Every finding on record at Las Ventanas De Socorro

Based on observation, interview, and record review the facility failed to provide proper treatment and care to maintain mobility and good foot health in accordance with professional standards of practice, including to prevent complications from the resident's medical conditions and if necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments for 1 (Resident #5) 7 reviewed for foot care. The facility failed to provide access to podiatrist for Resident #5.This deficient practice placed residents at risk of poor foot hygiene and decline in residents' physical condition.Record review of resident #5 face sheet date 5/15/2026 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Residents' diagnosis included severe weakness and weight loss (failure to thrive, cachexia, muscle wasting. She cannot move normally. And is mostly or completely bedridden ( functional quadriplegia, bed confinement). She needs help with all personal care. She also had brain mental status problems ( encephalopathy'), anxiety, and severe muscle weakness from critical illness. Record review of Resident #5's MDS assessment dated [DATE], reflected a BIMS score of 0, indicating severe cognitive impairment. The resident had impairment on one side in upper extremity (shoulder, elbow, wrist, hand) and impairment on both sides of lower extremities (hip, knee, ankle, foot). Record review of Resident #5's Care Plan dated 03/13/2026, reveled resident 2 requires assistance with ADLs, TOILETING HYGIENE: Dependent (X1 STAFF), PUTTING ON/TAKING OFF FOOTWEAR:Substantial/maximal assistance (X1 STAFF) PERSONAL HYGIENE: Substantial/maximal assistance (X1 STAFF) Record Review of Resident #5's orders dated 05/15/2026, revealed she had a podiatrist appointment order dated 03/13/2026. In an interview and observation was conducted by surveyor on 05/14/2026 at 2:04PM, on Residnet #2 regarding podiatry services per ombudsman as he told surveyor to check for podiatry services on this resident. Upon observation resident had long toe nails about 3 centimeters long, finger nails were trimmed. In an interview on 05/15/2026 at 11:21 am , RN A stated I work double weekends and 6am-2pm. I have been employed since August of 2025. We have a podiatrist in home., I heard he comes, but I dont know him; they just give me report twice that he's come. When they have an order, administration follows up, and if they were new patients, registered nurse place the order and let the DON know.I don't know if she calls directly or let the (admissions) case manager, know. Nursing does rounds all the time. When i do my rounds, the first one in the morning with report, we make sure they were breathing and alive. I am rounding all day long. I sit in the hallway and round constantly, it's more than every hour. I make sure their nails were cut and toenails were cut. If I see they need assitance and its something easy I can do, I do it myself. If I see its infected I put a wound care order and a order for podiatry. We have to check every 15 days and it pops up on every resident, not just specific. We have to check off and have options where it had 3 different options on what we can answer for this. Its just nursing, not CNAs. They don't get the pop up. Most of the CNAs here were really good. I don't ever have to tell them they usually tell me but it is not on their point of plan of correction to complete. My ADON, DON were the ones overlooking to make sure this is getting done. I always do progress notes and make sure its documented and we have huddles and make sure to let them know what is going on. The risk would be infection; the nails could get torn apart, pain, and discomfort. In an interview on 05/15/2026 at 11:42am,CNA A stated, I have been here for 3 years at the facility and work the 6am-2pm shift Mon- Friday. When I do my rounds, I make sure they were alive and start them to get ready for the showers. there were times when there were more patients to shower, so that the first thing we do is conduct hygiene and changed them and dress them and take them to the front and the nurses give meds and get them ready for breakfast. Our job is to keep them clean and make sure the nails were cut; that is one of our jobs if they were too long. we tell the nurse and we let them know they need to be cut, and some have a doctor to come in and do their nails. Only nurses do the nails; CNAs were not allowed to cut nails only nurses, but we do report. CNA's do not have notes for CNA in documenting; only the nursing staff, but we tell them vocally. Hospice patients have a CNA that come and shower them, but we do help them with changing and rotating, but the showers were done with hospice cnas. Hospice cnas have their own routine in regard to assessments for hygiene. In an interview on 05/15/2026 at11:49 am, CNA B stated I report it to the nurse automatically and she's the one that reports it to the nurse, if nurse says it's okay and I can cut them i can but the nursing staff does it most of the time but she needs to give me the okay to be able to because they can be diabetic. Every time we shower residents and change of socks, we make sure and check they were cut. We can't document on POC for nail care; we just tell the nursing staff. For hospice residents, no matter, i always check if they need care when I'm checking the resident. The hospice cnas, I'm sure does it, but im not sure since they were cna for hospice. In an interview on 05/15/26 at 11:54am, CNA C stated, The ones responsible were the nurses and the podiatrist. We let the nurse know when the residents need a nail cut, and then the nurse will do it or call the podiatrist to let them know. We do not have a place to document the POC for nails, but we do tell the nurses. The hospice resident's agency were responsible for the hospice residents at the facility, but we still take care of them if they need help or transfer or change them. And if they don't, they need help the nurse is told. I think hospice agency only come when they have appointments for podiatrist, the nurse usually does and contact the podiatrist, I have not seen in the time that i have worked here, anyone come in to cut nails. In an interview on 05/15/2026 at 12:06pm, the DON stated, The nurse will print it out for [CNA D] who transportation is and make the appointment and then give it back to the nurse. It should be on the progress note or on the 24-hour for podiatry. The CNAs, as long as they were not diabetic and usually the nurses on the skin check if they need to add something for a podiatrist, when they get them up to shower, i don't know if CNAs but we have a shower check where they should document, for hospice its them who were responsible for them so it is hospice that's responsible for it. The CNAs at the facility should still be responsible for letting us know at least voicing since they were in home. The nurse is responsible for the hall to make sure that [CNA D] is getting it done. We just make sure the appointments were made already but not actually seeing they have or need a appointment. In an interview on 05/15/2026 at 12:56pm, Hospice RN B, stated The family is responsible for paying the podiatrist. The the family needs to make sure they were getting paid, she's a new patient for me and I don't have any information in regards to her nail care. She's a new admission to me. She was living in her home and now she is at the facility. I am responsible for looking at this patient ; I tdid see the patient and completed my assessment, but i didn't talk to them about this, because i was following up for the wounds. My focus was on the wounds and not nail care. Also spoke to RN C support system on all the facilities, stated usually I'm in charge of the facility the family if she is not diabetes, our CNAs can cut the nails, but if they were diabetic, we request a podiatrist. the nurse did not understand the protocol, she just started. She started under us since [DATE]. If they have socks i don't take them off i need to in-service for them. It's a learning process. I need to do an in-service for nursing and the CNAs for hospice. I spoke to my administrator and gave him an update and was not aware of this so he's being a podiatrist to pay the cost and let him know that that there is an in-service and just for right now this so the best and intervention completed and we will collaborate on to what the cnas were going to do and what hospice were going to do so that doesn't happen again. In an interview on 05/15/2026b at 03:01 pm, the Administrator, stated the podiatry for the facility, I'm not versed on this. It's a hard and fast process on nail care on hospice patients. Specifically, it would be the CNA to bring it up, or patients to the nurses for hospice they would be responsible for providing podiatrist and the family wanted it. If this resident got care, it would be voiced by anyone's facility or hospice. The risk of a resident does not receive nail care would be discomfort, and not sure about other possible risks if there is no nail care, mostly a comfort thing. We have a contract with hospice. I am not aware of what each care for the resident received. Record review of the facility's policy titled Medical Services: Podiatrist dated on 11/17/2017 During the record review, it was noted that the facility maintained a policy titled Podiatry Services under Section VI: Medical Services. The policy stated that the facility leadership would provide podiatry services to patients/residents for conditions including, but not limited to, corns, neuromas, calluses, bunions, heel spurs, nail disorders, and preventive foot care for patients/residents with diabetes and circulatory problems when indicated.The review further showed that the policy included procedures requiring that:The podiatrist possesses a Doctor of Podiatry Medicine degree and holds a current state license.The facility develops and completes a contract with a podiatrist through the Legal Department.Each patient/resident had the right to choose his or her own podiatrist, and if unable, the facility would assist the patient/resident in obtaining services.The attending physician writes an order for the patient/resident to be seen by the podiatrist.The podiatrist documents a progress note in the patient/resident's medical record at each visit. Record review of the facility's undated Hospice and Inpatient Facility Services Agreement, no date, policy was reviewed. There was nothing stating or indicating in the contract with facility that reflects Hospice CNAs were solemnly responsible for hygiene: nail care for Resident #2.

Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the residents' status for 2 (Resident #70 and Resident #79) of 10 residents reviewed for assessment accuracy.The facility failed to accurately reflect Resident #70's ability to hear on his MDS.The facility to reflect Resident #79's surgical wound care and external Fixator on her MDS.This failure placed residents at risk for not receiving care specific to their condition.Findings includeRecord review of Resident #70's face sheet dated 2/18/2026 revealed a [AGE] year-old male with an admission date of 11/5/2024.Record review of the Resident #70's History and Physical dated 11/07/2024 revealed the resident had diagnoses of cerebrovascular accident (blood flow interrupted to part of the brain), unspecified dementia without behavioral disturbance (a syndrome characterized by decline in cognitive function, memory and ability to complete daily tasks), essential hypertension (high blood pressure), and atherosclerotic heart disease (plaque buildup in the arterial walls).Record review of Resident #70's MDS dated [DATE] revealed under Section B, Resident #70 was coded for having adequate hearing and did not utilize a hearing aid. Under Section C, Resident #70 scored a 10 on his BIMS score, this signified the resident had moderate cognitive impairment. Under Section Q, Resident #70 had himself and family listed as participants in assessment and goal setting.Record review of Resident #70's MDS dated [DATE] revealed under Section B, Resident #70 was coded for having adequate hearing and did not utilize a hearing aid.Record review of Resident #70's MDS dated [DATE] revealed under Section B, Resident #70 was coded for having adequate hearing and did not utilize a hearing aid.Record review of Resident #70's care plan dated 2/17/2026 revealed the resident had difficulty understanding others related to hard of hearing on right side with interventions of refer to audiologists, speech-language pathologists, repeat phrases as needed, speak clearly and adjust tone as needed.Record review of Resident #79's face sheet dated 02/16/2026 revealed a [AGE] year-old female with admission date 02/03/2026.Record review of Resident #79's history and physical dated 02/04/2026 noted the following medical history: Diabetes Mellitus, left eye prosthetic, right eye legal blindness. It also noted the resident had a fall at home which resulted in a left trimalleolar fracture that required a procedure and Resident #79 had a closed reduction and external fixation ().Record review of Resident #79's Comprehensive MDS dated [DATE] revealed a BIMS score of 15, indicating resident was cognitively intact. Section I-Active Diagnoses noted Resident #79's primary medical condition that best described the primary reason of admission was Fractures and other Multiple Trauma and Presence of other medical devices. Under Section M- Skin Conditions, it did not include surgical wound care or pressure ulcer wound care.Record review of Resident #79's care plan with revision date 02/09/2026, did not include the resident's wound care or the external fixator. The care plan noted Resident #79 was at risk for falls relating to the presence of external fixator with staff interventions as follows: keep the call light within reach, keep personal items within reach, and keep room clutter free.Record review of Resident #79's wound care order with start date 02/05/2026, noted daily wound treatment: Left medial ankle blister: Clean gently with Normal Saline or wound cleanser, pat dry, apply betadine and leave open to air.Record review of Resident #79's Wound Care Administration Record History dated 02/18/2026, revealed wound care was provided from 02/05/2026 to 02/16/2026.In an observation conducted on 2/15/2026 at 2:08 PM, Resident #70 was observed not responding to conversation attempts but was visually acknowledging surveyor. Resident #70 continued pointing to his right ear saying no oigo which translated to I can't hear. Resident #70 was able to converse with the surveyor after a higher tone was used but was observed speaking in low tone.In an interview on 2/15/2026 at 2:09 PM, Resident #70 stated he had been at the facility for 2 years and had been having trouble hearing for 1 year. He stated he needed loud speech to hear what was being said but sometimes his hearing capability in his right ear was completely gone and toned out with a continuous ringing. He denied having a hearing aid and receiving assistance from the facility to address hearing concerns. He stated he communicated with staff by calling his family members on the landline in his room.In an interview with RN A on 2/16/2026 at 2:10 PM, she stated Resident #70 was independent and completed his own ADLs. She stated Resident #70 would sometimes appear fearful of people he was unfamiliar with. She added that she spoke to Resident #70 in a normal tone and had no suspicion Resident #70 was hard of hearing. She stated that he usually responded the first time and displayed signs of comprehension to what she said. She stated Resident #70 never asked her to repeat what she had said. She clarified if she noticed hearing impairment in a resident she would notify the Doctor, document findings in a progress note, and request a referral from the Doctor to send the resident out to audiology. She stated that it was important to asses residents' hearing accurately because a hearing impairment affected the resident's ability to communicate. She stated there was not an annual hearing assessment completed for residents as it was only completed when staff noticed a change in condition. She stated she spoke to Resident #70 in Spanish and he would provide mostly non-verbal head nods/shakes and not much vocalization or elaboration. In an interview with CNA B on 2/16/2026 at 2:15 PM, stated Resident #70 was alert and oriented and was capable of telling staff when he did or did not want services. She stated she spoke to Resident #70 in English and would use standard communication tone with him but did have to repeat herself to Resident #70. She stated if she suspected a resident had a hearing impairment, she would speak louder, slower, and notify the nurse. She stated she needed to report it to the nurse because the resident might not be able to effectively communicate. She stated CNAs and nurses were responsible for reporting, documenting and notifying Doctors for residents with hearing impairments.In an phone interview on 2/16/2026 at 2:33 PM, Resident #70's family member stated Resident #70 did have an undiagnosed hearing impairment that the family began noticing over the past year. He stated the family had to speak to Resident #70 in a louder tone, and noted Resident #70 began speaking in a whispering tone and frequently used hand gestures. He stated the facility did complete a hearing assessment but could not recall when. He added the facility had not further assisted with Resident #70's hearing complication beyond the undated assessment.In an interview with the Social Worker on 2/16/2026 at 2:53 PM, stated she would speak a little bit louder to Resident #70 for him to understand what she had said. She added the resident spoke English and Spanish. She stated that the quarterly MDS assessment was completed every 3 months or whenever a significant change occurred. She stated family had never mentioned concerns about Resident #70's hearing capabilities during care plan meetings or over the phone conversations. She stated there was no tool or assessment utilized to measure a resident's hearing ability. She added that she would just ask the resident if they had difficulty hearing and monitored for abnormalities or consistent prompting during conversation. She stated that if she discovered an abnormality, she would share the information with the MDS nurse and the IDT. She stated a resident with an unaddressed hearing impairment could receive delay in treatment, impeded their needs, have trouble when provided instructions, and limit his ability to talk with people. She stated that the CNAs and nurses were responsible for continuous monitoring and reporting appropriate parties for change in condition. She stated Resident #70 had an referral with an Ear, Nose and Throat Doctor on 2/4/2025 regarding an intermittent ear and throat pain; she was uncertain as to what the outcome was or if the referral was fulfilled.In an interview on 02/17/2026 at 3:12 PM, MDS Nurse L stated the external fixator and wound care should have been included in the MDS. He stated the purpose of including the surgical wound care was to increase reimbursement as it was a service provided by the facility. He stated that not including the surgical wound care in Resident #79's MDS would not affect the resident. He stated that the MDS nursing reviewed the MDS quarterly or as needed for a significant change.In an interview with MDS C on 2/18/2026 at 4:38 PM, the MDS team was comprised of various staff members with different disciplines. She stated she reviewed the work completed by other team members when she would meet with the resident to complete her portion of the MDS assessment. She stated she was familiar with Resident #70 as she was his night nurse from October 2024 to October 2025. She stated Resident #70 never reported having difficulty hearing, and she never noted any hearing difficulty when she conversed with Resident #70. She stated she spoke to Resident #70 at a normal tone, and Resident #70 would respond to questions at a normal tone with delay between responses. She stated if a resident had a hearing impairment, they would be evaluated by Speech-Language Pathology, notify the Doctor, and obtain a referral to a specialist for the resident. She added that if she noticed a discrepancy in the MDS, she would speak to the DON and Social Worker to further evaluate the concern and update the resident's care plan and MDS accordingly. She stated that hearing impairment in residents could affect them by delay of care and communication issues. She stated no employees had mentioned concerns about Resident #70's hearing abilities to her. She stated that if there was a concern, the direct care staff would document progress notes and notify the MDS nurse immediately. She stated Resident #70's family was only involved in the care plan and collateral if they were in the room during the MDS assessment. She stated that the MDS assessments take 10-15 minutes to complete. She stated that was enough time to note for hearing deficits in Resident #70.Record review of the facility's Nursing Policy and Procedures, dated 05/05/2023, read in part: Policy: A licensed nurse will conduct or coordinate each assessment with the interdisciplinary team. It continued, Facility staff complete a comprehensive assessment of each resident's needs, strengths, goals, life history, and preferences, and offer guidance for further assessment once problems have been identified. Then, it read, The facility is responsible for addressing all the needs and strengths of each resident. Under Procedures, it read in part, 1. Review the resident's medical record. This review may include pre-admission activities. Identify resident's status, care, and services rendered during the Observation Period for the current assessment. Review is to include, but not to be limited to pre-admission, admission, and transfer notes; current plan of care, physicians' orders, progress notes, history and physical; nursing dietary, activit, social service, and therapy notes and assessments; monthly summaries, lab and x-ray reports consultations, medication administration records, treatment administration records, and resident, staff and family interviews. 2. If a Care Area Assessment is triggered, the facility will further assess the resident to determine whether the resident is at risk of developing, or currently has a weakness or need affects the resident. Supplemental infromation must be gathered and analyzed by the facility based on the triggered CAAs prior to developing the comprehensive care plan. It also read, The Facility addresses all risks identified within the context of the MDS assessment, even if they do not cause a CAA to trigger. It continued to read, 9. Each assessment must represent an accurate picture of the resident's status during the observation period of the MDS. When the MDS is completed, only those occurrences during the observation period will be captured on the assessment. If it did not occur during the observation period, it is not coded on the MDS.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for two (Resident #26 and Resident #79) of 9 residents reviewed for care plans.The facility failed to include Resident #26's wound care for her right lower leg wound on her care plan.The facility failed to include Resident #79's wound care and external fixator on her care plan.These failures could affect residents requiring wound care by placing them at risk for not receiving care and services to meet their needs.The findings include:Record review of Resident #26's face sheet dated 02/16/2026 revealed an [AGE] year-old female with admission date of 01/22/2026.Record review of Resident #26's history and physical dated 02/12/2026 revealed a medical history of the following: Chronic Kidney Disease (a condition meaning damage to the kidneys causing it to not filter the waste in the blood), Type II Diabetes Mellitus (metabolic condition that causes the body to become resistant to insulin or the pancreas fails to produce enough insulin), and had wounds on both legs.Record review of Resident #26's Discharge MDS dated [DATE] revealed a BIMS score of 15, indicating resident cognitively intact.Record review of Resident #26's care plan with revision date 02/04/2026 revealed Resident #26 had a wound/disruption of skin surface, left lower leg venous ulcer. Interventions for staff included to provide wound care as ordered, and to use aseptic techniques.Record review of Resident #26's Wound Care Order dated with start date 01/24/2026 and discharge date [DATE], noted: Daily wound treatment: Left lower Lateral Distal Leg: Clean with Normal Saline or wound cleanser, apply thin layer of Mupirocin ointment (an antibiotic ointment) followed by a small piece of Hydrofera Blue MUST be moistened with Normal Saline, cover with a 4x4 gauze, ABD pad, and roll gauze. Cover foot and leg with Tubigrip (a multi-purpose elasticated tubular bandage that provides uniform compression and support for wound dressings) from just below toes to just below the knee.Record review of Resident #26's Wound Care Orders dated 02/17/2026 noted with start date 02/04/2026, read: Daily wound treatment: Left lower Lateral Distal Leg: Clean with Normal Saline or wound cleanser, nickel thick layer of Santyl (an ointment used to treat chronic skin ulcers) followed by calcium alginate, apply ABD pad, and wrap roll gauze. Cover foot and leg with Tubigrip from just below toes to just below the knee.Record review of Resident #26's Wound Management Detail Report dated 02/18/2026 noted resident was seen on 02/03/2026 by the Wound Care Physician. The report noted a Venous Ulcer on the left shin lateral distal measured at 2 centimeters long, 1 centimeter wide, and 0.3 centimeters in depth. It was noted that the discharge was pale red to pink, thin, and watery. It was noted that the wound healing was stable. On 02/10/2026, the wound was noted as 1.8 centimeters long, 1 centimeter wide, and 0.3 centimeters in depth. The wound discharge was pale red to pink, thin, and watery. The wound healing was noted as stable.Record review of Resident #79's face sheet dated 02/16/2026 revealed a [AGE] year-old female with admission date 02/03/2026.Record review of Resident #79's history and physical dated 02/04/2026 noted the following medical history: Diabetes Mellitus, left eye prosthetic, right eye legal blindness. It also noted that the resident had a fall at home which resulted in a left trimalleolar fracture that required a procedure and Resident #79 had a closed reduction and external fixation ().Record review of Resident #79's Comprehensive MDS dated [DATE] revealed a BIMS score of 15, indicating resident was cognitively intact. Section I-Active Diagnoses noted Resident #79's primary medical condition that best described the primary reason of admission was Fractures and other Multiple Trauma and Presence of other medical devices. Under Section M- Skin Conditions, it did not include surgical wound care or pressure ulcer wound care.Record review of Resident #79's care plan with revision date 02/09/2026, did not include the resident's wound care or the external fixator. The care plan noted Resident #79 was at risk for falls relating to the presence of external fixator with staff interventions as follows: keep the call light within reach, keep personal items within reach, and keep room clutter free. The baseline care plan noted wound care but did not specify location of site, or frequency of wound care.Record review of Resident #79's wound care order with start date 02/05/2026, noted daily wound treatment: Left medial ankle blister: Clean gently with Normal Saline or wound cleanser, pat dry, apply betadine and leave open to air.In an interview on 02/17/2026 at 1:33 PM with RN I, she stated the baseline care plan and acute changes were completed by nursing staff, and MDS completed the Comprehensive care plans. She stated the purpose of a care plan was for nursing staff to be aware and follow the plan of care. She stated surgical incisions and equipment was to be added on the care plan so staff could be aware of the site, what type of incision, what to monitor, and type of equipment. She stated possible risks of not including wound care included infection, swelling, and even possibility of losing a limb. She stated there were many risks. She stated nursing reviewed care plans every shift, and MDS nursing reviewed it quarterly. In an interview on 02/17/2026 at 3:14 PM with MDS Nurse L, he stated baseline care plans were completed by the admitting nurse which was to be completed from 48 to 72 hours after a resident's admission into the facility. He stated that the Comprehensive care plan was completed up to 21 days after admission. He stated that the wound care relating to Resident #79's external fixator was not on the care plan. He stated care plans were to be specific to the residents and to communicate their needs to the facility staff. He stated Resident #79's wound care was included but was not specific. He stated care plans were reviewed quarterly by MDS nursing.During an interview on 02/18/2026 at 4:18 PM with the DON, she stated nursing staff were responsible for the basic care plan which was to be completed within 48 hours of admission. She stated MDS was responsible for the Comprehensive Care Plan and stated she was unaware how often they reviewed the care plans. She stated the purpose of the care plan was for facility staff to be aware of the residents' needs, including wound care and the external fixator. She stated the risks of not including wound care or the external fixator would be a delay in patient care.Record review of the facility's Nursing Policy and Procedures titled Care Plan Process, Person-Centered Care, with revision date 05/05/2023, read in part: Policy: The facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care. Under Procedures, read in part: 2. The baseline person-centered care plan will include the minimum healthcare information necessary to properly care for the resident, including but not limited to initial goals based on admission orders, resident goals, physician orders . and 4A. The baseline Person-centered care plan Summary includes immediate resident needs. It continued, 6 . For the comprehensive assessment the review will be completed . no more than 21 days after admission.

Based on observations, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 5 residents (Resident #4, Resident #7, and Resident #11) reviewed for ADL care.The facility failed to ensure Resident #4 and Resident #7 was groomed for facial hair on 2/15/2026.The facility failed to ensure Resident #11 had trimmed and clean nails on 02/15/2026.This failure could place residents who required assistance with ADLs at risk for unmet care needs.Findings included: Record review of Resident #4's face sheet dated 02/16/2026 revealed a [AGE] year-old female with initial admission date 04/28/2018 and readmission date 01/11/2026. Record review of Resident #4's history and physical dated 03/04/2025 revealed the resident was diagnosed with the following: Generalized Muscle Weakness, and Type II Diabetes Mellitus (metabolic condition that causes the body to become resistant to insulin or the pancreas fails to produce enough insulin). Record review of Resident #4's Discharge MDS dated [DATE] revealed the resident was unable to complete the BIMS interview and did not score. Section GG Functional Abilities revealed Resident #4 was completely dependent on showering/bathing, and oral hygiene, meaning the resident does none of the effort, and the helper does all the effort to complete the task. Record review of Resident #4's care plan with revision date 01/16/2026 revealed the resident required ADL assistance with intervention, one staff member to assist with personal hygiene. Record review of Resident #7's face sheet dated 2/18/2026 revealed a [AGE] year-old female with an initial admission of 8/14/2022 and readmission on [DATE]. Record review of Resident #7's history and physical dated 11/14/2024 revealed the resident was diagnosed with hemiplegia and hemiparesis affecting right dominant side (loss of function and movement to a side of one's body), cerebral infarction (blocked blood flow to the brain), unspecified dementia without behavioral disturbance (a syndrome characterized by decline in cognitive function, memory and ability to complete daily tasks). Record review of Resident #7's MDS dated [DATE] revealed under section C, Resident #7 had a BIMS score of 9 which implies the resident had moderate cognitive impairment. Under section GG, Resident #7 was coded for requiring partial/moderate assistance to substantial/maximal assistance for completing ADLs, dressing self, bathing, toileting, and oral hygiene. Under Section O, Resident #7 was coded for receiving Hospice services. Record review of Resident #7's care plan dated 1/16/2026 revealed Resident #7 required assistance with ADLs due to hemiplegia and hemiparesis to right dominant side and dementia. The care plan revealed that the resident required partial/moderate assistance for personal hygiene and substantial/maximal assistance for bathing and transferring. Resident #7 entered Hospice care in December 2024 with an agreement that Resident #7 would be kept clean and comfortable, will monitor skin needs during care daily. Record review of Resident #11's face sheet dated 02/16/2026 revealed a [AGE] year-old male with initial admission date 08/21/2025 and readmission date 08/29/2025. Record review of Resident #11's health and physical dated 08/22/2025 revealed a medical history of the following: depression (mood disorder that consists of persistent sadness or loss of interests in activities of interest), Dementia (a group of symptoms affecting memory, thinking and social abilities), and left hemiplegia (weakness of one side of a person's body, usually due from brain or spinal problems). Record review of Resident #11's Quarterly MDS 12/18/2025 revealed a BIMS score of 10, indicating moderate cognitive impairment. Section GG Functional Abilities revealed Resident #11 required substantial/maximal assistance with personal hygiene, meaning the helper does more than half the effort to finish the task. Record review of Resident #11's care plan with revision date 02/16/2026 revealed the resident required ADL assistance and intervention included for 1 staff member to provide maximal assistance with personal hygiene. An observation on 02/15/2026 at 9:30 AM, Resident #11 was in her bed resting with her eyes closed. Her nails were long and untrimmed, approximately 1 inch, and with black and dark debris under her fingernails of both hands. An observation and interview on 02/15/2026 at 10:09 AM, Resident #4 was observed with hair on her chin. She stated staff assisted her with showers and personal grooming every other day. She stated she was aware she had facial hair and would like it shaved if offered by the facility staff. An observation conducted on 2/15/2026 at 11:12 AM, revealed Resident #7 had a mustache and chin hair measuring approximately a quarter to half an inch in length (longer than normal stubble). When asked about her preference, Resident #7 became notably embarrassed based on facial expression, pigment variation, and seeking behavior through her nightstand for her personal trimmer. In an interview on 2/15/2026 at 11:02 AM, Resident #7 stated she was on Hospice care but could not recall for how long. She stated staff and Hospice provide her bathing services and assistance since she was non-ambulatory and had limited range of motion to her right dominant side. She stated she received showers on Monday, Wednesday, and Friday. She stated she did not like having facial hair and staff/Hospice had not offered to shave it for her during recent showers. In a follow-up interview on 2/18/2026 at 9:01 AM, with Resident #7 stated the staff was recently short staffed and were limited to provide shaving services. She added she did not like the electric shaver the facility used because it operated at a high temperature and caused discomfort; she denied being injured by the electric shaver staff used. She clarified that it was difficult for her to shave herself because of her condition and would often forget. She stated she had never denied grooming or showering services from staff and added that staff was aware she had her own personal electric shaver in her room that they could utilize for her shaving needs. In an interview on 2/17/2026 at 3:24 PM, RN E who stated residents could request assistance with ADLS throughout the day or during their showering schedule. She stated CNAs would usually provide showers and would document any new conditions in skin/appearance in addition to documenting when residents denied services. She stated if a resident denied service, the nurse would follow-up and enter progress notes for rationale of denial. She stated that facial hair on a female would take 2-3 weeks to grow half an inch. She stated any staff member could notify the nurse and CNA about a female resident's facial hair so that services could be offered. She stated the normal shower schedule for residents was every other day excluding weekends. She stated facial hair on a female resident could affect them by causing mental anguish or causing low self-esteem. She stated a female resident could become itchy and potentially scratch themselves and cause irritation. She stated the last time she received in-service training for ADLs was in January 2026 and patient advocacy training in November 2025. In an interview on 02/18/2026 at 9:53 AM, CNA G stated she was familiar with Resident #7 and listed the ADLs she required assistance for was: showering, grooming, changing incontinence, and transfers bed to chair. She stated Resident #7 had no strength or movement to one side of her body (unknown). She clarified because Resident #7 was on Hospice, facility staff did not provide showering or grooming anymore as this was Hospice CNAs responsibility. She stated Resident #7 never had long facial hair because she would use her personal electric shaver in her nightstand. She stated the facility used to provide shaving services using the facility's electric shaver before Resident #7 obtained her own; was unable to recall when Resident #7 obtained her personal electric shaver. She stated that if a resident denied services, she would document it and notify the nurse. She added that if Hospice did not complete the services, staff were permitted to offer and provide services to the resident to include showers and grooming. She stated facial hair on a female resident could potentially affect residents by making them feel ugly, bad, or embarrassed. She stated the last in service for Abuse Neglect and exploitation was the second week of February. She stated CNAs did not communicate with Hospice as this was a nurse's responsibility. In an interview on 2/18/2026 at 1:14 PM, RN F who stated hospice CNAs communicated with the charge nurse for refusal of services by resident and would additionally report refusals to the hospice nurse. He added the charge nurse was responsible for reviewing the hospice CNA log and sign off on the services provided during hospice visit; he clarified this was in the hospice database which the facility did not have immediate access to. Stated he would evaluate the hospice CNA's services and review for abnormalities found such as bruises, cuts, refusals, etc. He stated charge nurses would review for abnormalities and not compare documentation of services provided compared to the resident's appearance. He stated he had never been notified by hospice CNA that a female resident denied shaving services. He stated facial hair on a female resident affected them because it could bother the resident; He added the facility staff would be able to provide grooming services for female residents as well if hospice did not. In an interview on 2/18/2026 at 4:56 PM, the DON stated the charge nurse and CNA could review the resident's grooming status to notify the hospice company. She stated the nurse and CNA sign off on the hospice CNAs tablet on services provided. She stated the CNA would notify the charge nurse if the services provided do not match what was observed on the resident. She stated hospice provided bathing and grooming 2-3 times a week. She stated that facial hair on a female would take 2-3 weeks to grow half an inch. She stated the nurse was supposed to review services documented in comparison to the resident's appearance. Record review of the facility's Nursing Policies and Procedures, titled Activities of Daily Living, Optimal Function, read in part: Definition: Activities of Daily Living (ADLs), refer to tasks related to personal care including grooming . and, under Policy, it read The Facility provides care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. The facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming, hygiene. In an interview on 02/17/2026 at 1:57 PM, with RN I, she stated residents were monitored for nails and facial grooming during the provided showers which was three times a week, or as needed. She stated resident shower sheets were completed by CNAs and they notated any concerns such as nails and facial grooming was needed. She stated the nurses review shower sheets during their shift and sign off to confirm the information was reviewed. She stated if residents refused grooming, CNAs were to notify the nurse that shift. She stated the potential risk to residents with long, untrimmed nails included injury to self by cutting their skin with the nail. She stated that could lead to possible infection.

Based on observation, interview, and record review, the facility failed to ensure the resident's environment was as free from accident hazards as possible for 2 of 8 residents (Resident # 24 and Resident # 29) reviewed for accidents. The facility failed to properly dispose of a shaving razor in sharps container for Resident # 24 and # 29. This deficient practice could place residents at risk of injury and contribute to avoidable accidents. The findings included:Resident # 24 Record review of Resident 24's admission record dated 02/18/26 revealed a [AGE] year-old male admitted on [DATE]. Record review of Resident #24's History and Physical dated 01/15/2026 revealed a diagnosis of dementia (decline in mental ability). Record review of Resident #24's MDS assessment dated [DATE] revealed a BIMS score of 05 indicating severe cognitive impairment. Record review of Resident #24's care plan revised on 12/08/2025 revealed Resident #24 had a memory/recall problem related to cognitive loss/dementia, interventions included redirecting resident when entering unsafe areas. An observation on 2/15/26 at 12:50 pm of Resident # 24's room revealed two disposable shaving razors sitting in the slot of the sharp's container. Resident #29 Record review of Resident #29's admission Record dated 02/18/2026 revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. Record review of Resident # 29's History and Physical dated 02/17/2026 revealed a diagnosis of dementia (decline in mental ability). Record review of Resident # 29's MDS assessment dated [DATE] revealed a BIMS score of 10 indicating a moderate cognitive impairment. Record review of Resident #29's care plan revised on 11/26/25 revealed Resident #29 had moderate cognitive memory/ recall problem r/t dementia interventions included redirecting resident when entering unsafe areas.An observation on 2/15/26 at 12:50 pm of Resident # 29's room revealed two disposable shaving razors sitting in the slot of the sharp's container. In an interview on 2/17/2026 at 11:15 a.m., CNA N revealed razors were to be disposed of in the sharps container because it was considered a sharp and could hurt the resident if left within reach. She stated that the sharps were supposed to be disposed completely in the bin and not left in the slot. She stated that if the sharps were left in the slot, the resident could potentially hurt themselves if they happen to reach in or staff members could also get hurt when disposing of other sharp items. She stated that it was the responsibility of whoever was disposing of the object to ensure that it was completely in the bin and not in the slot. She stated that the last training over proper sharps disposal was upon hire. In an interview on 02/17/2026 at 1:17 PM, RN I revealed razors were to be disposed In the sharps container because it was considered a sharp and could hurt the resident if left with reach. She stated that it was the responsibility of the nurse to ensure all sharps were disposed of properly. She stated that she could not recall a recent Inservice or training over proper disposal of sharps, she stated that the last one she remembered was given upon hire. In an interview on 02/18/2026 at 3:42 p.m., the DON revealed that razors were to be disposed of in the sharps container so that residents would not get to them and accidently cut themselves. She stated that when staff were disposing of any sharp, they were to ensure that it was in the bin and not left in the slot. She stated that it was the responsibility of all staff to ensure that there weren't any sharps in the slot. She stated that she did not recall the last Inservice done about proper disposal of sharps. Review of facility policy titled Safety and Health Policy and Procedures read in part . The policy for management of biohazards wastes is designed to help protect patients/ residents, personnel, visitors, employees and community from exposure to biohazardous wastes. Biohazardous waste shall include the following categories: Sharps- all discarded sharps including hypodermic needles, syringes, and scalpel blades.

Based on observation, interviews, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 3 (Resident #23, Resident #62, and Resident #67) of 12 residents observed for oxygen management.The facility failed to clean the oxygen concentrator air filter for Resident #23 and Resident #67 while the oxygen was in use; concentrators were observed with air filters with dust, and lint collected on them on.The facility failed to ensure Resident #62's nasal canula was properly stored while oxygen was not in use.This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health. The findings include:Resident #23Record review of Resident #23's face sheet dated 2/18/2026 revealed an [AGE] year-old female admitted on [DATE].Record review of Resident #23's history and physical dated 11/25/2025 revealed Resident #23 was diagnosed with vascular dementia (a group of symptoms affecting memory, thinking, emotional regulation and social abilities) and chronic respiratory failure with hypoxia (damaged lungs cannot properly transfer oxygen into the blood).Record review of Resident #23's comprehensive MDS dated [DATE] revealed Resident #23 had a BIMS of 3 which signified severe cognitive impairment. Under section O, Resident #23 was coded to receive oxygen therapy while a resident at the facility.Record review of Resident #23's care plan dated 2/2/2026 revealed Resident #23 had an intervention in place of Licensed Nurse to monitor vital signs including temperature, blood pressure, pulse, respirations, and oxygen saturation weekly in reference to therapeutic treatment from medications. No additional goals/problems were identified in the care plan regarding respiratory therapy or oxygen concentrator.Record review of Resident #23's physician's orders dated 11/26/2025 revealed the resident was to receive 2 liters per minute of oxygen.In an observation on 1/15/2025 at 1:55 PM it was revealed Resident #23 had an oxygen concentrator in her room with the filter exposed with text that read, REPLACED 8.18.2021. Lint and dust build up were observed on the oxygen concentrator filter as well. Resident #23 could not participate in the interview because she was asleep. Follow-up visits were unsuccessful.Resident #62Record review of Resident #62's Face Sheet dated 02/18/2026 revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE].Record review of Resident #62's history and physical dated 02/17/2026 revealed resident had a diagnosis of chronic obstructive pulmonary disease (airflow prevention to lungs causing breathing problems).Record review of Resident # 62's Quarterly MDS dated [DATE] revealed a BIMS score of 11 indicating mild cognitive impairment.Record review of Resident # 62's physician's orders revealed an order for oxygen at 2-5 liters per minute via nasal canula as needed. Start date of 01/02/2024.Record review of Resident #62's care plan revised 11/26/25 revealed that resident was at risk for respiratory distress/ shortness of breath due to diagnosis of chronic obstructive pulmonary disease. interventions included administering oxygen as ordered.Observation on 02/15/2026 at 08:58am revealed Resident #62's nasal canula sitting on top of the oxygen concentrator, not stored in a plastic bag while not being used. Resident #67Record review of Resident #67's face sheet dated 2/18/2026 revealed the resident was an [AGE] year-old female with an admission date on 9/20/2023.Record review of Resident #67's history and physical dated 10/11/2023 revealed the resident had a diagnosis of chronic congestive heart failure (heart is unable to pump blood efficiently), anemia of chronic disease (reduce capacity for oxygen in blood from long-term inflammation due to illnesses), and chronic respiratory failure with hypoxia (damaged lungs cannot properly transfer oxygen into the blood).Record review of Resident #67's quarterly MDS dated [DATE] revealed Resident 67 had a BIMS score of 99 which signifies the resident was unable to actively participate and complete in assessment and was coded for having moderate cognitive impairment. Under section O, Resident #67 was coded to receive oxygen therapy while a resident at the facility. Under section I, Resident #67 was coded for having a diagnosis of anemia (reduce capacity for oxygen in blood), respiratory failure, and heart failure. Under section J, Resident #67 was coded for experiencing shortness of breath when lying flat.Record review of Resident #67's care plan dated 2/12/2026 revealed Resident #67 had an intervention in place of Licensed Nurse to monitor vital signs including temperature, blood pressure, pulse, respirations, and oxygen saturation weekly in reference to therapeutic treatment from medications. Resident #67 care plan identified history of heart failure with interventions to administer medications as ordered per physician and monitor for signs of respiratory distress. Resident #67 care plan identified a category under respiratory interventions, oxygen at 2-5 liters per minute change oxygen tubing, cannula, humidification weekly .In an observation on 1/15/2026 at 2:26 PM revealed the Resident #67 had a noticeably dusty air filter with no date of last service.In an interview on 2/15/2026 at 1:35 PM with Resident #23's family members, revealed Resident #23 had never complained of dry sinuses or reported nasal bleeding. Family members were unable to recall when the oxygen concentrator was serviced. Family members declined to see staff enter the room to review the oxygen concentrator beyond providing a new cannula and humidifier.In an interview on 2/18/2026 at 9:24 AM Resident #67 stated staff checked her oxygen concentrator once a day. Resident #67 clarified she did not pay attention to what staff did when they reviewed or replaced parts on her concentrator. She stated she did not know when the last time the facility replaced the oxygen concentrator filter.In an interview on 02/17/2026 at 2:10 PM with CNA B revealed that nasal cannulas were to be stored in the plastic bag while not in use to prevent it from getting dirty or contaminated. She stated that if the nasal canula was found on the floor or exposed on a surface, it was supposed to be thrown away and changed out for a clean one. She stated that it was the responsibility of the CNAs and the nurses to ensure that the nasal cannulas were stored properly. She stated that the risk of residents using dirty nasal cannulas would be introducing bacteria into the nose and the resident could possibly end up getting sick. She stated that oxygen concentrator filters were to be cleaned by the nurses. She stated that the risk of a dirty air filter could be the resident not receiving adequate oxygen. She stated that she was not sure how often the nurses were to clean them. She stated not remembering the last in-service held on oxygen concentrator filters and nasal canula storage.In an interview on 02/17/2026 at 2:42 PM with RN E revealed that nasal cannulas were to be stored in a plastic bag to prevent contamination. She stated that if a nasal canula was found on the floor or lying exposed on a surface, she would need to exchange it for a new one to prevent the resident from placing a dirty nasal canula on their face and in their nares preventing them from introducing pathogens into their respiratory tract. She stated that it was the responsibility of the nurses and CNAs to ensure the nasal canula was stored while not in use. She stated that oxygen concentrator filters were cleaned weekly on weekends by weekend nurses. She stated that a dirty filter could trigger allergies for the resident. She stated that it was the responsibility of the nurses to ensure that the concentrator filters were free of dust. She stated that all nurses were able to check upon rounds if filters were clean. She stated that the last in-service was held during summer 2025.In an interview on 2/18/2026 at 10:18 AM RN F stated the purpose of the oxygen concentrator was to deliver oxygen to residents who have low oxygen saturation levels (below 92%). He stated it required a physician's order to administer oxygen and the facility did not hire nor contract with a respiratory therapist. He stated that if there was a maintenance concern, the Administrator needed to be notified to request assistance from the contracted maintenance provider. He stated that if the oxygen concentrator began malfunctioning, it would begin alerting staff with an alarm. He stated there was no routine basis for maintenance on the concentrators, and direct care staff (CNA and nurses) were not responsible for maintenance (replacing filters). He stated a dirty air filter will set off the alarm on the concentrator causing the machine to fail and not allowing O2 saturation levels to be met for the resident. He stated central supply did the product replacement of filters, cannulas, and nebulizers. In an interview on 02/18/2026 at 3:42 pm with the DON revealed that nasal cannulas were supposed to be stored in the bag attached to the oxygen concentrator to be kept clean. She stated that was done to prevent infection in the residents. She stated that staff to include nurses and CNAs were to change the tubing if it was observed to be lying out on a surface because the tubing was considered contaminated at that point. She stated that all staff was responsible for ensuring the nasal cannulas were stored properly when not in use. She stated that oxygen concentrator filters were cleaned weekly by weekend nurses. She stated that it was the responsibility of all staff during morning rounds to look at the flites to ensure cleanliness. She stated that dirty oxygen filters could inhibit the proper oxygen flow to the resident. She stated the staff received yearly training over the topic. Review of facility policy titled Respiratory Treatment, Care and Services Program revised 05/2023 revealed in part . Infection control practices including standard and transmission- based precautions are followed during: handling of equipment, including cleaning, storage and disposal of regular and biohazardous waste .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen.-The facility failed to maintain safe consumable produce as evident by 4 visibly molded tomatoes, observed on 02/15/2026.-The facility failed to properly seal carrots to limit exposure, observed on 02/15/2026.-The facility failed to properly label prepared food being stored in the walk-in refrigerator/freezer/cart shelves with prepared and use by dates, observed on 02/15/2026.-The facility failed to dispose of 23 pudding sherbert nectars that were created on 2/8/2026 and had a use by date on 2/10/2026, observed on 02/15/2026.-The facility failed to accurately complete temperature logs as evidenced by afternoon logs being signed as completed on the morning of 2/15/2026.-The facility failed to ensure the grease traps above the grill and fryer were clean and free of dust/grease, observed on 02/15/2026.-The facility failed to properly thaw poultry as evident by diced turkey cubes left on the counter, observed on 02/15/2026.-The facility failed to ensure Dietary aide K was properly restraining hair while serving food, observed on 02/15-17/2026.These failures could place all residents who received meals from the kitchen at risk of food-borne illnesses. Findings included:During observation on 2/15/2026 at 8:38 AM of initial kitchen tour, it was observed in the walk-in freezer at 8:42 AM 23 pudding sherbert was on the cart shelves with a preparation date of 2/8/2026 and a use by date of 2/10/2026. At 8:43 AM, none of the other cart shelves had labels for preparation and use by dates for the desserts and cold sides that were going to be served during the upcoming meal services. At 8:44 AM, a bag of approximately 15 carrots was discovered on the shelf without am opened and use by label and was exposed to air. At 8:45 AM, 4 tomatoes with visible mold touched other tomatoes without visible mold. At 8:48 AM, large frozen iceicles had developed on boxes of food resting on the first, second, and third shelves (top to bottom) directly underneath the fan and condenser. At 8:49 AM, a plastic baggie of chile rellenos (Mexican dish of pepper, cheese, and egg wash) was not labeled with a use by date and a bag of breaded mozzarella reflected use me under the use by box without a date. At 8:55 AM, the temperature log for the refrigerator and freezer had the afternoon temperature completed in advance by [NAME] C. At 8:59 AM, a bag of diced turkey cubes was left on the counter near the entrance to the walk-in refrigerator and was cool to touch but not frozen. At 9:05 AM, the grease traps above the grill and fryer were visibly dirty with grease and dust and the log reflected they were cleaned on 2/13/2026.Observations on 2/15/2026 at 12:32 PM during dining/meal service, on 2/16/2026 at 10:55 AM during kitchen follow-up, and on 2/17/2025 at 9:16 AM during meal preparation revealed. Dietary Aide K was observed preparing food, handling food, or in the kitchen without properly restraining facial hair from his beard, sideburns, and mustache. In an interview on 2/17/2026 at 10:03 AM Dietary Aide K stated he was responsible for preparing beverages, desserts, nectars, condiments, and prepared breakfast for the next day. He stated that all dietary staff oversaw labeling and reviewing the ingredients' integrity. He stated his chores for cleaning were to: clean the serving area, tables, coffee/tea brewers, condiments container, sweep/mop the dry storage, empty trash cans, wipe the ice machine, clean/organize the dietary aide refrigerator, cleaning the preparation tables, and the steam table. He stated that the logs needed to be signed off once they were completed and not in advance. He stated that if a task was time sensitive, the next shift was responsible for completing the fridge/freezer check on the next shift. He stated that it was falsification and there might be an issue that occurred. He added it could be unclear as to when the issue occurred if the temperature log was completed in advance. He stated that the Dietary Manager was responsible for reviewing the logs to make sure they were completed and accurate. He stated that they could expose residents to cross contamination and foodborne illness if produce was left spoiled or uncovered in the fridge. He stated that hairnets needed to be worn upon entry into the kitchen to prevent hair from falling into the serving area or the resident's plate. He stated the hairnet should cover the hairline crown from front to back and women needed to tie their hair up. He stated that beards and mustaches should be always covered with a beard net while working in the kitchen, and the Dietary Manager was responsible for reviewing employees for dress code compliance. He stated that the grease traps above the grill and fryer were dirty as evidence by the grease and dust and added that the grease traps appeared to be dirtier than 2 days since the chore was documented as completed. He stated that the Dietary Manager was responsible for ensuring that chores were completed. He stated that the last in-service for cleaning, food storage, dates, and serving was in December 2025.In an interview on 2/18/2026 at 1:22 PM the Dietary Manager stated proper storage of produce was important to prevent cross contamination. He stated kitchen reviews were completed on Mondays and sporadically during the week by himself. He added that the cooks and dietary organizer assisted in reviewing the walk-in fridge. He stated staff were trained to discard food that was visibly spoiled, not labeled, or past their use by date to prevent cross contamination. He added staff would notify him when large amounts of food was tainted and discarded. He stated that frozen items that were cooked and prepared in the kitchen (chile rellenos) had to be used in 3 days. He stated that any processed food that was not in its original packaging or opened, needed a use by date to ensure its freshness. He stated that the temperature log needed to be filled once by the morning shift and once by the afternoon shift. He stated if it was recorded before its intended time then the fridge/freezer could have failed, and staff would not have had knowledge of it malfunctioning resulting in spoiled food for the residents. He stated the diced turkey thawing on the preparation table needed to be stored on ice, in the fridge, or freezer when not being actively used or thawed. He stated the hazard to leaving diced turkey on the table was the poultry could be spoiled and served to the residents unknowingly. He stated if a resident was to consume spoiled food, they could potentially feel ill. He stated that the dietary department was responsible for completing the chores on the log to maintain the integrity of the kitchen. He identified himself as the individual responsible for overseeing the operation of chores, cleanliness, and food storage for the kitchen. He stated staff was expected to always have their hairnets on while in the kitchen, preparing food, and when placing food in the meal carts. He stated facial hair needed to be covered to include mustache and beard to prevent the food from being cross contaminated by hair.In an interview on 2/18/2026 at 2:32 PM [NAME] M stated her responsibilities as a cook were to maintain the fridge/freezer, cook meals, and serve meals. She stated she was responsible for taking the temperatures for the fridge/freezer in the afternoon and completing the temperature log accurately. She stated the temperature for the fridge needed to be below 40 F and for the freezer 0 F. She stated she was trained to fill out the log at the time of completion. She clarified she could not fill in the log in advance because it provided inaccurate information and there could be an issue that arises between the time she reviewed the fridge/freezer and when it potentially became faulty. She added that she was also responsible for making sure food was labeled, discarding spoiled/expired food, and rotating inventory in the fridge. She stated she would review produce for spotting, mold, firmness, and change of color in produce. She stated it needed to be done to prevent serving bad/raw/expired food to the residents. She stated food with those qualities possessed risk for the development of bacteria or food borne illnesses. She stated that thawing procedures needed to be adhered to, especially for meats, to prevent the growth of bacteria. She stated she used the practice of rotating the frozen item to the fridge and placed on the lowest shelf or submerged the frozen meat under cold water and had cold water continuously running over the meat. She stated she would return unused diced turkey in the freezer/fridge to prevent it from spoiling instead of leaving it on the counter. She stated items needed to be labeled so that staff were aware of the expiration date of the food. She stated she would not serve food or use ingredients that were unlabeled. She stated dietary staff had a chore list per position with cleaning objectives for the kitchen. She stated that for the grease traps they would usually clean 2 at a time due to time restraints. She stated all head/facial hair needed to be covered while in the kitchen because there was potential for hair to get in the food. She stated this rule applied to all dietary staff and kitchen visitors.Record review of facility's Nutritional Policies and Procedures, dated 10/15/2025, titled Dress Code, revealed in part: The Dietary Department employees will adhere to a facility dress code that facilitate safe, sanitary meal production and service, and will present a professional appearance. Dietary staff involved in food production adheres to the department dress code that includes Appropriate hair restraints (hair covers or nets, beard restraints) while involved in food production activities.Record review of facility's Nutritional Policies and Procedures, dated 10/15/2025, titled Safe Preparation, revealed in part: During the food production process, food will be handled by methods to minimize contamination and bacterial growth to prevent food borne illnesses .Thawing: Thawing food at room temperature is not acceptable . Recommended methods to safely thaw frozen TCS foods include: under refrigeration that maintains the food temperature at 40 F or less. Completely submerged under running water of a temperature of 70 F or lower, or per local policy. Thawed in a microwave if the food is immediately transferred to conventional cooking equipment to finish cooking. Thawed as part of a continous cooking process Record review of facility's Nutritional Policies and Procedures, dated 10/15/2025, titled Food Safety in Receiving and Storage, revealed in part: Food will be received and stored by methods to minimize contamination and bacterial growth Foods that have been thawed and then refrozen can be contaminated; check for large ice crystals, solid areas of ice, discolored or dried-out food, or mishappen items Dampness or mold can be signs of spoilage or bacterial growth Inappropriate odors, colors, or textures in cold foods. Check expiration dates and use-by dates to assure the dates are within acceptable parameters Do not refreeze thawed food unless it has been thoroughly cooked. Refrigerated, ready to eat TCS are properly covered, labeled, dated with a use-by date, and refrigerated immediately. [NAME] them clearly to indicate the date by which the food shall be consumed or discarded. The day of preparation or day original container is opened shall be considered day 1. Follow USDA guidelines for food storage

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 5 steam table wells reviewed.The facility failed to ensure the furthest right steam table well was not used to hold food for breakfast and lunch due to it not being operational since 12/31/2025.This failure placed residents at risk for delay in meal service.Findings included:In an observation made on 2/15/2026 at 12:04 PM revealed [NAME] C was serving lunch from the steam table with 4 of 5 wells filled with food. The furthest right well was not hot to touch, did not emit any steam, and the electric knob was not illuminated to show it was on. [NAME] C and the Dietary Manager confirmed that the 5th well on the steam table was not operational.In an interview and observation on 2/18/2026 at 10:26 AM with [NAME] C stated the steam table well had not been working for 2 months because the previous shift had left it on all night. She stated that when she returned in the morning there were brown charring marks and white spots that took her hours to scrub clean. She stated since the steam table had not been fully operational, she had to use the steamer and oven to accommodate the missing well. She stated by holding food in the oven affected the food's appearance, taste, and texture. She stated she had reported it to the Dietary Manager on 12/31/2025 by word of mouth. [NAME] C provided image confirmation from her phone to confirm the timeline of the steam table malfunctioning. She identified the Dietary Manager was responsible for maintaining, documenting, and reporting faulty equipment to the Administrator or Maintenance Director. She stated having faulty equipment in the kitchen could potentially affect residents by influencing the quality of meal experience.In an interview on 2/18/2026 at 11:39 AM the Maintenance Director stated he was responsible for maintaining the building to the best of his ability and contract with vendors when specialty qualification was required. He stated staff provided work orders to him verbally as there was no documentation completed. He stated the documentation he had would only be for part orders or vendor invoices. He stated he was notified of the steam table 3 weeks ago by the Dietary Manager, verbally. He stated he had repaired the steam table but a week after its repair it became faulty again on the second week of February 2026. He stated any staff member could report equipment not properly functioning to him. He identified himself as the individual responsible for assessing equipment and contacting vendors when it was beyond his capability of repair. He stated one of the steam table wells not working did not affect the residents because staff was still able to complete their responsibilities with 4 wells. He denied having any documentation in place for the steam table work order besides a part order invoice from 2/16/2026 and was unable to recall specific timeline/dates for the steam table becoming inoperable from the well.In an interview on 2/18/2026 at 1:50 PM the Dietary Manager stated there was a binder at the nurse's station for staff/residents to file a work order request. He stated the steam table well had not been operational for 2-3 weeks and added that he notified the Maintenance Director verbally when it initially broke. He stated the Maintenance Director replaced a part on the steam table; however it did not resolve the issue permanently. He stated they had been trying to find out what the name of the part was and found the specific model and specific part recently. He stated if the part did not resolve the issue the whole 5th well for the steam table would need to be replaced. He stated the steam table not working has not affected staff's ability to complete their tasks because the facility census was low. He stated the steam table not being fully operational had not affected residents and he did not foresee it affecting residents. He stated he could keep the food warm on 2 electric wells that could be connected to the wall or hotel chafing platters (catering [NAME] burners). He stated that staff was trained to notify him if equipment was faulty by verbal notification, over the phone, or could directly notify the Administrator, or the director of dietary at a sister facility.In an interview on 2/18/2026 at 2:08 PM Dietary Aide P stated the equipment she used was operating correctly and she had no concerns. She stated she did not interact with the steam table at all as this was the cook's duty station. She stated she was aware the steam table became broken in December 2025 and was unable to recall if the Maintenance Director or Dietary Manager made repair attempts. She stated the cooks and the dietary aides had not been affected by the steam table not fully operating. She stated by not having the 5th well, the food's temperature could not be held at the appropriate temperature. She stated if the 5th well remained inoperable, there was potential for the kitchen to be backed up on meal orders and result in a delay in meal service for residents. She stated if she noticed malfunctioning equipment she would report it to her supervisor or Maintenance Director immediately so that it could be restored as soon as possible. She stated she would additionally write it down in the maintenance work order binder located in the nurse's station. She identified the Maintenance Director was responsible for ensuring kitchen equipment was operational or progressing repairs. Record review of facility's Nutritional Policies and Procedures, dated 10/15/2025, titled Safe Employee Work Practices, revealed in part: The maintenance department is responsible for a preventative maintenance program to avoid unnecessary breakdowns and hazards, as well as for routine inspections of items such as fans, vents, ducts, and large equipment .The CDM notified the maintenance department of any safety hazards or equipment breakdowns.Record review of an invoice submitted to a parts supplier by the Dietary Manager revealed 2 electrical components were ordered on 2/16/2026 at 3:51 PM with an additional note from the Dietary Manager, Please overnight air ship this order. Thank you.

Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two (Resident #26 and Resident #79) of 10 residents reviewed for quality of care, in that:RN O signed the TAR for treatment for Resident #26's treatment completion despite the treatment not being completed on 01/31/2026.The Wound Care Nurse failed to label Resident #79's wound dressing observed on her left ankle on 02/15/2026.These failures affected one resident and placed 72 additional residents who resided in the facility at risk of not receiving prompt medical interventions. The findings included:Record review of Resident #26's face sheet dated 02/16/2026 revealed an [AGE] year-old female with admission date 01/22/2026.Record review of Resident #26's history and physical dated 02/12/2026 revealed a medical history of the following: Chronic Kidney Disease (a condition meaning damage to the kidneys causing it to not filter the waste in the blood), Type II Diabetes Mellitus (metabolic condition that causes the body to become resistant to insulin or the pancreas fails to produce enough insulin), and had wounds on both legs.Record review of Resident #26's Discharge MDS dated [DATE] revealed a BIMS score of 15, indicating resident was cognitively intact.Record review of Resident #26's care plan with revision date of 02/04/2026 revealed Resident #26 had a wound/disruption of skin surface, left lower leg venous ulcer. Interventions for staff included to provide wound care as ordered, and to use aseptic techniques.Record review of Resident #26's Wound Care Order dated with start date 01/24/2026 and discharge date [DATE], noted: Daily wound treatment: Left lower Lateral Distal Leg: Clean with Normal Saline or wound cleanser, apply thin layer of Mupirocin ointment () followed by a small piece of Hydrofera Blue MUST be moistened with Normal Saline, cover with a 4x4 gauze, ABD () pad, and roll gauze. Cover foot and leg with Tubigrip (a multi-purpose elasticated tubular bandage that provides uniform compression and support for wound dressings) from just below toes to just below the knee.Record review Wound Care Order dated 02/17/2026 noted with start date 02/04/2026, read: Daily wound treatment: Left lower Lateral Distal Leg: Clean with Normal Saline or wound cleanser, nickel thick layer of Santyl (an ointment used to treat chronic skin ulcers) followed by calcium alginate, apply ABD pad, and wrap roll gauze. Cover foot and leg with Tubigrip from just below toes to just below the knee.Record review of Resident #26's Wound Care Administration history record dated 02/17/2026 from 01/01/2026-01/31/2026 revealed wound care was marked as completed on Saturday 01/31/2026 between 6 AM to 10 PM.Record review of Resident #26's Wound Management Detail Report dated 02/18/2026 noted resident was seen on 02/03/2026 by the Wound Care Physician. The report noted a Venous Ulcer on the left shin lateral distal measured at 2 centimeters long, 1 centimeter wide, and 0.3 centimeters in depth. It was noted that the discharge was pale red to pink, thin, and watery. It was noted that the wound healing was stable. On 02/10/2026, the wound was noted as 1.8 centimeters long, 1 centimeter wide, and 0.3 centimeters in depth. The wound discharge was pale red to pink, thin, and watery. The wound healing was noted as stable.Record review of Resident #79's face sheet dated 02/16/2026 revealed a [AGE] year-old female with admission date 02/03/2026.Record review of Resident #79's history and physical dated 02/04/2026 noted the following medical history: Diabetes Mellitus, left eye prosthetic, right eye legal blindness. It also noted that the resident had a fall at home which resulted in a left trimalleolar fracture (happens when you break your lower leg sections that form your ankle joint and help you move your foot and ankle ) that required a procedure and Resident #79 had a closed reduction and external fixation (closed reduction is a non-surgical procedure to realign broken bones, while external fixation involves stabilizing fractures using an external frame).Record review of Resident #79's Comprehensive MDS dated [DATE] revealed a BIMS score of 15, indicating resident was cognitively intact. Section I-Active Diagnoses noted Resident #79's primary medical condition that best described the primary reason of admission was Fractures and other Multiple Trauma and Presence of other medical devices. Under Section M- Skin Conditions, it did not include surgical wound care or pressure ulcer wound care.Record review of Resident #79's care plan with revision date 02/09/2026, did not include the resident's wound care or the external fixator.Record review of Resident #79's wound care order with start date 02/05/2026, noted daily wound treatment: Left medial ankle (refers to the inner side of the left ankle) blister: Clean gently with Normal Saline or wound cleanser, pat dry, apply betadine and leave open to air.In an observation and interview on 02/15/2026 at 11:08 AM, revealed Resident #79's left lower leg with a wound care dressing on her left ankle not dated or labeled with staff initials. Resident #79 stated she was provided wound care for her blister on her left ankle, which the Physician and team advised for it to rupture naturally, and it had ruptured with discharge which was why she got wound care. She stated she had wound care completed the day before on 02/14/2026.In a phone interview on 02/17/2026 at 11:33 AM, Resident #24's family member stated she was with Resident #24 on Sunday 02/01/2026. She stated she observed Resident #24's left foot red as a tomato, with brown discharge, and mentioned the socks Resident #24 was wearing was also brown. She stated she reported it to RN O. She stated RN O provided wound care at that time and she requested a change in ointment and for Resident #24 to have soak baths for both of her feet. She stated Resident #24 had the wound for a long time and she was familiar on how to care for the resident's wound. She stated she went to visit Resident #24 on Monday 02/02/2026, and Resident #24 reported to her that wound care was not completed on Saturday 01/31/2026. She stated she immediately notified the Wound Care Nurse and the DON. She stated the DON had reported reviewing the wound care notes for Resident #24 and it noted wound care was given that day. She stated she advised the DON to speak with Resident #24 about the allegation. She stated the DON stated Resident #24 was alert and oriented and reported not receiving any wound care on 01/31/2026. She stated the DON notified her of speaking with RN O, and RN O admitted to the DON that she did not provide wound care on 01/31/2026. She stated she wanted to make sure RN O did not do this with other residents.In a phone interview on 02/17/2026 at 3:14 PM, RN O stated she recalled Resident #24's allegation of not providing wound care on Saturday 01/31/2026. She stated she was to provide wound care that day as Resident #24 had daily wound care ordered, but she stated she did not have Normal Saline () that she needed for wound care that Saturday night. She stated it was approximately 9 PM when she was to provide Resident #26 with wound care. She stated she was trained to call the DON to notify the need for supplies but she did not. In a follow up phone interview on 02/18/2026 at 12:42 PM, RN O stated she did not notify any staff of not having supplies needed for wound care that night. RN O stated she did not provide wound care because she was tired as it was the end of her shift and she stated she thought she would be able to complete wound care the following morning as she worked double weekends.In an interview on 02/17/2026 at 3:36 PM with RN E, she stated wound dressings were to be dated and initialed by the nurse doing the dressing change. She stated that nurses would be responsible for not labeling dressing changes. She stated the purpose of dating wound dressings was to keep track of when the dressing was changed. She stated a potential risk of not labeling wound dressings included infection and sepsis (serious condition in which the body responds improperly to an infection). She stated the ADONs and the DON monitored wound dressings on a weekly basis.In an interview and observation on 02/18/2026 at 6:00 AM, the Wound Care Nurse, stated she was the Wound Care Nurse during the weekdays, Monday to Friday, and the floor nurses provided wound care on the weekends. She stated that the supplies were in the treatment cart and in the supply room. An observation of the treatment cart with the Wound care Nurse revealed multiple bottles of Normal Saline. She stated nurses were trained to notify the ADON and DON if there was a need for supplies if there was not any available on site. She stated the potential risks of not providing wound care as ordered included infection to residents. She stated Resident #24's family member reported to her on Monday 02/02/2026, the allegation of Resident #24 not receiving wound care on Saturday 01/31/2026. She stated that the family member notified the DON right away, while she spoke to Resident #24. She stated there was redness to Resident #24's left foot. She stated there was pale pink to clear, thin and watery discharge, and had no odor. She stated the family member had requested a change in ointment and soak baths that Sunday 02/01/2026, and the plan of care was to continue that wound care per family request. She stated wound care was done daily until Resident #24's discharge, and there were no signs of infection or complications. The Wound Care LVN, she stated she provided wound care to Resident #79's blister daily and as needed. She stated that she was the wound care nurse during the weekdays, and the floor nurses provided wound care on the weekends. She stated nurses were responsible for ensuring to date and label the dressing when wound care was done. She stated she forgot to label Resident #79's dressing with her initials and the date wound care was completed. She stated the nurse doing the wound care was responsible and the ADONs monitored the residents but was unsure how often. She stated the potential risks of not labeling wound dressings included risk of infection.In an interview on 02/18/2026 at 10:59 AM, RN F, stated he worked weekends mostly and performed wound care during those shifts. He stated if wound care supplies were not available in the wound care cart or supply closet, staff are to contact the physician for new wound care orders. He reported that the keys to the treatment cart were to be located on the side of the cart.In a phone interview on 02/18/2026 at 11:03 AM, Resident #24's Physician, stated he was notified of an RN not providing Resident #24 with wound care that following Monday 02/02/2026 by facility staff. He stated he was not reported of any signs or symptoms of infection and the plan of care was to continue with daily wound care. He stated Resident #24 was monitored and was not reported with infections or negative outcomes during their stay at the facility and when discharged . He stated the facility followed up, and it was identified as a sole incident.In a phone interview on 02/18/2026 at 1:40 PM, RN Q, stated she worked weekends and provided wound care to residents as needed. She stated there were wound care supplies in the treatment cart and the supply room. She stated if there were no supplies, she would notify the DON and Central Supply right away, as they provide supplies as needed. She stated the facility was also able to pull supplies from sister facilities as needed. She stated that not providing wound care per physician's orders could put the resident at risk of infection.In an interview on 02/18/2026 at 3:36 PM, the DON, stated she spoke with Resident #24's family member on Monday 02/02/2026, and the family member had reported Resident #24's allegation of wound care not being provided on Saturday 01/31/2026. She stated she reviewed the treatment record which noted wound care was provided on 01/31/2026 at 9 PM. The DON stated she spoke with Resident #24 who reported the same allegation, and Resident #24 was alert and oriented. She stated she called RN O and she confirmed she did not provide wound care to Resident #24 on 01/31/2026, even though she marked it on the Treatment Record. The DON stated that RN O reported she did not provide wound care that day because there were not enough supplies, and RN O reported to the DON, that she thought she could do it twice the following day. She stated that the treatment cart and supply room were reviewed on 02/02/2026 and there were enough supplies on-site. She stated nurses were trained to notify the ADON or the DON if there was a need for supplies to complete their tasks, as the facility can get supplies from sister facilities if needed. She stated an investigation was done by the facility and RN O was terminated. She stated the Physician and Wound Care Physician were notified. She stated that the Wound Care Physician assessed Resident #24 on 02/03/2026 and there were no signs of infection. She stated Resident #24 was monitored and provided wound care until discharge from the facility, and the wound was stable with no complications. The DON stated Resident #24 had that wound for a prolonged period. She stated potential risk to residents that were not to be provided with wound care per physician's order would include risk of infection.In an interview on 02/18/2026 at 4:54 PM with the ADON, she stated the nurses were responsible and expected to label dressings after providing wound care. She stated that the purpose of dating dressing changes was to monitor the wound and wound drainage, if any. She stated dating dressing changes helped track the amount of discharge from the wound which would be reported to the Wound Care Nurse and the Physician. She stated that the ADONs were responsible for monitoring wound dressings, including confirming it was labeled correctly. She stated the potential risk of not labeling wound dressings would be a delay in care for residents.Record review of the facility's Leadership Policies and Procedures titled Abuse, Neglect, Exploitation, or Mistreatment, with no date, read in part: Under Policy, it stated The facility's leadership prohibits neglect, mental, physical, and/or verbal abuse . ensures that alleged violations involving abuse, neglect, exploitation, or mistreatment . are reported immediately.Record review of facility's Nursing Policy and Procedures, dated 05/15/2023, titled Infection Prevention and Control Program and Plan, read revealed in part: Purpose: To establish a facility wide program that incorporates a system for preventing, identifying reporting, investigating, and controlling infections and communicate diseases. Under Procedures, it read revealed in part: 4.G. Appropriate personnel, environment, ventilation needs, supplies, and equipment are in place to provide infection prevention and control practices for the facility population.Record review of the facility's Nursing Policy and Procedures titled Wound Care evaluation did not have information regarding wound care labeling expectations.

Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 2 of 3 (Resident #67 and Resident #72) residents reviewed for urinary catheters. The facility failed to ensure Resident #72's Foley bag was off the floor and failed to ensure Resident #67 Foley tubing was draining urine into the Foley bag. This failure placed residents who had a urinary Foley at risk of contracting a UTI.Findings include:Record review of Resident #67's face sheet dated 2/18/2026 revealed the resident was an [AGE] year-old female with an admission date on 9/20/2023. Record review of Resident #67's of history and physical dated 10/11/2023 revealed the resident had a diagnosis of chronic congestive heart failure (heart is unable to pump blood efficiently), Age-related physical debility (muscular weakness because of age), and acute renal failure (rapid loss of kidney function). Record review of Resident #67's quarterly MDS dated [DATE] revealed Resident 67 had a BIMS score of 99 which signifies the resident was unable to actively participate and complete in assessment and was coded for having moderate cognitive impairment. Under Section GG, Resident #67 was coded for being dependent on staff for toileting hygiene. Under section H, Residency #67 was coded for having an indwelling catheter. Under section I, Resident #67 was coded for an active diagnosis of Obstructive Uropathy (blockage that prevents normal flow of urine).Record review of Resident #67's care plan dated 2/12/2026 revealed Resident #67 had an indwelling urinary catheter administered since 8/30/2024 with a goal to assist/provide catheter care as ordered. Resident #67's care plan revealed the resident contracted a UTI on 8/29/2025 with a goal to for the resident to achieve normal urinary elimination pattern with an absence of urinary disorders (infection).Record review of Resident #67's physician orders dated 5/15/2025 revealed the resident was prescribed an indwelling Foley catheter 18 French (6.0 mm) with a 10cc [NAME] for a diagnosis of obstructive and reflux uropathy unspecified. Record review of Resident #72's face sheet dated 2/18/2026 revealed the resident was an [AGE] year-old female with an initial admission date on 9/18/2024 and a readmission date on 5/12/2025.Record review of Resident #72's history and physical dated 9/19/2024 revealed Resident #72 was diagnosed with generalized weakness, UTI, dementia with behavioral disturbances/anxiety (a group of symptoms affecting memory, thinking, emotional regulation and social abilities), obstructive reflux uropathy (blockage that prevents normal flow of urine), and chronic kidney disease (progressive, long-term condition where kidneys are damaged).Record review of Resident #72's quarterly MDS dated [DATE] revealed Resident #72 had a BIMS score of 99 which signifies the resident was unable to actively participate and complete in assessment and was coded for having severe cognitive impairment. Under Section GG, Resident #72 was coded for being dependent on staff for toileting hygiene, personal hygiene, and lower body dressing. Under Section H, Resident #72 was coded for having an indwelling catheter. Under Section I, Resident #72 was coded for an active diagnosis of obstructive uropathy.Record review of Resident #72's care plan dated 2/16/2026 revealed Resident #72 required enhanced barrier precautions. Resident #72 had a care plan to address indwelling catheter with an approach to, always use appropriate infection precaution during care and assist/provide catheter care as ordered. Record review of Resident #72's physician orders dated 12/04/2025 revealed the resident was prescribed an indwelling Foley catheter 16 French (6.0 mm) with a 10cc [NAME] for a diagnosis of obstructive and reflux uropathy, unspecified.In an observation on 2/15/2026 at 10:08 AM, Resident #72 was observed in her bed in the fetal position with her Foley bag on the bed rail where it contacted the floor. Resident #72 was unable to participate in an interview and could not be redirected. In a follow-up observation on 2/15/2026 at 2:39 PM, Resident #72 was observed back in her bed with the Foley bag contacted with the floor laying nearly flat. In an observation on 2/15/2026 at 11:37 AM, Resident #67's Foley tubing was observed to have a urine and white film pooling in the line and not properly draining into the Foley bag as the tubing was below the height of the Foley bag. In a follow-up observation on 2/15/2026 at 1:01 PM, revealed Resident #67's Foley tubing still had urine and white film pooling and not properly draining into the Foley bag. In an interview on 02/15/2026 at 11:38 AM, Resident #67 stated she had 2 UTIs since she had been at the facility. She was unable to recall when and what treatment she received to address her previous UTIs. She stated she did not feel any pain, discomfort or burning at the moment. She stated her Foley tubing was secured to her thigh with a Velcro strap, and she did not feel any pulling at her urethra. Resident #67 did not appear to be in distress. She stated staff reviewed her Foley bag, tubing, and emptied it approximately 5 times per day. In an observation on 2/15/2026 at 2:17 PM, revealed CNA B entered Resident #67's room and did not adjust the Foley placement to remove urine build up in the Foley tubing. In an interview on 2/17/2026 at 2:43 PM with CNA J, he stated a catheter and Foley bag was used to extract the urine from the bladder or when a resident had skin issues in the area to prevent agitation to the skin. He stated that CNAs were responsible for measuring urine output, preventing overflow/backflow, reviewing leakage, and noting color. He stated he checked a resident's Foley tubing and bag every round which was about every 2 hours. He stated all staff were responsible for picking the Foley bag up off the floor and preventing it from lying flat. He added that correcting the Foley tubing was something CNAs could address as long as it was not an invasive correction. He stated if the Foley was on the floor, it could be stepped on or be an infection control issue. He added that the Foley catheter tube not draining into the Foley bag posed a risk to the resident by potentially contracting a UTI. He added the urine could back fill into the bladder for not draining properly, or the resident/visitor could trip on their tubing or bag if the Foley bag was left on the floor. He stated that CNAs were responsible for notifying the nurse for Foley catheter/bag concerns that exceeded CNAs capability. He stated the ADON and DON were responsible for making sure staff were reviewing and completing standard tasks for residents with catheters. He stated the last in- service he received for Foley catheter/bag care was January 2026. In an interview on 2/17/2026 at 3:05 PM with RN F, he stated the purpose of the subpubic Foley catheter was to remove urine from the bladder. He stated CNAs were responsible for emptying and adjusting the Foley bag and tubing if it was not invasive or had to deal with the orifice. He stated whoever was making the rounds was responsible for reviewing the Foley bag/catheter to ensure it was off the floor and draining properly. He stated it needed to be monitored because it could become clogged, pulled out, and there was a high risk for residents to develop an infection. He stated that a UTI affected residents by potentially causing pain, altered mental status, septic, and fever. He was provided an image of Resident #72's Foley bag on the floor and stated the Foley bag on the floor was the only place for the bag because the bed was in the lowest position. He was provided an image of Resident #62's Foley tubing pooling with urine and stated the urine in the tubing would eventually flow into the Foley bag because it was below the resident's bladder. He stated the ADON and DON were responsible for overseeing nurses and ensuring care standards were being completed. He stated there had been recent in-services but could not recall the last one for Foley tubing or Foley [NAME] an interview on 2/18/2026 at 4:27 PM with the DON, she stated the Foley bag could not be on the floor because it was an infection control issue. She stated urine pooling in the tubing and not draining into the Foley bag was not acceptable because it could cause an obstruction resulting in an infection for the resident. She stated the nurse and CNAs were responsible for ensuring the Foley bag and tubing are in their proper place and functioning correctly. She stated her staff reviewed residents' Foley catheters/bags whenever they made their rounds, measured the resident's intake and output, and when responding to call lights. She stated the clinical team (DON, ADON, clinical consulting nurse) and administration provided annual competency training to nurses and CNAs. She stated she was unaware if there was a return demonstration during annual competency for Foley catheters/bag. She stated that a Foley bag left on the floor or urine pooling in the tubing had potential to cause harm to the resident by infection or obstruction. She stated there was further potential for the resident to become hospitalized if a resident contracted an infection. She identified clinical team was responsible for ensuring the nurses were competent to complete their task. Record review of facility's Nursing Policy and Procedures, dated 05/15/2023, titled Infection Prevention and Control Program and Plan, read in part: Purpose: To establish a facility wide program that incorporates a system for preventing, identifying reporting, investigating, and controlling infections and communicate diseases. Under Procedures, read in part: 4A. Written standards and practice guidelines that comply with federal, state, local and The Joint Commision if the facility is accredited, infection prevention and control requirements .5. The infection prevention and control program consists of currently acceptable infection controsl standards, practices, and activities. Examples of these are 5B. Periodic environmental surveillance 6E-9 staff is provided with information and training on care of invasive devices, such as vascular access, urinary catheter

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility was labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 2 residents (Resident #4) reviewed for pharmacy services enteral feedings .The facility failed to label Resident #4's enteral feeding (also known as tube feeding, is a method of delivering nutrition directly into the stomach when a person cannot eat safely or adequately by mouth) with staff initials and the date on 02/15/26.This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects.The findings include:Record review of Resident #4's face sheet dated 02/16/2026 revealed a [AGE] year-old female with initial admission date 04/23/2018 and readmission date 01/11/2026.Record review of Resident #4's history and physical dated 02/17/2026 revealed a medical history of CVA, dysphagia (difficulty swallowing) and Type II Diabetes Mellitus. It noted that Resident #4 was on an NPO (Nothing By Mouth) diet related to her dysphagia and was receiving nutrition through a Gastric tube (also known as tube feeding, is a method of delivering nutrition directly into the stomach when a person cannot eat safely or adequately by mouth).Record review of Resident #4's Discharge MDS dated [DATE] revealed the resident was unable to complete the BIMS interview. Section K-Swallowing/Nutritional status noted Resident #14 received nutrition via feeding tube.Record review of Resident #4's care plan with revision date 02/10/2026, revealed resident was at Nutrition Risk related to her dysphagia. Staff interventions included for staff to Administer feeding via gastric tube as ordered: Jevity 1.2 at 70 ml/hour for 22 hours.Record review of Resident #4's General Order dated 01/14/2026 noted: Enteral feeding- Formula Jevity 1.2 rate 70 ml/hour via feeding pump per Gastric-tube.In an observation on 02/15/2026 at 9:30 AM of Resident #4 resting in her bed with an enteral feeding infusing via feeding pump at bedside. The feeding bad had no date or name labeled observed noted.In an interview on 02/17/2026 at 1:37 PM with RN I, she stated nurses were responsible for administering enteral feedings for residents. She stated nurses were trained to label each feeding, including initials of the nurse and the date. She stated enteral feedings without a label should be disposed of. RN I stated the possible risks of having enteral feedings without a label included residents being bloated, or diarrhea risks. She stated the enteral feedings were milk-based and it was at risk for being spoiled which could cause residents to become sick. She stated the night shift nurses were responsible for hanging a new enteral feeding during their shift, and morning nurses were to confirm the feeding was labeled during the day shift.In an interview on 02/18/2026 at 4:46 PM with the ADON, she stated nurses were responsible for administering enteral feedings. She stated that enteral feedings were only good to administer for 24 hours. She stated the possible risk to residents with unlabeled enteral feedings included delay of care. She stated that the nurse who administered the enteral feeding was responsible, and it was typically the night shift. She stated that the DON and other department supervisors conducted Angel Rounds, which included identifying any concerns.In an interview on 02/18/2026 at 4:05PM with the DON, she stated nurses were responsible for labeling enteral feedings when they were to administer and start the feeding. She stated nurses were expected to label it, including date, so staff could be aware of expiration and when a new feeding was needed. She stated that the nurse starting the feeding was responsible for labeling it. She stated that the ADONs and herself as the DON, were responsible for monitoring potential concerns. She stated Angel rounds were done daily, which were the supervisors rounding on residents. She stated not labeling the enteral feedings could possibly cause residents to become sick as it was an infection control issue.Record review of facility's Nursing Policy and Procedures with revision date 05/05/2023, titled Gastronomy Tubes, revealed in part: Gastronomy tubes may be used for residents who require enteral feedings to maintain nutrition the patient/resident will maintain acceptable parameters of nutritional status to include usual body weight or desirable body weight . The policy did not specify labeling or dating the enteral feeding.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement quality of life for one (Resident #14) of eight residents reviewed for dignity.CMA H failed to feed Resident #14 at eye-level on 02/15/26.This failure could place the residents at risk of poor self-esteem and decrease self-worth.Findings include:Record review of Resident #14's face sheet dated 02/18/2026 revealed an [AGE] year-old male with initial admission date 07/30/2019 and readmission date 03/23/2025.Record review of Resident #14's health and physical dated 02/17/2026 revealed a medical history of Dementia (a syndrome characterized by decline in cognitive function, memory and ability to complete daily tasks), and Dysphagia (difficulty swallowing).Record review of Resident #14's Comprehensive MDS dated [DATE] revealed Resident #14 was unable to complete the BIMS interview. Section C-Cognitive Patterns revealed Resident #14 had a Memory problem with Short-term and Long-term Memory and was noted as severely impaired for Daily Decision Making. Section GG-Functional Abilities revealed Resident #14 required Supervision or touching assistance with Eating, meaning the helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity.Record review of Resident #14's care plan revealed resident required ADL assistance with the intervention of 1 staff member to assist with eating through supervision or touching assistance.An observation was made on 02/15/2026 at CMA H fed Resident #14 a spoon of Jello while still standing.In an interview on 02/15/2026 at 2:25 PM, CMA H, stated she was not assigned with feeding but wanted to help the CNA's who were to feed the residents. CMA H stated that staff standing when assisting with feeding the residents was not correct. She stated there was no chair or stool for her to sit and assist during lunch which was why she stood. She stated she was to look for a stool or chair to sit when feeding the resident. CMA H stated the risks of assisting with feeding residents while they sit could be a sign of disrespect and was a dignity issue for residents. She stated nurses who were overseeing the meal service, were responsible for monitoring all staff providing and assisting residents appropriately. In an interview on 02/17/2026 at 1:30 PM, RN I stated staff were to assist with feeding residents while sitting down and at an eye-level with residents. RN I stated it was to make residents more comfortable. RN I stated potential risks of assisting with feeding, while the staff stands and residents sit, included the possibility of residents becoming agitated or threatened. She stated nurses were responsible for overseeing the dining room and ensure staff feed residents at eye-level.In an interview on 02/18/2026 at 4:01 PM, the DON, stated that staff were trained to feed residents while sitting. She stated CNA's assisted residents with feeding during mealtimes, and the nurses were responsible for monitoring the dining room to ensure residents were assisted correctly. She stated the risk to residents feeling inferior to staff if staff stood over them when assisting.Record review of the facility's Nursing Policies and Procedures, titled Activities of Daily Living, Optimal Function, read in part: Definition: Activities of Daily Living (ADLs), refer to tasks related to . eating . and Policy: The Facility provides care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. The facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming, hygiene.

Based on interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented for 1 of 4 residents (Resident #26) whose medical records were reviewed in that:The facility failed to accurately document on Resident #26's wound care on her Treatment Administration Record (TAR).This deficient practice affected one former resident and could place 14 residents with pressure sores at risk of inaccurate records.Record review of Resident #26's face sheet dated 02/16/2026 revealed an [AGE] year-old female with admission date 01/22/2026.Record review of Resident #26's history and physical dated 02/12/2026 revealed a medical history of the following: Chronic Kidney Disease (a condition meaning damage to the kidneys causing it to not filter the waste in the blood), Type II Diabetes Mellitus (metabolic condition that causes the body to become resistant to insulin or the pancreas fails to produce enough insulin), and had wounds on both legs.Record review of Resident #26's Discharge MDS dated [DATE] revealed a BIMS score of 15, indicating resident cognitively intact.Record review of Resident #26's care plan with revision date 02/04/2026 revealed Resident #26 had a wound/disruption of skin surface, left lower leg venous ulcer. Interventions for staff included to provide wound care as ordered, and to use aseptic techniques.Record review of Resident #26's Wound Care Order dated with start date 01/24/2026 and discharge date [DATE], revealed: Daily wound treatment: Left lower Lateral Distal Leg: Clean with Normal Saline or wound cleanser, apply thin layer of Mupirocin ointment (an antibiotic ointment) followed by a small piece of Hydrofera Blue (an antibacterial foam wound dressing that promotes healing by removing bacteria) MUST be moistened with Normal Saline (solution in water, commonly used in medicine for hydration, intravenous therapy, and wound care), cover with a 4x4 gauze, ABD pad (a specialized medical dressing designed for managing moderate to heavily exuding wounds), and roll gauze. Cover foot and leg with Tubigrip (a multi-purpose elasticated tubular bandage that provides uniform compression and support for wound dressings) from just below toes to just below the knee.Record review of Resident #26's Wound Care Order dated 02/17/2026 noted with start date 02/04/2026, revealed: Daily wound treatment: Left lower Lateral (a position away from the midline of the body) Distal (a position further from the point of attachment or the center of the body) Leg: Clean with Normal Saline or wound cleanser, nickel thick layer of Santyl (an ointment used to treat chronic skin ulcers) followed by calcium alginate, apply ABD pad, and wrap roll gauze. Cover foot and leg with Tubigrip from just below toes to just below the knee.Record review of Resident #26's Wound Care Administration history record dated 02/17/2026 from 01/01/2026-01/31/2026 revealed wound care was marked as completed on Saturday 01/31/2026 between 6 AM to 10 PM.Record Review of Resident #26's Wound Management Detail Report dated 02/18/2026 revealed resident was seen on 02/03/2026 by the Wound Care Physician. The report reflected a venous ulcer on the left shin lateral distal measured at 2 centimeters long, 1 centimeter wide, and 0.3 centimeters in depth. It was noted that the discharge was pale, red to pink, thin, and watery. It was noted that the wound healing was stable. On 02/10/2026, the wound was noted as 1.8 centimeters long, 1 centimeter wide, and 0.3 centimeters in depth. The wound discharge was pale, red to pink, thin, and watery. The wound healing was noted as stable.In a phone interview on 02/17/2026 at 11:33 AM, Resident #24's family member stated she was with Resident #24 on Sunday 02/01/2026. She stated she observed Resident #24's left foot red as a tomato, with brown discharge, and mentioned the socks Resident #24 was wearing were also brown. Resident #24's family member stated Resident #24 had an ulcer wound on her leg but was dressed in a wrapping around her leg to the resident's foot under the ankle. She stated the ulcer wound's discharge was dripping down to Resident #24's foot, causing it to be inflamed and red. She stated she reported this observation to RN O. She stated RN O provided wound care at that time and she requested a change in ointment and for Resident #24 to have soak baths for both of her feet. She stated Resident #24 had the wound for a long time, and she was familiar with how to care for the resident's wound. She stated she went to visit Resident #24 on Monday 02/02/2026, and Resident #24 reported to her that wound care was not completed on Saturday 01/31/2026. She stated she immediately notified the Wound Care Nurse and the DON. She stated the DON had reported reviewing the wound care notes for Resident #24 and it was noted wound care was given that day. She stated she advised the DON to speak with Resident #24 about the allegation. She stated that Resident #24 was alert and oriented and reported not receiving any wound care on 01/31/2026. She stated the DON notified her of speaking with RN O, and RN O admitted to the DON that she did not provide wound care on 01/31/2026. She stated she wanted to make sure RN O did not do that with other residents.In a phone interview on 02/17/2026 at 3:14 PM, RN O stated she recalled Resident #24's allegation of not providing wound care on Saturday 01/31/2026. She stated she was to provide wound care that day as Resident #24 had daily wound care ordered, but she stated she did not have normal saline that she needed for wound care that Saturday night. She stated it was approximately 9 PM when she was to provide Resident #26 with wound care. She stated she was trained to call the DON to notify for the need for supplies, but she did not. In a follow up phone interview on 02/18/2026 at 12:42 PM, RN O stated she did not notify any staff of not having supplies needed for wound care that night. RN O stated she did not provide wound care because she was tired as it was the end of her shift and she stated she thought she would be able to complete wound care the following morning as she worked double weekends.In an interview and observation on 02/18/2026 at 6:05 AM with the Wound Care Nurse, she stated she was the Wound Care Nurse during the weekdays, Monday to Friday, and the floor nurses provided wound care on the weekends. She stated that the supplies were in the treatment cart and in the supply room. An observation of the treatment cart with the Wound care Nurse revealed multiple bottles of normal saline. She stated nurses were trained to notify the ADON and DON if there was a need for supplies if there was not any available on site. She stated the potential risks of not providing wound care as ordered included infection to residents. She stated Resident #24's family member reported to her on Monday 02/02/2026, the allegation of Resident #24 not receiving wound care on Saturday 01/31/2026. She stated that the family member notified the DON right away, while she spoke to Resident #24. She stated there was redness to Resident #24's left foot. She stated there was pale, pink to clear, thin and watery discharge, and had no odor. She stated the family member had requested a change in ointment and soak baths that Sunday 02/01/2026, and the plan of care was to continue that wound care per family request. She stated wound care was done daily until Resident #24's discharge, and there were no signs of infection or complications. In an interview on 02/18/2026 at 10:59 AM with RN F, he stated he worked weekends mostly and performed wound care during those shifts. He stated that if wound care supplies were not available in the wound care cart or supply closet, staff are to contact the physician for new wound care orders. He reported that the keys to the treatment cart were to be located on the side of the cart.In a phone interview on 02/18/2026 at 11:03 AM with Resident #24's Physician, he stated he was notified of an RN not providing Resident #24 with wound care that following Monday 02/02/2026 by facility staff. He stated he was not reported of any signs or symptoms of infection, and the plan of care was to continue with daily wound care. He stated Resident #24 was monitored and was not reported with infections or negative outcomes during their stay at the facility and when discharged . He stated the facility followed up, and it was identified as a sole incident.In a phone interview on 02/18/2026 at 1:40 PM with RN Q, she stated she worked weekends and provided wound care to residents as needed. She stated there were wound care supplies in the treatment cart and the supply room. She stated if there were no supplies, she would notify the DON and Central Supply right away, as they provide supplies as needed. She stated the facility was also able to pull supplies from sister facilities as needed. She stated that not providing wound care per physician's orders could put the resident at risk of infection.In an interview on 02/18/2026 at 3:36 PM with the DON, she stated she spoke with Resident #24's family member on Monday 02/02/2026, and the family member had reported Resident #24's allegation of wound care not being provided on Saturday 01/31/2026. She stated she reviewed the treatment record which noted wound care was provided on 01/31/2026 at 9 PM. The DON stated she spoke with Resident #24 who reported the same allegation, and Resident #24 was alert and oriented. She stated she called RN O and she confirmed she did not provide wound care to Resident #24 on 01/31/2026, even though she marked it on the treatment record. The DON stated that RN O reported she did not provide wound care that day because there were not enough supplies, and RN O reported to the DON, that she thought she could do it twice the following day. She stated that the treatment cart and supply room were reviewed on 02/02/2026 and there were enough supplies on-site. She stated nurses were trained to notify the ADON or the DON if there was a need for supplies to complete their tasks, as the facility can get supplies from sister facilities if needed. She stated an investigation was done by the facility and RN O was terminated. She stated the Physician and Wound Care Physician were notified. She stated that the Wound Care Physician assessed Resident #24 on 02/03/2026 and there were no signs of infection. She stated Resident #24 was monitored and provided wound care until discharge from the facility, and the wound was stable with no complications. The DON stated Resident #24 had that wound for a prolonged period. She stated potential risk to residents that did not have accurate documentation depended on the type of charting, such as this case with wound care would be risk of infection. She stated the nurse doing the documentation was responsible, and she reviewed reports weekly.Record review of the facility's Nursing Policy and Procedures titled Documentation, with no date, read revealed in part: The facility will maintain complete and accurate documentation for each resident on all appropriate clinical records.

Based on interview and record review the facility failed to ensure that the assessment accurately reflected the resident's status for 1 (Resident #2) of 14 resident reviewed for accuracy of MDS assessment, in that:The facility failed to ensure that Resident #2's Significant Change Assessment reflected Resident #2 required total assistance of two persons with bed mobility. The facility failed to ensure that Resident #2's Significant Change Assessment documented in Active Diagnoses resident had two types of autoimmune skin diseases. This failure could place residents at risk of not receiving appropriate interventions or care to meet their current needs. Findings included:Closed record review of Resident #2's Face Sheet dated 10/03/25 revealed, initial admission date 02/19/25, and re-admission date of 07/01/25. Review of History & Physical, dated 06/10/25, for Resident #2 revealed a [AGE] year-old male with past medical history of diabetes mellitus (a condition where the body has high blood sugar (glucose) because it does not make enough insulin or cannot use it effectively), osteoarthritis (wear and tear disease where the protective cushion on the ends of your bones wears away overtime), rheumatoid arthritis (an autoimmune disease where your immune system mistakenly attacks the lining of your joints, causing them to become inflamed, painful, swollen and stiff), pemphigus vulgaris (an autoimmune disease where the body mistakenly attacks its own skin and mucous membranes, causing painful blisters to form on the skin and in the mouth, nose, throat, and eyes) and [NAME]-[NAME] Syndrome (a rare, serious, and life-threating reaction, often to a medication, that causes a painful, blistering rash and sores on the skin and mucous membranes, mouth, throat, eyes, genital). Skin superficial ulcer wound to neck, resident non-compliant with dermatologist appointment due to difficulty with arranging transportation to Drs. Clinics. General appearance - alert and oriented. Skin - coccyx wound. Multiple lesions, scabs, rash throughout the body due to history of [NAME]'s Syndrome and pemphigus Vulgaris. Activities of daily living- impaired by symptoms. Review of Significant Change MDS dated [DATE] for Resident #2 revealed, Section I - Active Diagnoses Stevent-[NAME] syndrome, reduced mobility.Review of Care Plan dated 09/22/25 for Resident #2 revealed: - Problem Start Date: 07/01/25. Edited 09/16/25. Chronic Pain R/T Stevens-Johnson Syndrome and Rheumatoid arthritis. Approaches: Administer Acetaminophen-codeine as ordered.During a telephone interview 10/01/25 at 2:46 PM, CNA A revealed he worked on 9/21/25 on the night shift and he was not given report about his assigned residents by the Nurse or CNAs at the start of shift and was just assigned to work in the 100-Hall. He said he was not given access to the Kiosk to check how much assistance the residents required with ADLS. He said he had provided care to Resident # in room [ROOM NUMBER], on that night. He said he had entered the room to check if the resident was incontinent. He said he did not know how many people needed to turn and reposition the resident in bed since he did not have access to the Kiosk. He said the resident could not assist with turning & repositioning in bed. He said he had turned and repositioned the resident to be able to change the soiled brief. During an interview and record review on 10/07/25 at 2:00 PM, LVN MDS Nurse E and RN MDS Nurse F revealed, Section I - Active Diagnoses [NAME]-[NAME] syndrome and did not document resident also had a diagnosis of pemphigus vulgaris.Review of Nursing Policies and Procedures dated 09/28/25 revealed, Subject: Minimum Data Set (MDS) Policy: A licensed nurse will conduct or coordinate each assessment with the interdisciplinary team. An MDS, which is a comprehensive, accurate, standardized reproducible assessment, will be completed for each resident, using the RAI process. Procedures: Review the resident's medical record. Review is to include, but not be limited to pre-admission, admission, and transfer notes; current plan of care, physician's orders, progress notes, history and physical; nursing, dietary, activity, social service, therapy notes and assessments; monthly summaries, medication administration records, treatment administration records, and resident and family interviews. Interview, observe and physically assess the resident to obtain validation of items identified on the medical record and to collect information for items where no documentation exists. Documentation of participation must include direct observation and communication with the residents, as well as communication with licensed and non-licensed direct care staff members on all shifts. Perform interviews and test of physical functioning as required by MDS RAI Manual. Be sure to speak to staff that have firsthand knowledge of the residents. Talk to staff from all shifts. Ask about the residents' performance on ADLs. GG functional status. Interview with the resident's physician. Ask about medication and treatment orders. Discuss any negative outcomes identified during assessment. Interview with the resident's family. Ask them to clarify conflicting information and to provide historical information when the resident is not able to do so. Each assessment must represent an accurate picture of the resident's status during the observation periods of the MDS. When the MDS is completed, only those occurrences during the observation period will be captured on the assessment.

Based on interview and record review the facility failed to establish procedures for storing and disposing of drugs and biological in accordance with federal, state, and local laws. The facility failed to ensure medications pending return to the pharmacy were stored in a locked cabinet in the DON's office. This failure could place 68 residents living at the facility at risk of drug diversion. The findings included:During an observation on 10/01/25 at 9:26 AM revealed, the door to the DON's office was opened and unsupervised. There was an opened cardboard box that contained medication blister packets stored on the floor by a cabinet and several medication blister packets were visible from the entrance to DON's office. During an observation on 10/01/25 at 10:12 AM revealed, the DON was not in the office while the Housekeeper was vacuuming the office and the opened cardboard box that contained medication blister packets was still stored on the floor in the DON's office. During an observation on 10/01/25 at 10:14 AM revealed, the Corporate Clinical Service director was working in DON's office and the opened cardboard box that contained medication blister packets was still stored on the floor in the DON's office. During an observation and interview on 10/01/25 at 12:38 PM, with DON confirmed there were two cardboard boxes that contained medications stored on the floor in her office. She said the boxes contained medications that were pending return to the pharmacy for credit. She said, One of those boxes was stored in the office when I started working here in March 2025. I do not know how often medications are returned to the pharmacy for credit. I know that medications should not be left unattended when stored in my office because someone can come in my office and take the medications. The DON said the risk of leaving medications in her office unattended could result in residents and/or other unauthorized individuals taking the prescribed medications from her office. During an interview on 10/02/25 at 10:30 AM revealed, the DON's office door was still open, and no one was in the office. It was observed that the two white cardboard boxes that contained medications were still on the floor. The top box was still opened, and the several blister medication packets were visible from the entrance to DON's office. During an interview on 10/02/25 at 12:06 PM revealed, the DON's office door was wide open and unsupervised. It was observed that the two opened white cardboard boxes that contained medications were still on the floor. The top box was still opened, and the several blister medication packets were visible from the entrance to DON's office. During an observation and interview on 10/02/25 at 12:32 PM, with the Administrator, confirmed there were two white cardboard boxes stored on the floor by the cabinet in the DON's office that contained medications. He confirmed the top cardboard box was opened. He demonstrated to the state surveyor that the second box was not sealed and contained medication. He said, The door to the DON's office should be kept locked if medications are not stored in a locked cabinet. He said, Let me close the door and go tell the DON. He said the risk of leaving the door open and unsupervised could result in someone coming into the office and taking the medications. The DON's office was located by the living room and next to the central nurse's station. During an interview on 10/02/25 at 12:40 PM, the Administrator revealed medications pending return to the pharmacy for credit should be stored in the medication room. He said, Medications pending return to the pharmacy should be placed in the locked plastic containers that are kept in the medication room. The large plastic containers are locked, and they have an opening where the staff can drop the mediations containers into the locked containers. During an interview on 10/06/25 at 12:47 PM with RN G revealed, medications pending return to the pharmacy for credit were dropped into a locked container stored in the medication room pick-up from the provider pharmacy. She said she usually worked on the weekends and did not know when the last time was return medication were picked up by the pharmacy. During an interview on 10/06/25 at 12:49 PM, with LVN Charge Nurse H on the 300-Hall revealed, medications pending return to the pharmacy for credit were dropped into a locked container stored in the medication room pending pick-up from the provider pharmacy. She said she did not know who called the pharmacy to pick up the medication containers to return the medications to the pharmacy. During an interview on 10/06/25 at 2:51 PM with the DON revealed, she calls the pharmacy after she and the ADON went through the locked medication containers stored in the medication to determine which medications could be returned to the pharmacy for credit. She said they listed the medications on the Medications Return Logs before the medications were returned to the pharmacy for credit. She said after the medications were listed on the Medication Return Logs the medications were placed in locked plastic containers and kept in the medication room until the pharmacy sent someone to pick up the container to return to the provider pharmacy. She said the pharmacy did not have a set date or time to pick up the locked medication containers since they had to send someone from out of town to pick up the returned medications. She said certain medications such as controlled substances and opened medication containers could not be returned to the pharmacy. The state surveyor asked the DON to provide copies of documentation given to the facility when locked medication containers that contained returned drugs were picked up by the pharmacy transporter. During a telephone interview on 10/06/25 at 1:03 PM, the Inventory Consultant Pharmacist at the provider pharmacy revealed, discontinued medications and/or medications with changes in medication orders were listed on the Medication Return Logs and must be signed by the facility's pharmacy consultant before faxing the form to the provider pharmacy to plan for picking up at the nursing home. The state surveyor requested a copy of the last Medication Return Logs completed by the nursing facility. The DON said there had been no pickups of medication for credit for 2025.Review of the Medication Return Log sheets pending pick up by the Pharmacy were dated 06/09/25 through 08/28/25. Review of the Pharmcy Pick-Up slip from the Provider Pharmacy were dated 12/12/24. Review of facility's Pharmacy Policy and Procedure, dated 4/17/204, revealed, Subject: Medication Returns to the LTC Provider Pharmacy. Policy: The Facility may return certain unused products for return and credit to the LTC Provider Pharmacy under specific conditions, based on LTC Provider Pharmacy policies and State and Federal Law. Procedures: When medication is discontinued or a resident is discharged , facility staff should refer to the LTC Provider Pharmacy policies regarding medication return eligibility and the process to be followed for returns. A medication return form must be completed when the medications are returned to the pharmacy to document the chain of custody of the returned medications. Facility should segregate and securely store the medications to be returned to Pharmacy until they are picked up by the Pharmacy.

Based on interview and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 1 of 14 residents (Resident #2) reviewed for clinical records with transfer assistance. The facility failed to give access to the contracted agency CNA to document in the residents' electronic record the care provided to assigned residents in the 100-Hall. This failure place residents at risk of having incomplete and accurate clinical records. Findings included:Closed record review of Resident #2's Face Sheet dated 10/03/25 revealed, initial admission date 02/19/25; and re-admission date 07/01/25. Review of History & Physical, dated 06/10/25, for Resident #2 revealed a [AGE] year-old male with past medical history of diabetes mellitus (a condition where the body has high blood sugar (glucose) because it does not make enough insulin or cannot use it effectively), osteoarthritis (wear and tear disease where the protective cushion on the ends of your bones wears away overtime), rheumatoid arthritis (an autoimmune disease where your immune system mistakenly attacks the lining of your joints, causing them to become inflamed, painful, swollen and stiff), pemphigus vulgaris (an autoimmune disease where the body mistakenly attacks its own skin and mucous membranes, causing painful blisters to form on the skin and in the mouth, nose, throat, and eyes) and [NAME]-[NAME] Syndrome (a rare, serious, and life-threating reaction, often to a medication, that causes a painful, blistering rash and sores on the skin and mucous membranes, mouth, throat, eyes, genital). Skin superficial ulcer wound to neck, resident non-compliant with dermatologist appointment due to difficulty with arranging transportation to Drs. Clinics. General appearance - alert and oriented. Skin - coccyx wound. Multiple lesions, scabs, rash throughout the body due to history of [NAME]'s Syndrome and pemphigus Vulgaris. Activities of daily living- impaired by symptoms. Review of Significant Change MDS dated [DATE] for Resident #2 revealed, a BIMs Score of 7 (severely cognitively impaired), clear speech, able to make self-understood; preferred language was Spanish. functional limitation in range of motion to upper and lower extremities; Section GG0130 - Functional Abilities -OBRA/Interim: Toileting hygiene, upper/lower body dressing, and personal hygiene-dependent; Section GG0170 Mobility - substantial/maximal assistance with Roll left and right; incontinent of bowel and bladder; Section I - Active Diagnoses Stevent-[NAME] syndrome, reduced mobility; Section J0100 Pain Management in the last 5 days - 0 had not received PRN pain medications; has not received non-mediation interventions for pain. J0200 Should Pain Assessment Interview be conducted? Yes. Section: J0300 Pain Presence Code: 1 Yes. J410 Pain Frequency Code: 4 Almost constantly. Section: J0510 Pain Effect on Sleep Code: 2 occasionally hard to sleep; Section: J0600 Pain intensity - Code: 9 in a scale form 00-10 pain scale. 10 being the worst pain. Section: K0520 Feeding tube on admission. Section: M1040 D. Open lesion(s) other than ulcers, rashes, cuts. Section: M1200 Skin Condition: Application of ointments/medications other than to feet. Section: Section V0200 A. CAA (Care Assessment Area Assessment Summary revealed Cognitive Loss/Dementia, ADL Functional, Urinary Incontinence, Feeding Tube, Pressure Ulcer, and Pain. Review of Care Plan revised 09/22/25 for Resident #2 revealed, -Problem Start Date: 09/22/25 Psychosocial Well-Being.- Problem Start Date: 07/01/25. Edited 09/16/25. Chronic Pain R/T Stevens-Johnson Syndrome and Rheumatoid arthritis. Approaches: Administer Acetaminophen-codeine as ordered.- Problem Start Date: 05/30/25. Edited 09/16/25. Incontinent of Bowel & Bladder. Approach: Provide incontinent care after each incontinent episode.- Problem Start Date: 05/30/25. Edited 09/16/25. The resident has a pressure ulcer to sacrum 7 Left heel R/T reduced mobility and Stevens-Johnson Syndrome. Approaches: Conduct a systemic skin inspection weekly. Wound Care Nurse to assess the pressure ulcer for location, stage, size, presence/absence of granulation issue and epithelization weekly and as needed.- Problem Start Date: 5/30/25. Edited 09/22/25. ADLS Functional requires assistance with ADLS. Approaches: Bed Mobility total dependence with assistance of 1-2 staff. Review of facility's CNA/Nurses assignment Sheet dated 09/21/25 revealed Contracted agency CNA was not listed on the assignment sheet. During a telephone interview 10/01/25 at 2:46 PM, with Agency CNA A agency revealed, he worked on the 10-6 shift on 09/21/25. He said he was not given access to the Kiosk to document the care that he had provided to the residents assigned to him on the 100-Hall on that day. During a telephone interview on 10/06/25 at 9:21 AM, Agency CNA A said, I was not granted access to the Kiosk so I could not document in the resident's electronic record the care that was provided to my assigned residents in the 100-Hall. He said no one assisted him in charting in the Kiosk at the end of the shift at the end of the night shift on 09/22/25. During an interview on 10/02/25 at 4:02 PM, the Administrator revealed it was the first time CNA A had worked at the facility. He said agency personnel were given access to document in the Kiosk prior to reporting to work so they could document the care that was provided during their shift. He said he had followed up with the DON today at 4:16 PM, and she did not know that CNA A had been scheduled to work on the day. So, he did not have access on 09/21/25 to document the care provided in the Kiosk for the residents in the 100-Hall. During an interview on 10/02/25 at 11:33 PM, with CNA I on the 10-6 shift revealed, she worked with the agency CNA A on 09/21/25 and he was assigned to work in the 100-Hall. She said CNA A was not given access to document the care provided to the residents during the night shift in the Kiosk. She said CNA A was not provided with any instructions on how to document the resident's care in the electronic record. She said, I offered to enter his resident's information in the Kiosk at the end of the shift in the morning on 09/22/25 and is why the documentation was showing under her name. She said, I would ask him the questions on the Point of Care Report and entered his responses under in the Kiosk and that was the reason the documentation was showing my name. During an interview on 10/02/25 at 11:25 PM, with LVN J on the 10-6 shift revealed, she worked with CAN I on 09/21/25 and said she was not sure if he had access to document in the Kiosk electronic record on that day. Review of Point of Care History reported provided by the DON on 10/03/25 at 8:52 AM, dated 9/21/25 - 9/22/25 for ADL documentation for Resident #2 revealed CNA I documented in the Kiosk on 09/22/25 at 00:22:44 (12: 22 a.m.) for CNA A. During an interview and record review on 10/07/25 with the DON revealed, CNA A picked up a shift at the last minute. She said, He showed up to work at the start of the shift on 09/21/25 and they had allowed him to stay and work. She said he was assigned to work on the 100-Hall. She said CNA A had not been granted access to document the care in the Kiosk, because she was not aware that CNA A had been scheduled to work on 09/21/25 in the night shift. She said, That is why CNA I documented for him on 09/22/25 at the end of the shift. During a telephone interview on 10/03/25 at 11:20 AM with, the contracted nursing agency employee who was responsible for scheduling staff to work at the nursing facility said, agency staff were given access by the contracted facilities to chart in the residents' electronic record before the start of shift. She said she was not aware of any concerns of access not provided to agency staff to document care provided to the residents at the nursing facility. Review of Nursing Agency contract signed 09/24/29 revealed, Responsibilities: Personnel have been advised to fully document services provided in accordance with Client's policies and procedures, current applicable standards of healthcare practices, and applicable federal, state, and local laws, rules and regulations.

Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 4 residents (Resident #15).The facility failed to ensure resident call lights were within reach for 1 resident (Resident #15).This failure placed residents at risk of having their needs unmet when they are unable to contact staff.Findings included:Record review of Resident #15's admission record, dated 10/01/2025, revealed an [AGE] year-old female with an original admission date of 06/30/2023.Record review of Resident #15's history and physical data, dated 09/24/2025, revealed the resident was diagnosed with dementia (a degenerative disease that alters an individual's cognition and functional capabilities), anxiety (a psychiatric disorder that makes an individual feel restless, nervous, and/or uneasy), and heart failure.Record review of Resident #15's Quarterly MDS, dated [DATE], revealed Resident #15 had a BIMS score of 14 (cognitively intact). Section GG -Functional Abilities (self-care) revealed Resident #15 required partial to moderate assistance for toileting, showering, upper/lower body dressing, and personal hygiene. Section GG- Functional Abilities (mobility) revealed Resident #15 required partial to moderate assistance for rolling to sides, sit to lying, lying to sitting, chair/bed-to-chair transfer, and was non-ambulatory.Record review of Resident #15's care plan, dated 07/09/2025, revealed Resident #15 was at risk for falling reaction to taking high fall risk medications with an intervention of keep call light in reach at all times.In an observation on 10/01/2025 at 9:23 AM, Resident #15's call device was out of reach. The call device was wrapped around the bed rail with the handle resting below mattress level.In an interview on 10/01/2025 at 1:33 PM, CNA N stated Resident #15 was non-ambulatory, could turn over, move in her bed unassisted but required one person for assistance with transfers. CNA N stated she did not remember who she assisted the morning during surveyor observation but believed she provided peri care to Resident #15. CNA N stated she did not know if it was in Resident #15 's care plan for the call light to be wrapped around the bed rail. CNA N stated that as per facility policy the call light must always be within resident reach. CNA N stated residents whose call light was not within reach would shout out to the staff. CNA N stated that residents who did not have a call light within reach cannot communicate needs to staff. CNA N specified that nurses and CNAs were responsible for ensuring call light was within reach. CNA N was unable to recall the last in service or training received for call lights. CNA N viewed the photo taken of Resident #15's call light position and stated the call light was out of reach for the resident. During an interview on 10/02/2025 at 10:29 AM, LVN M stated call lights must be next to the resident, at bedside, or clipped the call light within reach of the resident. LVN M stated an intervention utilized was continuously educating and reminding residents to utilize the call light. LVN M stated residents who do not have access to their call light could fall, injure themselves, or not receive services. LVN M stated staff made rounds at least every two hours to ensure call devices were within reach. LVN M stated when she left a resident's room, she ensured the resident did not have additional needs and ensured the call device was within reach. LVN M stated the facility's policy was that call lights must be within reach of the resident. LVN M was provided with a photo of a call light during a surveyor's observation and identified the call light was positioned out of reach for the resident.In an interview on 10/03/2025 at 12:45 PM, The DON stated call lights were used so residents could communicate their needs to staff. The DON stated the call light must be accessible to the patient, defined as next to the patient, on the bed or wheelchair depending on the resident's current location. The DON stated all staff were responsible for ensuring call lights were within reach to include CNAs, nurses, housekeeping, dietary, and leadership. The DON stated staff were trained to ensure the call light was within reach before leaving the room. The DON reported that even if the resident's neighbor was the one receiving care, staff should review the environment of both residents to ensure accessibility to call devices. The DON was provided a photo of the call device and stated it was out of reach for the resident. The DON stated a resident without access to a call device could potentially fall trying to get it, infringes on resident's rights, and could need assistance. The DON stated the last call light in service was approximately one to two months ago. In an interview on 10/03/2025 at 04:05 PM, The Administrator reported the call device was used for residents to express their needs to staff and request assistance. The Administrator stated nursing staff and CNAs as responsible for responding to call lights. The Administrator stated all staff as responsible parties for ensuring residents' call lights was always within reach. The Administrator stated staff were trained to review the residents' environment, ask the residents if they needed any additional assistance before leaving the room. The Administrator reported that staff should be checking that the call device was within reach for both residents in the room. The Administrator recognized the delay of care with ADLs as a potential outcome for residents who do not have their call device within reach. The Administrator stated this could cause the residents to be anxious or result in a loss of balance for residents that attempted to reach the call device or self-ambulate. The Administrator was provided with a photo of the call device and confirmed it was out of reach for the resident. The Administrator reported the last in-service for call devices was conducted on 05/26/2025.Review of the facility's policy titled (undated) Hospital nursing policies and procedures section: C - Call Lights stated the staff will provide an environment that helps meet the parent's need. Procedure number 7 stated, when leaving the room, be sure the call light is placed within the patients reach.

Based on observation, interview, and record review, the facility failed to develop and implement a person-centered comprehensive care plan to include measurable objectives and timeframes to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being for 1 of 14 (Resident #2) residents reviewed for comprehensive care plans in that: The facility failed to revise or update Resident #2's care plan to reflect the need for two people for bed mobility due to pain caused by autoimmune skin disease. The facility failed to revise or update Resident #2's care plan to reflect physician's orders to treat autoimmune skin disease. This failure could place residents at risk of not receiving appropriate interventions or care to meet their current needs. The findings included:Closed record review of Resident #2's Face Sheet dated 10/03/25 revealed, initial admission date 02/19/25; and re-admission date 07/01/25. Review of History & Physical, dated 06/10/25, for Resident #2 revealed a [AGE] year-old male with past medical history of diabetes mellitus (a condition where the body has high blood sugar (glucose) because it does not make enough insulin or cannot use it effectively), osteoarthritis (wear and tear disease where the protective cushion on the ends of your bones wears away overtime), rheumatoid arthritis (an autoimmune disease where your immune system mistakenly attacks the lining of your joints, causing them to become inflamed, painful, swollen and stiff), pemphigus vulgaris (an autoimmune disease where the body mistakenly attacks its own skin and mucous membranes, causing painful blisters to form on the skin and in the mouth, nose, throat, and eyes) and [NAME]-[NAME] Syndrome (a rare, serious, and life-threating reaction, often to a medication, that causes a painful, blistering rash and sores on the skin and mucous membranes, mouth, throat, eyes, genital). Skin superficial ulcer wound to neck, resident non-compliant with dermatologist appointment due to difficulty with arranging transportation to Drs. Clinics. General appearance - alert and oriented. Skin - coccyx wound. Multiple lesions, scabs, rash throughout the body due to history of [NAME]'s Syndrome and pemphigus Vulgaris. Activities of daily living- impaired by symptoms. Review of Care Plan dated 09/22/25 for Resident #2 revealed: - Problem Start Date: 07/01/25. Edited 09/16/25. Chronic Pain R/T Stevens-Johnson Syndrome and Rheumatoid arthritis. Approaches: Administer Acetaminophen-codeine as ordered.- Problem Start Date: 05/30/25. Edited 09/16/25. Incontinent of Bowel & Bladder. Approach: Provide incontinent care after each incontinent episode.- Problem Start Date: 5/30/25. Edited 09/22/25. ADLS Functional requires assistance with ADLS. Approaches: Bed Mobility total dependence with assistance of 1-2 staff. During a telephone interview 10/01/25 at 2:46 PM, CNA A revealed he worked on 9/21/25 on the night shift and he was not given report about his assigned residents by the Nurse or CNAs at the start of shift and was just assigned to work in the 100-Hall. He said he was not given access to the Kiosk to check how much assistance the residents required with ADLS. He said he had provided care to Resident # 2, on that night. He said he had entered the room to check if the resident was incontinent. He said he did not know how many people needed to turn and reposition the resident in bed since he did not have access to the Kiosk. He said the resident could not assist with turning & repositioning in bed. He said he had turned and repositioned the resident to be able to change the soiled brief. He said he had slipped his right hand under the resident's hip and the left hand under the shoulder to turn and reposition the resident on his own because he was the only CNA assigned to work in the 100-Hall. He said the resident would grimace and moan when he was moved in bed. During a telephone interview on 10/06/25 at 9:56 AM with Resident #2's family member revealed, Resident #2 said a young man that had been assigned to care for him during the night on 09/21/25 had moved him without assistance causing pain and discomfort. She said Resident #2 could not move in bed without assistance. Resident #2's family member said, The attendant was new, and he did not know what type of care (Resident #2) needed and the attendant did not speak Spanish so they could not communicate with each other. She said Resident #2 was alert and can tell you what happened on that day. The family member said, He is right here, let me ask him if he wants to talk to you so he can tell you what happened on that day. Interview with Resident #2 revealed he was alert, oriented to person, place and time. He said the young man who had cared for him at night on 09/21/25 was very rough when he moved him in bed to change the soiled brief without assistance causing a lot of pain and discomfort. During an interview on 10/06/25 at 1:19 PM with RN B Charge Nurse on the 6-2 shift on the 100-Hall revealed, Resident #2 was alert, oriented to person, place, time and situation. She said the resident had a skin condition that caused sores, pain and skin peeling all throughout his body that caused pain when he was touched to provide care. She said the resident needed to be always turned & repositioned with a sheet with the assistance of two people, to prevent direct contact with the skin. She said taking blood pressure on him caused a lot of pain. She said the resident always complained of pain, itching and burning sensations to the skin, especially when he was moved in bed. During an interview on 10/06/25 at 3:29 PM with CNA C assigned to the 100-Hall revealed, Resident #2 and he was alert, oriented to person, place and time. She said, The resident required total assistance with ADLs, and needed two-people for turning and repositioning because he had a skin condition all over his body that caused pain when they touched him to provide care. He had sores and skin peeling all over his body and they had to use a sheet to move him in bed because any movement caused pain. She said the resident always had a lot of pain when he was touched to provide any type of care. During an interview on 10/06/25 at 3:36 PM, with CNA D revealed, Resident #2 was alert, oriented to person, place, and time, required total care and always required two people to turn and reposition the resident in bed because the resident had a skin condition that caused pain with movement or when he was touched to provide care, because he had sores and skin peeling all over his body so they had to use a sheet to move him in bed because any movement caused pain. She said the resident had a lot of pain when he was touched to provide any type of care. He always complained of pain when he was touched or moved to provide care. She said the resident used the call-light for assistance with toileting. During an interview on 10/07/25 at 2:00 PM, LVN MDS Nurse E and RN MDS Nurse F revealed they gathered the information from the documentation in the resident's clinical record written by the nurses and the CNA documentation in the Kiosk. RN MDS F said, So according to the CNAs documentation, the resident did require two people for turning and repositioning most of the time. I did not talk to the nurses and the CNAs to determine if the resident required two people to for turning and repositioning in bed.During an interview and record review on 10/07/25 at 2:35 PM with RN MDS Nurse F in the presence of LVN MDS Nurse E and revealed, that according to the documentation done by the CNAs in the Kiosk documented Resident #2 required two-person assistance with bed mobility most of the time. RN MDS Nurse F said the resident had a skin condition that caused pain when he was touched. RN MDS Nurse F said the care plan did not document the resident also had pemphigus vulgaris and skin peeling all throughout his body, skin sensitivity that caused pain when touched to provide care and sores on his skin throughout his body. He said the care plan did not document resident was on EBP precautions related to G-tube, history of MDROs, pressure ulcer and open skin sores related to skin condition. RN MDS Nurse F said the care plan did not document resident was treated with Prednisone and Silvadene for skin condition. Review of Nursing Policies and Procedures, dated revised 5/05/23 revealed, Subject: Care Plan Process, Person-Centered Care. Policy: The facility will develop and implement a comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the residents that meet professional standards of quality care. The services provided or arranged by the facility, as outlined by the comprehensive person-centered care plan, will meet professional standards of quality. Procedures: Following RAI Guidelines develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframe to meet a resident's medical, nursing, and metal and psychosocial needs that are identified in the comprehensive assessment. The person-centered care plan includes Date, problem, interventions, discipline specific services, and frequency. Resolution/Goal Analysis.

Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for 1 (Resident #1) of 1 reviewed for quality of care.The facility failed to ensure that Resident #1 received an initial neurological check and continued neurological checks for 72 hours following an unwitnessed fall as per the facility's policy on fall management and and neurological checks, from 09/25/2025 to 09/27/2025. This failure could place residents at risk of head related injuries, decrease cognitive and functional abilities and not receiving the necessary care and services. Findings included:Record review of Resident #1's care plan, dated 09/16/2025, revealed Resident #1 has a history of falling related to age-related cognitive decline, unspecified dementia, unspecified severity, with other behavioral disturbance and has difficulty focusing attention/ understanding others due to age-related cognitive decline, unspecified dementia, unspecified severity, with other behavioral disturbance. Interventions included fall mat utilization (updated 09/24/2025), Keep personal items and frequently used items within reach (updated 09/02/2025; after 09/01/2025 fall incident), and provide proper, well maintained footwear (updated 09/02/2025; after 09/01/2025 fall incident).Record review of Resident #1's physical and health, dated 09/25/2025, revealed the resident was diagnosed with dementia (a degenerative disease that alters an individual's cognition and functional capabilities) with history of falls resulting in hospitalization and generalized weakness.Record review of Resident #1's MDS, dated [DATE], revealed a BIMS score of 99 (resident was unable to complete Brief Interview for Mental Status). Section GG -Functional Abilities (mobility) revealed Resident #1 required substantial/maximal assistance for rolling to sides, sit to lying, lying to sitting, sit to stand, and chair/bed-to-chair transfer; ambulation was scored an 88 signifying that attempts were not made due to the resident's medical condition or safety concerns.Record review of Resident #1's admission record, dated 10/01/2025, revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE].Record review of neurological checks binder and progress notes on 10/03/2025 at 09:00 AM, revealed Resident #1 there were no documented neurological checks for a fall that occurred on 09/25/2025 at 02:30 AM.During an interview on 10/02/2025 at 10:18 AM, LVN M, stated she was completing a neurological check sheet for a resident who experienced an unwitnessed fall. She stated that after a fall, the nurse completed the head-to-toe assessment, neurological check, SBAR, contacted the physician, family, hospice (if applicable), notified the DON and the administrator immediately. She reported that if the resident was not sent out for further evaluation, staff was to check the resident every 15-30 minutes following the fall and enter progress notes.In an interview on 10/02/2025 at 11:03 PM, CNA O stated she was on a break on 09/25/2025 at 2:30AM and walked by the resident's room out of familiarity with resident's sleep patterns. She stated she saw the call light illuminated and located the resident halfway on his bed with blood all over his face. She stated the resident said, I was asleep, and I fell. She stated the mattress was halfway off the bed with half the mattress protruding towards the window with the resident half way on the bed. She stated the resident climbed back on to his bed hallway, after the experienced fall. She stated she tried to readjust the mattress from the window side, while the resident was halfway on the mattress. She stated the resident slid against her legs; She stated the resident did not accrue additional injuries from transition. She stated she called for the shift nurses (LVN J and RN L). She stated the nurses conducted their assessments, cleaned resident, notified family, physician, and requested 911. She stated the last time the resident was checked on was at 1 am and he was asleep. She identified RN L who reported the incident to The DON and The Administrator. She stated how training and in-services were left at the nurse's station for third shift staff to read and sign or they were called in during the day for trainings. She stated the last in service was abuse, neglect and exploitation this week (09/30/2025 to 10/03/2025). She stated the steps for abuse and neglect reporting and identified shift nurse and The Administrator as key individuals to immediately report to. She stated the resident's injury was to the left side of his head, with no symptoms (nausea, headache, loss of consciousness, convulsions) present besides bleeding. She stated the resident denied being in pain, discomfort and did not want to go to the hospital.During an interview on 10/02/2025 at 11:24 PM, LVN J, stated the call light was illuminated on 09/25/2025 at 02:30 PM to Resident #1's room, and CNA O responded to call light. She stated CNA O had called out for assistance from room [ROOM NUMBER] where Resident #1 was assigned on the day of the incident. She stated she went to get the wound cart while RN L passed her to go tend to Resident #1. She stated the cut was less than an inch on the left side of his forehead and that he had a visible hematoma (swelling) the size of a golf ball. She stated Resident #1 had a history of falling She stated the resident moved a lot in his sleep She stated the resident was unaware what had happened and woke up upon hitting his head; She stated she was uncertain what Resident #1 hit his head on. She stated she printed the summary of health paperwork for the EMT to take with the resident to ensure continuous care for diagnosed conditions. She stated that RN L stayed with Resident #1 to complete vitals, assessment, and provide wound care. She stated Resident #1 did not lose consciousness during the assessment or before being transported to hospital. She stated that after a resident had fallen, she would report the incident to the physician, the resident's family, The DON, and The Administrator after assessing injuries. LVN J stated nursing staff were trained to complete neurological checks if it was unwitnessed fall. LVN J stated that the physician would order CT scans and x-rays for further evaluation. LVN J stated neurological checks were completed every 15 minutes for the first hour, every 30 minutes for the next two hours, every hour for the next two hours, and every shift for the next 72 hours after the fall.Records were requested from The DON on 10/03/2025 at 10:42 AM for the neurological checks for Resident #1 on 09/25/2025.The DON stated no neurological checks were documented for the incident on 09/25/2025 because the resident was sent out to the hospital.In an interview on 10/03/2025 at 12:30 PM with The DON, she stated she received a call from RN L at approximately 2:30AM that the resident had fallen from bed and had a laceration to the left side of his head. She stated RN L notified the PCP, family, and herself. She stated reported she notified The Administrator in the morning during regular business hours. She stated PCP requested the resident to be sent to local hospital. She stated neurological checks were performed in response to unwitnessed falls. She stated neurological checks were completed on the resident but were not documented because the resident was sent to the hospital; She stated there were progress notes and SBARs entered. DON reported the staff have been trained to conduct neurological checks upon locating the resident and per facility fall and neurological check policy. DON stated the staff did not adhere to the facility's policy for the resident's fall on 09/25/2025. DON identified potential outcomes to staff not adhering to their policy in conducting neurological checks could result in the resident experiencing, brain bleed, contusion, could be anything. DON reported for staff to continue neurological checks after hospital discharge they needed to obtain orders from the physicians. DON reported there was no in-service or training recently completed for neurological training. The DON reported neurological checks were not conducted upon the Resident #1's return from the hospital on [DATE].In an interview via telephone call on 10/03/2025 at 01:32 PM with RN L, he stated he had checked on Resident #1 earlier in the night of 09/25/2025 and at approximately 02:00 AM to 02:30 AM CNA O began her rounds. He stated the resident used his call device at approximately 02:00 AM to 02:30 AM and was observed halfway off the bed near the window side He stated the resident stated he was asleep, rolled in his sleep and fell to the floor. He stated he suspected Resident #1 fell on the corner of the cabinet in his room due to the 2.5-centimeter laceration to the left side of the resident's forehead. He stated he notified the PCP, The DON and family. He stated that the resident denied being in pain at the time of the incident and denied wanting to go to the hospital. He stated he completed a fall assessment, skin assessment, progress note, and hospital transfer note for the ambulance to take to the hospital. He stated he physically conducted the neurological check but did not document them on the facility provided sheet. He stated the neurological check sheet was not necessary to complete if the resident was sent out for further evaluation per facility policy. He stated that a resident who experienced an unwitnessed fall/direct head injury could have a neurological deficit, blown pupil, stroke, and encephalitis (swelling of the brain) if not identified during a neurological check. He stated potential outcomes for the diagnosis could result in pain to the resident, hospitalization, and even death. He stated any unwitnessed fall that occurred must have a neurological check completed.In an interview via telephone call on 10/03/2025 at 02:10PM with The PCP, he reported he was notified of both instances of the resident falling on 09/01/2025 and 09/25/2025 by nursing staff at the facility. He stated the resident's falls were attributed to non-compliance on the resident's behalf with instructions for care and required more redirection. He stated the resident was sent out to the hospital which provided more advanced evaluations, therefore nursing staff were not required to continue neurological checks. He stated that nurses needed physician orders to continue neurological checks upon hospital discharge. PCP stated he received a report from his colleague who was on call for the weekend of 09/25/2025. As per the PCP, Dr. [NAME] met with the resident's family at the hospital; family declined further neurological assessments and evaluations at the hospital. PCP reported no further intervention was necessary due to family's request.In an interview on 10/07/2025 at 11:00 AM with RN Clinical service Director reported neurological checks were to be completed when residents sustained an unwitnessed fall or witnessed if resident hit their head. RN Clinical service Director stated that neurological checks should be done for 72 hours following a fall. RN Clinical service Director reported the nurses should have continued neurological checks if the resident returned from the hospital in less than 72 hours from the fall. The RN Clinical service Director reported this was per facility policy.In an interview on 10/07/2025 at 11:10 AM with RN B stated that neurological checks were done to make sure that after a resident fell, they were cognitively intact. RN B continued stating the neurological checks were to make sure there were not any fractures, concussion, head aches or anything affecting the resident's neurological state. RN B stated neurological checks were to be done for 3 or 4 days after a fall either witnessed or unwitnessed, because the resident might complain later. RN B stated that the staff needed physician's orders if the resident returned from the hospital the same day. RN B stated she did not complete neurological checks for Resident #1 when he returned on 09/27/2025. RN B stated neurological checks were to be resumed with the physician's orders. RN B identified some risks of not continuing neurological checks would be concussions, headaches, and brain bleeding. RN B stated that the facility provided an in-service regarding neurological checks about 2 to 3 weeks ago.In a record review conducted on 10/03/2025 at 05:00 PM of the facility's nursing policies and procedures - subject: neurological checks under procedure 1: neurological checks are performed following an actual or suspected head injury or change in level of consciousness per physician ordered or frequency OR: initially then, every 15 minutes for 1 hour, then every 30 minutes for 2 hours, then every 1 hour for 2 hours, then every shift for 72 hours; and under procedure 3: documentation is completed on the neurological evaluation flow sheet, via the Glasgow Coma Scale. Secondary record review of PM of the facility's nursing policies and procedures - subject: fall management under procedure 7: neurological evaluations will be performed for a resident who sustains an unwitnessed fall, regardless of the resident's cognitive status at the time of the incident. The facility failed to follow their policy in continuing neurological checks for a resident who experienced and unwitnessed fall for the first 72 hours following the incident on 09/25/2025.Record review of Resident #1's electronic medical documentation completed by RN L revealed a progress note from 09/25/2025 with no mention of neurological checks conducted and an SBAR documentation with no mention of neurological assessment.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for one of fourteen residents (Resident #2) reviewed for Enhanced Barrier Precautions. The facility failed to implement their policy on Enhanced Barrier Precautions for Resident #2 who had wounds, indwelling medical devices and was incontinent of bowel and bladder. This failure could place residents at risk for healthcare associated cross-contamination and at risk of the transmission of multi-drug-resistant organisms (MDROs). The findings included:Closed record Review of Resident #2's Face Sheet dated 10/03/25 revealed, initial admission date 02/19/25; and re-admission date 07/01/25. Review of History & Physical, dated 06/10/25, for Resident #2 revealed a [AGE] year-old male with past medical history of pemphigus vulgaris (an autoimmune disease where the body mistakenly attacks its own skin and mucous membranes, causing painful blisters to form on the skin and in the mouth, nose, throat, and eyes) and [NAME]-[NAME] Syndrome (a rare, serious, and life-threating reaction, often to a medication, that causes a painful, blistering rash and sores on the skin and mucous membranes, mouth, throat, eyes, genital). Skin superficial ulcer wound to neck, resident non-compliant with dermatologist appointment due to difficulty with arranging transportation to Drs. Clinics. General appearance - alert and oriented. Skin - coccyx wound. Multiple lesions, scabs, rash throughout the body due to history of [NAME]'s Syndrome and pemphigus Vulgaris. Activities of daily living- impaired by symptoms. PEG tube feedings (Is a feeding tube that goes directly from the outside of the body, through the skin of the belly, and into the stomach). Review of Significant Change MDS dated [DATE] for Resident #2 revealed, a Section I - Active Diagnoses Multidrug-Resistant Organism (MDRO), Septicemia, Gastrostomy status, Stevent-[NAME] syndrome, Feeding tube on admission. Section: M0300 one stage 2 pressure ulcer present upon admission. Section: M1040 D. Open lesion(s) other than ulcers, rashes, cuts. Section: Section V0200 A. CAA (Care Assessment Area Assessment Summary revealed ADL Functional, Urinary Incontinence, Feeding Tube, Pressure Ulcer, and Pain. Review of Care Plan revised 09/22/25 for Resident #2 revealed, - Problem Start Date: 07/01/25. Edited 09/16/25. Chronic Pain R/T Stevens-Johnson Syndrome and Rheumatoid arthritis. Approaches: Administer Acetaminophen-codeine as ordered.- Problem Start Date: 07/01/25. Edited 09/16/25. Requires feeding tube R/T Dysphagia. Approaches:- Problem Start Date: 05/30/25. Edited 09/16/25. Incontinent of Bowel & Bladder. Approach: Provide incontinent care after each incontinent episode.- Problem Start Date: 05/30/25. Edited 09/16/25. The resident has a pressure ulcer to sacrum 7 Left heel R/T reduced mobility and Stevens-Johnson Syndrome. Approaches: Conduct a systemic skin inspection weekly. Wound Care Nurse to assess the pressure ulcer for location, stage, size, presence/absence of granulation issue and epithelization weekly and as needed.Review of Physician Order Report dated 07/01/25 - 09/22/25, for Resident #2 revealed required Enhanced Barrier Precautions for wounds. During a telephone interview 10/01/25 at 2:46 PM with CNA A revealed he had worked on 9/21/25 on the night shift and he was not given report about his assigned residents by the Nurse or CNAs at the start of shift and was just assigned to work in the 100-Hall. He said he was not provided with an orientation prior to providing care to the residents on that day. He said he had provided care to Resident #2, on that night. He said he had entered the room to check if the resident was incontinent. He said the resident could not assist with turning & repositioning in bed and he had turned and repositioned the resident on that day on his own to provide incontinent care. He said he did not know which residents were on Enhanced Barrier Precautions, so he had not used PPE when providing direct care to the residents on that day. He said he had not seen postings by the entrance to the residents' rooms, that indicated which residents were on Enhanced Barrier Precautions. He said PPE was not available in the 100-Hall on that day when he had worked at the nursing facility. He said the risk of not using PPE when residents were on Enhanced Barrier Precautions could result in cross contamination of uniforms and spread of infection. During an interview on 10/06/25 at 1:19 PM with RN Charge Nurse B on the 6-2 shift on the 100-Hall revealed, Resident #2 had a skin condition that caused painful sores and skin peeling all throughout his body. She said Resident #2 was on Enhanced Barrier Precautions because of the skin sores, pressure ulcer and G-tube. She said the facility only posted the small CDC Pocket Guide by the entrance to the resident rooms. She said they had been trained to use EBP for residents with indwelling medical devices, wounds, or those who are colonized by or infected with a multidrug-resistant organism (MDRO). She said the staff should use EBP when dressing or bathing, transferring, changing linens, assisting with toileting, accessing indwelling medical devices, providing wound care, and other high-contact resident care activities. During an observation and interview on 10/06/25 at 1:24 PM, with RN Charge Nurse B on the 6-2 shift in the 100-Hall revealed Resident in room [ROOM NUMBER]-A had a G-tube; Resident in room [ROOM NUMBER] had a G-tube and Resident #3 had a UTI. Rounds made with RN Charge Nurse B revealed there was no PPE readily available for staff to use in the 100-Hall. She said PPE should always be readily accessible for staff to use as needed to prevent cross-contamination and spread of infections. During an interview on 10/06/25 at 1:29 PM with CNA K assigned to the 100-Hall in the morning shift revealed, there were no residents at this time on any type of isolation. The state surveyor asked the CNA where they kept the PPE in the 100-Hall. She said, We do not have any PPE in the 100-Hall because we currently do not have any residents on any type of isolation. The CNA could not explain to the state surveyor what Enhanced Barrier Precautions were and what they needed to do. She said, We just use gloves when providing care to the residents. She said she did not remember being trained on Enhanced Barrier Precautions. She said she had not noticed the CDC pocket guide posted by the entrance to the resident rooms. During an interview on 10/06/25 at 1:38 PM with LVN Charge Nurse H assigned to the 300-Hall revealed, the facility posted a copy of the Enhanced Barrier Precautions CDC Pocket Guide by the entrance to the resident rooms. She said EBP were followed by the staff when residents have indwelling medical devices, wounds, or those who are colonized by or infected with a multidrug-resistant organism (MDRO). She said when a resident is on EBP, the staff should use an isolation gown, gloves and goggles as needed when dressing or bathing, transferring, changing linens, assisting with toileting, accessing medical devices, providing wound care, and other high-contact resident care activities. She said we usually keep a plastic container with PPE by the Kiosk, but it is not there today. She said that failure to use PPE when residents are on EBP could result in cross-contamination and the spread of infection. During an observation and interview on 10/05/25 at 3:35 PM with CNA C working on the 100-Hall in the evening shift revealed, she did not know why residents were placed on Enhanced Barrier Precautions. She said we only use gloves when direct care is provided to the residents. She said, We do not have any PPE such as gowns, masks, or goggles in the 100-Hall since we do not have any residents on isolation. She said, Central Supply Clerk keeps PPE in the small supply room in the hallway by the 100-Hall. Let me take you to the small supply room to show you the plastic container where they keep the PPE to use as needed. The CNA demonstrated to the state surveyor the drawers labeled Gowns and Gloves were empty. She said, We always have PPE in the container. I don't know why there is no PPE in the small supply room. During an interview on 10/06/25 at 3:36 PM with CNA D revealed, the facility placed residents on EBP when the resident had a urinary infection, skin infection, or COVID. She said, I know that we are supposed to use gowns, mask, and gloves when providing direct care. She said she could not remember if they had been trained on EBP. She said sometimes PPE was not readily available to use in the Resident Halls as needed. She said Resident [NAME] initially was in isolation for a urinary tract infection and was on antibiotics. She said after he had completed the antibiotic he was taken off isolation and they only used gloves when direct care was provided. She said the resident had a G-tube and a pressure ulcer on the buttocks. She said failure to have PPE could result in cross contamination and spread of infection. During an interview on 10/06/2025 at 3:50 PM with CNA Q in the 300-Hall revealed, contact precautions were in place when the resident had infections and EBP were for residents with foleys and g tubes. She stated that people on isolation have both signs because extra precautions were needed for them. She stated that sometimes there weren't any gowns available and that she had gone into the rooms without a gown only with gloves because that was all that was available. She stated that she had told the DON and ADON when this would happen, but it would take them a while to restock, and she could not keep residents waiting. She could not recall the last in-service regarding PPE, contact precautions and EBP. During an interview on 10/06/2025 at 3:57 PM with CNA R revealed, she did not wear the PPE unless the residents were on isolation because those residents were contagious, so it was protection for her from the resident as well as protecting the resident from any new infections. She stated that she did not wear PPE when she went into rooms with residents with foleys and would only wear gloves when foleys were emptied. She could not tell the difference between residents needing enhanced barrier precautions and residents on isolation/ contact precautions. She stated that she was just PRN, and she did not remember the last time there was a training over this, she stated that the facility did give training, but she just could not remember the last one. During an interview on 10/06/25 at 4:10 PM, with RN ADON/Infection Control Preventionist revealed, all department heads except for the Administrator and DON completed hourly Angel Rounds on their designated Resident Halls. She said she randomly checked during rounds nursing staff were following EBP and using gloves when providing direct care to the residents. She said Central Supply placed plastic containers with PPE by Kiosk in each unit. She said, I check every day in the morning to make sure PPE is always available on the Resident Units to use as needed to prevent cross contamination and the spread of infection. She said, We post a sign on the door to the resident's room when a resident needs to be on EBP. She said, When a resident is on EBP, we place cardboard boxes in the resident's room for them to dispose the contaminated PPE prior to leaving the resident's room. She said she had started working as the ADON on September 28, 2025, and did not know if the staff had been trained in EBP. During an interview on 10/07/25 at 10:14 AM with the DON revealed she had started working at the facility on March12, 2025 and did not know when the staff had been trained on EBP. She said the administrator was out and would not be returning to work this week. The DON said, I am acting administrator until the administrator returns. She said, The Infection Control Preventionist and I are responsible for checking direct care staff are following EBP to prevent cross contamination and the spread of infection. During an interview on 10/07/25 at 11:27 AM with the Central Supply worker revealed, she was responsible for stocking PPE on the Resident Halls and in the small supply room by the 100-Hall. She said PPE was placed in plastic containers by the entrance to the resident rooms if the residents were placed on any type of isolation. She said she kept a plastic container with isolation gowns, gloves, masks, and gloves by the Kiosk in all resident units by the Kiosk for the direct care staff to use when direct care was provided to the residents. She said she checked the PPE levels at start of shift and twice before the end of the day on all Resident Halls and the small supply room by the 100-Hall to ensure PPE was always available for the direct care staff to use as needed. During an observation on 10/07/25 at 11:32 AM with the Central Supply worker revealed, the plastic container in the 300-Hall by the Kiosk contained masks and isolation bags and the gown drawer was empty. She said, We usually keep the isolation gowns in the plastic container by the Kiosk. I will put gowns in the container as soon as possible. During an observation on 10/07/25 at 11:34 AM with the Central Supply worker revealed, the plastic container by the Kiosk in the 200-Hall contained isolation gowns, masks, goggles, and isolation bags. She said, We don't have anyone on isolation at this time. During an observation on 10/07/25 at 11:35 AM with the DON and Central Supply worker revealed, the plastic container stored in the locked supply room by the 100-Hall revealed the gown and mask drawer were empty. Central Supply Clerk said, I check the PPE levels twice a day. I did not restock the PPE this morning in the small supply room because I have been busy. The DON said that failure to have PPE readily available for direct care staff to use could result in cross contamination and spread of infection. During an interview on 10/07/25 at 11:40 AM with the DON revealed she and ADON made rounds several times during the day. She said I check for hand sanitizer and PPE to ensure these items are readily available in the Resident Halls for the staff to use as needed. She said, Today, I did not check the mini supply room by the 100-Hall today to see if PPE was available in the plastic container. She said we have not provided any training on EBP since I started working here in March 2025 and do not know when the last time the staff were trained on EBP. The state surveyor requested to see the in-service training binder for 2025. The DON said, EBP pocket guides are posted by the entrance of each resident rooms, and they know they need to gown up and put on gloves when they enter the room to provide any type of care to the residents. We do this to protect the residents from infections. That is all that we do. She said Central Supply usually checks that PPE is available in Resident Halls. The DON said, She is fairly new as well and is trying to learn what she needs to do. The DON said the failure to use EBP put the residents and staff at risk of cross contamination and spread of infections. Review of the facility's Infection Prevention and Control Policies and Procedures provided by the DON on 10/07/25 revised on May 15, 2023, revealed the following:Subject: Transmission Based/Standard Precautions, and Enhanced Barrier PrecautionsPolicy: Health Care workers will implement Universal/Standard Precautions whenever there is occupational exposure to blood and body fluids. The type of PPE and precautions implemented depends on the potential for exposure, route of transmission, and infectious organism/pathogen.Health Care will implement enhanced barrier precautions according to policy with additional measure to protect resident and staff from Multidrug-resistant Organisms (MDROs) MDROs refers to microorganisms predominantly bacteria that are resistant to one or more classes of antimicrobial agents.Procedures:Enhanced Barrier Precautions (EBP) documented in part:Enhanced Barrier Precautions expand the use of PPE (gowns and gloves) during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.EBP will be implemented for ALL residents with the following:1) Infection or colonization with MDRO when Contact Precautions do not otherwise apply2) Wounds and/or indwelling medical devices (central lines, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization statusEBP will be implemented during the following high-contact resident care activities: dressing, bathing/showering, transfers, providing hygiene, changing Linens, changing briefs or assisting with toilet, device care or use: central lines, urinary catheter, feeding tube, tracheostomy/ventilator.A. EBP requires the following PPE: Gloves, Gowns, Face Protection if performing activity with risk of splash or spray. All PPE is donned and doffed with appropriate hand hygiene and disposable after individual use or when visibly soiled.B. EBP does not require any room restrictionsThe facility will post clear signage on the door or wall outside of the room indicating the type of precautions and required PPE (gowns and gloves). The facility will post signage that clearly indicates the high-contact resident care activities that require the use of gown and gloves. The facility will provide gowns and gloves immediately outside of the resident's room and position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. The facility will provide education to the facility staff on the implementation and procedure of EBP. The facility will perform periodic monitoring and assessment of the EBP procedures to determine additional training and education. The facility will provide education on EBP to residents and visitors.

Based on observation, interview, and record review facility failed to ensure residents were provided supervision and assistive devices to prevent accidents for 1 of (Resident #1) of 10 residents reviewed for accidents. The facility failed to ensure Resident #1 had adequate supervision to prevent a choking episode on 02/06/24 when CNA F left her lunch bag unsupervised out in the hallway. Resident #1 grabbed a granola bar from CNA F and choked, resulting in loss of consciousness. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 02/23/24. The IJ template was provided to the Administrator and DON. The IJ was removed on 02/23/24, but the facility remained out of compliance at a scope of isolated and a severity of potential of more than minimal harm that is not an Immediate Jeopardy, due the facility's need to monitor their plan of removal. This failure placed Residents at risk of choking. Findings included: Record review of Resident #1's face sheet dated 02/07/2024 revealed a [AGE] year-old male who was admitted on [DATE] with diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), mood disturbance, anxiety (feeling of fear, dread, and uneasiness), and dysphagia (difficulty swallowing). Record review of Resident #1's admission MDS assessment dated [DATE] revealed a BIMS score of 6, he was severely cognitively impaired who did not require any assistance with eating and was on a mechanically altered diet. Resident #1 was able to eat independently with no assistance and did not have a swallowing problem. Record review of Resident #1's physician order dated 01/10/2024 revealed a dietary order for level 5- minced/moist consistency. Record review of texture modifications guide (not dated) provided by facility revealed minced moist consisted of ground mechanical soft consistency, 4mm size particles and no bread. Record review of Resident #1's speech therapy dated 1/11/24 revealed diagnoses of dysphagia and suggested thin liquids with mechanical soft/chopped diet. Record review of texture modifications guide (not dated) provided by facility revealed mechanical soft consisted of soft was referenced as minced moist consistency, chopped was 1.5 cm size particles and no bread. Record review of Resident #1's care plan dated 01/14/2024 revealed Resident #1's care plan did not address the minced moist consistency it states it did not address regular consistency and had behavioral issues of wandering and entering other rooms. Record review of Resident #1's POC response dated 02/01/2024-02/06/2024 revealed no swallowing problems noted. Record review of Resident #1's progress note dated 02/06/2024 written by LVN C revealed [Resident #1] was brought to nurses' station due to being restless, resident was eating a granola and he started choking. Other nurse on board started Heimlich Maneuver on resident, [Resident #1] lost conscious approximately 30 seconds. [Resident #1] was laid on floor, nurse started one compression and [Resident #1] recuperated consciousness. Vitals blood pressure 160/108, pulse 104, respirations 16, oxygen 90% room air. EMS (Emergency Medical Services )was called [Resident #1] was transported to [local hospital], RP, DON, MD, PA notified. Record review of Resident #1's incident report dated 02/06/2024 written by LVN C revealed time of incident was 5:50 am and location was nurse's station. Type of incident was choking, MD was notified at 6:36 am, RP was notified at 6:14 am, and [Resident #1] was transported to hospital/ emergency room . Vitals signs taken were temperature 96 degrees Fahrenheit, pulse 73, respirations 22, blood pressure 160, 108. Incident described was [Resident #1] due to not staying and being restless was brought to nurses' station, had a snack, he was eating and started choking. Heimlich Maneuver performed and EMS called'. Record review of Resident #1's local hospital physician note dated 02/06/2024 revealed this is a [AGE] year-old male here s/p (status post) an episode of choking on a granola bar. Patient is in no acute distress and in in stable condition. Decision was made to de-escalate care and discharge to previous living arrangement was made due to acute uncomplicated illness/injury. Rationale reassessment at the time of disposition that patient is in no acute distress. Patient has remained hemodynamically stable (blood pressure and heart rate are stable) throughout the entire emergency department visit and is without objective evidence for acute process requiring urgent intervention of hospitalization . No necessity for further emergent imaging or laboratory analysis. The patient is stable for discharge. Record review of Resident #1's physicians order dated 02/06/2024 revealed a dietary order for level 4- puree consistency. Review of texture modifications provided by facility revealed pureed consisted of smooth, pudding like consistency. Record review of in-services dated 02/06/2024 for: minced moist snacks, checking diet before snacks, therapeutic diets, and do not enter kitchen after hours. Record review of Snack list for Texture Modified Diets (not dated) provided by facility revealed examples for minced moist snacks were minced fruit, cottage cheese, minced tune, minced egg, pudding, applesauce, yogurt, ice cream, and cereal moistened with excess milk drained. During an interview on 02/07/2024 at 8:23 am, the DON stated he had received a text yesterday morning (02/06/2024) from LVN C where she said Resident #1 had eaten a granola bar at the nurses' station and had a choking episode. The DON stated LVN C had also mentioned they had performed Heimlich Maneuver and he had lost consciousness for about 30 seconds, when brought down for compressions he [Resident #1] had regained consciousness and EMS had been called and was transported to hospital for further evaluation. The DON stated he asked her to complete the incident report. The DON stated he was still in the process of the investigation and was unclear on how he [Resident #1] had gotten the granola bar. The DON stated Resident #1 was on a minced moist diet. The DON stated Resident #1 food consistency was downgraded to puree upon return from hospital. The DON stated he was pending interview with LVN C and had already started in-services with staff on minced moist snacks, therapeutic diets, checking diets before snacks provided, and do not enter kitchen after hours to get a head start on possible outcomes. During observation on 02/07/2024 at 9:17 am, Resident #1 was in bed sleeping and no snacks were noted at bedside. During an interview on 02/07/2024 at 1:59 pm, Speech Language Pathologist stated Resident #1 was admitted on minced moist diet. Speech Language Pathologist stated she had evaluated Resident #1 the day after admission (01/11/2024) and had determined to continue the minced moist diet due to not having issues chewing and/or swallowing. Speech Language Pathologist stated she was made aware of Resident #1 choking yesterday (02/06/2024) on a granola bar. Speech Language Pathologist although the granola was soft, it was not moist and was not considered safe for Resident #1 to consume. During an interview on 02/07/2024 at 6:37 pm, LVN C stated she had worked night shift (10 pm-6 am) on 02/05/2024 going into the morning of 02/06/2024. LVN C stated Resident #1 had a minced moist food consistency ordered and had not had choking episodes prior to the incident on 02/06/2024 early morning. LVN C stated Resident #1 had woken up around 5:30 am due to an incident that occurred that required EMS activity and that noise had disturbed Resident #1's sleep . LVN C stated Resident #1 appeared restless and was placed in wheelchair and brought out to the hallway for staff the have eyes on him. LVN C stated the CNA F assigned to that hallway was going to start last rounds and had advised her she would be down the hall providing brief changes. LVN C stated she was at the nurse's station and had eyes on Resident #1 and had seen him standing up. LVN C stated she ran to Resident #1 to assist him back to his wheelchair, when she approached him (Resident #1) was going thru a lunch bag and asked him to put everything back. LVN C stated she then took Resident #1 with her to a different hallway on his wheelchair to have him closer for observation. LVN C stated as she was down the hallway to administer a medication to a different resident, she heard Resident #1 coughing. LVN C stated she turned and saw Resident #1 was choking and ran to start Heimlich Maneuver. LVN C stated she noticed crumbs on the floor and saw a granola bar wrap on the floor. LVN C stated LVN E was across the hallway and saw the incident and had approached to take over the Heimlich maneuver. LVN C stated when called EMS due to Resident #1 head dropped and lost consciousness for about 20 seconds. LVN C stated when his (Resident #1) head dropped and lost consciousness LVN E assisted him to the floor to start chest compressions. LVN C stated when Resident #1 was placed on the floor and LVN E started first chest compression, Resident #1 had regained conscious. LVN C stated when Resident #1 had regained conscious, he was alert and was able to answer questions. LVN C stated EMS arrived when Resident #1 had regained conscious and was still taken for further evaluation. LVN C stated the granola bar wrapper was from the snacks the facility usually provided to the residents and the texture was within his food consistency due to being soft. LVN C stated she reported to DON, RP and MD. LVN C stated she completed incident report and was later notified Resident #1 had returned to hospital with no injuries and/or concerns. LVN C stated she had asked CNA F to not leave her lunch bag out next time to address the unsupervised foods being a risk for residents. During an interview on 02/23/2024 at 8:35 am, the ADON stated after Resident #1 choking incident the facility provided in-services addressing following diets. The ADON stated it was not common practice for staff to leave their personal belongings anywhere unattended. The ADON stated she had verbally reminded staff to not leave any personal belongings unattended. The ADON stated the facility had not provided a written in-service to address personal belongings/ snacks left unattended. During an interview on 02/23/2024 at 9:27 am, CNA F stated she had worked the night shift (10pm-6 am) on 02/05/2024 going into the morning of 02/06/2024. CNA F stated Resident #1 had woken up at around 5:30- 5:45 am and had been restless. CNA F stated Resident #1 had history of falls and she placed him in his wheelchair outside in the hallway for more observation. CNA F stated when she had walked out of another unidentified room, she had noticed Resident #1 had a granola bar and did not take it away. CNA F stated she did not think Resident #1 would have been able to open the granola bar wrap. When asked why she thought that Resident #1 would have not been able to open the wrapper, CNA F only answered she just did not think Resident #1 would had been able to open the granola bar wrap. CNA F stated she did not know Resident #1 food consistency diet and stated she assumed he was regular because she had seen him well before. CNA F denied lunch bag left out in the hallway on top of a bedside tray table was hers. CNA F stated appeared defensive after that questions was asked and her answer were very short. CNA F stated there were snacks left behind out in the hallway on top of a bedside tray table by the previous shift. CNA F stated she had seen the snacks out in the hallway since the beginning of her shift. CNA F stated she did not remove the snacks from the hallway on top of a bedside tray table and should had placed them in a more secured place. During an interview on 02/23/2024 at 9:48 am, the DON stated after Resident #1 choking incident he had started in-service on diet textures, double checking diets before providing snacks and had started system to add labels to snacks. The DON stated he had not provided an in-service to address personal belongings/ snacks left out unsupervised. The DON stated expectations were to not to leave any personal belongings at nurses' station to include snacks. The DON stated the staff had a breakroom available to place their belongings. The DON stated there was a verbal notice to staff regarding personal belongings/ snacks being placed in a secured place, but no written in-service was completed. The DON stated CNA F should have checked the consistency for Resident #1 before leaving him with the granola bar. The DON stated CNA F should have removed the snacks from the hallway and placed in secured room. Record review of Nutrition Policies and Procedures: Therapeutic Diets (not dated) read in part Therapeutic and mechanically altered diets are ordered by the physician and planned dietician. A mechanically altered diet is a diet specifically prepared to alter the consistency of food to facilitate oral intake. Examples include 4- pureed, 5-minced moist, 6- bitesize, and 7 easy to chew. Use of therapeutic and mechanically altered diet is continually monitored to ensure they continue to be medically indicated. Evening snacks are planned to correspond with the therapeutic and mechanically altered diet unless contraindicated. Prepare and serve all therapeutic and mechanically altered diets as planned. Check trays for accuracy before they are served to the resident. The policy did not address snacks left unsupervised. The Administrator and DON were informed on 02/23/2024 at 1:08 PM that Immediate jeopardy (IJ) had been identified and copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested within the hour. The plan or removal was accepted on 02/23/2024 at 3:36 pm. The Plan of Removal revealed the facility took the following actions: 1. Resident #1 was immediately attended to at time of incident with appropriate measures taken place. Resident #1 was assessed immediately and sent to higher level of care for evaluation and treatment if indicated. Resident #1 returned on 2/22/24 and was receiving care per physician orders and plan of care. 2. Residents who reside at the facility who are cognitively impaired with dysphagia have the potential to be affected by this alleged deficient practice. An audit of residents who are cognitively impaired with dysphagia was completed by the Director of Nursing/designee to validate appropriate diets are being followed per order, appropriate interventions are in place to prevent choking incidents, interventions are on resident profile to communicate with facility personnel regarding assistance required. Any issues identified will be addressed upon discovery. Audit to be completed 2/23/2204. A facility wide observation was conducted to validate employee personal belongings were not stored in resident care areas. None discovered. Audit completed 2/23/2204. Beginning 2/8/24 snacks are placed in nutrition room allowing facility staff only to have access to snacks for distribution. 3. Director of Nursing and/or designee will re-educate Licensed Nurses and Certified Nursing Assistants on the following: 1. Employee personal belongings are to be placed in designated employee breakroom at all times. 2. Facility provided snacks are placed in nutrition room This re- education will be completed by 2/23/2024. Any Licensed Nurse or Certified Nursing Assistant not receiving this re-education by this date will receive prior to next scheduled shift. This information will be presented in new hire orientation. 4. Director of Nursing and/or designee to conduct random observation to validate no personal belongings are noted in resident care areas to ensure safety of the residents. Assistant Director of Nursing and/or designee will validate night shift no personal belongings in resident care areas to ensure safety of the resident. The above audits to be completed five days a week for four weeks, then weekly for an additional eight weeks then randomly thereafter, any issues identified to be addressed upon discovery. A QAPI meeting was held 02/23/2024. Facility Administrator will be responsible for the overall implementation and validation of this plan. Facility Medical Director will be informed of this plan and given progress updates. The Medical Director was notified of the Immediate Jeopardy on 2/23/2024. Observations, Interviews and Record Review to confirm implementation of the Plan of Removal were conducted as follows: Observations on 2/23/24: 3:52 pm, 400 hall no personal belongings/ snacks noted in the hallway/ med carts. 3:57 pm, no personal belongings/ snacks noted in nurses' station. 3:58 pm, 300 hall no personal belongings/snacks noted in hallway/med carts. 4:05 pm, kitchen no personal belongings/ snacks noted left out. 4:06 pm, no personal belongings / snacks noted in lobby area. 4:06 pm, 100 hall no personal belongings/ snacks noted in hallway/med cart. 4:07 pm, 200 hall no personal belongings/ snacks noted in hallway/ med cart. 4:11 pm, common area next to kitchen no personal belongings/snacks noted. Interviews on 2/23/24: 3:45 pm, called MD stated he was notified of IJ. 3:53 pm, LVN G- 2-10 pm shift, confirmed in-services on no personal items, no snacks, no drinks to be left in hallway, nurses' station, or med cart. Was told to utilize lockers in break room. If residents seen with food, verify texture to ensure they are following correct diet order. 3:55 pm, MA H - 6am-2 pm shift, confirmed in-services on no personal items, no snacks, no drinks to be left in hallway, nurses' station, or med cart. Was told to utilize lockers in break room. If residents seen with food, verify texture to ensure they are following correct diet order. 3:58 pm, LVN I, wound care nurse, confirmed in-services on no personal items, no snacks, no drinks to be left in hallway, nurses' station, or med cart. Was told to utilize lockers in break room. If residents seen with food, verify texture to ensure they are following correct diet order. 4:00 pm, LVN J 2pm-10pm shift. confirmed in-services on no personal items, no snacks, no drinks to be left in hallway, nurses' station, or med cart. Was told to utilize lockers in break room. If residents seen with food, verify texture to ensure they are following correct diet order. 4:02 pm, CNA K rotates 2pm-10 pm shift, confirmed in-services on no personal items, no snacks, no drinks to be left in hallway, nurses' station, or med cart. Was told to utilize lockers in break room. If residents seen with food, verify texture to ensure they are following correct diet order. 4:08 pm, MA L and CNA M, confirmed in-services on no personal items, no snacks, no drinks to be left in hallway, nurses' station, or med cart. Was told to utilize lockers in break room. If residents seen with food, verify texture to ensure they are following correct diet order. 4:21 pm, MDS Nurse A, stated she works night shift on the weekend and oversee the restorative aides, confirmed in-services on no personal items, no snacks, no drinks to be left in hallway, nurses' station, or med cart. Was told to utilize lockers in break room. If residents seen with food, verify texture to ensure they are following correct diet order. 4:24 pm, LVN D/ telephone- 10-6 shift, confirmed in-services on no personal items, no snacks, no drinks to be left in hallway, nurses' station, or med cart. Was told to utilize lockers in break room. If residents seen with food, verify texture to ensure they are following correct diet order. 4:40 pm, CNA F/telephone, did not answer left VM to return call. 4:43 pm, LVN N/telephone double weekends 6a-10p, confirmed in-services on no personal items, no snacks, no drinks to be left in hallway, nurses' station, or med cart. Was told to utilize lockers in break room. If residents seen with food, verify texture to ensure they are following correct diet order. 4:46 pm, LVN E/telephone 10-6 shift, confirmed in-services on no personal items, no snacks, no drinks to be left in hallway, nurses' station, or med cart. Was told to utilize lockers in break room. If residents seen with food, verify texture to ensure they are following correct diet order. 4:48 pm, ADON and DON, confirmed in-services on no personal items, no snacks, no drinks to be left in hallway, nurses' station, or med cart. Was told to utilize lockers in break room. If residents seen with food, verify texture to ensure they are following correct diet order. The DON and ADON stated they would have the binders with residents' census and diet orders for reference. The DON and ADON stated they would monitor 5 times a week at random to include all shifts. The DON and ADON stated any findings, if any, would be documented in calendar. The DON and ADON stated they both conducted audits and no concerns identified. The DON and ADON stated they both assisted with observations rounds earlier today with no concerns identified. The DON and ADON stated they both assisted with completing all staff in-services. The DON and ADON stated they were part of the QAPI held meeting today. 4:56 pm, Administrator, confirmed in-services on no personal items, no snacks, no drinks to be left in hallway, nurses' station, or med cart. Was told to utilize lockers in break room. If residents seen with food, verify texture to ensure they are following correct diet order. The administrator stated ADON and DON or designee would be conducting random observations 5 times a week to include all shifts and will document on calendar. The Administrator stated she was part of QAPI meeting held today. Record review: Reviewed QAPI (Quality Assurance and Performance Improvement) dated 2/23/24 at 1:20 pm revealed personal belongings secured. Facility floor plan with handwritten notes to address observation rounds dated 2/23/24 validated by nursing administration. Reviewed clinical diagnoses census used to cross reference diets dated 2/23/24 validated by regional clinical manager. Reviewed in-service dated 2/23/24: all snacks are to be placed in secured nutrition room, facility staff to pass out snacks. Reviewed in-service dated 2/23/24: verify snacks to ensure correct diet/texture is followed. Reviewed in-service dated 2/23/24:do not leave residents alone while eating. Reviewed in-service dated 2/23/24: no personal belongings should be at the nursing station, hallways, or med carts. Reviewed in-service dated 2/23/24: belongings should only be in the assigned area with placement in breakroom. Reviewed in-service dated 2/23/24: any items to include water bottles, mugs, backpacks, handbags, and storage bags to be stored in breakroom. The IJ was removed on 02/17/24 at 3:35 pm, the facility remained out of compliance at a scope of isolated and a severity of potential of more than minimal harm that is not an Immediate Jeopardy, due the facility's need to monitor their plan of removal.

Based on interviews and record reviews the facility failed to ensure a resident received adequate supervision to prevent and accident for 1(Resident #1) of 5 residents reviewed for accidents in that: Resident #1 sustained a laceration on her head from a fall after being left unattended in the bathroom, causing her to be sent to the hopsital resulting in 7 stitches. This deficient practice could cause harm to fall risk residents if adequate supervision is not being implemented. Findings included: Review of Resident #1's face sheet dated 04/17/2023 revealed an [AGE] year-old female that was admitted on [DATE]. Review of History and Physical dated 07/26/2022 revealed she had a history of falls due to a diagnosis of syncope (fainting due to low blood pressure or heart rate). It also revealed she required assistance with ADLs. Review of physician order dated 09/24/2020 revealed Toileting with assist of staff. Review of Quarterly MDS dated [DATE] revealed a BIMS score of 5. This indicated she had severe cognitive impairment with memory impairment. It also revealed she was totally dependent on staff for toileting and bathroom activities. Review of comprehensive care plan dated 12/14/2022 revealed Resident #1 was at risk for falls due to abnormalities of gait and mobility. Goal was for Resident #1 to be free from falls with interventions of increased staff supervision with intensity based on resident need and provide individualized toileting interventions based on needs/patterns. Review of fall risk assessment dated [DATE] revealed Resident #1 had scored a 50 indicating she was a high fall risk due to history of falls, weak gait, and forgetting limitations. Review of incident reports dated 02/12/23 at 11:18 AM, revealed Resident #1 had been found on the floor in the bathroom. She had received a laceration on her forehead and EMS had been called. Review of nursing progress note dated 02/13/2023 at 11:18 AM, written by LVN E revealed Resident #1 was found on the floor with a laceration on her head. Resident #1 stated she fell forward and unto her head while sitting on the toilet. Swelling was noted on her left eye and bruising to right knee. EMS was called and Resident #1 was assessed by physician. Review of nursing progress note dated 02/14/2023 at 11:36 AM, written by LVN F revealed Resident #1 was assessed after returning from the hospital post-fall. Resident #1 had a laceration to her left forehead with a measurement of 4.5 cm. She received 7 stiches for her laceration, with bruising and swelling still present. In an interview on 04/14/2023 at 4:20 PM with Resident #1, she revealed she fell in the bathroom and hit her head but could not remember how she had done so. She stated the staff had placed her on the toilet, told her not to get up and left her in the bathroom. She stated she got a cut on her forehead. In an interview on 04/17/2023 at 9:10 AM with CNA A, revealed that on 2/13/23 she was assisting another resident when her co-worker asked her for assistance with taking Resident #1 to the bathroom. She stated she went to Resident #1's room and assisted her co-worker into placing Resident #1 in the bathroom. Once Resident #1 was on the toilet, she walked out and went back to her resident. She stated she was not sure if her co-worker had remained in the bathroom with the resident when she walked out, but assumed she had. She stated she had been taught to stay in the bathroom for residents who were fall risk, because they could have a fall while trying to get up from the toilet. In an interview on 04/17/2023 at 10:00 AM with LVN B, she revealed the process for taking residents who are a fall risk to the bathroom was to first ask for help from a co-worker to take the residents to the bathroom. Once they were on the toilet, they staff member was to stay in the bathroom to ensure they do not fall. She stated it was policy to do so. She revealed that for residents that would not require assistance, the staff would stay by the door because sometimes they would forget to press the bathroom call light to ask for assistance. In an interview on 04/17/2023 at 10:26 AM with MA C, she revealed that when assisting a resident to the bathroom, the staff had to remain close to the bathroom and not leave them alone because they could fall. She could not remember the date or when the training had occurred. In an interview on 04/17/2023 at 3:54 PM with DON, revealed that for high-risk residents, staff knew to not leave the residents by themselves and to check on them more frequently because there was a possibility that they could fall. She stated the process was for the staff to stay with them to ensure they are safe. Review of facility's policy titled Fall Management dated 2022 read in part .The Fall Risk Evaluation assists in identifying the appropriate preventative interventions that will be initiated by the facility to assist in fall prevention for the resident .the facility provides therapies based on individual resident needs to facilitate mobility .safe toileting .to assist the resident with fall prevention .

Based on observation, interview and record review the Facility failed to ensure that the resident environment remained free of accident hazards and that each resident had adequate assistance devices to prevent accidents for one (Resident #1) of eight residents reviewed for a hazard free environment and adequate assistance devices. Facility staff failed to ensure Resident #1's Right-Side Swing Away [MEDICAL CONDITION] Support (residual limb support) with a broken latch on her wheelchair was promptly replaced or repaired. Resident #1's residual limb support was not replaced or repaired until investigation by a state surveyor began. On 12/19/2019 Resident #1 fell from her wheelchair when the right residual limb support swung open unexpectedly resulting in an oblique nondisplaced distal tibia fracture of her right lower residual limb. An Immediate Jeopardy (IJ) was identified on 01/08/2020 at 7:46 PM. While the IJ was lowered on 01/09/2020 at 3:54 PM the facility remained out of compliance at a severity level of actual harm at a scope identified as isolated due to the facility's need to monitor its corrective actions for effectiveness, and to ensure all staff received a scheduled training. This failure could put other residents at increased risk of injury or death due to accident hazards and inadequate assistance devices. Findings include: Review of Resident Face Sheet dated 12/17/2019 documented Resident #1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. Review of Physician's Progress Note dated 05/24/2019 documented Resident #1 had decreased muscle strength, a right [MEDICAL CONDITION] with cast, alert and oriented times three, debility, anxiety disorder, Major [MEDICAL CONDITION], pressure ulcer of sacral region, amputated below knee - right leg, Restless Leg Syndrome, Hypertension and Diabetes Mellitus Type 2. Review of Quarterly MDS dated [DATE] documented Resident #1, Hearing adequate; clear speech; makes self understood, understands others, adequate vision, BIMs (Brief Interview for Mental Status) score 11 (moderately impaired); required extensive assistance of one person with bed mobility, locomotion off unit, dressing, toilet use, and personal hygiene; total assistance of two persons with transfer; total assistance of one person with bathing; supervision with eating; Balance During Transition and Walking: Surface-to-surface transfer (transfer between bed and chair or wheelchair) Code: 2 (not steady, only able to stabilize with staff assistance; Functional Limitation in Range of Motion: Lower Extremity-Impairment on both sides; Mobility Device: Wheelchair; Incontinent of bowel and bladder; Diagnoses: [REDACTED]. Review of Resident #1's Care Plan dated 12/19/2019 documented Problem Start Date: Resident #1 had a fall on 12/19/2019. Approaches: Implement exercise program that targets strength, gait and balance; Increased staff supervision with intensity based on resident need; and Provide individualized toileting interventions based on needs/patterns. Problem Start Date: documented 12/09/2019 resident #1 had a bruise to her left hand. Approaches: Wound team to determine etiology, evaluate wound(s), treatment(s), and healing weekly. Problem: Revised 01/06/2019 documented I have and ADL (activities of daily living) self-care performance deficit. Interventions: assistance from one staff member to transfer, total dependence on staff to bathe and dress; extensive assistance from one staff member tor turn and reposition in bed and for toileting. There was no care plan to address her pressure ulcer or her bilateral below-the-knee amputations. Review of Quarterly Fall Risk assessment dated [DATE] for Resident #1 documented: Total Fall Risk Score: 13. Level: Moderate Fall Risk. Resident #1's specific fall risks included her age; incontinence of bowel and urine, the number and type of medications she was taking; requiring assistance and supervision for mobility, transfer or ambulation; unsteady gait; and altered awareness of her immediate physical environment. Review of Situation, Background, Assessment, Recommendation (SBAR) Communication Form dated 12/09/2019 documented that Resident #1 had a bruise to her left hand and an open area to her back and would be referred to wound care for assessment and orders. Review of Nurse's Progress Notes for Resident #1 dated 12/09/2019 written by Licensed Vocational Nurse (LVN) D documented: Nurse noted resident with bruise to her left hand, upon assessment, resident stated the leg rests to her wheelchair sometimes become loose and she tries to fix them herself instead of calling for help, verbalized that's how the bruise to hand happened. Review of Nurse's Progress Notes for Resident #1 dated 12/09/2019 written by LVN F documented: wound assessment completed, noted previous wound site to sacrum reopened, stage 2 measuring 2.8 x 1.0 x 0.1 cm (centimeters), scant serous drainage noted, resident states she feels she has been shearing/causing friction when attempting to reposition self in wheelchair when leg rests move, notified maintenance. Review of the facility Maintenance Log for 12/08/2019 through 01/03/2020 documented: 12/09/2019 Location: 306-A (Resident #1's room and bed); Request Description: leg rests not locking - therapy states they have the piece that broke off. Complete: No leg rests on chair. Review of Resident #1's Physician order [REDACTED]. Wound Treatment 12/9/2020 - 12/15/2019: Cleanse PU (pressure ulcer) to sacrum with normal saline, pat dry, apply collagen and cover with [MEDICATION NAME]. Wound Treatment 12/23/2020 - 12/27/2019: Cleanse PU to sacrum with Normal Saline, pat dry, apply collagen and cover with protective dressing. Review of a Nurse's Progress Notes for Resident #1 dated 12/19/2019 written by LVN O documented: Resident resting in bed. No c/o (complained of) pain noted or reported by resident at this time. 2-10 nurse reported resident stated that she had fallen during dinner off her chair in room, and that another resident was passing by her room and assisted her to get on her wheelchair. NP and DON notified. Review of Nurse's Progress Notes for Resident #1 dated 12/19/2019 written by LVN P documented: After dinner while this nurse was checking resident's B/S, resident reported she had fallen during dinner off her chair in room, and that another resident was passing by her room and assisted her to get on her wheelchair. This nurse initiated head to toe assessment, no injuries found resident voiced pain to right knee. This nurse administered PRN medication as per MAR. DON notified and NP notified. Review of the Provider Investigation Report dated 12/30/2019 documented: 12/19/2019 at about 9:30 PM Resident #1 reported that she fell from her wheelchair earlier in the evening while attempting to get water from her night stand. She was picked up by another resident and returned to her wheelchair. On 12/20/19 Resident #1 complained of pain in her right stump and an x-ray was ordered which revealed an oblique nondisplaced distal tibia fracture. In response to the x-ray an order was received to transport Resident #1 to a local emergency room for further evaluation and treatment. Resident #1 returned to the facility on [DATE] with a cast to the right stump due to the right oblique distal tibia fracture. During the facility investigation into the resident's fall Resident #1 stated her leg rest swung open and when she leaned forward in her chair she fell . The resident was counseled not to place a pillow case on top of her wheelchair cushion as this could cause slipping. The Investigation Report documented that Resident #1's wheelchair was switched out for another wheelchair with proper functioning leg rests. Review of Resident #1's Situation, Background, Assessment, Recommendation (SBAR) note dated 12/20/2019 documented that she was experiencing bruising, pain and swelling to her right knee as evidenced by new pain at an 8 out of 10 level, grimacing and groaning. Review of Nurse's Progress Notes for Resident #1 dated 12/20/2019 written by LVN D documented: resident complained of pain to right leg, upon assessment, nurse noted bruising and swelling to below knee, resident has BKA, as per report resident stated she had a fall on 12/19/19 where another resident assisted her back onto w/c , nurse administered prn dose t3, NP notified, new order for stat x-ray. Review of Resident #1's Physician order [REDACTED]. Stat X-ray of the right knee dated 12/20/2019 Stat x-ray of the right leg/stump dated 12/20/2019 Review of a radiology report for Resident #1 dated 12/20/2019 documented that an X-ray indicated that the resident had an oblique nondisplaced distal tibia fracture. Review of a nurse's Progress Note for Resident #1 dated 12/20/2019 documented in response to the x-ray the physician gave an order to transport the resident to the hospital for further evaluation. Review of a nurse's Progress Note for Resident #1 dated 12/21/2019 documented that the resident returned from the hospital with a cast applied to the right stump for the oblique distal fracture. In an interview/observation on 01/07/2020 at 8:50 AM Resident #1 stated that in early (MONTH) she was alone in her room when she fell from her wheelchair as she reached for a glass of water and the leg rest (residual limb support) for her right leg suddenly swung open. She stated that she had mentioned that the leg rest was broken to many staff members and it still was not fixed. Resident #1 was observed to have bilateral below-the-knee amputations (BKAs) and her right lower residual limb was in a cast. In an interview/observation on 01/07/2020 at 11:32 AM, Resident #1 was observed seated in a wheelchair in her room. CNA A was present and stated that this was the wheelchair with the broken residual limb support. Observation of the wheelchair revealed that there was white tape wrapped around a portion of the right residual limb support where it attached to the wheelchair. Comparison of the left residual limb support with the right residual limb support revealed that there was a yellow lever present on the left residual limb support that was not present on the right residual limb support. CNA A verified that this was Resident #1's wheelchair. Resident #1 stated that this was the wheelchair from which she fell , as she had mentioned earlier in the day (01/07/2020 at 8:30 AM). Review of the Installation Guide for the (company name) Swing Away [MEDICAL CONDITION] support accessed on 01/14/2020 (https://www.spinlife.com/files/[MEDICAL CONDITION].pdf) diagrammed the support the mechanism which allowed the limb support to swing open. It included a swing plate with a yellow keeper - a small lever which extended out from the swing plate. The document stated that the yellow keeper locks the swing away assembly into position, and that pressing the yellow keeper would unlock the swing away assembly. To lock the swing away assembly, swing it toward the center of the wheelchair until the keeper locks into position. In an interview on 01/07/2020 at 11:15 AM CNA A stated that Resident #1 had mentioned the broken residual limb support on the wheelchair to her daily. CNA A stated that the lever that locked the leg rest in place was broken. CNA A stated that the resident still had the same wheelchair and that it was still broken. She stated she told the Central Supply Manager that the resident's leg support was broken in (MONTH) of 2019. In an interview on 01/08/2020 at 3:24 PM LVN F stated that she initially discovered there were issues with Resident #1's right residual limb support before 12/09/2019 when the limb support was jammed and would not open. LVN F stated that Resident #1 kept readjusting herself in her chair because of the jammed limb support, resulting in skin shear and reopening of an old wound to the resident's sacrum. LVN F stated she reported this to an unnamed therapist who told her that Therapy was already aware of the broken residual limb support. On 12/09/2019 LVN F noticed that the residual limb support was now swinging open unexpectedly and mentioned it to Therapist G who told her to write it down in the Maintenance Log which she did. LVN F was subsequently out of the facility for vacation and she when returned was advised that the resident's skin shear had healed, and the resident had since fallen. In an interview on 1/7/2020 at 12:18 PM and 01/08/2020 at 11:30 AM the Maintenance Director stated he reviewed the Maintenance Log dated 12/09/2019 indicating that Resident #1's right residual limb support was broken but that when he went to look at the wheelchair the residual limb supports were not on it. He stated he verified with Therapy that the Resident #1 was wheelchair was supposed to have limb supports. He stated he did not follow up or take any action regarding the residual limb supports because shortly after looking at the wheelchair to repair the left residual limb support he went on vacation. In an interview on 01/08/2020 at 10:30 AM Physical Therapist (PT) [NAME] stated that he noticed on 12/11/2019 that Resident #1's right side residual limb support was broken and kept swinging out and that at that time he spoke with the Central Supply Manager to order a new part. In an interview on 01/07/2020 at 4:49 PM CNA C stated that Resident #1 had mentioned that the limb supports on her wheelchair would open unexpectedly. CNA C said that the last time the resident mentioned the problem with the limb supports was about two weeks prior to the interview. CNA C stated she had mentioned this problem to an unnamed nurse. In an interview on 01/09/2020 at 10:10 AM CNA H stated that on 01/05/2020 she noticed that Resident #1's right residual limb support was not locking. The CNA was transferring the resident to her wheelchair and noticed that the limb support was missing the little lever on the side. She stated that she mentioned the broken limb support to the nurse on duty who said that the broken support had already been reported. In an interview/record review on 01/08/2020 at 11:00 AM the Central Supply Manager stated he had received a text from the Activities Director stating that Resident #1's residual limb support was broken and kept swinging out. He stated he believed he received the text on 12/20/2019. He stated that the residual limb support part had not been ordered because he had been trying to find out if they could replace the broken piece of the part and not have to replace the whole residual limb support. He stated that he had ordered the residual limb support part on 01/07/2020 and provided the surveyor a copy of the Purchase Order for the residual limb support. The Purchase Order documented that the Central Supply Manager ordered a (company name) Swing Away [MEDICAL CONDITION] Support w/ Pad on 01/07/2020. In an interview on 01/08/2020 at 11:20 AM the Activities Director stated that on 12/20/2019 she reported a problem with Resident #1's wheelchair to the Central Supply Manager because the resident said the chair was uncomfortable and that she fell in her room as a result. In interviews on 01/08/2020 at 11:42 AM and 01/08/2020 at 12:18 PM Assistant Director of Nurses (ADON) B stated that while investigating Resident #1's fall on 12/20/2019 ADON B stated that during the investigation of the fall on 12/20/2019 she became aware that the broken right residual limb support was originally documented on 12/09/2019 when the resident bruised her hand trying to fix the broken part. When ADON B went to assess Resident #1, the resident was no longer in a wheelchair with a broken right residual limb support. She did not know how or when the wheelchair with the broken right residual limb support returned to use by Resident #1. ADON B did not know if any action had been taken between 12/09/2019 and 12/20/2019 to repair or replace the broken right residual limb support. In an interview on 01/06/2020 at 3:00 PM the Facility Administrator stated that she was leaving town to attend a training and that in her absence the Director of Nurses and Regional Vice President would be in charge and able to answer any questions. In interviews on 01/08/2020 at 12:43 PM and 01/09/2020 at 3:01 PM the Director of Nurses (DON) stated that on 12/9/2019 a nurse noted in the Maintenance Log that Resident #1's residual limb support was broken, and that between 12/9/2019 and 12/20/2019 nothing was done to address the issue. She stated that not having the residual limb support repaired probably contributed to the resident's fall. She stated that as part of the investigation of the resident's fall on 12/20/2019 ADON B and the Facility Administrator had gone to the resident's room and, not seeing limb supports on her wheelchair, thought the broken limb support had been replaced or repaired. She stated that she became aware yesterday (01/08/2020) that Resident #1 still had the wheelchair with the broken residual limb support. Review of the facility's policy Nursing Policies and Procedures; Subject: Fall Management dated 3/29/2019 documented that the facility will identify residents who are at risk for falls and plan care and implement interventions to manage falls. The facility will provide assistive devices based on individual resident needs to facilitate mobility and prevent falls. If a fall occurs staff evaluates the resident and determines what may have caused the fall, including ascertaining what the resident was trying to do before the fall. The facility would address risk factors for the fall such as the resident's medical condition and issues in the facility environment and determine appropriate interventions to prevent future falls. A policy regarding repair and maintenance of durable medical equipment was requested three times from the DON (Administrator Designee) and Regional Vice President. The policy was not received at the time of exit. Review of the facility's policy Maintenance/Housekeeping Policies and Procedures, Subject: Biomedical Equipment Management Program dated 3/2006 documented in the Procedures Variance Reporting that: Whenever an out-of-limit condition is found during the safety testing inspections, the equipment is immediately taken out of service and either repaired in the center or is returned to the manufacturer for repair. If the equipment cannot be removed immediately due to its size or function, the device is red-tagged until it is repaired to prevent it from being placed in service before repairs are completed and the Director is notified about the variance. An IJ was identified on 01/08/2020 at 7:46 PM. The DON (Administrator Designee) and Regional Vice President were informed. IJ template was given to the DON. Plan of removal was accepted on 01/08/2020 at 11:51 PM and included the following: 1. Affected resident's broken adaptive equipment was removed and a therapist evaluated and provided an operable Right side swingaway [MEDICAL CONDITION] support on 1/7/20. Medical Director will assess the resident by 1/9/20 and review and approve the adaptive equipment for safety. Provider was notified of the event. No new orders received. 2. Residents who utilize wheelchair adaptive equipment have the potential to be affected by the alleged deficient practice. 100% audit was conducted on 1/8/20 by nursing management to identify all wheelchairs in the facility. 100% audit was initiated 1/8/20 and will continue early 1/9/20 by therapy to evaluate all wheelchair adaptive equipment and validate operable condition. A 90-day look back of the maintenance log will be completed by the Administrator or designee and the Maintenance Director to validate that no other repairs are needed. This will be completed by 1/9/20. Any discovered broken equipment will be removed from operation and clearly marked with a red tag and stored in a designated area. The resident who may be affected by the removal of the equipment will be evaluated by therapy for safety with alternate adaptive equipment. 3. Clinical staff and interdisciplinary team received re-education on immediate removal, clearly marked labeling and reporting of inoperable broken equipment utilizing the maintenance log. Therapy will be contacted in the event of inoperable equipment for evaluating and recommending alternate equipment. If no therapy is in the facility the director of nursing will be contacted for direction. This re-education will be completed by 1/9/20. Any staff member not re-educated by this date will be re-educated prior to start of next shift. The Maintenance Director was re-educated on 1/8/20 by the Director of Nursing on daily review of the maintenance log and communicating status of repairs to Department heads. 4. The Maintenance Director or designee will review the maintenance log daily and address new entries timely. After the repair is completed, maintenance director will alert a Nurse Manager to inspect and approve the repaired equipment. Nurse Manager will co-sign the repair. The Maintenance Director or designee will bring the log to morning stand-up Monday-Friday and report all communicated repairs to Department heads. The administrator will review and validate that any entry in the maintenance log has been addressed. This review will occur daily Monday through Friday for 4 weeks then weekly for 2 months. 5. Ad Hoc Quality Assurance Performance Improvement was held on 1/8/20. The Medical Director was notified of the Immediate Jeopardy and this plan on 1/8/20 Results of these audits will be presented to the Quality Assurance Performance Improvement Committee for review and recommendations monthly for 3 months. Monitoring: Confirmed through observation of the wheel chair with residual limb support and interview with Resident #1 on 01/09/2020 at 9:50 AM and interview/observation with COTA N on 01/09/2020 at 3:19 PM. On 1/9/2020 at 2:07 PM interview with Maintenance Director and record review confirmed 100% audit identifying all wheelchairs in the facility and 100 % therapy evaluation of all wheelchair adaptive equipment and validating operable condition. Verified clinical staff and interdisciplinary team received re-education on immediate removal, clearly marked labeling and reporting of inoperable broken equipment utilizing the maintenance log through sixteen staff interviews (five CNAs - 6:00 AM-2:00 PM; three CNAs - 2:00 PM to 10:00 PM; two LVNs - 2:00 PM to 10:00 PM; one RN- 6:00 AM to 2:00 PM; one Activities staff member; two Therapy staff members; one Housekeeping staff member; one Maintenance staff member). Questions asked of the direct care staff included the following: Were you aware Resident #1's wheelchair was broken? If so, who and when did you report it to? What actions were taken by the nursing home? If you did not report your concerns, why not? What action should be taken if you identify broken equipment? Questions asked of the supervisory staff included the following: How do you monitor and provide oversight in order to assure equipment is in good working order? What do you do if a broken piece of equipment is identified? What is your response if a resident is using a piece of broken equipment? Questions asked of the DON (Administrator Designee) included the following: What policies/procedures were in place regarding equipment repair and how have these been revised to address broken equipment? How will you monitor to ensure that the revised system is effective? In-services of staff with the following titles/topics were confirmed though interview and record review: Proper use of adaptive equipment - 01/09/2020 Procedures for faulty equipment and communication - 01/08/2020 Malfunctioning equipment (logged onto maintenance log, completion of Communication Form, removal from floor, attaching red tag, placing in room [ROOM NUMBER] - 01/08/2020 Equipment Management Program - 01/08/2020 Angel Caregivers will check and report broken equipment in IDT daily - 01/08/2020 Verified through interview and record review that the Maintenance Director was re-educated on 1/8/20 by the Director of Nursing on daily review of the maintenance log and communicating status of repairs to Department heads. Verified through interview that the Maintenance Director or designee will review the maintenance log daily and address new entries timely. On 01/09/2020 at 3:54 p.m. the DON was informed the IJ was lowered. Although the IJ was lowered the facility remained out of compliance at a severity level of actual harm at a scope identified as isolated due to the facility's need to monitor its corrective actions for effectiveness, and to ensure all staff received a scheduled training.

Based on observation, interview and record review the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #47) of 21 residents reviewed for accidents. The facility failed to perform a 2 person transfer with a lift as required for Resident #47. On 1/23/19 Certified Nurse Aide (CNA) A attempted to perform a 1-person transfer, without a mechanical lift, on Resident #47 who required a 2-person transfer with a mechanical lift. CNA A was unable to complete the transfer and with assistance lowered Resident #47 to the floor. The resident was lifted onto a shower chair by CNA A and 3 other staff without notifying Licensed Vocational Nurse (LVN) D. On 1/25/19 when Resident #47 indicated she was in pain, an x-ray was ordered. The results came back on 1/26/19 documenting Resident #47 had a fractured left humerus (upper arm). This was determined to be past non-compliance immediate jeopardy from 1/23/19 to 1/26/19 due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents who require a 2 person transfer, with or without a mechanical lift, at risk of injury. The findings included: Review of the face sheet dated 2/26/19 documented Resident #47 was an [AGE] year old female admitted on [DATE] and readmitted on [DATE]. Review of the facility History and Physical dated 10/06/18 documented Resident #47 had [DIAGNOSES REDACTED]. She is deaf and dumb. Patient is bed bound. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #47 was not assessed for speech and cognitive patterns, had no behaviors, was a total dependence of 2 persons for transfer and had no falls. She weighed 120 pounds and was 61 inches tall. Review of Resident #47's care plan dated 1/03/19 revealed he following: Problem: I have an ADL self-care performance deficit related to [MEDICAL CONDITION]. Interventions included Transfer: The resident requires Mechanical lift - Hoyer with 2 staff assistance for transfer. Date initiated: 1/03/19 Review of the Nurse Practitioner's (NP) progress note dated 1/23/19 (prior to the incident) documented Resident #47 denied pain and had no concerns at that time. NP J documented Resident #47 had muscle weakness and decreased muscle strength. She had mild swelling of the left arm but no [DIAGNOSES REDACTED] (redness). Review of Nurse Practitioner (NP) J's progress note dated 1/25/19 documented Resident #47's chief complaint was pain in the left arm. There was no mention of a fall. There was documented swelling and redness of the resident's left arm. The plan was to get an x-ray and start [MEDICATION NAME] gel. Review of the Incident /Accident Action Plan dated 1/26/19 revealed Resident #47 was transferred without use of Hoyer, lowered to floor by CNA in controlled fall. Appropriate safety precautions and devices were not in place. Review of the Provider Investigation Report dated 2/1/19 revealed Resident #47's functional ability was total assistance, required no special supervision, was not independently ambulatory, not interviewable and did not have the capacity to make informed decisions. An incident occurred on 1/23/19 at 9:30 AM. The investigation summary stated CNA transferred Resident #47 by herself without Hoyer on 6-2 shift on 1/23/19 from the bed to the shower chair when she was going to take her (Resident #47) to the shower. The shower chair moved and she was not able to maintain control of patient and was forced to lower her to floor in controlled fall. During this time she yelled for help and other staff responded including a housekeeper, CNA and Med Aide. At this time the CNAs and Med Aide picked Resident #47 up and placed her onto the shower chair while the housekeeper held it still. Resident #47 was then showered and returned to bed. Incident was reported to Charge Nurse by CNA B, CNA A and Med Aide. An incident report was not completed at this time nor was any documentation of the event. Friday (1/25) the nurse had the NP see the resident for complaints of pain another CNA had reported while giving Resident #47 a bed bath. Orders were obtained for an x-ray. X-ray results were reported Saturday (1/26) morning as a positive fracture to the humerus. Provider Action Taken Post-Investigation - Termination of CNA initially transferring Resident #47; Termination of Nurse; Continued in-servicing and education with all staff and Report of Incident to Board of Nursing/CNA registry for Nurse and CNA. Review of the mobile Radiology Report dated 1/25/19 documented Resident #47 had an acute fracture involving the humeral neck with displacement. Review of the hospital x-ray report dated 1/26/19 documented Resident #47 had diffuse demineralization of the (left) humerus. Comminuted slightly impacted [MEDICAL CONDITION] humeral neck. There was no dislocation. Review on 2/27/19 of CNA Proficiencies for CNA A revealed she had been trained on both the Invacare Hoyer and the Hydraulic Hoyer on 5/08/18 and 12/09/18. Review of an interview dated 1/26/19 at 6:15 AM, told by CNA A and written by Assistant Director of Nurses (ADON) F revealed CNA A on Wednesday 1/23/19 at 9:30 AM was getting Resident #47 up to transfer her to the shower chair, the shower chair moved and I called for help. (Med Aide C) and (CNA B) went to help me. I had (Resident #47) on my arms, I was holding her with my arms wrapped around her waist and I sat her down on the floor. (Med Aide C) and (CNA B) helped me. (Med Aide C) for her left arm. I got her from her right arm and (CNA B) was holding her from her legs with a pillow case for support. When I showered her (CNA B) helped me transfer her to the bed. I went with (LVN D) and he went to check her. He moved her hand and she (resident) did not complain of pain. A telephone interview on 2/27/19 at 8:25 AM was attempted with CNA A but she hung up the phone when the surveyor identified herself and the purpose of the call. Review of an interview conducted on 1/27/19 at 1:40 PM, told by LVN D, written by ADON F and witnessed by Former Administrator V, was as follows Question: What happened with (Resident #47) on Wednesday 1/23 Answer: Nothing Question: No one reported anything to you about a fall or transfer? Answer: No Question: What happened Friday with (Resident #47)? Answer: (CNA I) reported that she was moaning and groaning when she moved her arm. She has arthritis and it's her non-dominant hand, it gets swollen. (Nurse Practitioner (NP) J) ordered an x-ray and [MEDICATION NAME] gel. ([MEDICATION NAME] Gel contains [MEDICATION NAME], a nonsteroidal anti-[MEDICAL CONDITION] drug (NSAID). [MEDICATION NAME] works by reducing substances in the body that cause pain and inflammation. [MEDICATION NAME] Gel is used to treat joint pain caused by [MEDICAL CONDITION] in the hands, wrists, elbows, knees, ankles, or feet.) Question: 3 staff members report that you were told about an assisted fall. Are you sure you don't know anything? Answer: No. It was a very busy shift but I don't recall that. Question: Did you notice any discoloration or asymmetry? Answer: No Question: Anything different with (Resident #47) on Thursday? Answer: No. Question: Why do you think it was arthritis? Answer: We had gotten a few other xrays on her due to arthritis and since it's cold weather I figured it was the sane thing. An attempt was made to contact LVN D but he did not return the call. Review of the Orthopedic Physician's note dated 2/5/19 revealed Resident #47 had left-sided [MEDICAL CONDITION] due to [MEDICAL CONDITION]. The physical exam revealed Resident #47 was tender to palpation over the proximal left arm with swelling and echymosis. The x-ray showed left proximal humerus fracture displaced at the level of the surgical neck with slight apex anterior angulation. [MEDICAL CONDITION] was noted as well. Observation on 2/25/19 at 9:58 AM, Resident #47 was lying in bed with the head of the bed elevated and a low air loss mattress was on the bed. She received oxygen via a nasal cannula at 2 liters/minute. There was a tube feeding infusing at 70 cc/hour into her gastrostomy tube. The resident's left arm was straight and had a sling around it. CNA I came into the room and adjusted the sling to bring the left arm closer to the chest. This awakened the resident and she shook her right fist towards the CNA. Resident #47 did not move her left arm. In an interview on 2/26/19 at 4:09 PM, CNA G said Resident #47 could not be transferred by 1 person because she has paralysis on her left side and required a Hoyer lift. The resident cannot help. In an interview on 2/28/19 at 8:22 AM, Housekeeper U said she was at the threshold of the next room when she heard CNA A call for Med Aide C. She looked into Resident #47's room and saw CNA A holding Resident #47 from underneath her shoulders and the two were between the bed and the shower chair. She went in and Med Aide C told her to get the shower chair. There were no brakes on the chair and it moved. Another CNA came in and CNA A and Med Aide C had their arms under the resident's armpits and the free hand held onto a sheet that had been placed underneath the resident. The other CNA had the sheet at the resident's legs and they lifted her into the shower chair. Resident #47 moaned, which was her norm, but did not scream. Housekeeper U said Resident #47 would scream to get attention. In an interview on 2/27/19 at 8:56 AM, CNA B said said she heard Med Aide C call for help. She went into Resident #47's room and the resident was on the floor. There was no Hoyer lift in the room and Resident #47 was a Hoyer lift with 2 people. Med Aide C on the Resident's left arm and CNA A on right and She (CNA B) had the legs and they lifted the resident into the shower chair while Housekeeper U held chair. CNA B said she did not know if LVN D had been told of the fall before they picked Resident #47 up. CNA B said she was trained to tell the nurse before getting a resident off of the floor. CNA B said Resident #47 did not act like she was in pain and did not point to her arm. She did not feel the resident showed any increase in pain when she helped on subsequent days. CNA A said she would tell LVN D, but CNA B said Med Aide C told LVN D. On Saturday 1/26/19 ADON F called her in and she told her what happened. CNA B said she was suspended for Saturday to Tuesday. CNA B said she always uses 2 people to help with/Hoyer and there is always someone available to help. In an interview on 2/27/18 at 9:18 AM, Medication Aide (MA) C said she was doing her med pass. Housekeeper U called said CNA A needed her. MA C said Resident #47 was heavy and CNA A had the resident off of the bed with her arms under the resident's arms and was putting her on the floor. MA C said she told CNA A to continue the resident to the floor. MA C said she got CNA B. MA C said they were going to lift the resident into the bed but the shower chair was there. MA C said they should have called LVN D, but didn't. CNA A said was going to tell LVN D but we all should have. CNA A still showered her and MA C asked CNA A if she told LVN D and she said no. MA C said she went over to LVN D and LVN D said CNA A told him Resident #47's arm was hurting. MA C said she told LVN D the whole story. He said he was going to assess her. He got up and went down the hall but she did not see him go into the room. She kept asking him how Resident #47 was and he said fine. He said she has arthritis and has been complaining about that. On Friday (1/25/19), NP J was here and LVN D said he would ask him to see Resident #47. NP J ordered an x-ray. MA C said she came in Saturday and the x-ray report had come in at 6 AM and ADON F gathered every one up. LVN D denied that MA C had told him about the incident. CNA A said she did tell him. MA C said CNA A put everyone in a predicament. MA C said CNA A never asked for help. In an interview on 2/27/19 at 9:32 AM, LVN E said she did not know Resident #47 had fallen. There was nothing passed on in report about a fall. She said Resident #47 would complain of pain when she was turned but it would subside. She would complain of pain about the time her [MEDICATION NAME] was due. LVN E said she administered the [MEDICATION NAME] and the resident seemed to get relief. LVN E said the CNAs could tell when she was in pain as she would grimace. She had a communication book and sometimes she would use it to communicate use it and the resident also has a sign for pain and can point to where there is pain. LVN E said those abilities were not an every day thing. LVN E said the CNAs are trained to alert the nurse when someone falls and they are supposed to leave the resident where they are until the nurse assesses and vital signs are taken. If then there is no obvious/suspected injury, they can get the resident up. In an telephone interview on 2/27/19 at 1:08 PM, CNA I said she was giving Resident #47 a bed bath on 1/25/19 and she was moaning and crying. CNA I said she noticed the resident's arm was pink and swollen and when she elevated the arm the resident screamed in pain which was not normal for her. CNA I said she told LVN D about the pain and he looked at Resident #47 and said he would tell the doctor because he was here. CNA I said Resident #47 was a 2 person transfer with a Hoyer and always 2 is the rule for Hoyers. If a patient falls she is supposed to call the nurse and not reposition until the nurse looks at the patient. In a telephone interview on 2/27/19 at 10:55 AM, Weekend Supervisor, ADON F said she received a call from LVN W who had received the x-ray results at 5:35 AM for Resident #47. The x-ray was positive for a fracture to the left shoulder. ADON F called the Director of Nurses (DON) and the doctor. The staff denied Resident #47 had a fall (she had been lowered to the floor by staff but did not fall to the floor). The resident was sent out to the hospital for evaluation. During the investigation and interviews ADON F said she found out the resident had sustained a fall. CNA B told ADON F about assisting Resident #47 off the floor. CNA B said CNA A was calling for help and that Med Aide C was already in there. ADON F said when she spoke to CNA A the CNA said she transferred Resident #47 by herself from the bed to the shower chair and the shower chair moved. CNA A said she usually transferred her by herself and denied the resident was a Hoyer lift. ADON F said the staff lifted the resident to the shower chair before the nurse assessed. They did not say why they did not tell the nurse; they just got her up. ADON F asked them what they had been trained to do. She said they knew what to do, they just freaked out. The other staff said they told CNA A to tell LVN D. ADON F said she did not speak to LVN D. There was no incident report filed until after the fracture was reported by x-ray. ADON F said the CNAs have training on Hoyer lifts and therapy gives training on transfers. ADON F said the CNAs can find the residents' care profiles on their Kiosk, including transfer requirements. In an telephone interview on 2/27/19 at 2:35 PM, Nurse Practitioner (NP) J said the nurse (LVN D) told him Resident #47 complained of pain in her left arm. NP J said he went to check her out and her shoulder looked different - looked dislocated so wanted to get an x-ray. He thought he saw her in the morning on 1/25/19. The nurse did not tell him the resident had a fall. NP J said he knew Resident #47 had [MEDICAL CONDITION]. He said her joints are a little off and can break/dislocate quickly. NP J said he found out a day or two later her arm was broken. NP J said Resident #47 is fragile but a fall would make her more likely to sustain a fracture. In an interview on 2/27/19 at 3:06 PM, the Director of Nurses (DON) said she was notified on early Saturday (1/26/19) about a positive x-ray for Resident #47 showing a fractured left shoulder. She said she immediately questioned the staff and at that time they reported Resident #47 had a fall during the week, unknown to her. Resident #47 was transferred out of her bed without using a Hoyer and without assistance and was lowered to floor. LVN D was notified several times. There was no incident report and no report to anyone else. The DON said LVN D reported to her that Resident #47 had a history of [REDACTED]. The DON said there was no documentation of an assessment performed on Resident #47 by LVN D. The DON said the resident cannot be transferred alone, the nurse should have reported the fall, and the CNA should have reported to someone else if she felt the nurse did not follow-up. The DON said the facility has a Stop and Watch program on the CNA Kiosks where they can document anything that is different on the residents. This will then alert the nurses and the nurses have to assess the resident, call the doctor and document everything that was done in response to the CNA report. None of this was done on Resident #47. The DON said the facility did not have a policy on the Stop and Watch program. Review of the undated facility policy Incident/Accident Policy stated in part it was the policy of this center to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The Procedure included the following: Complete an incident/accident report when staff is aware that an incident occurred. Review each incident report at morning clinical meting. Complete a fall investigation after every fall. A head to toe assessment must be completed at the time of the incident/accident and every shift X 72 hours. Notify physician and resident representative. Complete Incident Action Plan and update Plan of Care. Review of the undated facility policy Change in Resident Condition stated in part a significant change in a resident's status is defined as deterioration or marked improvement in the health, mental or psychological status of the resident in either life-threatening conditions or in incidents of clinical complications. The nurse needs to contact the provider for conditions such as below, but are not limited to (3) accidents and injuries involving the resident. Documentation regarding the change of condition is documented in the resident record as to date, time(s), all pertinent observations noted, all unusual information obtained from the complete physical and mental assessment done and an accurate record of all interventions initiated including the date and time of notification of physician(s) and responsible party (family). It was determined these failures placed Resident #47 in an Immediate Jeopardy (IJ) situation from 1/23/19 through 1/26/19. The facility took the following actions to correct the non-compliance on 1/26/19: 1. Attending Physician N, Administrator V, the Director of Nurses and Resident #47's Responsible Party were notified 1/26/19 2. CNA A, CNA B, Med Aide C and LVN D were all suspended on 1/26/19 3. Resident #47 was transferred to the emergency room (ER) and returned from the ER with a sling and orders for Tylenol #3 on 1/26/19 4. In-services were conducted by the DON/ADON and Weekend Supervisor: a. Abuse and Neglect Policy to include definition, signs/symptoms, reporting, prevention, and who to report to. Staff in-serviced to report signs of abuse/neglect to Administrator immediately (1/26/19) b. Reporting of falls and incidents to the charge nurse immediately. All falls must be reported, and the resident is not to be moved until the resident is assessed by the nurse. Incident report must be completed in the electronic medical record (EMR) by charge nurse. DON/ADON must be immediately notified of all falls/incidents by a phone call. (1/26/19) c. Change of Condition/Stop and Watch (1/26/19). Completion of form in the EMR by the CNA, Stop and Watch to alert nurse to observe changes of condition. CNA to notify nurse upon completion of Stop and Watch. Nurses in-serviced on location of Stop and Watch alerts in EMR throughout the shift and when notified by CNA. d. Chain of Command. If staff feels nurse is not assessing or taking action for a resident, nursing chain of command is to be initiated. 1-Charge Nurse, 2 - ADON, 3 - DON, 4 - Administrator, 6 - Corporate Hotline. Phone calls can be made at anytime of day. Phone numbers are posted in the facility. e. Where to locate how to properly transfer resident in the EMR. (1/26/19). Resident transfer status X1, X2 or X 2 with Hoyer life are located in EMR with guidance in how to safely transfer a resident. All Hoyers require 2 staff members present to perform mechanical lift. Any discrepancies with transfer status need to be directed to change nurse/ADON/DON/Weekend Supervisor and/or therapy. 5. Hoyer return demonstration/proficiency check offs started on 1/26/19 by ADON/DON and Weekend supervisor of nursing floor staff. 6. Complete audit of residents for transfer status in EMR P[NAME]/Kardex to ensure status is correct and updated to reflect X1, X2 or Hoyer transfer and available for all staff to view (1/26/19) 7. Charge nurses in-serviced on how and what transfer status must be entered at time of admission. (How many people it takes to transfer a resident/Hoyer). ADON/Weekend Supervisor check that transfer status is updated in P[NAME]/Care Plan at time of admission review on following day. (1/26/19) 8. Spot check completed by ADON/DON and weekend supervisor to identify retention of in-serviced education materials and proper Hoyer transfer use from 1/27/19 - 2/13/19 each shift. This included where to locate transfer status in EMR (X1, X2, Hoyer), where to report incidents, Stop and Watch/change of condition/chain of command. Random monitoring by observation and supervision performed thereafter by DON/ADON/Weekend Supervisor to monitor for proper Hoyer lift use and transfer of residents in the facility. 9. Off-cycle QAPI meeting conducted with Administrator/DON/Medical Director to discuss appropriateness of facility response (1/26/19) 10. Termination of CNA A and LVN D. Nurse reported to the Board of Nursing 2/4/19 11. CNA B and Med Aide C were disciplined and re-educated for moving the resident before assessment by nurse and allowed to return to work (1/29/19) Interviews on 2/27/19 to 3/1/19 with 5 CNAs and 1 Med Aide on 3 shifts revealed they understood the policies regarding reporting incidents and change of condition, where to find transfer status of residents and the use of mechanical lifts for transfers. Four LVNs on 3 shifts were interviewed and they understood about documenting resident transfer status, change of condition and reporting. On 2/28/19, 2 CNAs were observed transferring Resident #23 with a mechanical lift using good technique.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well being consistent with the comprehensive assessment and plan of care for 1 of 11 (ID #1) residents reviewed for diabetic management. The facility failed to monitor and treat diabetes for Resident #1 who was an insulin dependent diabetic. Resident #1 was not given insulin and her blood sugar was not checked for six and a half days after admission. After becoming lethargic and unresponsive, she was admitted to the hospital intensive care unit for [MEDICAL CONDITION]. On 11/10/17 an Immediate Jeopardy (IJ) was identified. While the Immediate Jeopardy was removed on 11/11/17, the facility remained out of compliance at actual harm, pattern due to the facility's need to evaluate and monitor their corrective action system. This failure could affect 11 insulin dependent diabetic residents by placing them at risk of diabetic complications such as hyper or [DIAGNOSES REDACTED], altered level of consciousness, and death The findings include: Closed record review of the Resident Face Sheet dated 10/31/17 documented Resident #1 was admitted to the facility on [DATE] at 7:00 PM. Transferring paperwork: Review of Confidential Fax dated 10/19/17 from transferring facility for Resident #1 documented in part: History & Physical, Progress Notes, Face Sheet, and MARs (Medication Administration Records). Review of the physician progress notes [REDACTED].#1 from the transferring facility documented in part: Past Medical History: Dementia, Diabetes Mellitus, CAD, [MEDICAL CONDITION], and HTN. Assessment & Plan: DM (Diabetes Mellitus) Type II - at risk of [DIAGNOSES REDACTED] secondary to low oral intake. Discontinue [MEDICATION NAME]. Decrease [MEDICATION NAME] and [MEDICATION NAME]. Review of physician progress notes [REDACTED].#1 from the transferring facility documented in part: Chief Complaint (CC) documented in part: Poor appetite, eats very small amounts of food less than 25%. Review of the Medication Administration Record (MAR) for Resident #1 from the transferring facility documented in part: [MEDICATION NAME] 5 units subcutaneous three times a day before meals. Hold if blood sugar is less than 130. [MEDICATION NAME] 12 units subcutaneous every morning and hour of sleep. Hold if blood sugar is less than 130. Review of Laboratory (Lab) Report dated 10/19/17 from the transferring facility for Resident #1 documented in part: Hemoglobin A1C 10/17/17 Result H (High) 8.30, 07/06/17 Result H 9.30, 06/07/17 Result H 9.00 Reference Range 4.20-5.80. Review of the Post-Discharge Plan of Care dated 10/30/17 for Resident #1 from the transferring facility did not document any medications. Review of the Release of Responsibility for Medications (discharged Medication List) from the transferring facility for Resident #1 dated 10/30/17 at 3:30 PM, revealed there was no written documentation that Resident #1 was on insulin and accuchecks. Review of the undated Admission Telephone Report written by LVN G on 10/30/17 at 7:30 PM, documented in part: Primary DX/Reason for admission: Dementia, DM, [MEDICAL CONDITION], HTN, CAD. Review of the admission orders [REDACTED]. Labs: CMP (Comprehensive Metabolic Panel), CBC (Complete Blood Count), Lipid, HGA1C, TSH ([MEDICAL CONDITION] Stimulating Hormone), Vitamin D. Review of Admission Nursing Evaluation dated 10/30/17 written by LVN G for Resident #1 documented in part: Admission time 5:20 PM, admitted from another nursing facility, [AGE] year Old female. Admitting Diagnoses: [REDACTED]. Medications: See MAR. Review of New Admission Plan of Care dated 10/30/17 written by LVN G for Resident #1 documented in part: Scheduled Labs: was left blank. Requires assistance of one staff with Activities of Daily Living. Primary DX/Medications Placing Resident at Risk: Dementia, HTN, DM. Review of the Nurses Progress Notes dated 10/30/17 written by LVN G for Resident #1 documented in part: Patient arrived at approximately 7:00 PM, with daughter. Previously at another nursing facility. DX (diagnosis) Dementia. Resident is alert only speaks Spanish. In an interview on 11/09/17 at 6:04 PM, LVN G reported that she had worked on 2-10 shift on 10/30/17 Nothing was mentioned during report that a new admission was coming in on my shift. I don't know when or how Resident #1 got here. After I finished my medication pass at approximately 7:00 -7:15 PM, I noted Resident #1 was sitting in a wheel chair with a woman that identified herself as Resident #1's daughter at the Nurses Station. One of the other Nurses at that time told me that my new admission was here. I did not see a History & Physical or a MAR from the transferring facility on 10/30/17 when I did the admission. I remember that on that day 10/30/17, the daughter handed me a copy of the Power of Attorney and a list of medications from the transferring facility and nothing else was given to me on 10/30/17 by the DON or ADONs. I noted that there was a MAR and History & Physical from the transferring facility in the resident #1's clinical record after she had been sent to the hospital over the weekend on 11/05/17 by the weekend nurse on Monday 11/06/17 when I came in to work. I do not know who put them in her chart. I placed a telephone call to the transferring facility to get report on 10/30/17. I did not ask if Resident #1 was an insulin dependent diabetic or if accuchecks were being done. I did not ask the daughter if her mother was an insulin dependent diabetic. I had just started working and had 3 days of orientation and it was my second day of working by myself on that day when Resident #1 was admitted . I was trained to check and verify the medication list with the physician upon admission. After the incident with Resident #1 we were given some training on how to reconcile medications from the MAR that we receive from the transferring facility and now the ADONs (assistant director of nurses) are checking the new admissions. Review of the History & Physical dated 11/02/17 for Resident #1 documented in part: [AGE] year old female admitted from another facility with [DIAGNOSES REDACTED]. Not oriented to time, person or place. Assessment and Plan: Diabetes Mellitus - check Accuchecks (test blood sugar), monitor. Ordered labs. Reviewed records from transferring facility. Review of the Nurses Progress Notes dated 11/5/17 written by LVN C documented in part: Patient's Responsible Party (RP) approached this nurse to report that patient is not like herself. No viable concern noted, but was reassured that patient will be monitored for changes. At 7:20 PM, RP requested that nurse check patient's blood sugar, RP was informed that patient was not on Accuchecks or none were available on MAR. RP informed this nurse that patient is a diabetic and takes insulin. Concern was verified with patient's chart, MD (physician) on call, DON were notified of MAR error. MD ordered stat 1 liter of Normal Saline bolus IV, 25 units of [MEDICATION NAME]SQ, and report changes in one hour. At 8:20 PM, blood glucose reading High. Results reported to physician, administered 15 units [MEDICATION NAME] SQ. Report findings to MD after one hour. Initial B/P (blood pressure) 88/42, pulse 62, respirations 16. At 9:45 PM, patient is now non-arousable, B/P remains low 88/52, blood glucose High. MD contacted for new orders. Call back pending. At 10:30 PM MD order to send resident out via EMS (Emergency Medical Services) to hospital. In an interview on 11/11/17 at 12:49 PM, LVN C reported that he worked from 6:00 AM to 10:00 PM on the weekends. On Sunday 11/05/17, the daughter for resident #1 reported to me that her mother was withdrawn and was not the same and I explained to her that it was related to the recent transfer from another facility. The resident was sitting in her wheel chair in the 300 hall when I assessed her. The resident was alert and responsive. She was able to answer simple questions with yes or no. After dinner on that day at approximately 6:30 PM, maybe closer to 7:00 PM, the daughter wheeled the resident to the hallway where I was working in the 300 hall. The resident was sitting in her wheel chair with her eyes closed and was mumbling as she was trying to answer questions. The daughter approached me and stated, I wonder what my mom's sugar level is at this time? I told the daughter that we did not have orders to check the blood sugar. I went to check the resident's chart and noted that the transfer paperwork in the chart documented resident #1 was on [MEDICATION NAME] and blood sugar checks were done before meals and hour of sleep. I took her vital signs and checked her blood sugar. The Glucometer reading was showing HI which indicates the blood glucose is above 600 so I called the physician on call and he gave orders for 25 units of [MEDICATION NAME] SQ and to give one liter of Normal Saline bolus IV and to call him back in one hour. Resident's blood sugar remained HI and her blood pressure reading was still low so I reported this to the physician on call. He gave anther order to administer another liter of Normal Saline IV bolus and another 15 units of [MEDICATION NAME] SQ and to call him back in another hour. When I called the physician back, I reported to him that the resident's blood sugar was still HI and the blood pressure was still low. At this time he gave orders to call 911 and send the resident to the hospital for evaluation. Review of the Manufacturer for the Glucometer User Manual provided by Assistant Director of Nurses (ADON) A documented in part: If you see HI the blood glucose level may be above 600 mg/dL (milligrams per deciliter). Review of the Physician Telephone Order dated 11/05/17 for Resident #1 documented, [MEDICATION NAME] Flex Pen 15 units, subcutaneous x 1 dose for Diabetes Mellitus Type II. 1 Liter normal saline IV (intravenous). Review of the Physician Telephone Order dated 11/05/17 for Resident #1 documented Send out to hospital. Diagnosis: [REDACTED]. Review of the undated MAR for Resident #1 documented in part: Accuchecks at 7:25 PM High; 8:45 PM High. [MEDICATION NAME] Flex Pen 25 units 1 x dose documented two times on MAR and initialed by LVN C with no documentation of times of administration. Hospital paperwork: Review of the Hospital emergency room (ER) report dated 11/05/17 at 11:45 PM for Resident #1 documented in part: Patient with Altered Mental Status . As per family patient has Dementia but she has been more confused since yesterday. Patient alert, oriented x 2. Patient confused and not answering questions properly. Blood sugar +600 at this time. Blood pressure 85/25. Review of Hospital Consultation Report dated 11/06/17 for Resident #1 documented in part: Chief Complaint: Altered Mental Status. History of Present Illness: [AGE] year old female with significant past medical history of [REDACTED]. The patient apparently was transferred from different nursing home and apparently there was no report about the use of insulin, so the patient went without insulin for about 6 days. In the ER, she was evaluated due to altered mental status with findings of glucose above 600. She was transferred to ICU (Intensive Care Unit) for insulin drip. Review of the Hospital Laboratory Report dated 11/06/17 at 12:14 AM, for resident #1 documented in part: Glucose 643 Critical Level. Telephone interview on 11/10/17 with Resident #1's daughter stated, I kept telling the Nurses for about a week that my mother was not her usual self. She was very sleepy, more than usual and her head would hang down towards her chest and was not able to open her mouth when I attempted to feed her. As time went by, I had to spoon feed my mother. I kept telling everyone that would listen and was told it was related to the move. I reported this to LVN C and another guy on Saturday 11/04/17 when I went to see my mother. On Sunday Night 11/05/17, I asked the LVN C what was my mother's last blood sugar, his eyes opened widely and he asked me if my mother was a diabetic because at that time my mother was unresponsive. I attempted to feed her lunch meal on that day and she only took about 2-3 teaspoons of mashed potatoes. I also noted that my mother was coughing when she attempted to swallow or kept the food in her mouth and would not swallow. He walked real fast to the Nurses Station almost running to check my mother's chart. LVN C told me that he notified the doctor and the DON that her mother had not been given her insulin for 6 ½ days since she was admitted to the facility on [DATE]. LVN C told me that the doctor had given orders to check her blood and to administer insulin because her sugar level was high. When she was first admitted my mother was alert, and could answer simple questions. She required total assistance with her personal care but was able to eat by herself when she was transferred from the other facility. The daughter reported that the transferring facility had given her some papers and she gave them to the facility's van driver when she went to pick up her mother. The daughter reported that she had not looked at the paperwork. I went to the facility to talk to the Administrator after my mother was sent to the hospital on [DATE] because I wanted to know what had gone wrong. The Administrator told me that she was going to look over the paperwork that was sent from the transferring facility and that she would call me back. The Administrator called and left me a telephone message either on Tuesday 11/07/17 or Wednesday 11/08/17 reporting that the insulin was not on the list of medications that was sent from the transferring facility. The daughter stated, she did not think of checking with the facility staff to see if they knew that my mother was a diabetic and was taking insulin. I took it for granted that the insulin was listed on the list of medications that was sent by the transferring facility. In an interview on 11/11/17 at 1:08 PM, Medical Director reported that the weekend Nurse had called him to report that Resident #1 was not responding as usual and reported resident's blood sugar reading was showing High and had a low blood pressure. I ordered insulin and IV fluids in attempts to raise the blood pressure and lower the blood sugar levels. After two attempts after giving insulin and IV fluids the Nurse reported to me that the blood sugar reading was still High and the blood pressure was still low so I gave orders to send the resident to the hospital for evaluation. The Nurses have been trained to call me right away in an emergency if the attending physician does not return telephone calls immediately. I talked to the resident's attending physician and he said that he had ordered Labs and for accuchecks to be done. However, he did not write the order for the accuchecks, he just wrote it down in his Progress Notes dated 11/02/17. In an interview on 11/11/17 at 12:02 PM, with the DON in the presence of the Administrator reported that she reviews the medical paperwork for admission referrals and approves them clinically. Then I give the medical paperwork back to the Admission Coordinator. I don't remember which documents I reviewed for Resident #1. The DON reported that the Director of Business Development and the Admission Coordinator are responsible for coordinating the transfer. The DON stated, The weekend nurse called me and reported that resident #1 had altered mental status and blood sugar read High which is higher than 600. At that time the nurse reported that he had checked the resident's chart and noted that the transfer paperwork for resident #1 documented that the resident was on two different types of insulin and had blood sugar checks done before meals and hour of sleep. The nurse at that time reported that resident #1 had not received her insulins or had blood sugar checks done since admission on 10/30/17. I instructed LVN C to call the physician. I don't know what happened. No one alerted me that the transferring paperwork appeared in the resident's chart after the resident #1 was admitted to the facility. The ADONs have been tasked and it's their responsibility to check the admissions. The DON reported that she had not reported this incident to the Administrator on 11/05/17. As of today, I am currently investigating what happened with Resident #1 and implementing measure to ensure that this does not happen again. In an interview on 11/09/17 at 8:20 PM, ADON A reported that she had not been involved in the admission process for resident #1. The DON approved this admission. I reviewed the admission and completed the Admission checklist. I did not see any problems. The ADON reported that she was not aware of anything else besides the blood sugar checks not being done since admission. ADON A reported that admission referrals are reviewed by the Department Heads to make sure that the charts and necessary equipment are ready when the resident arrives to the facility. After this meeting we will have a clinical meeting with the charge nurses to review pending admissions. In an interview on 11/13/17 at 5:35 PM, the Administrator reported that she had called the daughter to report that they did not have orders to administer the insulin. The Administrator reported that she had been informed by the Admission Coordinator that she had talked to the company's corporate staff and was informed that the company did not have an admission policy. In a telephone interview on 11/10/17 at 5:23 PM, Director of Business Development reported that the clinical team consist of the DON and ADONs. I am an LVN. I will send any referral information by fax to the Admission Coordinator and she will print the information which includes History & Physical, MARS, Physician Orders, Therapy Notes and Labs and gives it to the DON for review and clinical approval. Once the resident is approved an e-mail will be sent to the department heads that includes the [DIAGNOSES REDACTED]. I was aware that the resident was a diabetic and was on insulin. She had her blood sugar checked before meals and hour of sleep because I reviewed her MAR. I remember that the DON approved the resident clinically and I contacted Resident #1's daughter to make arrangements to admit her mother to the facility on [DATE]. The Director of Business Development reported that she does not attend the morning stand up meetings. Once transportation arrangement are made, that is the end of my responsibility. In an interview on 11/10/17 at 5:08 PM, Admission Coordinator reported that she works with the Director of Business Development and the nursing administrative staff to coordinate new admissions. If a resident is transferring from another Nursing Home, they will send the referral information directly to the nursing facility. The information will include a History & Physical, Physician Orders, MARS, Nurses Notes, Therapy Notes and Labs. I do remember that Resident #1 was referred to us from another nursing home on 10/26/17 and we received the History & Physical and MARS. That's all I remember from the top of my head. I will print the information and give it to the DON or ADONs, depending who is available to receive the information. I remember that I gave the information for resident #1 to the DON on 10/26/17 when I received the referral. Once the Director of Business Development makes transportation arrangements, I'm done with my part. Review of the facility's policy on Diabetes - Clinical Protocol dated 2001 provided by ADON A documented in part: Assessment and Recognition: As part of the initial assessment, the Physician will help identify individuals with elevated blood sugar. The Physician will order pertinent screening for example A1C.; For residents with confirmed diabetes, the nurse shall assess and document/report the following during the initial assessment: Dose and time of most recent anti-glycemic given; All other current medications; Resident's blood sugar history over 48 hours; Usual patterns (fluctuations, trends) of blood sugar over recent months; Recent labs. Based on the preceding assessment, the Physician will order appropriate interventions, which may include: Oral [DIAGNOSES REDACTED] agents; and/or Insulin. The Physician will order appropriate lab test (for example, periodic finger sticks or A1C) and adjust treatments based on these results and other parameters such as weight gain or loss etc. Review of the facility's policy on Reconciliation of Medications on admitted d 2001 provided by ADON A on 11/11/17 documented in part: Purpose: The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. Preparation: Gather the information needed to reconcile the medication list: Approved medication reconciliation form; Discharge Summary from referring facility; Admission order sheet; All prescription obtained from the resident/family during the medication history; and Most recent medication administration record (MAR) if this is a readmission. General Guidelines: Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omission at transition points in care. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosage and routes, during the admission/transfer process. Medication reconciliation helps to ensure that medications, routes and dosages have been accurately communicated to the Attending Physician and care team. Steps in the Procedure: Using an approval medication reconciliation form or other record, list all medications from the medication history, the discharge summary, the previous MAR (if applicable), and the admitting orders. Review the list carefully to determine if there are discrepancies or conflict in medications, dose, route or frequency, determine the most appropriate action to resolve the discrepancy. For example: Contact the nurse, from the transferring facility; Contact the attending physician from the transferring facility; Discuss with the resident or family. An immediate Jeopardy was identified on 11/10/17 and the Nursing Facility Administrator (NFA) was informed at 6:01 PM. On 11/12/17 at 12:36 PM, the 2nd Plan of Removal was accepted, which included: Resident #1 was transferred to the hospital on [DATE]. Facility conducted a 100% audit on all insulin dependent diabetic residents to verify that the residents were receiving their insulin and blood sugar checks were being done as ordered. Systemic Changes to be made: 1. Admission referral process: a. Referral paperwork will be reviewed by the DON/designee prior to admission for acceptance to the facility. b. Referral paperwork will be placed in the chart prior to the transfer by DON/designee so this information will be available to the admitting nurse at the time of admission to reconcile a history and orders with MD/NP (nurse practitioner). 2. Telephone report from transferring facility will be required before a resident transfers. If a resident arrives without report the admitting nurse will be required to call the discharging facility to obtain a report immediately and ensure that referring paperwork includes a H&P (history & physical), printed physician orders, and MARS/TARS (treatment records). Admitting nurse will review any questions they may have with discharging nurse at the time of telephone report. 3. MD/NP will be immediately notified by telephone of admission and the admitting nurse will review a complete medical history with the provider including the H&P, as well as printed physician orders, MARS/TARS, and discharge med (medication) reconciliation. 4. Medical Director was involved and has helped develop a plan to prevent reoccurrence. Medical Director will initiate standing orders for finger sticks and sliding scale insulin coverage for all diabetics admitted to the facility to establish baseline blood glucose readings and standing labs to be drawn at admission. 5. All referral paperwork and discharging facility's paperwork will remain in the clinical record until the MD has evaluated the resident after admission. 6. ADONs will be responsible for reviewing all new admissions chart to check that all medical history is present, MARS, Physician order [REDACTED]. 7. A lab review system has been initiated to include review of all orders in morning clinical meeting, a tracking system to ensure that lab requisitions have been made, labs drawn, lab results reported, and any orders written after reporting. In-servicing of all involved staff of these processes began on 11/08/17 and continued through 11/11/17. Admission/Referral process in-servicing completed 11/11/17. An in-service to the admitting nurses to check the presence of the referral packet in the chart and review this information with the MD at the time of admission was started on 11/10/17 and completed on 11/11/17. In-service on receiving telephone report was initiated on 11/10/17 and completed on 11/11/17. In-service on new standing protocols for finger sticks, sliding scale insulin and admission labs given by the medical director. In-service on new lab tracking system started on 11/10/17 and completed on 11/11/17. All in-servicing was completed on 11/11/17 at 10:30 PM. The Plan of Removal was verified as having been implemented as follows: Interviews done with Licensed Staff on all three shifts and the weekend staff on 11/13/17 from 10:42 AM through 5:09 PM, revealed they had been trained on the new admission process. The DON/ADONs will now give the Licensed Staff the admission paperwork from the transferring facility for new admissions. The transferring paperwork will include an H&P, MD orders, MARs/TARs, and Labs. Licensed Staff will get telephone report from the transferring facility at which time the nurses will review MD orders using the MARS/TARS. The DON/ADONs/Weekend supervisor will audit new admission using the Admission Audit form the day after admission. New Protocol was implemented by the Medical Director on getting a baseline blood glucose on admission and new protocol on how to treat Hypo/[MEDICAL CONDITION]. Implemented a Lab Log to log new lab orders, file requisition in Lab binder pending draws, track date lab results were received and reported to physician. Trained to immediately report allegations of abuse and neglect immediately to the Administrator and DON. Trained that to do a two person transfer using a Hoyer Lift. On 11/13/17 at 5:18 PM, the Administrator and ADON A were informed that the IJ had been lifted on 11/11/17 at 10:30 PM. While the Immediate Jeopardy was lifted, the facility remained out of compliance at actual harm, pattern due to the facility's need to evaluate and monitor their corrective actions and systemic changes. No additional information was brought forth during the survey. The Census dated 11/15/17 documented 29 residents in the 300 Hall of the facility. ADON A provided a list that documented there were 11 insulin dependent diabetic at the facility.

Based on observation, interview and record review, the facility failed to provide supervision to prevent accidents for 1 resident (Resident #1) of 2 residents reviewed for accidents and supervision. The facility failed to adequately supervise and monitor Resident #1, who was identified at risk of wandering; and failed to assure the front entrance to the facility was not left unattended. The front door key pad was deactivated from 8 AM and 5 PM. On 08/04/17 Resident #1 left through the front entrance of facility, walked through parking lot, walked over a bridge where there was a canal and crossed a five lane highly trafficked street. The facility staff were not aware Resident #1 had eloped until they were notified by a local high school. It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation on 08/04/17. The facility took actions to correct the non-compliance on 08/04/17 prior to surveyor entrance. This failure could affect 2 residents identified by the facility as having wandering risk behaviors, placing them at risk of injury or death during an elopement. The findings include: Resident #1 Review of Face Sheet (undated) revealed Resident #1 was admitted to the facility on [DATE]. Review of the History & Physical dated 7/201/7 for resident #1 documented in part: [AGE] year old male was brought from home by family members. He has become agitated and occasionally aggressive. He was seen in the hallway talking about wanting to go back home to his wife. Diagnoses: [REDACTED]. Monitor closely for wandering & escape, Major Depression, Generalized Anxiety-Monitor & re-direct; and insomnia. Review of Risk of Elopement/Wandering Assessment for resident #1 dated 7/24/17 for Resident #1 documented in part: Cognitively impaired with poor decision-making skills, resident has a pertinent [DIAGNOSES REDACTED]. indicates history of anxiousness and desire to go home unsupervised. Review of Resident #1's Minimum Data Set ((MDS) dated [DATE] documented in part: Short/Long term memory problems; Cognitive skills for daily decision making severely impaired; Never/rarely made decisions; limited assistance of one person with transfers, walking in room/corridor supervision. Review of Resident #1 Care Plan dated 07/24/17 documented in part: Resident high wandering risk. Problem: Wanders around facility. Approaches: Place resident in area where frequent observation is possible, alert staff to wandering behavior, provide diversional activities, approach positively and in calm accepting manner, if wandering away from unit, instruct staff to stay with resident, converse and gently persuade to walk back to designated area with them and monitor and document behavior. Resident high wandering risk. Review of the Provider Investigation Report dated 08/04/17 at 11:21 PM, documented in part: Resident #1 was located on the premises of high school by security guard. Resident #1 was able to give the staff member name and he stated he was trying to go to Colorado. The facility staff did not know he was missing until it was reported to them by school police. Resident #1 was transferred back to nursing facility by staff. Facility actions were put into place after resident was returned by conducting head to toe assessment of Resident #1, 100 percent head count of all nursing facility residents, Resident #1 placed on 1 on 1 care, front door of facility locked and required code to exit. Medical Director, Physician, and family were notified. In-services were conducted with facility staff. Observation on 08/21/17 at 5:00 PM, the facility's front door exit faced the parking lot directly. Path to street would consist of going through parking lot, crossing bridge over a canal, and reaching a 5 lane street. The speed limit was 45 miles per hour and was 0.1 miles away from facility. In an interview on 08/21/17 at 3:15 PM Director of Nurses (DON) said the receptionist received a call on 08/04/17 at 9:40 AM from a local high school notifying them Resident #1 was found at the school. DON stated facility staff went to the school to pick up Resident #1 and was assessed at that time. She said the physician and family were notified of the incident. Resident #1 was put on 1:1 monitoring immediately. DON said Resident #1's family came to the facility and was monitoring him after 5:30 PM. DON stated a referral was made to Behavioral Unit but was declined admission. She stated she was trying to find another facility that would be more suitable for Resident #1 needs to be met. She stated Resident #1's daughter opted to take him home for the weekend and would bring him back on Monday, August 7, 2017. DON said the facility does not have wanderguards in place for wander risk residents identified at facility. She said the facility completes Elopement/Wandering review upon admission, thirty days after admission, quarterly and at significant change in condition to review if a resident is at risk for elopement/wandering. DON said she could not recall if Receptionist A was at the front desk at time of Resident #1's elopement. She said at the time of notification, the facility was not aware Resident #1 was off facility property. DON stated after the incident the front door will remain closed and be opened only by code from staff members. She stated the code will not be shared with family members. In an interview on 08/22/17 at 8:30 AM Receptionist A said she was the full-time receptionist at the facility and works 8 AM to 5 PM Monday through Friday. Receptionist A said she was assisting with Medical Records on 08/04/17. She said the front door was left unattended when she stepped away to Medical Records office. She stated Administration temporarily gave her duties of Medical Records and were aware the front was left unattended at 8:00 AM while she performed those duties. She stated she was unaware Resident #1 had left the facility. In an interview on 08/22/17 at 9:53 AM, Maintenance Director stated before the elopement incident with Resident #1 the procedure for the front door was that the front door remained open from 8 AM to 5 PM. After 5 PM would lock front door with code, the families had entrance and exit codes to the front door. Maintenance Director stated after the incident the procedure changed to the front door will remain locked at all times and families will not be provided with the codes to enter or exit the facility. He stated he implemented the change on 08/04/17 at 10:05 AM. The front was to have a staff member at all times stationed at the front entrance and staff cannot share the code with families. He stated door codes are changed every month to ensure facility resident's safety. In an interview on 08/23/17 at 9:32 AM, Physician B stated Resident #1 had a [DIAGNOSES REDACTED].#1 was a wander risk due to his dementia and it would be dangerous for him to be on his own. In an interview on 08/23/17 at 8:05 AM, CNA C said Resident #1 wandered the halls of the facility everyday. She said the last time she had seen Resident #1 on 08/04/17 was at 8:30 AM in the dining area. She said she was in the 200 hall taking trays to the residents that eat in their rooms. She said that morning she was very busy assisting the residents that remained in the 200 hall. She said she did not notice Resident #1 was missing from the facility until the staff were notified. In an interview on 08/23/17 at 8:48 AM, LVN D stated the day Resident #1 eloped on 08/04/17, he was on the 200 Hall passing out medications. He stated he did not see Resident #1 wander to the halls or front door. LVN D said he was not aware Resident #1 had left the facility until Administration notified him. He stated he conducted the head to toe assessment upon Resident #1 return on 08/04/17 at 9:40 AM. He stated Resident #1 did not have any injuries and was calm. He stated he was assigned to one on one supervision throughout the day. LVN D stated staff got in-serviced on new procedures and changes went into effect immediately; in-service on front door of facility locked and required code to exit, do not share code with families or vendors, front door coverage by a staff member at all times, usage of monitoring sheets, 1:1 monitoring of Resident #1 and head count of all residents. In an interview on 08/23/17 at 9:15 AM, CNA E said the last time she had seen Resident #1 on 08/04/17 was in the dining area eating. She stated she assisted other residents back to their rooms and did not notice where Resident #1 was at that time. CNA C stated she found out Resident #1 had eloped because the nurse notified them. She stated she was assigned to do one on one supervision after Resident #1 returned to facility. CNA C stated Resident #1 had told her he left through the front door, cross the bridge over canal and street to school. CNA C stated the staff got in-serviced on new procedures to front door code entrance and documentation for elopement risk residents. Review of facility's policy on Elopement Risk Program (undated) documented in part: -Utilizing the Risk of Elopement/Wandering Review evaluate the resident for exit seeking risk on admission/quarterly/with significant change of condition. -Implement the Wandering Monitoring Form when a resident is evaluated elopement/wandering risk, to account for the resident's location every two hours. -For the resident identified as a risk for elopement/wandering complete the Missing Resident Profile with the resident's picture, and place it in a binder kept at the nursing stations and receptionist desk. -Initiate the Behavior Monitoring form with the behavior wandering to monitor the residents wandering behavior. Review of facility's policy on Facility Security/Resident Safety (undated) documented in part: -The facility admits and retains residents that are confused and have the tendency to wander about the facility. To meet this need the facility will obtain information during pre-admission or admission conferences with the resident and family regarding any history of wandering or the potential for wandering. -A plan of care will be developed and implemented with specific approaches and goals for the wanderer. -A resident's name, picture, and physical description are placed in the wander book located at the nurses' station. -Every new employee will be informed of the wandering policy at orientation. Door Testing -Check courtyards, patios, fences and outside property for security and safety The Nursing Home Interim Administrator was informed of the Immediate Jeopardy (IJ) on 08/23/17 at 1:38 PM. It was determined that this was past non-compliance. It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation on 08/04/17. The facility took the following actions to correct the non-compliance on 08/04/17 prior to surveyor entrance, which included: -9:45 AM completed head count of all residents in facility started. -9:55 AM all residents accounted for. -10:05 AM Maintenance asked to change code to front door and lock front door. -10:30 AM In-service started by Charge Nurse on elopement risk evaluation/wandering monitoring form. Completed at 11:00 AM. -11:00 AM Elopement policy/procedures code green in-service started and DON asked charge nurses to complete elopement risk assessment on all residents. DON to be notified of any residents that are a risk. -11:10 AM all doors checked for alarm operation and lock and were operational. -Continued in-servicing to follow with next on-coming shift. -All shifts in-serviced at 10:00 PM on 08/04/17 Elopement Incident Interventions Interviews conducted on 8/23/17 with 3 LVNs, 4 CNAs, Maintenance Director, and receptionist revealed understanding of wander risk residents, assessments to be done, monitoring form to be filled, code change and front door lock at all times and staff present in front reception area. Record review of 2 resident care plans had been updated to show risk of wandering. Record review of in-services conducted on 08/04/17 revealed 89 staff were in-serviced on wander risk residents, assessments to be done, monitoring form to be filled, code change and front door lock at all times and staff present in front reception area. Observation on 08/21/17 through 08/23/17 revealed visitors would ring door bell and facility staff would enter a code on the key pad to let visitor into the facility. In an interview on 08/22/17 at 9:53 AM, Maintenance Director revealed he knew to change the code to front door and should remain closed at all times. Corrective actions was verified as having been implemented as follows: Interviews and record reviews done 08/22/17 through 08/23/17 with DON revealed: -All available staff had been trained by 08/04/17 on policy and procedures and were aware of the residents identified as wander risk. -Resident identified as wander risk had care plan in place. -Maintenance staff was aware of the monitoring and maintenance of facility door code and facility policy on front door closure. Interview on 08/21/17 at 2:00 PM, DON stated there was 1 resident identified as a wander risk at the facility.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free from accident hazards as was possible and each resident received adequate supervision to prevent accidents for two (Residents #1 and #2) of ten residents reviewed for supervision. A. Resident #1 - Van Supervision 1. The facility failed to ensure drivers checked the van after returning residents from appointments to ensure no residents were left unattended in the van. 2. Driver A failed to assist Resident #1, who was in a wheelchair, off the facility van after returning to the facility after the resident's dialysis treatment. Resident #1 was left in the van without supervision with the windows rolled up from approximately 10:30 AM to approximately 12:00 - 1:00 PM. The temperature outside was 79 degrees Fahrenheit. Resident #1, who had contractures of his right side and could not use his right leg or arm, had to maneuver out of his wheelchair and scoot on his back from the back of the van to the driver's seat in the front of the van to honk the horn to attempt to get help. 3. The facility failed to train facility drivers on ensuring no residents were left unattended in the facility van. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the inspection. These failures could affect all 75 residents, who could be transported in the facility van at any time, by placing them at risk for neglect, injuries, pain and stress on their well-being and causing other serious mental/physical harm and/or death. B. Resident #2 - Showering Supervision Certified Nurse Aide (CNA) B failed to provide adequate assistance in the shower while bathing Resident #2 who had severely impaired cognitive ability, had lower extremity contractures and had poor trunk balance making him unsteady in a seated position. During the shower on 9/02/16 Resident #2 leaned forcefully forward in his shower chair and fell out of the shower chair hitting the corner of the tile shower causing a laceration on his forehead requiring staples and abrasions/scratches to his body and extremities. This failure could have placed 4 residents identified with contractures and poor trunk balance at risk of injury from falls. Findings included: A. Resident #1 - Van Supervision Review of the face sheet dated 9/12/16 documented Resident #1 was a [AGE] year old man admitted on [DATE]. Review of the facility History and Physical dated 4/21/16 documented Resident #1 had [DIAGNOSES REDACTED]. Review of the quarterly MDS (Minimum Data Set) dated 6/15/16 documented Resident #1 had a BIMS (Basic Interview for Mental Status) score of 10 out of 15 (moderately impaired cognitive ability for daily decision making), rejected care 4-6 days per week, required 2 person extensive assistance for bed mobility and transfer, was total dependence of 1 person for locomotion off of the unit and had non-Alzheimer's dementia. Review of the Incident Report dated 9/06/16, documented at 12:00 PM noon approximately Resident #1 was left in transportation bus by Driver A. Hospitality Aide C from activities heard someone honking the bus and noticed resident in bus. No apparent injury except for redness on lower back. Review of the Provider Investigation Report dated 9/06/16 documented on 9/06/16 at 11:50 AM, Driver A returned from picking up two residents at dialysis, removed one resident from the van and left Resident #1, who was not independently ambulatory but interviewable and capable to make informed decisions, on-board approximately 1.5 to two hours until noticed by receptionist. Head to toe assessment, no injuries, psycho-social assessment completed by social worker. Resident #1 stated no injuries or concerns. Driver A was suspended. Driver A failed to check van upon parking for residents on board. Temperature was approximately 73 degrees Fahrenheit. Driver A was terminated 9/07/16. Record review of nursing Progress Notes dated 9/06/16 documented at 12:15 a head-to-toe assessment was performed on Resident #1. Resident #1 had redness to his buttocks and sacral area and small scratches on his upper back. He denied pain, dizziness or headache. Review of www.wunderground.com <http://www.wunderground.com> (weather underground) on 9/22/16 revealed in Socorro, Texas on 9/06/16 the temperature at 11:51 AM was 79 degrees Fahrenheit. Review of the American Veterinary Medical Association web site (www.AVMA.com) contained an Estimator Vehicle Interior Air Temperature vs. (versus) Elapsed Time table supplied by the Department of Geosciences, San Francisco State University. According to the table, when the outside temperature is 80 degrees F, after 1 hour the interior vehicle temperature is 123 degrees F and greater than 1 hour the temperature is 125 degrees F. Observation of the facility van on 9/12/16 at 11:28 AM revealed the van was a 15 passenger van with wheelchair access in the rear passenger side of the vehicle. Where the wheelchairs were secured was approximately 3-1/2 feet from the back of the van to the back of the seat in front of the wheelchair locks. There was approximately 10 feet from the back of the last seat to the front of the van. The height from the floor to the horn was approximately 18 inches. In an interview on 9/12/16 at 10:18 AM, the Director of Nurses (DON) said Driver A had a personal appointment scheduled for the next day (9/7/16) and she was preoccupied with that. The DON said on 9/06/16 Driver A dropped one resident off at the front door and went to the back of the building to park the van. She got out of the van and came into the building and started working. The DON said the resident unbuckled himself and crawled to the front of the van and honked the horn. The weather was in the 70's. Staff going to lunch heard the honking and told Driver A, who replied, No way. The DON said a new procedure was implemented that before the van is parked someone has to go with the driver to check the van and sign that the van is empty. When asked for the facility policy and procedure for transportation of residents, the DON said she did not think they had one since they were such a new building. When asked about the corporate policy, she said she would look. In an interview on 9/12/16 at 11:05 AM, Resident #1 said he got up about 4 AM on 9/06/16 to go to dialysis and he fell asleep in the back of the van on the way back to the facility. Resident #1 said he woke up when he started getting hot, realized he had been left alone in the van and started yelling ,Ayudame! (Help Me!) Resident #1 said he was a Marine and knew what to do so when he began losing his voice he fell out of his wheelchair and scooted on his back up to the driver's seat because he can't use his leg, reached up and began honking the horn. Resident #1 said a lady saw him and went to get help. Resident #1 said he was not sure how long he was in the van. In an interview on 9/12/16 at 11:12 AM, Hospitality Aide C said she went out to her truck about 12:30 PM. She heard the van horn honking, but she did not see anyone. She thought the van driver was honking at a group of dogs that had been running on the grounds. As she was coming back in the building, Receptionist D was running outside and Hospitality Aide C went with her and saw Resident #1 in the van. Receptionist D ran back into the building to get help and soon Driver A came out and opened the van door. In an interview on 9/23/16 at 3:09 PM, Receptionist D said she did not remember what time the van returned but it was in the morning. Driver A brought in 2 residents and then said she was going to park the van. Receptionist D said on 9/06/16, about 1 PM because that's when she goes to lunch, Hospitality Aide C called an emergency that someone was in the van. Receptionist D said she ran to tell ADON F and the Dietary Supervisor who went outside with another nurse and Driver A. In an interview on 9/12/16 at 12:05 PM, Assistant Director of Nurses (ADON) F said Driver A forgot about Resident #1 when she returned to the facility and parked the van on 9/06/16. ADON F said Resident #1 was on his back in the van. He was doing just fine, except he was hungry and thirsty. ADON F said Driver A was terrified and she said she would never intentionally leave a resident in the van. She kept saying, Why me? ADON F said it was a cloudy day. ADON F said water is now kept in the van at all times and 2 staff have to check the van for residents, belongings, etc. and sign a checklist before the van is parked. ADON F said Driver A told him it was her routine to come back to the facility, drop off passengers, pick up more passengers and then be off. ADON F said Driver A told him Resident #1 was the only wheelchair resident and that it was a special pick-up and it threw her out of her routine. ADON F said someone would have eventually gone back to the van for more transports. In a telephone interview on 9/12/16 at 11:38 AM, Driver A said she was stressed because a new driver was making mistakes with transport. Driver A said she was also thinking about another resident who was going to have an amputation. Driver A said she remembers putting Resident #1 in the van, driving back to the facility, taking other residents out of the van and parking the van in the back parking lot of the building. Driver A said she did not leave Resident #1 in the van on purpose, it was an accident. She said she knew something could have happened to the resident. Driver A said she was never trained on the facility process of what to do when she returned to the facility with residents. In an interview on 9/23/16 at 12:49 PM, the Maintenance Director said all the drivers were trained on how to use the van - the mechanicals such as oil change and tire pressure. He goes with them to verify they know how to drive and use the lift and secure residents. The drivers watch a safety video. The Maintenance Director said he has them sign that they have received instructions on van operation. He said the People Strategy Representative (Human Resources) keeps the training records. Record review of driver training records revealed the following: a. Drivers M (5/02/16) and N (June 2016) signed statements they had been trained on the safe and proper operation of the wheelchair lift and the proper use of the wheelchair tie downs and restraint system of the transport van and did a return demonstration. There was no documentation signed by Driver A that she had received training. b. Van Training documented the Maintenance Director showed Drivers A (3/15/16), M (5/02/16) and N (6/09/16) on proper training on van, seat belt locks, maintain upkeep and driving procedure. Review of the corporate policy, Driving Policy effective 1/18/10 addressed requirements to drive facility vans and procedures while driving. There was a vehicle checklist entailing what the driver does prior to transporting residents. There was not a procedure for unloading residents and parking the van. On 09/23/16 at 12:58 PM, the administrator was informed an Immediate Jeopardy (IJ) was identified. It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation from 9/6/16 through 9/7/16. The facility took the following actions to correct the non-compliance prior to the beginning of the inspection: Points of failure: Transporter failed to check van for people and property left behind when parked. No redundant check point/process. Immediate Response (on 9/06/16): Resident #1 examined for any physical harm by Nursing, psycho-social interview by Social Worker for emotional disturbance, both negative. Driver A suspended pending investigation Medical Director informed of incident and result of examinations, no new orders other than to continue observation per policy. Reported incident to State Agency and corporate. Next Day (9/07/16): Transporters, CNAs, nurses, department heads in-serviced on proper return-to-base procedure for transportation of residents. Points covered: Walk the length of the van to check for passengers and personal property left behind. Ensure van is always parked in visual range from the main building Always have a second employee check the van and sign off. Any employee may perform the second safety check and sign off. Supervision: DON or ADON reviews safety check log M-F, charge nurse on weekends if transportation occurs. Driver A was terminated. A redundant check system was implemented to have a second employee check the bus to ensure all residents have been removed. Transporters trained on this process, logs created and in-use since 9/07/16. The Plan of Removal was verified 09/23/16 - 09/26/16 as follows: Review of Resident Van Safety Checks form revealed dates and times of return to facility was documented with 2 signatures verifying no residents or property were left on the van. Review of Record of In-Service dated 9/07/16 documented staff from nursing, receptionists, admissions, housekeeping/laundry, dietary, maintenance and administration were in-serviced on Transportation Safety. The in-service included to always check the inside of the bus for patients and personal items. Always have 2 signatures on a sheet of paper for double identification. The in-service was given by ADON F. Interviews with Drivers M (9/12/16 at 11:28 AM) and N (9/26/16 at 8:41 AM), Maintenance Director (9/23/16 at 12:49 PM), LVN O and Receptionist D (9/23/16 at 3:09 PM) revealed they knew the new procedure for checking the van prior to parking and needing a 2nd person to check and sign the van log with the driver. B. Resident #2 - Showering Supervision Review of the face sheet dated 7/27/16 documented Resident #2 was a [AGE] year old man admitted on [DATE]. Review of the hospital History and Physical dated 5/25/16 documented Resident #2 had [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed Resident #2 had severely impaired cognitive skills for daily decision making, continuous inattention, altered level of consciousness and psychomotor retardation, no behaviors, was 2 person total dependence for transfer and total dependent 1 person for bathing and no falls occurring before or since admission. Review of Resident #2's Care Plan effective 6/06/16 documented the following: Problem: at risk for falls/frequent falls related to (impaired decision making, poor safety awareness, decreased rom (range of motion) and other related complications). Goals: Will have no falls/injuries during the next 90 days Interventions (included): Assess for prior history of falls To the extent possible provide a safe environment (floors that are even and free from spills or clutter, adequate, glare-free lighting, call light within reach). Encourage to remain in open areas when appropriate There was no mention of his balance problems, need for hi-backed wheelchair, that he would lean to the sides and forward or updating the care plan to list falls he had up to and including 9/02/16 and what measures the staff were taking to decrease Resident #2's risk for falls and injuries. Review of the Fall Risk Evaluation dated 7/10/16 documented Resident #2 had a fall risk score of 20. A resident who scores a 10 or higher is at risk. Review of Clinical Notes dated 6/22/16, 7/02/16, 7/10/16, 8/31/16 and 9/02/16 documented Resident #2's falls on those dates. Record review of Progress Note dated 7/22/16 documented Resident #2 had contracted bilateral knees. Review of Physician Order Sheet for July 2016 revealed an order for [REDACTED]. Review of the Falls Investigation Worksheet documented on 9/02/16 at 10:45 AM, Resident #2 fell in the bathroom while seated in a shower chair. CNA B was with him. The worksheet documented the injury as a Major Injury; a laceration to his forehead. Medical considerations were incontinence, loss of arm or leg movement and cognitive impairment. In an attached statement emergency services were contacted and Resident #2 was transported to the hospital. Review of the PT (Physical Therapy) - Therapist Progress dated 8/24/16 documented Resident #2 was total assist (100%) for balance and coordination, fall recovery. He had decreased balance, functional tolerance, functional mobility, active range of motion and coordination. Complicating factor included decreased cognition. In an interview on 9/22/16 at 2:27 PM, the Director of Therapy said Resident #2 had contractures to both lower extremities and had poor balance. In a regular wheelchair he could not keep his balance. In his sitting evaluation Resident #2 could tolerate upright sitting with stand-by to moderate assistance. He could initiate balance when he was over his center of gravity and last for about 5 minutes but he eventually loses his balance. In an interview on 9/22/16 at 2:30 PM, Physical Therapy Aide (PTA) H said Resident #2 had problems with his posture - he could not hold a neutral position and leaned to his sides. Resident #2 was not assessed in a shower chair but PTA H said he believed the resident would not be able to maintain his posture in a shower chair, just like the wheelchair. PTA H said Resident #2 is not able to brace himself if he goes forward. Review of the 200 Hall Assignment Book (what the CNAs call the shower book) revealed special instructions for one resident, but none for Resident #2. Review of Record of In-service dated 9/02/16, after Resident #2 fell and was transported to the hospital, documented an in-service, Safety - Showers. It included a statement to always ask for help even if resident is 1 person shower. A statement signed by the DON said in-service done due to resident falling. He is a risk for falls and has fallen before, even before he was admitted . He was being showered and has always been showered by one person, however, he can also be showered by two people if the CNA wants assistance. Observation on 9/12/16 at 11:54 AM, Resident #2 was seated in the 200 hallway in a high-backed wheelchair. He was non-verbal with a blank stare. A GT feeding was in progress. Resident #2 had steri-strips across his forehead. His legs were contracted. LVN E said the resident had fallen in the shower on Friday a week ago. (9/2/16). Observation on 9/22/16 at 1:50 PM, Resident #2 was lying in bed with his arms folded and his legs drawn up towards his abdomen. He was in a low bed with a low air loss mattress. There was a mat on the floor. He had a scar where the steri-strips had been. In an interview on 9/12/16 at 1:38 PM, CNA G said Resident #2 will sometimes go forward when he is in the shower chair and he is very strong. In an interview on 9/12/16 at 1:45 PM, CNA B said on 9/02/16 was the first time she had worked on the 200 hallway and she took Resident #2 to the shower in a shower chair. She was holding him so he would not fall, but he quickly leaned forward and she could not stop him from falling. CNA B said she had been pulled to the 200 hallway to work on 9/02/16 as there was only one other CNA that day on the 200 hallway. CNA B said she knew Resident #2 always moved a lot and his legs are always bent. CNA B said she had given Resident #2 a shower before and she thought Resident #2 would be an easy shower, but no one told her he would go forward. CNA B said she can find out what care a resident needs by asking the nurse. CNA B said her mistake was not asking the nurse that day. In an interview on 9/22/16 at 1:52 PM, ADON I said CNA B called her to the shower room on 9/02/16. CNA B told her Resident #2 was in the shower chair and he went forward. When ADON I saw him, he was on the floor and had hit his head on the corner of the shower. He was lying on his left side and had a laceration on his forehead, a scratched nose, abrasions on his knees and a skin tear on his hand. ADON I said he was positioned on the floor in a fetal position which is how he lies in bed. ADON I said when Resident #2 was admitted he fell and was placed in a low bed with a fall mat. He moves and scoots to the edge of the bed. In a telephone interview on 9/22/16 at 2:06 PM, the Hospital Social Worker (SW) said, according to the emergency room nurse and doctor, Resident #2 had been placed on a commode (shower chair) even though he had severe contractures. This patient was at a high risk for falls. This patient fell off of the commode (shower chair) and sustained a laceration to his forehead with irregular edges. It was star-shaped and opened in several directions requiring 4 staples. He also had abrasions to his knees and his nose. The SW said the doctor said the patient was on aspirin and could have bled into his brain. Review of www.mayoclinic.org <http://www.mayoclinic.org> on 9/26/16 stated aspirin interferes with the blood's clotting action. In an interview on 9/22/16 at 4:33 PM, the DON said the State Attorney General's office came out to investigate as the hospital had called in a complaint that Resident #2 should have been given a bed bath rather that bathed in a shower chair because of the resident's contractures. The DON said the residents cannot be cleaned well enough in a bed bath so they showered the residents. The DON said the facility had reclining shower chairs, no shower beds. The surveyor asked the DON to show the reclining shower chairs and both went into the shower room on the 200 hallway. There were 2 shower chairs, both had upright backs. The DON pointed to one of the chairs and said, This is it. When asked to demonstrate how the shower chair reclined, the DON pulled apart the left arm which swung open the left arm of the chair, opening it to a side entrance, but it did not recline the chair. The DON said all of the other shower chairs were like this one; they did not recline. The DON demonstrated how to pull out the footrest on the shower chair, but did not answer when asked if a resident with contracted legs could use the foot rest. In an interview on 9/23/16 at 8:48 AM, CNA J said she needs another person in the room when she showers Resident #2 because he likes to move. He leans forward and to the sides. He has been like this since he was admitted . In an interview on 9/23/16 at 8:57 AM, CNA K said it takes 2 people to shower Resident #2. One person to shower him and 1 to steady him. CNA K said Resident #2 is very strong and always leans. If you step away from him to get a towel, he will fall forward. CNA K said the information about showering Resident #2 is not written down anywhere, it is communicated by mouth. In an interview on 9/23/16 at 9:21 AM, CNA G said Resident #2 was a 2 person shower because he always leans forward. If only 1 person is available, everything has to be set up and close by because of you step away from him, he will fall forward. He cannot put his arm out and stop himself. In an interview on 9/23/16 at 9:46 AM, LVN L said Resident #2 was very strong. He can hold and grab and push. He can grab the arms of his wheelchair and pull himself forward. He has no balance whatsoever. In a regular wheelchair he had no balance and could pull himself forward. LVN L said he has the same balance in a shower chair. LVN L said to safely shower Resident #2, there should be 2 people because of his activity. LVN L said CNA B had been on the 200 hallway before. LVN L said CNA B, on 9/02/16, did not ask him how to shower Resident #2 or if there were any concerns and he did not know if she was instructed by anyone else. In an interview on 9/23/16 at 12:38 PM, the DON said Resident #2 was a fall risk because of the way he sits and he is tall. The DON said Resident #2 was a 2 person transfer, but once in the shower chair he was a 1 person shower. The DON said he was usually calm and had always only needed one person to shower him. The DON said she had seen him lean to his sides and he had contracted lower extremities. When asked about the investigation into the fall, the DON said she was there. She knew what happened. Resident #2 went really fast and fell forward. When asked if she had asked any of the CNAs that regularly care for Resident #2 what kind of care he needed during showers, she said no because she was there. Review of the facility Fall Prevention Policy, undated and provided by the DON on 9/23/16, stated, in part, Policy Statement: Falls can cause people to restrict their activities, lead to depression, helplessness, social isolation, loss of confidence in independent mobility, injuries and even death. Most falls occur as a result of multiple intrinsic and extrinsic factors. The facility should form a fall risk management program which requires an interdisciplinary team approach to prevent and minimize falls. Policy Interpretation and Implementation: A care plan for fall risk management and injury prevention should be implemented. Effectiveness of the interventions identified in the care plan are evaluated for effectiveness. Review of the facility policy Care Plans - Comprehensive revised September 2010, stated in part Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. The census of 75 residents was obtained from the Detail Midnight Census dated 9/12/16 and the list of 4 residents who have contracted lower extremities and poor trunk balance was obtained by interview on 9/22/16 at 2:27 PM with the Director of Therapy.