still refused. R. On 06/25/18 at 10:00 am, during an interview, R #28 stated they sent me to a psych (psychiatric) hospital emergency room Department .they kidnapped me in the middle of the night .they tried to take me before (earlier that day, 06/01/18) and I refused .so they came in the middle of the night .they refused to take me back (to the facility) .they (the local hospitals emergency room staff) called several times . it is my home .I fired (Name of PA-C) .I fired (Name of medical Director) .I am trying to find another doctor. S. Record review of emergency room documents from local hospital where resident was sent revealed he arrived there on, 06/01/18 at 10:10 pm. T. On 06/27/18 at 2:45 pm, during interview, with the Social Services Directors (SSDs) #'s 1 and 2 both report they were present in the conference room during the altercation on 05/14/18 and that the resident was following the PA-C down the hall while she was dealing with Emergency Medical Service (EMS) and trying to report to the team in care conference and she asked the resident to give her some time and closed the door on him and he opened the door and started yelling (expletives at the PA-C) and she closed the door again but she did not slam it. SSD #1 confirms that no one in the room went out to assist the resident at that time. U. Record review of R #28's provider orders revealed a verbal order from the Medical Director on 05/14/18, (Name of group of psychiatric care practitioners) Eval (evaluation) and Tx (treatment) for Anxiety. V. Record review of R #28's provider orders revealed that the facility Medical Director ordered the resident sent to the local hospital on [DATE] .there is no documentation in the orders that revealed that the resident was not to be readmitted when the hospital had finished treating him. W. Record review of R #28's nursing progress notes dated 06/02/18 at 4:13 am reported, (Name of local acute care hospital) called at about 0330 (3:30 am) to enquire about the reason resident had been sent out .they were discharging the client back to the facility as there was no reason to hold him since he was calm and compliant .my manager (Unit Manager, Interim Chief Nursing Executive) told me we could not accept the resident back as he did not have a primary physician . and he told me that this was instructions from the Director (first name of Administrator) and Physician (Medical Director). X. Record review of a letter from the Medical Directors Practice Manager, dated 06/15/18 and sent to resident revealed, In our (MONTH) 15, (YEAR) letter to you we stated we would provide you up to 30 days of care. (The resident had not obtained a different physician at the time of this event and he was being treated under the care of the Medical Director.)

Based on observation, record review and interview, the facility failed to monitor a residents' pressure ulcers (areas of damaged skin caused by pressure, shear or friction) and to provide the necessary treatment and services, to include new interventions if current treatments are not affecting healing, and to prevent new ulcers and/or heal existing pressure ulcers for 3 (R #s 204, 18 and 43) of 3 (R #s 204, 18 and 43) residents looked at for pressure ulcers. This deficient practice resulted in residents developing pressure ulcers while at the facility and no indication that the treatments used assisted in the healing of existing ulcers. The findings are: Findings for R #204 Pressure Ulcer Care A. Record review of R #204's medical chart indicated the resident was admitted [DATE]. R #204's hospital progress notes dated 03/26/18 indicated the resident had five pressure sores. 1. Coccyx (tailbone), suspected deep tissue injury, unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed), 9.5 cm (centimeter) x 9.5 cm with indeterminate depth. 2. Left Trochanter (upper part of the thigh bone), unstageable 5 cm x 5 cm with indeterminate depth. 3. Left lateral (the outside of) foot, suspected deep tissue injury (a pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise), unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed), resurfaced/healed. 4. Left lateral foot plantar (sole of the foot) surface, suspected deep tissue injury, unstageable 1.5 cm x 1.7 cm with indeterminate depth 5. Right medial (inside of ) heel, suspected deep tissue injury, 3 cm x 3.2 cm with indeterminate depth. B. Record review of R #204's facility Skin Integrity Report Sheets (SIRS) dated 03/28/18, 04/04/18 and 04/11/18 indicated that there were 6 wounds documented on six separate Skin Integrity Reports. The reports indicated the following: 1. Pressure wound, buttocks bi-lateral (both sides). This wound was present on admission. The first documentation of the wound is dated 03/28/18 which is the date R #204 was admitted . This wound was marked in size as 11.5 length, 12.0 width and 0 depth. This was an intact deep purple/maroon wound. The same documentation occurs for dates 04/04/18 and 04/11/18. 2. Pressure wound, right sacral crest (lower back). This wound was present on admission. The first documentation of the wound is dated 03/28/18 which is the date R #204 was admitted . This wound was marked in size as 8.0 length, 6.0 width and 0 depth. This was a granulating (granulation tissue is new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process), deep purple/maroon, serosangineous (referring to a body fluid that is both serous (thin and watery, as serum, or containing serum) and bloody) draining wound. The same documentation occurs for dates 04/04/18 and 04/11/18. 3. Pressure wound, left sacral crest (lower back). This wound was marked as in house acquired. The first documentation of the wound is dated 03/28/18 which is the date R #204 was admitted . This wound was marked in size as 8.0 length, 6.0 width and 0 depth. This was a granulating, deep purple/maroon, serosangineous draining wound. The same documentation occurs for dates 04/04/18 and 04/11/18. 4. Pressure wound, right lateral foot. This wound was marked as in house acquired and is a deep tissue injury. The first documentation of the wound is dated 03/28/18 which is the date R #204 was admitted . This wound was marked in size as 0.7 length, 0.5 width and 0 depth. This was an intact, deep purple/maroon wound. The same documentation occurs for dates 04/04/18 and 04/11/18. 5. Pressure wound, right medial foot. This wound was marked as present on admission and is a deep tissue injury. The first documentation of the wound is dated 03/28/18 which is the date R #204 was admitted . This wound was marked in size as 2.0 length, 4.0 width and 0 depth. This was an intact, deep purple/maroon wound. The same documentation occurs for dates 04/04/18 and 04/11/18. 6. Pressure wound, left hip trochanter. This wound was marked as present on admission and is unstageable. The first documentation of the wound is dated 03/28/18 which is the date R #204 was admitted . This wound was marked in size as 4.8 cm length, 3.5 cm width and 1.3 cm depth. This was marked as slough (slough is characterized as being yellow, tan, green or brown in color and may be moist, loose and stringy in appearance) and necrotic (necrosis is a form of cell injury which results in the premature death of cells in living tissue) tissue with serosangineous drainage. The same documentation occurs for dates 04/04/18 and 04/11/18. C. Record review of the SIRS (no date) indicated that R #204 had pressure ulcers on the right and left sacral crest (a large, triangular bone at the base of the spine) at 8.0 x 6.0 and 0 depth. These wounds were not documented on the hospital progress notes dated 03/26/18. There is also a pressure ulcer of the left lateral foot plantar surface, which was suspected deep tissue injury, unstageable measured at 1.5 cm x 1.7 cm with indeterminate depth. This wound did not have a SIRS form filled out for it by the facility. D. Record review of R #204's medical chart indicated that no wound care or treatments were ordered for R #204 immediately on admission 03/28/18. Three wound care treatments were ordered on [DATE], two of the wound treatments were to start on 04/03/18 and one on 04/04/18. The physician's orders indicated that the following wounds were to have wound care: 1. Cleanse area to lateral right foot with wound cleanser pat dry and paint with iodine every day shift for wound care. 2. Cleanse wound to buttock with wound cleanser pat dry apply alginate and cover with dry dressing every day shift. 3. Cleanse wound to left trochanter (hip/thigh) with wound cleanser pat dry apply santyl (a sterile enzymatic [MEDICATION NAME] ointment) and cover with opti foam (Adhesive Foam Wound Dressings) every day shift every Monday, Wednesday and Friday. E. On 06/29/18 at 2:30 pm, during an interview with Unit Manager #2, he stated that because the Skin Integrity Report was not completed until 04/02/18, no wound treatments were completed. UM #2 also stated that he takes responsibility for two of the wounds and marked them as being in-house acquired. He stated that he could not be sure that the resident did or did not come to the facility with those wounds. He stated that because the nursing staff did not feel out a Skin Integrity Report on each wound when the resident was admitted he was not aware of the wounds. He stated that no wound treatments were ordered by the physician within 24 hours so no wound treatments were done. The UM #2 stated that there was a communication breakdown between the nursing staff and himself. UM #2 also stated that he dated all the wounds as being seen and measured on 03/28/18, but he had not seen them on that date. He saw and marked them on the 04/04/18 and filled in the 03/28/18 information because that was the date that R #204 arrived at the facility. F. On 06/29/18 at 1:18 pm, during an interview with R #204's family member, he stated that his father was still in the hospital. He also stated that his father will likely need the pressure ulcer on his left buttocks debrided (the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) due to infection. Findings related to R #18 G. Record review of R #18's face sheet revealed his initial admission to the facility was on 09/27/16. His [DIAGNOSES REDACTED]. in the legs caused by an injury to or disease of the spine that impairs nerve function) and urinary tract infections (an infection of the kidney, bladder or urethra). H. On 06/25/18 at 3:32 pm, during an interview with R #18 he revealed, I have MS .it only took 6 months to put me in a wheel chair .I got the sore (PU) about a year ago .was sitting in my chair and got a pressure sore .this is the mattress I have had since I have been here .now they get two people in to turn me so they are not giving me the shear (a perpendicular force that angulated blood vessels and decreases or cuts off circulation) .I can't have my head all the way down (head of bed down decreases pressure to wound area) .when I can get in my chair I go out and about .go outside .now I read and watch TV .talk on the phone .that is enough I guess. I can't get up in my chair now because of the ulcer except for maybe once every 3 weeks or so. I. On 06/27/18 at 2:30 pm, during an interview with the Unit Manager #2 he revealed, the ischial (a bone at the right and left back of the hip that is what bears weight in humans when they sit up) wound has never completely healed, it gets better, then worse when he goes into the hospital. J. Record review of the facility policy titled, Skin Integrity Management, (Revision date 11/28/16), revealed, Perform wound observations and measurements and complete Skin Integrity Report .upon initial identification of altered skin integrity, weekly, and with anticipated decline of wound .Develop comprehensive, interdisciplinary plan of care including prevention and wound treatment, as indicated .review care plan weekly and revise as indicated. K. Record review of R #18's wound treatment orders dated 06/01/17 to 06/30/18 revealed 3 wound care orders during that time frame that seem to address the topical care for the right Ischial ulcer (two of the three did not specify where the wound was located). They were as follows: 1. On 08/21/17 a verbal order reading, Cleanse area in gluteal (a group of three muscles which make up the buttocks) fold with wound cleanser, pat dry, pack with collagen (a topical wound care product meant to accelerate healing), cover with border gauze every evening shift. This order end date was 08/25/17. 2. On 05/22/18 a verbal order reading, Pressure Ulcer-Deep moderate to heavy drainage. Cleanse wound -location R (right) Ischium with Skinintegrity (a brand name) Wound Cleanser and apply Sureprep ( a brand name) No Sting (a skin protectant product) and adhesive contact area (where adhesive from the dressing will be). Apply Maxsorb Extra (an absorbent wound care product) cover with [MEDICATION NAME] Composite Dressing ( a dress to cover, seal and absorb drainage in a wound) as needed and every shift. The order, end date on this was 06/07/18. 3. On 06/09/18 a verbal order reading, Cleanse wound with normal saline (a salt and water fluid) of (sic) wound spray , pat dry with clean gauze, apply collagen powder, cover with Opti-FOAM (brand name of absorbent wound care product) or border gauze (a gauze with tape attached), as needed for wound care and every day shift for wound care. There was no end date specified. L. Review of R #18's care plan (undated) revealed that he has no current care plan to address his wound treatment Findings for R #43 M. Record review of R #43's the face sheet revealed his initial admission to the facility was on 04/26/18. His [DIAGNOSES REDACTED]. N. On 06/26/18 at 10:11 am, during an interview with R #43 he stated, feet hurt. O. Record review of R #43's care plan revealed resident is on Hospice care as of 05/01/18. P. On 06/28/18 during observation of R #43's wound care it was noted he had a right and left heel ulcers, non-blanchable brown discolored areas on the right and left 5th metatarsals (lateral aspect of foot just next to 5th toe) as well as left and right non blanchable brown discolored area on the tips of great toes. Q. Record review of R #43's nursing assessment of resident skin dated 6/28/18 revealed, The following New skin injury/wound(s) were identified: Pressure Area(s): Location(s): Left heel; Other Wound(s): Location(s): DTI (Deep Tissue Injury, a form of pressure ulcer that is likely to deteriorate) bilateral feet. R. Record review of R #43's care plan (undated) had no documentation of planning for wound prevention or healing.

Based on interview and record review the facility failed to ensure that residents were free from alleged sexual abuse for 1 (R #1) of 4 (R #1, 2, 3, 4) residents reviewed for abuse. This deficient practice resulted in R #1 experiencing feelings of anxiety, fear, discomfort and led to her having nightmares. The findings are: A. On 12/30/16 at 8:22 am, during an interview with the PTA (physical therapy assistant), she stated that R #1 came to therapy and told her that something strange happened. R #1 told PTA that on 09/12/16 she woke up to CNA #1 (certified nursing assistant) massaging her. PTA stated that R #1 told her that she woke up and CNA #1 was sitting on her bed and rubbing her. PTA also stated that R #1 was very concerned when telling her what happened. B. On 12/30/16 at 8:31 am, during an interview with the DON (Director of Nursing), she stated that R #1 told her that there was not penile penetration, but that CNA #1 did put his hand in R #1's vagina. The DON stated that after R #1 disclosed this to her she (R #1) did agree to get a SANE (Sexual Assault Nursing Exam). C. On 12/30/16 at 10:10 am, during an interview with the SSD (social services director) she stated that she was the first person to interview R #1 regarding the alleged abuse. The SSD stated that R #1 informed her that the encounter took place after she (R #1) went to bed and lasted around thirty minutes. The SSD also stated that R #1 wasn't able to pinpoint the exact time of the alleged abuse because it was very dark in the room at that time. R #1 told SSD #1 that CNA #1 was going to massage her leg and she told him that is not my leg. D. On 12/30/16 at 10:45 am, during an interview with CNA #1, he stated that he was called in by the Administrator and the Administrator told him that there was a complaint filed against him alleging that he touched one of the residents inappropriately and he was being suspended. CNA #1 stated that he didn't know who said these things about him. He stated that he was currently still suspended from going back to work. CNA #1 stated that he had not ever given a resident a massage. When asked again, CNA #1 then stated that he had given one resident a neck massage and that this resident was very independent and he had given this resident a neck massage in front of everyone. E. On 12/30/16 at 1:58 pm, during an interview with R #1, she stated that CNA #1 had come into her room about one month prior and had told her that he would massage her leg because he knew it had been hurting. She stated that he told her that his wife lived in Mexico and also told her don't worry, don't worry my wife is a white woman. She stated that she didn't understand or know why he had told her that. She thought it was odd. R #1 stated that she woke up and CNA #1 was massaging her. She stated that she didn't have a roommate at that time. She stated that she was unsure of the exact time, but that she had the TV on because the TV helps her fall asleep at night and that the curtain was drawn and it was dark, but she thought that this happened between 9:00 pm and 10:00 pm. R #1 also stated that she saw CNA #1 the next day and he told her that he would see her tonight. She stated that she just didn't feel right about it and it wasn't ok, so she told the PTA. R #1 also stated that Massaging my leg is one thing and probing my crotch is another. She also stated that she started having nightmares a couple of weeks ago. She stated. that another thing about rape and incest is you let them do it and then you get out alive. At 62, I'm not a sexy person so I'm not sure why he did that or why he chose me. She indicated that she had a good rapport with CNA #1 before the incident happened with him and that after the incident and after she told everyone, she withdrew and became more depressed. G. On 01/03/16 at 10:45 am, during a phone interview with the Registered Nurse (RN) who performed the SANE exam, she stated that R #1 arrived in her wheelchair and notified her (nurse) that she (R #1) had some right sided weakness. The SANE Nurse stated that R #1 told her that she was digitally (by hand) penetrated by CNA #1. The SANE Nurse stated that anytime there is bruising on the cervix, it is caused by internal friction or trauma. She stated that the specific bruising on R #1's cervix, in her professional experience, appeared like it could have been caused by a fingernail. She also stated that there has to be penetration and trauma to the cervix to create a bruise. She stated that R #1 told her that she was unable to use her call light/call button, because the button was on the right side of the bed, she was unable to get it and she was scared. R #1 told the SANE nurse that she (R #1) was concerned about the [AGE] year old resident's and didn't want this happen to one of them. H. On 01/11/17 at 10:45 am, during an interview with the Violent Crimes Detective, she stated that when she interviewed R #1 she was clear, consistent and detailed. She stated that her investigation was ongoing at that time. I. Record review of R #1's medical record indicated that on the night of 09/12/16, the day of the alleged abuse, R #1 did not have a roommate. J. Record review of the investigative report dated 09/12/16 indicated that CNA #1 worked the night of 09/12/16. He clocked in at 1:55 pm and clocked out for dinner at 9:11 pm, clocked back in at 9:40 pm and clocked out for the evening at 10:10 pm. R #1 stated that she thought the incident occurred between 9 pm and 10 pm. K. Record review of the SANE report written and filled out by the SANE RN indicated that her findings were: 1. Redness at urethral meatus (opening of the urethra) noted and tenderness to touch. 2. Redness to cervix and tenderness to touch surrounding cervix. 3. Red/bruise yellow/brown to cervix at 6 1/2 o'clock. Note: white/cream discharge noted on cervix, collected with cervical swabs.

Based on interview and record review the facility failed to implement policies and procedures to prevent abuse for 1 (R #1) of 4 (R #s 1, 2, 3 and 4) residents reviewed for abuse. This deficient practice resulted in R #1 experiencing of feelings of anxiety, fear, discomfort and led to her having nightmares. The findings are: A. On 12/30/16 at 8:22 am, during an interview with PTA (physical therapy assistant), she stated that R #1 came to therapy and told her that something strange happened. R #1 told PTA that on 09/12/16 she woke up to CNA #1 (certified nursing assistant) massaging her. PTA stated that R #1 told her that she woke up and CNA #1 was sitting on her bed and rubbing her. PTA also stated that R #1 was very concerned when telling her what happened. B. On 12/30/16 at 8:31 am, during an interview with DON (Director of Nursing), she stated that R #1 told her that there was not penile penetration but that CNA #1 did put his hand in R #1's vagina. The DON stated that after R #1 disclosed this to her she (R #1) did agree to get a SANE (Sexual Assault Nursing Exam). C. On 12/30/16 at 10:10 am, during an interview with SSD (social services director) she stated that she was the first person to interview R #1 regarding the alleged abuse. The SSD stated that R #1 informed her that the encounter took place after she (R #1) went to bed and lasted around thirty minutes. The SSD also stated that R #1 wasn't able to pinpoint the exact time of the alleged abuse because it was very dark in the room at that time. R #1 told SSD #1 that CNA #1 was going to massage her leg and she told him that is not my leg. D. On 12/30/16 at 10:45 am, during an interview with CNA #1, he stated that he was called in by the 4 Administrator and the Administrator told him that there was a complaint filed against him alleging that he touched one of the residents inappropriately and he was being suspended. CNA #1 stated that he didn't know who said these things about him. He stated that he was currently still suspended from going back to work. CNA #1 stated that he had not ever given a resident a massage. When asked again, CNA #1 then stated that he had given one resident a neck massage and that this resident was very independent and he had given this resident a neck massage in front of everyone. E. On 12/30/16 at 1:58 pm, during an interview with R #1, she stated that CNA #1 had come into her room about one month prior and had told her that he would massage her leg because he knew it had been hurting. She stated that he told her that his wife lived in Mexico and also told her don't worry, don't worry my wife is a white woman. She stated that she didn't understand or know why he had told her that. She thought it was odd. R #1 stated that she woke up and CNA #1 was massaging her. She stated that she didn't have a roommate at that time. She stated that she was unsure of the exact time, but that she had the TV on because the TV helps her fall asleep at night and that the curtain was drawn and it was dark, but she thought that this happened between 9:00 pm and 10:00 pm. R #1 also stated that she saw CNA #1 the next day and he told her that he would see her tonight. She stated that she just didn't feel right about it and it wasn't ok, so she told the PTA. R #1 also stated that Massaging my leg is one thing and probing my crotch is another. She also stated that she started having nightmares a couple of weeks ago. She stated that another thing about rape and incest is you let them do it and then you get out alive. At 62, I'm not a sexy person so I'm not sure why he did that or why he chose me. She indicated that she had a good rapport with CNA #1 before the incident happened with him and that after the incident and after she told everyone, she withdrew and became more depressed. G. On 01/03/16 at 10:45 am, during a phone interview with the Registered Nurse (RN) who performed the SANE exam, she stated that R #1 arrived in her wheelchair and notified her (nurse) that she (R #1) had some right sided weakness. The SANE Nurse stated that R #1 told her that she was digitally (by hand) penetrated by CNA #1. The SANE Nurse stated that anytime there is bruising on the cervix, it is caused by internal friction or trauma. She stated that the specific bruising on R #1's cervix, in her professional experience, appeared like it could have been caused by a fingernail. She also stated that there has to be penetration and trauma to the cervix to create a bruise. She stated that R #1 told her that she was unable to use her call light/call button, because the button was on the right side of the bed, she was unable to get it and she was scared. R #1 told the SANE nurse that she (R #1) was concerned about the [AGE] year old residents and didn't want this happen to one of them. H. On 01/11/17 at 10:45 am, during an interview with the Violent Crimes Detective, she stated that when she interviewed R #1 she was clear, consistent and detailed. She stated that her investigation was ongoing at that time. Record review of R #1's medical record indicated that on the night of 09/12/16, the day of the alleged abuse, R #1 did not have a roommate. J. Record review of the investigative report dated 09/12/16 indicated that CNA #1 worked the night of 09/12/16. He clocked in at 1:55 pm and clocked out for dinner at 9:11 pm, clocked back in at 9:40 pm and clocked out for the evening at 10:10 pm. R #1 stated that she thought the incident occurred between 9 pm and 10 pm. K. Record review of the SANE report written and filled out by the SANE RN indicated that her findings were: 1. Redness at urethral meatus (opening of the urethra) noted and tenderness to touch. 2. Redness to cervix and tenderness to touch surrounding cervix. 3. Red/bruise yellow/brown to cervix at 6 1/2 o'clock. Note: white/cream discharge noted on cervix, collected with cervical swabs. L. Record Review of the facility's Abuse Prohibition Policy dated 07/01/13 and reviewed 10/10/16 indicated the following: (Name of Corporation) will prohibit abuse, neglect, misappropriation of resident property, and exploitation for all residents. This includes, but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The Center will implement an abuse prohibition program through the folllowing: 1. Screening of potential hires; 2. Training of employees (both new employees and ongoing training for all employees); 3. Prevention of occurrences; 4. Identification of possible incidents and allegations which need investigation; 5. Investigation of incidents and allegations; 6. Protection of patients during investigations; and 7. Reporting of incidents, investigations, and Center response to the results of their investigations.

The facility failed to ensure that residents were free from physical and verbal abuse and the resident was not assured of a safe environment free of retaliation by staff. This deficient practice resulted in an Immediate Jeopardy at a scope and severity of J being identified on 11/10/15 at 3:15 pm. The administrator was notified at that time. A Plan of removal was received at 4:15 pm which included the following: 1. Investigations will begin immediately upon Administrator being informed of the event. Administrator/designee will follow the seven steps of incident/accident reporting per policy. 2. If substantiated a plan of correction, that will include re-education, disciplinary action if warranted and evaluation to see if education is effective. This action will be put into place to prevent reoccurrence of stated incident. 3. Social services will meet with the resident alleging abuse to discuss the progress and the outcome of the investigation. 4. Social Services will meet with the resident alleging abuse and ask if the resident feels retaliated against, if so, staff identified will suspended and a new investigation will be started. 5. Resident council will meet on 11/12/2015 and Social Services will educate residents on retaliation and who to report this to. The Nurse Practice Educator (NPE)/designee will educate staff on resident ' s rights to complain/file a grievance without retaliation by 11/15/2015. As a result of the Plan of Removal, the scope and severity was lowered to a level G. Based on record review and interview, the facility failed to ensure that residents were free of verbal abuse, physical abuse, intimidation and restraint for 1 (R #11) of 1 (R #11) residents reviewed for abuse during a complaint investigation. This deficient practice likely resulted in R #11 feeling afraid and uncomfortable in the facility. The findings are: A. On 10/08/15 at 11:58 am, during interview with LPN (Licensed Practical Nurse) #1, she stated that R #11 heard that surveyors were in the building and wanted to speak someone. B. On 10/08/15 at 12:09 pm, during interview, R #11 appeared clean, alert and oriented. R #11 was sitting in her wheelchair, and stated (to the surveyor) that she wanted to know if the State Agency had received her complaint about an incident of alleged abuse. C. On 10/08/15 at 12:09 pm, during interview R #11, stated, I made a report to (Name of Social Services Director) a week ago. I was trying to get some help, for the patient next to me who is comatose because she had sat in her chair with poop for over an hour. They (staff) kept saying 'We'll be right there', but they didn't come. I went to get (Name of Certified Nursing Assistant (CNA) #1). I asked (Name of CNA #1) and she said 'Yeah I'll be right there', she never came. When I went down the hall, she saw me and yelled 'I said I'll be right there!' I went the other way and when I started to come back, she started screaming at me again. She grabbed my wheelchair and then she grabbed my arm. I reported it and I was told that because I screamed back that it didn't warrant any punishment. (Name of Administrator) told me that she talked to the State (State Agency) and that it didn't warrant punishment. (Name of Administrator) said 'Witnesses said it was the two of you (R #11 and CNA #1). 'I (Administrator) want to put you two in a room to apologize to each other.' (Name of Administrator) turned right around and put her (CNA #1) to work in my station and (Name of CNA #1) brings my food tray, and says 'Here' and throws it down. I have a history of abuse and I have always tried to run away and now if I have to deal with this. I feel it (abuse allegation) should've been addressed, and (Name of Administrator) said it had. (Name of CNA #1) still works on the South Unit (where Resident resides). She (CNA #1) came in my room on Tuesday and asked if I wanted a shower and I said I didn't feel good because I don't want to be showered by her. R #11 was asked if she felt afraid, she stated Yes I am. I'm afraid she'll yell at me again. I shouldn't have to be uncomfortable here for a reason like that. R #11 stated (of the alleged incident) It happened Sunday the 27th of September in the evening right around 6 or 7. When she (CNA #1) yelled at me, I went the other way. She (CNA #1) was in room [ROOM NUMBER]. She was in the doorway, I was sitting outside the doorway. I was trying to get away from her and she grabbed the wheelchair. She was holding me from getting away. Then she grabbed my left arm and I pulled away. I just had to get away. During the interview, R #11 started to cry when talking about CNA #1 yelling at her and grabbing her wrist. D. On 10/08/15 at 1:14 pm, during interview with LPN #1 regarding R #11's allegation of abuse, she stated I was doing her dressing, (on 09/28/15), she just was kind of different that day, I asked what was wrong. She started crying a little bit and she said 'I had a rough weekend. On Saturday (Name of CNA #1) was my aide and she raised her voice.' (R #11) said when she was backing up (Name of CNA #1) grabbed her wheelchair and jerked her. (Name of R #11) said 'Let go' and (Name of CNA #1) grabbed her arm. After she told me that, I felt like I had to tell somebody, I talked to (Name of Administrator) and (Name of Director of Nursing (DON)) and they said they would take care of it. (Name of DON) said 'We will talk to her.' She (CNA #1) came back the next day and she was on (Name of R #11's) floor. She (R #11) was scared, she said 'I'm afraid, what if she retaliates?' I told her to tell somebody, to tell me, if that happens. (Name of R #11) talked to (Name of Social Service Director) and (Name of Social Service Director) moved her to the other side (of the facility). I thought that was weird, to move the resident and not the aide. She (R #11) was really uncomfortable. They (Administration staff) continued to put (Name of CNA #1) on her (R #11's) side and do her showers. Now she is very different. She (R #11) told me (Name of Administrator) talked to her and talked to the State (State Agency) and it (the alleged incident) didn't warrant discipline. From my side, I think it should've been reported. She (R #11) is a very social person, she gets along with everybody. I don't want (Name of R #11) to be afraid. She always asks who's working or who's doing showers. (Name of CNA #1) did showers last night, and (Name of R #11) didn't take a shower. If (Name of CNA #1) is doing showers, she is not going to take showers, she is not going to be alone in the shower room with her. (Name of Administrator) told her (R #11) she wanted them to be in the same room to reconcile. I don't think she should be pressured to be in the same room with someone who terrifies her. On the other side (of the facility), all the aides were saying, 'That's the lady you can't touch because she'll tell on you.' The smoke group residents are not talking to (Name of R #11) because of (Name of CNA #1). That's why she isolates. They (Administrative Staff) still are putting her (CNA #1) on showers and putting her on R #11's hall. E. On 10/08/15 at 2:53 pm, during interview regarding the allegation of abuse, the Administrator stated that she was aware of the incident and that When I talked to (Name of R #11), she said I didn't want anything done with this. The Administrator was unable to provide any documentation to indicate that the allegation of abuse had been addressed and/or resolved. F. On 10/08/15 at 3:43 pm, during interview with the Social Services Director (SSD) she stated, I interviewed (Name of R #11), she had told me that she had asked for help for her roommate. She said a little time had gone by and she went and found (Name of CNA #1). (Name of CNA #1) was coming out of another patient's room. (Name of CNA #1) said 'I know you need help, I just got on the floor.' (Name of R #11) said she went away and when she was coming back down the hall, (Name of CNA #1) yelled at her. (Name of R #11) said she started rolling away and (Name of CNA #1) grabbed the handle (of her wheelchair) and said 'I want to talk to you' and (Name of R #11) said she didn't want to talk to her and she rolled away from the situation. I moved (Name of R #11) to (another unit) for the night. She (R #11) said she was afraid of (Name of CNA #1). (Name of R #11) has a history of abuse by her mother and siblings. (Name of R #11) stated that when (Name of CNA #1) put her hand on her arm it brought up bad memories. I thought it (the move) was best for her mentality. G. On 10/08/15 at 4:46 pm, during interview with R #12 regarding the incident involving R #11, she stated I do remember the one employee (CNA #1) saying 'I know. I will get to it.' She (CNA #1) was harsh about it. She said it loudly. I just saw her harshly tell her. I. Record review of facility's Alleged Perpetrator/Victim Interview Record dated 09/28/15, revealed that (Name of R #11) states (Name of CNA #1) told her she was not yelling at (Name of R #11) and (Name of R #11) tried to move her wheelchair when (Name of CNA #1) grabbed the back of the wheelchair. (Name of R #11) stated 'Let go' and (Name of CNA #1) grabbed (Name of R #11's) arm and stated she wanted to talk to (Name of R #11) and (Name of R #11) said 'No.'

The facility failed to ensure that resident allegations of physical and verbal abuse were investigated and acted upon. Without follow-up, the facility could not ensure that residents remained free of retaliation or harm. This deficient practice resulted in an Immediate Jeopardy at a scope and severity of J being identified on 11/10/15 at 3:15 pm. The administrator was notified at that time. A Plan of removal was received at 4:15 pm which included the following: 1. Investigations will begin immediately upon Administrator being informed of the event. Administrator/designee will follow the seven steps of incident/accident reporting per policy. 2. If substantiated a plan of correction, that will include re-education, disciplinary action if warranted and evaluation to see if education is effective. This action will be put into place to prevent reoccurrence of stated incident. 3. Social services will meet with the resident alleging abuse to discuss the progress and the outcome of the investigation. 4. Social Services will meet with the resident alleging abuse and ask if the resident feels retaliated against, if so, staff identified will suspended and a new investigation will be started. 5. Resident council will meet on 11/12/2015 and Social Services will educate residents on retaliation and who to report this to. The Nurse Practice Educator (NPE)/designee will educate staff on resident ' s rights to complain/file a grievance without retaliation by 11/15/2015. As a result of the Plan of Removal, the scope and severity was lowered to a level G. Based on record review and interview, the facility failed to report an allegation of abuse for one (R #11) of one (R #1) residents reviewed for abuse during a complaint investigation. The facilities failure to report an allegation of abuse to the State Agency, likely resulted in R #11 feeling afraid and uncomfortable in the facility. The findings are: A. On 10/08/15 at 11:58 am, during interview with LPN #1, she stated that R #11 heard that surveyors were in the building and wanted to speak someone. B. On 10/08/15 at 12:09 pm, during interview, R #11 appeared clean, alert and oriented. R #11 was sitting in her wheelchair, and stated (to the surveyor) that she wanted to know if the State Agency had received her complaint about an incident of alleged abuse. C. On 10/08/15 at 12:09 pm, during interview R #11, stated, I made a report to (Name of Social Services Director) a week ago. I was trying to get some help, for the patient next to me who is comatose because she had sat in her chair with poop for over an hour. They (staff) kept saying 'We'll be right there', but they didn't come. I went to get (Name of Certified Nursing Assistant (CNA) #1). I asked (Name of CNA #1) and she said 'Yeah I'll be right there', she never came. When I went down the hall, she saw me and yelled I said I'll be right there!' I went the other way and when I started to come back, she started screaming at me again. I'm trying to back up from her because she was screaming at me. She grabbed my wheelchair (indicating the handles of her wheelchair) and then she grabbed my arm. I reported it and I was told that because I screamed back that, that didn't warrant any punishment. (Name of Administrator) told me that she talked to the State (State Agency) and that it didn't warrant punishment. (Name of Administrator) said 'Witnesses said it was the two of you (R #11 and CNA #1). I (Administrator) want to put you two in a room to apologize to each other.' (Name of Administrator) turned right around and put her (CNA #1) to work in my station and (Name of CNA #1) brings my food tray, and says 'Here' and throws it down. I have a history of abuse and I have always tried to run away and now if have to deal with this. I feel it (abuse allegation) should've been addressed, and (Name of Administrator) said it had. (Name of CNA #1) still works on the South Unit (where Resident resides). She (CNA #1) came in my room on Tuesday and asked if I wanted a shower and I said I didn't feel good because I don't want to be showered by her. R #11 was asked if she felt afraid, she stated Yes I am. I'm afraid she'll yell at me again. She (CNA #1) knows I reported her. I spent the night on the other side (referring to another unit) and they (staff) were saying things like 'That's the one you can't touch. And I did tell (Name of Administrator) about that, and she said she would take care of it. Now if feel like I can't talk to anybody. I shouldn't have to be uncomfortable here for a reason like that. R #11 stated (of the alleged incident) It happened Sunday the 27th of September in the evening right around 6 or 7. When she (CNA #1) yelled at me, I went the other way. She (CNA #1) was in room [ROOM NUMBER]. She was in the doorway, I was sitting outside the doorway. I was trying to get away from her and she grabbed the wheelchair. She was holding me from getting away. Then she grabbed my left arm and I pulled away. I just had to get away. During the interview, R #11 started to cry when talking about CNA #1 yelling at her and grabbing her wrist. D. On 10/08/15 at 1:14 pm, during interview with Licensed Practical Nurse (LPN) #1 regarding R #11's allegation of abuse, she stated I was doing her dressing, (on 09/28/15), she just was kind of different that day, I asked what was wrong. She started crying a little bit and she said 'I had a rough weekend. On Saturday (Name of CNA #1) was my aide and she raised her voice.' (R #11) said when she was backing up (Name of CNA #1) grabbed her wheelchair and jerked her. (Name of R #11) said 'Let go' and (Name of CNA #1) grabbed her arm. After she told me that, I felt like I had to tell somebody, I talked to (Name of Administrator) and (Name of Director of Nursing (DON)) and they said they would take care of it. (Name of DON) said 'We will talk to her.' She (CNA #1) came back the next day and she was on (Name of R #11's) floor. She (R #11) was scared, she said 'I'm afraid, what if she retaliates?' I told her to tell somebody, to tell me, if that happens. (Name of R #11) talked to (Name of Social Service Director) and (Name of Social Service Director) moved her to the other side (of the facility). I thought that was weird, to move the resident and not the aide. She (R #11) was really uncomfortable. They (Administration staff) continued to put (Name of CNA #1) on her (R #11's) side and do her showers. Now she is very different. She (R #11) told me (Name of Administrator) talked to her and talked to the State (State Agency) and it (the alleged incident) didn't warrant discipline. From my side, I think it should've been reported. She (R #11) is a very social person, she gets along with everybody. I don't want (Name of R #11) to be afraid. She always asks who's working or who's doing showers. (Name of CNA #1) did showers last night, and (Name of R #11) didn't take a shower. If (Name of CNA #1) is doing showers, she is not going to take showers, she is not going to be alone in the shower room with her. (Name of Administrator) told her (R #11) she wanted them to be in the same room to reconcile. I don't think she should be pressured to be in the same room with someone who terrifies her. On the other side (of the facility), all the aides were saying, 'That's the lady you can't touch because she'll tell on you.' The smoke group residents are not talking to (Name of R #11) because of (Name of CNA #1). That's why she isolates. They (Administrative Staff) still are putting her (CNA #1) on showers and putting her on R #11's hall. E. On 10/08/15 at 2:53 pm, during interview regarding the allegation of abuse, the Administrator stated that she was aware of the incident and that When I talked to (Name of R #11), she said I didn't want anything done with this. The Administrator was asked if she reported the allegation of abuse to the State Agency and she stated I didn't. The Administrator confirmed she was made aware of the allegation of abuse from LPN #1. F. On 10/08/15 at 3:43 pm, during interview with the Social Services Director (SSD) she stated, I interviewed (Name of R #11), she had told me that she had asked for help for her roommate. She said a little time had gone by and she went and found (Name of CNA #1). (Name of CNA #1) was coming out of another patient's room. (Name of CNA #1) said 'I know you need help, I just got on the floor.' (Name of R #11) said she went away and when she was coming back down the hall, (Name of CNA #1) yelled at her. (Name of R #11) said she started rolling away and (Name of CNA #1) grabbed the handle (of her wheelchair) and said 'I want to talk to you' and (Name of R #11) said she didn't want to talk to her and she rolled away from the situation. I moved (Name of R #11) to (other unit) for the night. She (R #11) said she was afraid of (Name of CNA #1). (Name of R #11) has a history of abuse by her mother and siblings. (Name of R #11) stated that when (Name of CNA #1) put her hand on her arm it brought up bad memories. I thought it was best for her mentality. G. On 10/08/15 at 4:46 pm, during interview with R #12 regarding the incident involving R #11, she stated I do remember the one employee (CNA #1) saying 'I know. I will get to it.' She (CNA #1) was harsh about it. She said it loudly. I just saw her harshly tell her. H. Record review of the Incident Reports to the State Agency from 07/01/15 to 10/08/15, did not reveal any reports related to R #11. I. Record review of facilities Alleged Perpetrator/Victim Interview Record dated 09/28/15, revealed that (Name of R #11) states (Name of CNA #1) told her she was not yelling at (Name of R #11) and (Name of R #11) tried to move her wheelchair when (Name of CNA #1) grabbed the back of the wheelchair. (Name of R #11) stated 'Let go' and (Name of CNA #1) grabbed (Name of R #11's) arm and stated she wanted to talk to (Name of R #11) and (Name of R #11) said 'No.' J. Record review of facility Abuse Prohibition Policy dated 07/01/13, revealed the following: 1. Upon receiving information concerning a report of suspected or alleged abuse, the Administrator or designee will perform the following: Confirm that the allegation has been reported according to State and federal requirements. 2. The Administrator or designee will report findings of all completed investigations to officials (including the state survey and certification agency) within five working days of the incident or in accordance with state law, and take all necessary, corrective actions depending on the results of the investigation.

The facility failed to implement its policies and procedures that prohibit mistreatment and neglect of residents, through failing to act on grievances. Without follow-up, the facility was unable to ensure that residents remained free of retaliation or harm. This deficient practice resulted in an Immediate Jeopardy at a scope and severity of J being identified on 11/10/15 at 3:15 pm. The administrator was notified at that time. A Plan of removal was received at 4:15 pm which included the following: 1. Investigations will begin immediately upon Administrator being informed of the event. Administrator/designee will follow the seven steps of incident/accident reporting per policy. 2. If substantiated a plan of correction, that will include re-education, disciplinary action if warranted and evaluation to see if education is effective. This action will be put into place to prevent reoccurrence of stated incident. 3. Social services will meet with the resident alleging abuse to discuss the progress and the outcome of the investigation. 4. Social Services will meet with the resident alleging abuse and ask if the resident feels retaliated against, if so, staff identified will suspended and a new investigation will be started. 5. Resident council will meet on 11/12/2015 and Social Services will educate residents on retaliation and who to report this to. The Nurse Practice Educator (NPE)/designee will educate staff on resident ' s rights to complain/file a grievance without retaliation by 11/15/2015. As a result of the Plan of Removal, the scope and severity was lowered to a level G. Based on record review and interview, the facility failed to implement a policy and procedure for investigating and reporting the results of an investigation for an allegation of abuse or mistreatment to the State Agency (SA) for 1 (R #11) of 1 (R #11) residents reviewed for allegations of abuse/mistreatment. This has the potential to affect the residents in the facility by the facility not being able to determine the cause of the incident, the need for education of staff, and implement needed changes. The findings are: A. On 10/08/15 at 11:58, during interview with LPN #1, she stated that R #11 heard that surveyors were in the building and wanted to speak someone. B. On 10/08/15 at 12:09 pm, during observation, R #11, she appeared clean, alert and oriented. R #11 was sitting in her wheelchair, and stated that she wanted to know if the State Agency had received her complaint about an incident of alleged abuse. C. On 10/08/15 at 12:09 pm, during interview R #11, she stated, I made a report to (Name of Social Services Director) a week ago. I was trying to get some help, for the patient next to me who is comatose because she had sat in her chair with poop for over an hour. They (staff) kept saying 'We'll be right there', but they didn't come. I went to get (Name of Certified Nursing Assistant (CNA) #1). I asked (Name of CNA #1) and she said 'Yeah I'll be right there', she never came. When I went down the hall, she saw me and yelled I said I'll be right there!' I went the other way and when I started to come back, she started screaming at me again. I'm trying to back up from her because she was screaming at me. She grabbed my wheelchair (indicating the handles of her wheelchair) and then she grabbed my arm. I reported it and I was told that because I screamed back, that that didn't warrant any punishment. (Name of Administrator) told me that she talked to the State (State Agency) and that it didn't warrant punishment. (Name of Administrator) said 'Witnesses said it was the two of you (R #11 and CNA #1). I (Administrator) want to put you two in a room to apologize to each other.' (Name of Administrator) turned right around and put her (CNA #1) to work in my station and (Name of CNA #1) brings my food tray, and says 'Here' and throws it down. I have a history of abuse and I have always tried to run away and now if have to deal with this. I feel it (abuse allegation) should've been addressed, and (Name of Administrator) said it had. (Name of CNA #1) still works on the unit (where R #11 resides). She (CNA #1) came in my room on Tuesday and asked if I wanted a shower and I said I didn't feel good because I don't want to be showered by her. R #11 was asked if she felt afraid, she stated Yes I am. I'm afraid she'll yell at me again. She (CNA #1) knows I reported her. I spent the night on the other side (referring to another unit) and they (staff) were saying things like 'That's the one you can't touch. And I did tell (Name of Administrator) about that, and she said she would take care of it. Now if feel like I can't talk to anybody. I shouldn't have to be uncomfortable here for a reason like that. R #11 stated (of the alleged incident) It happened Sunday the 27th of September in the evening right around 6 or 7. When she (CNA #1) yelled at me, I went the other way. She (CNA #1) was in room [ROOM NUMBER]. She was in the doorway, I was sitting outside the doorway. I was trying to get away from her and she grabbed the wheelchair. She was holding me from getting away. Then she grabbed my left arm and I pulled away. I just had to get away. During the interview, R #11 started to cry when talking about CNA #1 yelling at her and grabbing her wrist. D. On 10/08/15 at 1:14 pm, during interview with Licensed Practical Nurse (LPN) #1 regarding R #11's allegation of abuse, she stated I was doing her dressing, (on 09/28/15), she just was kind of different that day, I asked what was wrong. She started crying a little bit and she said 'I had a rough weekend. On Saturday (Name of CNA #1) was my aide and she raised her voice.' (R #11) said when she was backing up (Name of CNA #1) grabbed her wheelchair and jerked her. (Name of R #11) said 'Let go' and (Name of CNA #1) grabbed her arm. After she told me that, I felt like I had to tell somebody, I talked to (Name of Administrator) and (Name of Director of Nursing (DON)) and they said they would take care of it. (Name of DON) said 'We will talk to her.' She (CNA #1) came back the next day and she was on (Name of R #11's) floor. She (R #11) was scared, she said 'I'm afraid, what if she retaliates?' I told her to tell somebody, to tell me, if that happens. (Name of R #11) talked to (Name of Social Service Director) and (Name of Social Service Director) moved her to the other side (of the facility). I thought that was weird, to move the resident and not the aide. She (R #11) was really uncomfortable. They (Administration staff) continued to put (Name of CNA #1) on her (R #11's) side and do her showers. Now she is very different. She (R #11) told me (Name of Administrator) talked to her and talked to the State (State Agency) and it (the alleged incident) that didn't warrant discipline. From my side, I think it should've been reported. She (R #11) is a very social person, she gets along with everybody. I don't want (Name of R #11) to be afraid. She always asks who's working or who's doing showers. (Name of CNA #1) did showers last night, and (Name of R #11) didn't take a shower. If (Name of CNA #1) is doing showers, she is not going to take showers, she is not going to be alone in the shower room with her. (Name of Administrator) told her (R #11) she wanted them to be in the same room to reconcile. I don't think she should be pressured to be in the same room with someone who terrifies her. On the other side (of the facility), all the aides were saying, 'That's the lady you can't touch because she'll tell on you.' The smoke group residents are not talking to (Name of R #11) because of (Name of CNA #1). That's why she isolates. They (Administrative Staff) still are putting her (CNA #1) on showers and putting her on R #11's hall. E. On 10/08/15 at 2:53 pm, during interview regarding the allegation of abuse, the Administrator stated that she was aware of the incident and that When I talked to (Name of R #11), she said I didn't want anything done with this. The Administrator was asked if she reported the allegation of abuse to the State Agency and she stated I didn't. The Administrator confirmed she was made aware of the allegation of abuse from LPN #1. F. On 10/08/15 at 3:43 pm, during interview with the Social Services Director (SSD) she stated, I interviewed (Name of R #11), she had told me that she had asked for help for her roommate. She said a little time had gone by and she went and found (Name of CNA #1). (Name of CNA #1) was coming out of another patient's room. (Name of CNA #1) said 'I know you need help, I just got on the floor.' (Name of R #11) said she went away and when she was coming back down the hall, (Name of CNA #1) yelled at her. (Name of R #11) said she started rolling away and (Name of CNA #1) grabbed the handle (of her wheelchair) and said 'I want to talk to you' and (Name of R #11) said she didn't want to talk to her and she rolled away from the situation. I moved (Name of R #11) to (other unit) for the night. She (R #11) said she was afraid of (Name of CNA #1). (Name of R #11) has a history of abuse by her mother and siblings. (Name of R #11) stated that when (Name of CNA #1) put her hand on her arm it brought up bad memories. I thought it was best for her mentality. G. On 10/08/15 at 4:46 pm, during interview with R #12 regarding the incident involving R #11, she stated I do remember the one employee (CNA #1) saying 'I know. I will get to it.' She (CNA #1) was harsh about it. She said it loudly. I just saw her harshly tell her. H. Record review of the Incident Reports to the State Agency from 07/01/15 through 10/08/15, did not reveal any reports related R #11. I. Record review of facilities Alleged Perpetrator/Victim Interview Record dated 09/28/15, revealed the following: (Name of R #11) states (Name of CNA #1) told her she was not yelling at (Name of R #11) and (Name of R #11) tried to move her wheelchair when (Name of CNA #1) grabbed the back of the wheelchair. (Name of R #11) stated 'Let go' and (Name of CNA #1) grabbed (Name of R #11's) arm and stated she wanted to talk to (Name of R #11) and (Name of R #11) said 'No.' J. Record review of facility Abuse Prohibition Policy dated 07/01/13, revealed the following: 1. Upon receiving information concerning a report of suspected or alleged abuse, the Administrator or designee will perform the following: Confirm that the allegation has been reported according to State and federal requirements. 2. The Administrator or designee will report findings of all completed investigations to officials (including the state survey and certification agency) within five working days of the incident or in accordance with state law, and take all necessary, corrective actions depending on the results of the investigation.

Based on observation, record review and interviews, the facility failed to ensure that residents were free from verbal abuse while providing care 1 (R # 170) of 1 (R #170) resident reviewed for abuse. This deficient practice has the potential to cause physical and psychological harm to the residents. The findings are: Findings for R #170: A. Record review of the facility Abuse Prohibition Policy dated 07/01/13, indicated Policy: (name of facility) will prohibit abuse.neglect.for all patients through the following: Definitions: Verbal Abuse is any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients regardless of their age, ability to comprehend, or disability. B. On 07/20/15 at 2:42 pm, during interview R #170 stated that she filed a complaint regarding (Name of Certified Nursing Assistant) #1 when he was changing her (R #170) clothes and she had asked (Name of CNA #1) to be covered up. According to R #170 (Name of CNA #1) stated, What do you have that anyone would care about. C. On 07/22/15 at 12:10 pm, during interview Director of Nursing stated, I recall there was an incident where the particular CNA (CNA #1) did not change her (R #170) depends (adult briefs) on the night shift. As I recall, she (R #170) requested for this CNA to not care for her anymore. D. On 07/23/15 at 4:22 pm, during a second interview R #170 stated, I ran into a problem with the CNA (referring to CNA #1). R #170 states I asked him to change me, so when he came to change me he pulled my brief off and left me laying on my bed naked. The gown I was wearing at the time was wet as well, so he just took it off and threw it on the floor. I asked for something to cover myself with because I didn't like the way it made me feel. I felt awkward and uncomfortable because I was laying there naked. He (CNA #1) said 'Well who would want to look at you anyway.' It made me feel horrible because I never had anything like that happen to me. E. On 07/23/15 at 4:30 pm, during interview the Administrator stated, that the complaint I received was that she (R #170) had complained that she was not changed all night. He (CNA #1) was told she (R #170) was alert and oriented, but she didn't want him to care for her any longer because she wasn't comfortable with him. The Administrator also stated that she had received this complaint as a customer service report. F. Record review of an Incident Report dated 07/23/15 filled out by the Administrator indicated, Description of Incident: Neglect. Date of Incident was 07/23/15. Before the Incident: Resident had stated staff had not changed her brief. During the incident: When interviewed by Administrator today 07/23/15, resident stated (Name of CNA#1) left her naked during the brief change and stated, No one would want to see her anyway. G. On 07/24/15 at 8:25 am, during interview R #270 (who was the roommate to R #170) at the time of the incident stated, Actually there were two incidents that occurred with (Name of CNA #1). R #270 stated, This happened on night shift on the 22nd of June (2015). I woke up almost gasping for air because my oxygen was turned off. R #270 then stated, I believe it was that same night, but I overheard my roommate (Name of R #170) complaining about (Name of CNA #1). She mentioned to me that he (CNA #1) came into change her brief and just took it off and stripped her down naked and left her there on the bed. I do remember her (R #170) saying she was cold and she felt totally exposed. At that time, I wasn't physically able to get her anything to cover up with, but I do know she was very upset about it. H. Record review of the Minimum Data Set ((MDS) dated [DATE] for R #170 indicated, there are no concerns with memory recall, no issues with cognitive skills for daily decision making, no behaviors, and no disorganized thinking. It also indicated there were no altered level of consciousness.

Based on record review and interview, the facility failed to ensure that services provided met professional standards of quality and accepted standards of practice by failing to provide wound care per physician order [REDACTED]. The findings are: A. Record review of Hospital Discharge Summary dated 04/17/15 indicated the following: (Name of resident) is a [AGE] year old male who was initially seen and evaluated at (Name of Hospital) where patient underwent exploratory laparotomy (a surgical procedure involving a large incision through the abdominal wall to gain access to the abdomen).Due to the patient's kidney injury, the patient was transferred to (Name of Hospital) .The abdominal fascia (connective tissue fibers, primarily collagen, that form sheets or bands beneath the skin to attach, stabilize, enclose, and separate muscles and other internal organs) was closed but skin was left open and a wound VAC placed on the 6th. B. Record review of Hospital Discharge Order dated 04/17/15 indicated the following: Wound Care: wound vac to midline (of abdomen), changed q (every) 48-72 hours, ostomy (surgically created opening in the body for the discharge of body wastes) to lower left quadrant changed as needed. C. Record Review of Physician order [REDACTED]. Negative Pressure WoundTherapy (NPWT, Wound Vac) to midline set to continuous. Cleanse with NSS (Normal Sterile Saline)/Wound Cleanser/other, place (gauze/black foam/white foam/other) into wound. Apply skin prep to intact skin around the wound. Cover with occlusive dressing and secure tubing per manufacturer guide every 72 hours and as needed. If NPWT needs to be turned off for any care, tests/procedures (Bathing, MRI, etc.), or for transport; remove dressing entirely, cleanse wound and apply hydrogel gauze. D. Record Review of Interdisciplinary Progress Notes from 04/17/15 to 05/04/15 revealed no documentation to indicate that wound care was performed as ordered. E. Record review of the Care Plan dated 04/17/15 indicated the following: Focus: Resident is at risk for complications of infection related to abdominal abscess Goal: Resident will remain free of complications/infection daily Interventions: Administer medication as ordered, monitor and evaluate for pain and medicate as ordered, monitor for changes in nutritional/hydration status, monitor for signs and symptoms of infections and report to physician as indicated, monitor for skin breakdown and report to physician as indicated, monitor level of consciousness, mental status, monitor vital signs and report to physician as needed. Obtain labs/cultures as ordered and report results to physician Focus: Resident has actual skin breakdown related to recent surgery resulting in abdominal [MEDICATION NAME] for draining abdominal fluid from abscess and abdominal wound vac Goal: Resident's wound will remain free from signs/symptoms of infection by 90 days Interventions: Evaluate wound area daily including surrounding tissue and presence or absence of drainage/infection and/or new wound pain and report to MD as indicated, monitor for verbal/non-verbal signs of pain related to wound or wound treatment and medicate as ordered, monitor skin for signs/symptoms of breakdown i.e. redness, cracking, blistering, pressure redistribution surfaces to bed and chair as per protocol, weekly skin assessment by licensed nurse, weekly wound assessment to include measurements and description of wound status. F. Record review of Treatment Administration Record for 04/01/15 to 04/30/15 indicated the following: Negative Pressure Wound Therapy (NPWT, Wound Vac) to midline set to continuous. Cleanse with (NSS (Normal Sterile Saline)/Wound Cleanser/other) place (gauze/black foam/white foam/other) into wound. Apply skin prep to intact skin around the wound. Cover with occlusive dressing and secure tubing per manufacturer guide every 72 hours and as needed. If NWPT needs to be turned off for any care, tests/procedures (Bathing, MRI, etc.), or for transport; remove dressing entirely, cleanse wound and apply hydrogel gauze. No dates marked to indicate that the above treatment was performed. G. Record review of Treatment Administration Record for 05/01/15 to 05/20/15 indicated the following: Negative Pressure Therapy to midline set to continuous. If NPWT needs to be turned off for any care (bathing, MRI etc.), remove dressing entirely, cleanse wound and apply hydrogel gauze: No dates marked H. Record review of Hospital History and Physical dated 05/04/15 indicated the following: Assessment and Plan: This is a [AGE] year old gentleman with an extensive surgical history that is documented above with a wound VAC application that is in place and unchanged at (Name of Nursing Facility) since, the patient states, 04/17/15, which is also written on the dressing. Now, trying to remove this application today revealed that the black foam is adhering to the patient's skin causing an extreme amount of pain and bleeding in some areas when force is used to try to remove it .At this point, the patient will be admitted to (Name of Hospital) under the Emergency General Surgery Service for wound care. I. Record review of Operative Report dated 05/06/15 indicated the following: This is a pleasant [AGE] year old man well known to the EGS Service who returns to the clinic with a wound VAC dated April 17th which appears to have not been changed for an extended period of time. He was transported to the operating room for removal of this wound VAC and cleaning of his wound .The retained foreign body was in the midline wound was consistent with the wound VAC sponge was grasped and elevated and excised (cut out) .The wound was taken down to healthy appearing fat and skin. J. On 05/20/15 at 1:17 pm, during interview with the MD (Medical Doctor), he stated that he saw the resident one time on 04/21/15. The MD stated that the resident's orders from wound care came from the hospital and that they were to be continued at the facility. The MD stated that the standards of practice for wound vac care would be to perform wound care anywhere from daily to every third day and that he ordered this resident's wound care to be continued consistent with the hospital discharge instructions of treatment every 3 days. K. On 05/20/15 at 1:27 pm, during interview with the Assistant Director of Nursing (ADON), he stated that at the time of this incident, the facility had two nurses who were caring for this resident and that after interviewing the nurses involved, he stated that the nurses had no explanation for why the wound care was not done. The ADON stated that the wound canister was being changed but that the actual wound care was not performed as ordered by the physician. The ADON stated that the two nurses involved in the care of R #1 received in-service training and an Individual Performance Improvement Plan and that all nurses are scheduled to receive the in-service training by 05/30/15. L. On 05/20/15 at 1:30 pm, during interview with the Director of Nursing (DON), she stated that the two nurses involved in the care of R #1 were in-serviced and received disciplinary action due to the failure to perform wound care for R #1. The DON stated that the wound care was not done due to rushing and lack of attention to detail on the part of the nurses.

Based on record review and interview, the facility failed to follow the physician's orders which resulted in a resident not receiving wound care as ordered for 1 (R #1) of 4 ( R #s 1, 2, 3 and 4) residents reviewed for wounds. This deficient practice caused actual harm to the resident who subsequently had to have a surgical procedure to separate parts of a wound vac (a therapeutic dressing using a vacuum to promote healing of wounds) from his body. The findings are: A. Record review of Hospital Discharge Summary dated 04/17/15 indicated the following: (Name of resident) is a [AGE] year old male who was initially seen and evaluated at (Name of Hospital) where patient underwent exploratory laparotomy (a surgical procedure involving a large incision through the abdominal wall to gain access to the abdomen).Due to the patient's kidney injury, the patient was transferred to (Name of Hospital) .The abdominal fascia (connective tissue fibers, primarily collagen, that form sheets or bands beneath the skin to attach, stabilize, enclose, and separate muscles and other internal organs) was closed but skin was left open and a wound VAC placed on the 6th. B. Record review of Hospital Discharge Order dated 04/17/15 indicated the following: Wound Care: wound vac to midline (of abdomen), changed q (every) 48-72 hours, ostomy (surgically created opening in the body for the discharge of body wastes) to lower left quadrant changed as needed. C. Record Review of Physician Orders dated 04/17/15 indicated the following: Negative Pressure WoundTherapy (NPWT, Wound Vac) to midline set to continuous. Cleanse with (NSS (Normal Sterile Saline)/Wound Cleanser/other) place (gauze/black foam/white foam/other) into wound. Apply skin prep to intact skin around the wound. Cover with occlusive dressing and secure tubing per manufacturer guide every 72 hours and as needed. If NPWT needs to be turned off for any care, tests/procedures (Bathing, MRI, etc.), or for transport; remove dressing entirely, cleanse wound and apply hydrogel gauze. D. Record Review of Interdisciplinary Progress Notes from 04/17/15 to 05/04/15 revealed no documentation to indicate that wound care was performed as ordered. E. Record review of the Care Plan dated 04/17/15 indicated the following: Focus: Resident is at risk for complications of infection related to abdominal abscess Goal: Resident will remain free of complications/infection daily Interventions: Administer medication as ordered, monitor and evaluate for pain and medicate as ordered, monitor for changes in nutritional/hydration status, monitor for signs and symptoms of infections and report to physician as indicated, monitor for skin breakdown and report to physician as indicated, monitor level of consciousness, mental status, monitor vital signs and report to physician as needed. Obtain labs/cultures as ordered and report results to physician Focus: Resident has actual skin breakdown related to recent surgery resulting in abdominal [MEDICATION NAME] for draining abdominal fluid from abscess and abdominal wound vac Goal: Resident's wound will remain free from signs/symptoms of infection by 90 days Interventions: Evaluate wound area daily including surrounding tissue and presence or absence of drainage/infection and/or new wound pain and report to MD as indicated, monitor for verbal/non-verbal signs of pain related to wound or wound treatment and medicate as ordered, monitor skin for signs/symptoms of breakdown i.e. redness, cracking, blistering, pressure redistribution surfaces to bed and chair as per protocol, weekly skin assessment by licensed nurse, weekly wound assessment to include measurements and description of wound status. F. Record review of Treatment Administration Record for 04/01/5 to 04/30/15 indicated the following: Negative Pressure Wound Therapy (NPWT, Wound Vac) to midline set to continuous. Cleanse with (NSS (Normal Sterile Saline)/Wound Cleanser/other) place (gauze/black foam/white foam/other) into wound. Apply skin prep to intact skin around the wound. Cover with occlusive dressing and secure tubing per manufacturer guide every 72 hours and as needed. If NWPT needs to be turned off for any care, tests/procedures (Bathing, MRI, etc.), or for transport; remove dressing entirely, cleanse wound and apply hydrogel gauze. No dates marked to indicate that the above treatment was performed. G. Record review of Treatment Administration Record for 05/01/15 to 05/20/15 indicated the following: Negative Pressure Therapy to midline set to continuous. If NPWT needs to be turned off for any care (bathing, MRI etc.), remove dressing entirely, cleanse wound and apply hydrogel gauze: No dates marked H. Record review of Hospital History and Physical dated 05/04/15 indicated the following: Assessment and Plan: This is a [AGE] year old gentleman with an extensive surgical history that is documented above with a wound VAC application that is in place and unchanged at (Name of Nursing Facility) since, the patient states, 04/17/15, which is also written on the dressing. Now trying to remove this application today revealed that the black foam is adhering to the patient's skin causing an extreme amount of pain and bleeding in some areas when force is used to try to remove it .At this point, the patient will be admitted to (Name of Hospital) under the Emergency General Surgery Service for wound care. I. Record review of Operative Report dated 05/06/15 indicated the following: This is a pleasant [AGE] year old man well known to the EGS Service who returns to the clinic with a wound VAC dated April 17th which appears to have not been changed for an extended period of time. He was transported to the operating room for removal of this wound VAC and cleaning of his wound .The retained foreign body was in the midline wound was consistent with the wound VAC sponge was grasped and elevated and excised (cut out) .The wound was taken down to healthy appearing fat and skin. J. On 05/20/15 at 1:17 pm, during interview with the MD (Medical Doctor), he stated that he saw the resident one time on 04/21/15. The MD stated that the resident's orders from wound care came from the hospital and that they were to be continued at the facility. The MD stated that the standards of practice for wound vac care would be to perform wound care anywhere from daily to every third day and that he ordered this resident's wound care to be continued consistent with the hospital discharge instructions of treatment every 3 days. K. On 05/20/15 at 1:27 pm, during interview with the Assistant Director of Nursing (ADON), he stated that at the time of this incident, the facility had two nurses who were caring for this resident and that after interviewing the nurses involved, he stated that the nurses had no explanation for why the wound care was not done. The ADON stated that the wound canister was being changed but that the actual wound care was not performed as ordered by the physician. The ADON stated that the two nurses involved in the care of R #1 received in-service training and an Individual Performance Improvement Plan and that all nurses are scheduled to receive the in-service training by 05/30/15. L. On 05/20/15 at 1:30 pm, during interview with the Director of Nursing (DON), she stated that the two nurses involved in the care of R #1 were in-serviced and received disciplinary action due to the failure to perform wound care for R #1. The DON stated that the wound care was not done due to rushing and lack of attention to detail on the part of the nurses.

Based on record review and interviews, the facility failed to maintain resident's highest practicable physical and mental well-being by failing to perform wound care for 1 (R #1) of 4 ( R #s 1, 2, 3 and 4) residents reviewed for wounds. This deficient practice caused actual harm to the resident who subsequently had to have a surgical procedure to separate parts of a wound vac (a therapeutic dressing using a vacuum to promote healing of wounds) from his body. The findings are: A. Record review of Hospital Discharge Summary dated 04/17/15 indicated the following: (Name of resident) is a [AGE] year old male who was initially seen and evaluated at (Name of Hospital) where patient underwent exploratory laparotomy (a surgical procedure involving a large incision through the abdominal wall to gain access to the abdomen).Due to the patient's kidney injury, the patient was transferred to (Name of Hospital) .The abdominal fascia (connective tissue fibers, primarily collagen, that form sheets or bands beneath the skin to attach, stabilize, enclose, and separate muscles and other internal organs) was closed but skin was left open and a wound VAC placed on the 6th. B. Record review of Hospital Discharge Order dated 04/17/15 indicated the following: Wound Care: wound vac to midline (of abdomen), changed q (every) 48-72 hours, ostomy (surgically created opening in the body for the discharge of body wastes) to lower left quadrant changed as needed. C. Record Review of Physician order [REDACTED]. Negative Pressure WoundTherapy (NPWT, Wound Vac) to midline set to continuous. Cleanse with (NSS (Normal Sterile Saline)/Wound Cleanser/other) place (gauze/black foam/white foam/other) into wound. Apply skin prep to intact skin around the wound. Cover with occlusive dressing and secure tubing per manufacturer guide every 72 hours and as needed. If NPWT needs to be turned off for any care, tests/procedures (Bathing, MRI, etc.), or for transport; remove dressing entirely, cleanse wound and apply hydrogel gauze. D. Record Review of Interdisciplinary Progress Notes from 04/17/15 to 05/04/15 revealed no documentation to indicate that wound care was performed as ordered. E. Record review of the Care Plan dated 04/17/15 indicated the following: Focus: Resident is at risk for complications of infection related to abdominal abscess Goal: Resident will remain free of complications/infection daily Interventions: Administer medication as ordered, monitor and evaluate for pain and medicate as ordered, monitor for changes in nutritional/hydration status, monitor for signs and symptoms of infections and report to physician as indicated, monitor for skin breakdown and report to physician as indicated, monitor level of consciousness, mental status, monitor vital signs and report to physician as needed. Obtain labs/cultures as ordered and report results to physician Focus: Resident has actual skin breakdown related to recent surgery resulting in abdominal [MEDICATION NAME] for draining abdominal fluid from abscess and abdominal wound vac Goal: Resident's wound will remain free from signs/symptoms of infection by 90 days Interventions: Evaluate wound area daily including surrounding tissue and presence or absence of drainage/infection and/or new wound pain and report to MD as indicated, monitor for verbal/non-verbal signs of pain related to wound or wound treatment and medicate as ordered, monitor skin for signs/symptoms of breakdown i.e. redness, cracking, blistering, pressure redistribution surfaces to bed and chair as per protocol, weekly skin assessment by licensed nurse, weekly wound assessment to include measurements and description of wound status. F. Record review of Treatment Administration Record for 04/01/15 to 04/30/15 indicated the following: Negative Pressure Wound Therapy (NPWT, Wound Vac) to midline set to continuous. Cleanse with (NSS (Normal Sterile Saline)/Wound Cleanser/other) place (gauze/black foam/white foam/other) into wound. Apply skin prep to intact skin around the wound. Cover with occlusive dressing and secure tubing per manufacturer guide every 72 hours and as needed. If NWPT needs to be turned off for any care, tests/procedures (Bathing, MRI, etc.), or for transport; remove dressing entirely, cleanse wound and apply hydrogel gauze. No dates marked to indicate that the above treatment was performed. G. Record review of Treatment Administration Record for 05/01/15 to 05/20/15 indicated the following: Negative Pressure Therapy to midline set to continuous. If NPWT needs to be turned off for any care (bathing, MRI etc.), remove dressing entirely, cleanse wound and apply hydrogel gauze: No dates marked H. Record review of Hospital History and Physical dated 05/04/15 indicated the following: Assessment and Plan: This is a [AGE] year old gentleman with an extensive surgical history that is documented above with a wound VAC application that is in place and unchanged at (Name of Nursing Facility) since, the patient states, 04/17/15, which is also written on the dressing. Now trying to remove this application today revealed that the black foam is adhering to the patient's skin causing an extreme amount of pain and bleeding in some areas when force is used to try to remove it .At this point, the patient will be admitted to (Name of Hospital) under the Emergency General Surgery Service for wound care. I. Record review of Operative Report dated 05/06/15 indicated the following: This is a pleasant [AGE] year old man well known to the EGS Service who returns to the clinic with a wound VAC dated April 17th which appears to have not been changed for an extended period of time. He was transported to the operating room for removal of this wound VAC and cleaning of his wound .The retained foreign body was in the midline wound was consistent with the wound VAC sponge was grasped and elevated and excised (cut out) .The wound was taken down to healthy appearing fat and skin. J. On 05/20/15 at 1:17 pm, during interview with the MD (Medical Doctor), he stated that he saw the resident one time on 04/21/15. The MD stated that the resident's orders from wound care came from the hospital and that they were to be continued at the facility. The MD stated that the standards of practice for wound vac care would be to perform wound care anywhere from daily to every third day and that he ordered this resident's wound care to be continued consistent with the hospital discharge instructions of treatment every 3 days. K. On 05/20/15 at 1:27 pm, during interview with the Assistant Director of Nursing (ADON), he stated that at the time of this incident, the facility had two nurses who were caring for this resident and that after interviewing the nurses involved, he stated that the nurses had no explanation for why the wound care was not done. The ADON stated that the wound canister was being changed but that the actual wound care was not performed as ordered by the physician. The ADON stated that the two nurses involved in the care of R #1 received in-service training and an Individual Performance Improvement Plan and that all nurses are scheduled to receive the in-service training by 05/30/15. L. On 05/20/15 at 1:30 pm, during interview with the Director of Nursing (DON), she stated that the two nurses involved in the care of R #1 were in-serviced and received disciplinary action due to the failure to perform wound care for R #1. The DON stated that the wound care was not done due to rushing and lack of attention to detail on the part of the nurses.