Every finding on record at Legacy Nursing and Rehabilitation

Based on interviews and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 10 of 89 days reviewed for RN coverage.The facility failed to ensure they had an RN on duty on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].This failure placed residents at risk of missed nursing assessments, interventions, care, and treatment.Findings included:Review of the Nursing Master Schedule for the months of January, February, and [DATE] revealed zero hours worked by an RN on the week-end days of [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].In an interview conducted on [DATE] at 4:05 PM, the HR Director reviewed the time sheets for the days that were in question. The HR Director stated that no RN clocked in on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The HR Director stated the facility is expected to have an RN on all days. She explained that the absence of RN coverage could delay or prevent the performance of duties that are within the RN scope of practice only, such as pronouncing a resident deceased and other clinical responsibilities that cannot be performed by an LVN.In an interview conducted on [DATE] at 4:17 PM, the Administrator stated that the facility is required to have RN coverage for eight consecutive hours per day, seven days per week. He stated he could not speak on the facility's staffing from [DATE] through [DATE], as he had only been at the facility since [DATE]. The Administrator stated that since his employment began, the facility has maintained daily RN coverage, which has been verified. He further stated that failure to maintain the required RN coverage could negatively affect Payroll-Based Journal (PBJ) reporting, quality measures, and resident care due to the absence of an RN in the building.In an interview conducted on [DATE] at 4:26 PM, the DON stated the facility was required to have RN coverage for eight hours each day. She stated that if she became aware there was no RN coverage, she would typically come to the facility and provide coverage, or the facility utilized agency nursing staff. She stated the Staffer is over the scheduling, but she does not work on weekends. The DON stated the floor staff are expected to notify her when scheduled staff do not report to work. She further stated the facility's procedure is for the floor nurses to notify supervisory staff if RN coverage is unavailable; however, she acknowledged that notifications may sometimes be missed. The DON stated the potential for harm associated with the lack of RN coverage is that an emergency could occur without RN supervision available to assess the situation and provide nursing oversight.RN Hours Coverage Policy was requested on [DATE] at 3:56 PM from DON and Administrator, was told, the facility did not have a policy specific to RN hours.Review of facility policy titled Quality of Care and Procedure undated reflected: . 14. The facility will have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments, and plans of care.15. The facility will use the services of a registered nurse (RN), seven days a week.

Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive care plan that describes the services that are to be furnished to maintain the residents' highest practicable physical, mental, and psychosocial well-being for 3 of 9 residents reviewed for care plans (Resident #9, Resident #53 and Resident #99). 1. The facility failed to ensure Resident #9's comprehensive care plan reflected a plan for her indwelling urinary catheter that included her physician ordered interventions dated 07/02/2026 Urethral catheter (20 Fr) with (30 cc) bulb. every shift Urinary catheter and catheter bag: Tubing secure; Check for placement of dignity cover; Ensure bag is below the level of the bladder; Ensure bag is not touching or dragging the floor/ground. 2. The facility failed to ensure Resident #53's Comprehensive Care Plan reflected a plan for indwelling foley catheter and BPH indwelling catheter interventions. Resident #53 preferred for his catheter to be up on the wheelchair arm, above his bladder, as evidenced by 3 observations. 3. The facility failed to ensure Resident #99's Comprehensive Care Plan reflected a plan for resident to be allowed adequate time to urinate. Resident is incontinent of urine and wears a brief, so can urinate at any time. Care Plan was not updated correctly with focus and interventions that is individualized to the resident. These failures could place residents at risk for not having care needs identified and a plan to address Findings included: 1. Review of Resident #9's face sheet dated 07/09/2026 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses chronic obstructive pulmonary disease (a common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough.) and retention of urine (inability to fully empty the bladder). Review of Resident #9's quarterly MDS dated [DATE] reflected she was assessed to have a BIMS score of 11 indicating she had moderate cognitive impairment. Resident #9 was assessed to require maximal assist with ADLs and was assessed to have an indwelling catheter. Review of Resident #9's consolidated physician orders reflected an order dated 07/02/2026 urethral catheter (20 Fr) with 30 cc bulb every shift assess for discomfort or pain related to urinary catheter. Further review reflected an order dated 07/02/2026 Urethral catheter (20 Fr) with (30 cc) bulb. every shift Urinary catheter and catheter bag: Tubing secure; Check for placement of dignity cover; Ensure bag is below the level of the bladder; Ensure bag is not touching or dragging the floor/ground. Review of Resident #9's comprehensive care plan reflected a focus are dated 05/11/2024 I use an indwelling urinary catheter. Interventions included Change my catheter tubing/bag as appropriate Date Initiated: 05/11/2024. Provide catheter care for me every shift Date Initiated: 05/11/2024. Further review of Resident #9's care plan reflected no plan of care for her catheter secure device, or her physician ordered interventions to check for placement of dignity cover; ensure bag is below the level of the bladder; or to ensure bag is not touching or dragging the floor/ground. In an interview on 07/09/2026 at 10:25 am MDS Coordinator A stated she was assigned to update Resident #9's care plan. She stated she had not reviewed Resident #9's care plan, but her care plan should include all her physician ordered interventions including her Cath secure device. In an interview on 07/09/2026 at 10:30 am MDS Coordinator B stated she updated Resident #9's care plan to include all the interventions that should have been on the care plan. Review of the updated care plan for Resident #9 dated 07/09/2026 reflected the added interventions of: ensure my catheter bag is below the bladder; tubing secure; check for placement of dignity cover; and ensure bag is not touching or dragging the floor/ground. In an interview on 07/09/2026 at 1:44 pm, the DON stated, regarding care plans, that all physician orders and interventions for residents' care should be on the residents' care plans, and if they were not, the resident may not get the appropriate care. 2. Review of Resident #53's face sheet dated 07/07/2026 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses chronic kidney disease stage 2 (mild but permanent damage to kidneys where they work about 60%), diabetes mellitus (A condition results from insufficient production of insulin, causing high blood sugar.), venous insufficiency (Poor circulation of blood), benign prostatic hyperplasia without lower urinary symptoms (noncancerous enlargement of the prostate), neuromuscular dysfunction of bladder (communication break between brain and bladder), essential hypertension (chronic high blood pressure) and mild cognitive impairment of uncertain or unknown etiology (memory and decision making decline). Review of Resident #53's quarterly MDS dated [DATE] reflected that he was assessed to have a BIMS score of fifteen indicating he has intact cognitive status. MDS also shows resident requires assistance with setting up for all personal hygiene and activities of daily living. The MDS assessment indicated Resident #53 had an indwelling catheter (tube inserted into the bladder). Review of Resident #53's comprehensive care plan reflected I use a suprapubic catheter (18 FR 10cc) related to BPH, urine retention date initiated: 03/24/2025. Interventions included: assess me for symptoms of urinary tract infection as needed date initiated 6/29/2023; change my catheter tubing/bag as appropriate date initiated 6/29/2023; ongoing assessment of my urine date initiated 6/29/2023 with a revision on 6/20/2024; provide catheter care for me every shift date initiated 6/29/2023; watch me for acute behavioral changes that my indicate UTI date initiated 12/17/2024. Review of Resident #53's comprehensive care plan reflected I have BPH; I have an indwelling foley catheter (I refuse to allow staff to cover my drainage bag with a privacy/dignity cover- I like to see how much urine output I have and to read the numbers), date initiated 6/29/2023. Interventions included: notify my MD of retention initiated 6/29/2023; watch me for bladder distention and discomfort; change my catheter as ordered by the physician date initiated 6/29/2023; watch my intake and output date initiated 6/29/2023. Review of Resident #53's physician orders reflected an order dated 05/7/2026 Suprapubic Catheter=18 French with 10 cc bulb. Review of Resident #53's physician orders reflected an order dated 04/3/2026 Enhanced barrier precautions to every shift for catheter. Observation and interview on 07/07/2026 at 9:30 am Resident #53 was observed in bed with catheter above bladder level hanging on WC (wheelchair) arm beside the bed. He stated he tells them (staff) to put catheter there. Observation on 7/8/26 at 2:35pm Resident #53 sleeping in bed and catheter hanging on wheelchair arm rest and not below level of bladder, but above the level of the bed. Observation and Interview on 7/9/2026 at 9:40 am Resident #53 refused to have catheter care done, resident said he does not have time for questions now or for catheter care. Resident is lying in bed with catheter stabilizer/holder holding tubing against body and tubing running upward to the bag that is secured to the arm rest of his wheelchair above the level of the resident. 3. Review of Resident #99's face sheet dated 07/07/2026 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses unspecified intracranial injury with loss of consciousness of unspecified duration (head trauma causing brain disruption and lost consciousness), spastic hemiplegia affecting right dominate side (paralysis or weakness with muscle stiffness that affects the side the person prefers to use), hemiplegia affecting right dominate side (severe or complete paralysis of the side the person prefers to use), unspecified injury of head (head injury or bump to the head), benign prostatic hyperplasia without lower urinary symptoms (noncancerous enlargement of the prostate) , dysphasia oropharyngeal phase (difficult swallowing and moving food), essential hypertension (high blood pressure). Review of Resident #99's quarterly MDS dated [DATE] reflected that he was assessed to have a BIMS score of eight indicating he had moderate cognitive impairment. MDS also shows resident requires assistance with all personal hygiene, daily living care, and transfers. Review of Resident #99's comprehensive care plan reflected I have BPH Date initiated on 7-11-2023. Interventions included allow me adequate time to urinate date initiated on 7-11-2023; notify MD of retention date initiated on 7-11-2023; watch me for bladder distention and discomfort date initiated on 7-11-2023. Another focus reflected I am incontinent of urine date initiated on 7-11-2023. Interventions included assist me with perineal cleaning as needed date initiated on 7-11-2023; Observe my skin daily for irritation and redness date initiated on 7-11-2023; watch me for behavioral changes that indicate a UTI date initiated on 7-11-2023. Observation and interview on 07/07/2026 at 12:17 pm revealed Resident #99 was observed in his geriatric chair, after lunch, drinking from his cup with a straw. He was wearing a brief and pants over brief. Resident has difficulty answering questions related to dysphasia. In an interview on 07/09/2026 at 09:34 pm, Admin RN C stated, about Resident #99, We added about hanging his catheter above his bladder to the care plan, we added it after seeing how he hangs it because he will not listen to us. We constantly tell him not to hang it above his bladder. In interview on 7/9/2026 at 12:02 pm after looking at Resident #99's care plan she stated I guess we added the dignity bag and not the hanging of the catheter on the side of the chair above the bladder regarding updating interventions. She stated Resident #99 was non-compliant, when they find it high the staff move it and Resident #99 is argumentative and moves it back. She also stated Resident #99's care plan is just not individualized like it should, and they are working on that. The facility has an improvement plan where they have identified that the care plans are generic and need to be updated. The plan is to revise the whole building, and they have divided all the residents out to get them all done. In an interview on 7/9/2026 at 11:47 am, MDS Coordinator A stated she will oversee care plans but is new and just getting started. She stated she is going to update care plans as the MDS is due or as they are admitted . She states that resident #53 is not hers yet and stated they need to update that, and they know he is non-compliant. After looking at care plan for resident # 99, she states she sees that it is wrong, but they just need updating. States she sees that does not make sense. She states that it could cause urinary infections or skin breakdown issues if the care plan is incorrect. They are trying to correct as they come due for anything they will update care plans. They have a performance improvement plan they are working on from now on. In an interview on 7/9/2026 at 1:33 pm, the Director of Nurses stated care plans are on their Quality Assurance and Performance Improvement Plans; the facility has identified the problem. When looking at care plan for resident #53, she states that they know he keeps his catheter above his bladder and they have repeatedly told him not to do that. When looking at care plan on resident #99, she states that it is just a general plan and does not seem to be individualized. She states his care plan should be updated and the plan is to re-do the whole building's care plans. We will break the residents into groups and do the whole building, so they are individualized. Director of Nurses states that the problem with the catheter being up to high can cause backflow thus causing infection or urinary issues. She states the problem with not updating #99s plan can also cause urinary tract issues because it is general and does not fit him. She stated the facility has identified that the care plans need to be updated and we just had issues last week. Review of the facility's undated Care planning policy and procedures reflected To provide a comprehensive plan of care addressing resident's needs, strengths, goals, and approaches. Each resident's care plan will remain current and inform staff of resident's needs, strengths, goals, and approaches. A Comprehensive Care plan will be completed according to the RAI manual upon admission, annual, significant change and as needed. These Policies and Procedures are intended only as a guide to our staff and should not be applied blindly across the board. These policies and procedures should be considered along with the experiences of staff and sound reasoning. Our Policies and Procedures must be flexible to the extent that the care provided to our residents meets the individualized needs of each resident. Regardless of the Policies and Procedures, care provided by staff must be specific to the individual needs of each resident to achieve the most desirable results for the residents.

Based on observation, 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 two of eight residents (Resident # 7, Resident #12 and Resident # 68) reviewed for ADL care. The facility failed to ensure Resident #7, Resident #12 and Resident #68's nails were clean on 07/07/2026. This failure could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings include: Findings include: 1. Record review of Resident #7's face sheet, dated 07/08/2026, reflected an [AGE] year-old-female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #7 had diagnoses which included, Parkinson's disease without dyskinesia, with fluctuations (a movement disorder of the nervous system that causes unintended, dance-like, or writhing movements of the face, arms, legs, or trunk), and anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrollable fear or worry. Record review of Resident #7's admission MDS Assessment, dated 06/09/2026, reflected Resident #7 had a BIMS score of 12, which indicated her cognition was moderately impaired. Resident #7 required partial/moderate assistance (helper does less than half the effort) with personal hygiene and upper body dressing. Resident #7 was totally dependent on staff for lower body dressing. She required substantial/maximal assistance (helper does more than half the effort) with putting on/ taking off footwear, showers, and toileting hygiene. Record review of Resident #7's Comprehensive Care Plan, completed on 06/12/2026 reflected Resident #7 had Parkinson's Disease. Interventions: Assist as needed. She required staff assistance with all ADLs. Interventions: Resident #5 required assistance with hygiene and grooming. Observation and interview on 07/07/2026 at 9:55 a.m. revealed Resident #7 was in her room sitting in her wheelchair watching a talk show on television. Underneath Resident #7's fingernails on her right hand of her forefinger, middle and ring fingernails had a blackish/ brownish substance. She stated I don't know when asked about if staff cleaned her fingernails. Resident #7 stated she was unable to clean or trim her own fingernails. She stated she had Parkinson's diseases and needed assistance with cleaning her fingernails. Resident # 7 stated she did not remember if she reported to anyone her nails needed to be cleaned. She did not respond to any further questions about her ADL care of fingernails. 2. Record review of Resident #12's face sheet, dated 07/08/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #12 had diagnoses which included type 2 diabetes mellitus with other diabetic kidney complication ( a chronic condition where the body cannot use insulin properly or make enough insulin with kidney damage caused by long- term, uncontrolled high blood sugar and blood pressure), pain, unspecified ( a person experiences discomfort, but the doctor has not identified the exact cause, underlying condition, or specific bodily location), and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety ( a person exhibits memory decline, but a doctor has not yet determined the exact underlying cause without any behaviors). Record review of Resident #12's Quarterly MDS Assessment, dated 05/26/2026, reflected Resident #12 had a BIMS score of 12, which indicated her cognition was moderately impaired. Resident #12 required substantial/maximal assistance (helper does more than half the effort) with personal hygiene. She required supervision or touching assistance (helper provides verbal cues and touching assistance as resident completes activity) with the following: showers upper and lower body dressing. Record review of Resident #12's Comprehensive Care Plan, dated 05/29/2026, reflected Resident #12 required staff assistance for ADLs. Intervention: Resident #1 required staff assistance with showers, hygiene, and grooming. Observation and interview on 07/07/2026 at 10:08 a.m., Resident #12 was in her room sitting in her wheelchair waiting to be assisted to dialysis. Underneath Resident #12's fingernails on her left and right hands of her middle and ring fingernails had a blackish/brownish substance. Resident #12 did not want to answer any questions. In an interview on 07/08/2026 at 9:40 a.m., CNA G stated if a CNA observed any problems with a resident's nails, the CNA was to report it to the nurse supervisor with any resident. CNA G stated the CNAs completed all nail care for residents without a diabetes diagnosis. She stated if there was a blackish substance on the residents' fingertips or underneath their nails, and the resident swallowed the blackish substance, there was a possibility a resident may become ill, such as nausea and diarrhea. CNA G stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. CNA G stated anytime a resident refused any type of care she reported it to the charge nurse and the charge nurse would document it in the resident's medical record. CNA G stated she had given some care to Resident #7 and Resident #12, however, she stated they did not refuse nail care. She stated she was not aware of Resident #7 and Resident #12's shower schedules. CNA G stated she was not assigned to Resident #7 or Resident #12 on 07/07/2026. In an interview on 07/08/2026 at 9:15 a.m., ADON A stated the CNAs were responsible for Residents #7 and #12's nail care. She stated nail care was usually completed during showers, and as needed. ADON A stated if a resident had brownish/blackish substance underneath their nails, and if a resident swallowed the substance, there was a possibility a resident may become ill, such as an infection in the stomach. She stated there was a possibility a resident may have nausea and vomiting. ADON A stated if a resident refused showers, nail care, or any type of care, the nurses documented it in the nurse's progress notes. ADON A stated she was in-serviced on ADL care, and all staff were to report any nail issues with the resident to the nurse. She stated she was not aware of Resident #7 or Resident #12 refusing nail care. In an interview on 07/09/2026 at 10:20 a.m., the Director of Nurses stated the CNAs were responsible for cleaning and trimming all residents' nails, except for the residents with diabetes. She stated the nurses were responsible for nail care of all residents with a diagnosis of diabetes. The Director of Nurses stated the residents' nails were usually cleaned during showers and as needed. She stated if a resident ingested the blackish/brownish substance underneath their nails, there was a potential the resident may experience vomiting or diarrhea. The Director of Nurses stated it depended on the type of bacteria if a resident needed to be assessed at the Emergency Room. She stated anytime there was an issue with nails the CNAs was to report it to the nurse supervisor. The Director of Nurses stated any refusal of care would be documented on the resident's care plan. In an interview on 07/09/2026 at 10:45 a.m., CNA H stated if a CNA observed any problems with a resident's nails the CNAs was to report it to the nurse supervisor with any resident. CNA H stated the CNAs completed all nail care for residents without a diabetes diagnosis. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill, such as nausea and diarrhea. CNA H stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. CNA H stated anytime a resident refused any type of care she reported it to the charge nurse and the charge nurse would document it in the resident's care plan. CNA H stated she had given some care to Resident #12 and Resident #7, however, she was not aware of these residents refusing nail care. She stated she was not aware of Resident #12 or Resident #7 shower schedules. CAN C stated she was not assigned to Resident #12 or Resident #7 on 07/07/2026. 3. Review of Resident #68's face sheet dated 07/09/2026 reflected a 78-yearold female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), osteoarthritis (A condition when bone strength weakens and is susceptible to fracture. It usually affects hip, wrist, or spine.), and diabetes mellitus (A condition results from insufficient production of insulin, causing high blood sugar.). Review of Resident #68's quarterly MDS dated [DATE] reflected Resident #68 was assessed to have a BIMS score of 3 indicating severe cognitive impairment. Resident #68 was assessed to have limitation of range of motion of her upper and lower extremities on both sides. Resident #68 was assessed to be dependent on staff for the ADLs of shower/bathe self and personal hygiene. Review of Resident #68's comprehensive care plan reflected a focus area reflected I require staff assistance for all ADL's date initiated 11/29/2025. Interventions included .assist me with bathing. Further review of Resident #68's care plan reflected nail care was not directly addressed. Observation on 07/07/2026 at 11:50 am revealed Resident #68 up in a Geri-chair in the dining room. Observation of her left hand revealed there was a thick brown substance on her hand and fingers, and there was a brown substance under her fingernails. Observation and interview on 07/07/2026 at 11:52 am, Admin RN C stated Resident #68 hands were dirty and it looked like the substance could be BM. She stated she would take Resident #68 to get her hands clean before lunch was served. In an interview on 07/07/2026 at 12:30 pm, CNA J, who was working on Resident #68 hall, stated she did not see Resident #68's fingers dirty when she got the resident up at 8:00 am. CNA J stated she did her rounds at 9:40 am and did not see it. She stated Resident #68 had a bed bath this morning. She stated nail care should be done with baths and stated she did not get to it this morning; she was running late. In an interview on 07/09/2026 at 1:44 pm, the DON stated it was her expectation that staff made sure all residents' fingernails and hand are clean. She stated if a resident had feces under her fingernail she could put them in her mouth and could cause the resident to become ill. Record review of the facility's undated policy on Nail Care reflected Nail care Policy and Procedure:Policy: 1. To prevent infection; 2. To prevent irritation; 3. To prevent break in skin integrity;4. To promote cleanliness; 5. To relieve pain.Procedure:1. Care of fingernails and toenails is part of the bath. 2. Be certain nails are clean.3. If nails are difficult to cut, inform the charge nurse. 4. Nails are to be clipped and filed smoothly. 5. Cut straight across the nails.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the 1 of 1 kitchen reviewed. The[KS33.1] facility failed to ensure food safety by not discarding expired food in the kitchen, not maintaining a sanitary kitchen, and not implementing infection control when taking food temperatures. These failures can place residents at risk for foodborne illness. An Observation on 7/7/2026 at 9:00 AM of the walk-in cooler revealed the following. A opened container of Grape Jelly , , had an open date of 7/5/2026 and no use-by date. Flour Tortillas with the production date of 11/07/2025 with no use-by date. Opened yogurt in a sealed bag with an open date of 6/13/2026 with no use-by date. Sheet Tray of Jell-O in the cooler, not labeled with a date of manufacture or a use-by date.An Observation on 7/7/2026 at 9:10 AM: The walk-in freezer revealed the following. Piecrust with an open date of 7/3/2026 with no use-by date. Fried Okra in the original bag, had no open or used by date on the bag[KS34.1]. Opened hamburger patties with no open date or use-by date on the bag. Taquitos in a resealable plastic bag with an open date of 5/7/2026 and no use-by date. Meatloaf In a resealable plastic bag with an open date of 7/04/2026 with no use-by date.An Observation on 7/7/2026 at 9:15 AM of the pantry revealed the following: Open bag of corn flakes with an open date of 7/1/2026 and no used by date. Open bag of powdered sugar with an open date of 6/24/2026[KS35.1] and no use-by date. Open bag of marshmallows with an open date of 6/24/2026[KS36.1] and no use-by date. [NAME] In a sealable container with no open date or use-by date. Flour In a resealable container with no open date or use-by date. Cornmeal in a sealable container with no open date, or used or use-by date. bread mix and a sealable container with no open or used by date.[KS37.1] Sugar in a sealable container with no open date, or used by date bananas in a box that were black with no use by date on the box.An Observation of the kitchen on 7/7/2026 at 9:25 AM revealed the following. [NAME] plastic bin containing kitchen utensils had food debris in the bottom of the bin. The ice machine had a white, grime-like substance on the inside and outside of the container.An Observation on 7/7/2026 of the kitchen food temperatures at 10:56 AM revealed the following: CK[KS38.1] M used her gloves for multiple different tasks, then took the French fries out of the fryer, and while putting them in a container, she touched the fries with her glove. CK M Took the temperature of the steak fingers with an infrared light gun and not with a thermometer. CK M [KS39.1]wiped the thermometer on a rag and not the alcohol wipes. CK M was stopped and she had to go ask how it was to be done. An Observation on 7/7/2026 at 10:56 AM during lunch service revealed the following; DA K was observed with no beard guard while in the kitchen. DA K was touching his clothes and nose while using gloves and did not change his gloves before handling drinks and food trays in the kitchen.An[KS40.1] interview on 7/9/2026 at 10:18 AM with DA K. He stated everyone in the kitchen is responsible for labeling and dating food products. He stated he is responsible for labeling and dating items such as juices, cheeses, drinks, and side items, and for putting them in the cooler. He stated that staff check for out-of-date items daily and throw them away if they are out of date. He stated he was not wearing a beard guard because he had forgotten to put one on. He stated that everyone in the kitchen with exposed hair should wear a hairnet or beard guard. He stated it is everybody's responsibility to clean the kitchen. He stated the cooks are responsible for cleaning the utensil drawers. He stated if out-of-date food was served or hair fell onto a food item, it could make the residents sick. He stated he has had training on labeling and dating food items in the kitchen. He stated the last time they talked about it was a couple of months ago. He stated that he is not supposed to touch his face and not change his gloves. An interview on 7/9/2026 at 10:24 AM with DA L. She stated that labeling and dating depend on which side you were on[KS41.1]. She stated the cook will lable prepared foods and the aides will lable all other foods. She stated that she is responsible for labeling and dating items placed on residents' trays, such as desserts and juices. She stated the kitchen cook is responsible for labeling, dating, and everything else, and that everybody in the kitchen should be wearing a hair cover. She stated if she sees someone not wearing a hairnet or a beard cover, she will remind them to put one on. She stated that everybody is responsible for cleaning the kitchen. She stated the cooks are responsible for cleaning the utensil drawers. She stated there used to be a check-off list[KS42.1] for cleaning, but they no longer have it. She stated that if residents are served food that is outdated, or food with hair in it, they could get sick. She stated she has had in-service training on labeling and dating food items in the kitchen. She stated they are reminded daily about hairnets and beard covers.And interview on 7/9/2026 at 10:32 AM with CK M. She stated she was not trained on cleaning the thermometer with alcohol between taking temperatures of each food item. She stated that the person who trained her did not show her that she was not told to change her gloves in between each task in the kitchen. She stated that everybody is responsible for labeling and dating food items in the kitchen. She stated that all food items should have an opening date and a use-by date. She stated if there is any outdated food[KS43.1] in the kitchen, it should be thrown away. She stated that cooks and dietary aides have their own area to clean and are supposed to be clean as they work. She stated they used to have a check-off list for cleaning, but they no longer do. She stated that they are supposed to clean as they go. She stated all hair should be covered if someone is in the kitchen area handling food. She stated if she sees somebody not wearing a hairnet, then she will remind them. She stated that if a resident is served food out-of-date food date, or if there is hair and food[KS44.1], it could get the residents sick. She stated that if gloves are not changed and hands are not sanitized, residents could get sick. An interview on 7/9/2026 at 10:43 AM with DM. She stated she was not aware that CK M was not trained on taking food temperatures and hand cleanliness while handling food. She stated the thermometer should be cleaned with an alcohol pad between taking the temperature of each food item. She stated all staff should have hair covered while they were working in the kitchen. She stated that maintenance is the one that cleans the ice machine. She stated the ice machine is supposed to be cleaned monthly. She stated she does not know when maintenance last came to clean the ice machine.An interview on 7/9/2026 at 3:05 PM with MD. He stated the ice machine was cleaned once a month. He stated when they cleaned the ice machine they empty the ice machine and clean it thoroughly. He stated there is supposed to be a check off list that shows when the ice machine has been cleaned. He stated there is no check off list right now, but there should be. He stated if the ice machine is not cleaned regularly then mold could grow in the ice machine. He stated if the ice machine is not clean residents could get sick.An interview on 7/9/2026 at 3:05 PM with the ADM. He stated all staff are expected to label all [KS45.1]food items in the kitchen. He stated all food items should be used by day. He stated he did not know the process on how the temperatures should be taken and the thermometer be cleaned. He stated all kitchen staff should be cleaning the kitchen. He stated he was not aware that there was no cleaning checklist, and there should be. He stated staff should be changing their gloves between each task in the kitchen before going back to certain food items. He stated he was unaware who was responsible for cleaning the ice machine in the kitchen. He stated all staff in the kitchen should have hair nets and a beard guard if they have facial hair. He stated if residents were served out of date, food, or food with the hair in it the residents could get sick. He stated touching food with unclean gloves could get residents sick. He stated if the ice machine is not clean residents could get sick.Record review of the Food Safety And Sanitation Policy And Procedure that was not dated revealed the following. 1.All staff will be in good health, will have clean personal habits and will handle all foods safely.4.Hair restraints are required and should cover all hair on the head.6.All staff will wash their hands just before they start to work in the kitchen and when they have used their hands in an unsanitary way such as smoking, sneezing, using the restroom, handling poisonous compounds, dirty dishes, touching face, hair, other people, etc.9.All time and temperature control for safety (TCS) leftovers are labeled, covered, and dated when stored.10.Foods with expiration dates are used prior to the use by date on the package.

Based on observations, interviews, and record reviews, the facility failed to ensure the residents received services with reasonable accommodation of resident's needs and preferences, except when to do so would endanger the health and safety of the resident or other residents, for 2 of 26 residents (Residents #20 and #80) reviewed for call light accessibility. The[KS46.1] facility failed to ensure the call light system was accessible to Residents #20, and #80.This failure could place residents at risk of not being able to call for staff assistance to meet care needs, This could put the residents at risk of injury or pain.Record review of Resident #20's Face sheet dated 07/09/2026 indicated that the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: acute and chronic respiratory failure with hypoxia[KS47.1] (organs don't get enough oxygen to function properly), obesity (Excess body weight), and acute pulmonary edema (buildup of fluid in the air sacs of the lungs). Record review of Resident #20's Quarterly MDS dated [DATE] reflected a BIMS of 09, indicating moderate cognitive impairment. He was dependent on all tasks.Record[KS48.1] review of Resident #20's care Plan dated 5/08/2026 reflected that Resident #20 had impaired mobility. Interventions included: Assistance with some[KS49.1] of his ADLs, such as (Assist with bathing). There was no mention if the call lights in the care plan. Record review of Resident #80's Face sheet dated 07/09/2026 indicated that the resident was a female admitted to the facility on [DATE]. Her diagnoses included: sequelae of cerebral infarction[KS50.1] (prolonged lack of blood supply), hypertension (condition where the force of blood pushing against your artery walls is consistently too high), hyperlipidemia (plaque builds up inside the arteries), and muscle weakness.Record review of Resident #80's Quarterly MDS dated [DATE] reflected a BIMS of 00, indicating severe cognitive impairment. She was dependent on all tasks.Record review of Resident #80's care Plan dated 06/10/2025 reflected that Resident #80 had impaired mobility. Interventions included: Assistance with all her ADLs and placement of the call light within reach.During an observation and interview on 07/07/2026 at 2:20 PM with Resident #80 her call light was on the floor. She stated that she can sometimes get out of bed but needs help at other times. She stated that she did not know that the call light was on the floor. She stated that she has not been hurt because she cannot reach the call lights.During an observation and interview on 07/07/2026 at 2:31 PM with Resident #20 the call light was on the floor. He stated that he cannot reach it on the floor. He stated that he needs assistance with all his ADLs and getting out of bed. He stated that he has not been injured from falling when he cannot use the call light. He stated that he feels safe at the facility. During an interview on 7/9/2026 at 2:01 PM with CNA I she stated that call lights should be close to the resident's hand or within an easy reach. She stated that there are some residents that will move the call light. She stated that they make frequent rounds to the residents' rooms to make sure call lights are close to the residents. She stated that she tries to look in the rooms when she goes up and down the hall every 15 minutes. She stated that if call lights are not close to residents, they could miss out on care, or have a fall. She stated that she has received in service training on call lights, and the last time was one or two weeks ago.During an interview on 7/9/2026 at 2:15 PM with CNA J she stated that call lights should be within reach of the residents all the time. She stated that she checks residents' rooms often to make sure that call lights are close. She stated that they are required to make rounds at least every two hours. She stated that she does it more frequently. If residents are known to move the call lights she stated that she often reminds the residents to use the call light for help. She stated that if a resident's call light is not close to them there was a risk of falling and not getting help. She stated that she had in-service training on call lights frequently. She said that the last time she had in-service training on call lights was a couple days ago.During[KS51.1] an interview on 7/9/2026 at 3:05 PM with ADON B he stated that rounds are made with residents every two hours to make sure that all call lights are within range. He stated that they do verbal reminders for the residents to let them know to use the call lights. He stated they talk about call lights regularly throughout the week. He stated that if the call light is not within range then a resident could fall and get hurt because they are not able to reach the call light for help. He stated he is responsible for the hall that Resident #20 and #80 are on. He stated that staff should be checking on the call lights to make sure they are close to the residents.An interview on 7/9/2026 at 3:15 PM with ADM. He stated that call lights should be close to residents when they are in the room. He stated that residents are reminded to use their call light when they need something. He stated that staff should be checking on residents at least every two hours to make sure the call light was within reach. He stated that it depends on the resident and what could happen to them if the call light is not close to them. He stated that he has had in-service training with call lights, and the last time was two weeks ago[KS52.1]. Record Review of the Call Lights, Use of Policy and Procedure, not dated, revealed the following, Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand.

Based on interview and record reviews, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with a mental illness was completed correctly and were provided with a PASRR Level II assessment for one (Resident #62) of 4 residents reviewed for PASRR assessments. The facility failed to ensure the Social Worker entered Resident #62's PASRR Level l correctly into SimpleLTC portal (portal used by nursing facilities to manage resident's information). The PASRR entered did not indicate a diagnosis of mental illness, although diagnosis of major depressive disorder was present upon admission on [DATE]. This failure could place all residents who had a mental illness at risk for not receiving needed assessment (PASRR Evaluation), individualized care, and services to meet their needs.Findings included:Record review of Resident #62's MDS Assessment, dated 06/17/2026, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her BIMS score was 14, indicating her cognitive skills were intact. Her diagnoses included chronic diastolic (congestive) heart failure, anxiety disorder (excessive, uncontrollable worry), and major depressive disorder, unspecified (feelings of sadness, loss of interest in daily activities).Record review of Resident #62's PASRR Level 1 screening, completed 03/17/2026 by the MDS Nurse of referring facility, reflected the resident had a mental illness.Record review of Resident #62's PASRR Level 1 screening entered by the facility's Social Worker on 3/19/2026 reflected the resident did not have a mental illness.In an interview conducted 7/09/2026 at 8:33 AM, the MDS Coordinator A stated the MDS department was not responsible for entering PASRR I information into the system. She stated the Social Worker was responsible for entering the PASRR I information and if a resident was positive for mental illness or intellectual disability, it would generate a PASRR Evaluation. The MDS Coordinator stated their department becomes involved if a resident is PASRR positive and admits to PASRR services. In an interview conducted 07/09/2026 at 12:20 PM, the Social Worker stated she was designated in February 2026 to complete and input the PASRR I into the SimpleLTC portal system. She stated the first PASRR Level 1 screening prepared by Resident #62's referring nursing facility was yes for a mental health diagnosis, but she completed a new one and marked it no. She stated she had been told depression did not qualify so she updated the information to no. The Social Worker further stated her PASRR training was quick, and she was still new at completing the PASRR. She stated it was all her fault that the mental health diagnosis was negative on the second copy of the PASRR Level 1 that she inputted into SimpleLTC. She stated she would complete a new PASRR I for Resident #62 on that day. The Social Worker stated a negative PASRR Level 1 screening could cause residents to miss PASRR services they were possibly eligible to have.In an interview conducted 07/09/2026 at 1:26 PM, The DON stated they initially identified residents with possible serious MI or intellectual disability from the PASRR sent from the previous facility. She stated that the Social Worker was responsible for completing the PASRR Level 1 screenings into the SimpleLTC system. She stated if a resident was positive, the system would send an alert to the state for further review. The DON stated she was not aware that Resident #62 had a diagnosis that would have triggered a PASRR review and indicated she would need to review resident's chart to see if she had an accurate diagnosis. The DON stated if the diagnosis was accurate and Resident #62 screened positive, she should have received a PASRR Evaluation. The DON further stated if a resident with a qualifying mental illness is not properly identified through the PASRR process, the resident could be prevented from receiving mental health services.Review of the facility's policy titled, Preadmission Screening, PASARR (Resident Review) Policy and Procedure undated reflected: Policy:This facility shall coordinate assessments with the pre-admission screening and resident review (PASARR) programunder Medicaid to the maximum extent practicable to avoid duplicative testing and effort.Purpose:Preadmission Screening and Resident Review (PASARR) is a federal requirement to help ensure that individuals whohave a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care.PASARR requires that:1. All applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectualdisability;2. Be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting);and3. Receive the services they need in those settings.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained free of accidents hazards as was possible for one of three housekeeping carts (Housekeeping Cart #1) reviewed for hazards. The facility failed to ensure Housekeeping Cart #1, with chemicals inside the compartments, was locked when unsupervised on 07/07/2026 This failure could place residents at risk for injuries, illness, and hospitalization. Findings included: During an observation on 07/07/2026 at 1:15 p.m., Housekeeping Cart #1 was located on 400 hall in front of room [ROOM NUMBER] Observation reflected the compartment where chemicals were stored was not locked, and contained micro-kill bleach, disinfectant cleaner, and two bottles filled with chemicals without a label on the bottles. Observation reflected Housekeeper A was not standing near the housekeeping cart. She exited room [ROOM NUMBER] at 1:20 p.m., walked to the housekeeping cart, and was standing beside the cart. There were no residents or staff in the hallway when the observation was made of Housekeeping Cart #1 unlocked. During an interview on 07/07/2026 at 1:19 p.m., Housekeeper N stated Housekeeping Cart #1 was expected to be locked anytime the housekeeper walked away from the cart. Housekeeper N stated she could not see Housekeeping Cart #1 from inside room [ROOM NUMBER] with the door partially closed. She stated there was a possibility that if a resident drank some of the chemicals, the resident may become sick with stomach issues or have an allergic reaction. She stated it was possible a resident may need to be evaluated at the hospital. Housekeeper N stated she did have a key to the housekeeping cart. She stated she forgot to ensure the chemicals were in a secured place in her housekeeping cart. During an interview on 07/07/2026 at 1:30 p.m., the Housekeeping Supervisor stated all housekeeping carts were expected to be locked anytime the housekeeper was not standing in front of the cart. The Housekeeping Supervisor stated if a resident ingested some chemicals, there was a potential for an allergic reaction, such as burning their throat, stomach and they may need to be assessed at the hospital. She stated all housekeeping staff were in-serviced on locking housekeeping carts. The Housekeeping Supervisor stated there was a possibility that if a resident spilled a chemical on their skin, it may cause irritation to the skin. During an interview on 07/07/2026 at 3:00 p.m., the Administrator stated he expected the housekeeping cart to be locked at all times when the housekeeper was not obtaining an item from the housekeeping cart. The Administrator stated all housekeeping staff had been in-serviced on locking the housekeeping carts. He did not answer any further questions on housekeeping carts or chemicals. Record review of the in-service of locking chemicals in housekeeping carts, dated 03/10/2026, reflected All chemicals needed to be locked in the cart at all times. Housekeeping carts were to be locked and always next to the housekeeper. Housekeeper N signed the in-service on 03/10/2026. The in-service was given by the Housekeeping Supervisor. Record review of the facility's in-service of storing chemicals in housekeeping cart, dated 04/14/2026, reflected all chemicals were to be locked in your housekeeping cart. Housekeeping carts are to be locked at all times. Housekeeper N signed the in-service given by the Housekeeping Supervisor. Record review of the facility's undated policy on Storage of Hazardous Chemicals reflected: The facility shall ensure that hazardous materials and waste are stored in a safe manner to prevent injury to residents, visitors, and staff.

Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for two of three residents reviewed for quality of care (Resident #9 and Resident #53). 1. The facility failed to ensure Resident #9's foley catheter was secured on 07/7/2026.2. The facility failed to ensure Resident #53's foley catheter collection bag was not at or below the level of the bladder o at 3 observed times on 7/7/2026, 7/8/2026 and 7/9/2026. These failures to place residents with urinary catheters at risk for traumatic removal and catheter acquired infections.Findings included: 1. Review of Resident #9's face sheet dated 07/09/2026 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses chronic obstructive pulmonary disease (a common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough.) and retention of urine (inability to fully empty the bladder). Review of Resident #9's quarterly MDS assessment dated [DATE] reflected she was assessed to have a BIMS score of 11 indicating she had moderate cognitive impairment. Resident #9 was assessed to require maximal assist with ADLs and was assessed to have an indwelling catheter. Review of Resident #9's consolidated physician orders reflected an order dated 07/02/2026 urethral catheter (20 Fr) with 30 cc bulb every shift assess for discomfort or pain related to urinary catheter. Further review reflected an order dated 07/02/2026 Urethral catheter (20 Fr) with (30 cc) bulb. every shift Urinary catheter and catheter bag: Tubing secure; Check for placement of dignity cover; Ensure bag is below the level of the bladder; Ensure bag is not touching ordragging the floor/ground. Review of Resident #9's comprehensive care plan reflected a focus are dated 05/11/2024 I use an indwelling urinary catheter. Interventions included Change my catheter tubing/bag as appropriate Date Initiated: 05/11/2024. Provide catheter care for me every shift Date Initiated: 05/11/2024. Observation and interview on 07/08/2026 at 11:22 am revealed the RN Treatment nurse was in Resident #9's room to perform wound care. She removed Resident #9's cover to reveal a foley catheter to bedside drainage. The catheter tubing was not secured to Resident #9's leg. The RN Treatment nurse stated that the floor nurses were responsible for monitoring urinary catheters. The RN Treatment nurse stated that Resident #9 should have her catheter secure device in place to prevent her catheter from pulling or becoming dislodged. In an interview on 07/08/2026 at 11:36 am, LVN F stated she was responsible for catheter care on her assigned residents. She stated she checked Resident #9's urinary catheter earlier; but did not check to see if the secure catheter device was in place. LVN F stated he would go to Resident #9's room to check and make sure a Cath secure device was in place. In an interview on 07/08/2026 at 11:45 am, Admin RN C stated any residents with urinary catheters should have Cath secure devices in place to ensure the Cath was not pulled out. The Admin RN C stated she would provide the facility policy on urinary catheters. In an interview on 07/09/2026 at 1:44 pm, the DON stated she expected all residents with indwelling urinary catheters to have their catheters secured to their body with a Cath secure device, and for it to be monitored every shift to ensure the catheter was not pulled which could lead to dislodgement and trauma. 2. Review of Resident #53's face sheet dated 07/07/2026 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses chronic kidney disease stage 2 (mild but permanent damage to kidneys where they work about 60%), diabetes mellitus (A condition results from insufficient production of insulin, causing high blood sugar.), venous insufficiency (Poor circulation of blood), benign prostatic hyperplasia without lower urinary symptoms (noncancerous enlargement of the prostate), neuromuscular dysfunction of bladder (communication break between brain and bladder), essential hypertension (chronic high blood pressure) and mild cognitive impairment of uncertain or unknown etiology (memory and decision making decline). Review of Resident #53's quarterly MDS dated [DATE] reflected that he was assessed to have a BIMS score of fifteen indicating he has an intact cognitive status. MDS also reflected the resident requires assistance with setting up for all personal hygiene and activities of daily living. The MDS assessment indicated Resident #53 had an indwelling catheter . Review of Resident #53's comprehensive care plan reflected I use a suprapubic catheter (18 FR 10cc) related to BPH, urine retention date initiated: 03/24/2025. Interventions included: assess me for symptoms of urinary tract infection as needed date initiated 6/29/2023; change my catheter tubing/bag as appropriate date initiated 6/29/2023; ongoing assessment of my urine date initiated 6/29/2023 with a revision on 6/20/2024; provide catheter care for me every shift date initiated 6/29/2023; watch me for acute behavioral changes that may indicate UTI date initiated 12/17/2024. Review of Resident #53's comprehensive care plan reflected I have BPH; I have an indwelling foley catheter (I refuse to allow staff to cover my drainage bag with a privacy/dignity cover- I like to see how much urine output I have and to read the numbers), date initiated 6/29/2023. Interventions included: notify my MD of retention initiated 6/29/2023; watch me for bladder distention and discomfort; change my catheter as ordered by the physician date initiated 6/29/2023; watch my intake and output date initiated 6/29/2023. Observation and interview on 07/07/2026 at 9:30 am, Resident #53 was observed in bed with his catheter positioned above his bladder level, hanging on his WC (wheelchair) arm beside the bed. He stated he told them (staff) to put catheter there. Observation on 7/8/26 at 2:35pm, Resident #53 was sleeping in bed, and his catheter was hanging on the wheelchair arm rest; not below level of bladder, but above the bed. Observation and interview on 7/9/2026 at 9:40 am, Resident #53 refused to have catheter care done. The resident said he did not have time for questions or for catheter care. Resident is lying in bed with no catheter stabilizer/holder holding tubing against body and tubing running upward to the bag that is secured to the arm rest of his wheelchair above the level of the resident. In an interview on 07/09/2026 at 09:34 pm, Admin RN C stated about Resident #53, we added about hanging his catheter above his bladder to the care plan. I think we added it after seeing how he hangs it because he will not listen to us. We constantly tell him not to hang it above his bladder. In an interview on 7/9/2026 at 12:02 pm, after looking at Resident #53's care plan, she stated she could have added the dignity bag and not the hanging of the catheter regarding updating interventions. She stated Resident # 53 is non-compliant. She stated when they find it high, the staff move it and Resident #53 is argumentative and moves it back. She states the problem with hanging it above the bladder is backflow and can cause resident to have constant UTIs.In an interview on 7/9/2026 at 11:47am, MDS Coordinator A stated Resident #53 was non-compliant. She states that hanging the catheter bag on the WC could cause urinary infections or skin breakdown issues. She stated they have a performance improvement plan they are working on. In an interview on 7/9/2026 at 1:33 pm, the Director of Nurses s, when looking at the care plan for Resident #53, she stated they know he keeps his catheter above his bladder, and they have repeatedly told him not to do that. Director of Nurses states that the problem with the catheter being up to high can cause backflow thus causing infection or urinary issues. Review of the facility's undated policy Catheter indwelling, insertion and removal policy and procedures reflected Purpose: 1. To provide continuous drainage of the urinary bladder. 14. AT NO TIME SHOULD THE TUBING BE PLACED ABOVE THE LEVEL OF THE BLADDER TO ALLOW BACK FLOW OF URINE INTO THE BLADDER.15. Secure urinary drainage bag below the level of the bladder AND KEEP OFF THE FLOOR AT ALL TIMES. Coil extra tubing and secure.

Based on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to 1 of 4 medication carts (Medication Cart #1) reviewed for pharmacy services. The facility failed to ensure Medication Cart #1, was locked, medications secured, and not accessible to other staff, residents, or visitors on 07/07/2026. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.Findings included: During an observation of the 300 hall on 07/07/2026 at 11:20 a.m., Medication Cart #1 was facing toward the hall area near the DON office located on 300 hall. The lock was protruding outward on Medication Cart #1. Observation reflected there was no staff in the hall or located near the observed unlocked Medication Cart #1. LVN E exited a resident's room approximately 11:27 a.m. on 300 hall and walked toward the medication cart located near the Director of Nurses office. During an interview with LVN E on 07/07/2026 at 11:31 a.m., she stated she was trained on medication storage. She stated the Nurse or Medication Aide who was working on the cart was responsible for locking the medication cart. She stated if the staff left the medication cart unlocked and unattended, a resident could get into the medication cart and take medication that did not belong to them. LVN E stated everyone monitored to ensure the medication carts were locked. LVN E stated she was unable to view Medication Cart #1 from where she was standing in a resident's room. She stated she had been in-serviced on locking medication cart; however, she did not recall the date or time. LVN E did not respond to why she left the Medication Cart #1 unlocked. During an interview on 07/09/2026 at 10:20 a.m., the DON stated all medication carts were expected to be locked when the med-aide or nurse was not standing in front of the medication cart. She stated the nurse or the medication aide, who was on the medication cart, was responsible for ensuring the medication cart was locked. She stated if the medication cart was left unlocked and unattended a resident could get into the medication cart and take medications. The DON stated leadership monitored to ensure staff locked the medication cart. She stated nurse leadership were to monitor by doing observations and in-service training. She stated she did not know why LVN E left the medication carts unlocked. Record review of the facility's undated policy titled, Medication Administration Policy and Procedure, reflected, Medication carts shall be locked when left unattended.

Based on observations, interviews, and record review, the facility failed to ensure results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to survey were readily available to examine for 1 of 1 facility in that:1. The results of the most recent survey were not posted in a location readily accessible to all residents, their legal representatives, or family members as required.2. The facility failed to maintain the survey binder; the binder failed to include 3 previous years of required state visit results from 1/07/23, 3/29/24, 5/8/25 and recent visits 1/15/26 and 02/05/226.This failure placed residents of the facility at risk of not knowing past and present citations of the facility and potentially being negatively affected by an area of citation.Findings included:An observation and interview conducted through facility on 07/08/26 at 3:44 PM revealed the survey results were not posted readily available in the lobby or any common areas of the facility nor a sign indicating where the survey results were posted. The Receptionist was asked for location of the survey results binder, and she stated, let me find it. she led the way to a table [NAME]-cornered (diagonally opposite) on a wall behind receptionist desk, not visible to anyone entering the building nor easily accessible to residents. Observation revealed the survey book was sitting on the table. Record review of the survey binder reflected it included results of the May 2025 annual survey.During a confidential group interview conducted on an undisclosed date and time 9 of 10 residents revealed they did not know where or how to access the survey results in the facility. Several of the residents stated they would have liked access to that information. They had not understood or been aware that the survey book existed or that they were able to review the results. In an interview conducted 07/09/2026, at 2:51 PM, The Social Worker stated that the survey results binder was located on a table in the facility lobby. She stated that signage identifying the location of the survey results binder should be posted; however, she was unsure whether the signage was currently in place. The Social Worker stated that the Administrator was responsible for maintaining the survey results binder. She further stated that the binder should include the results of all complaint investigations and annual survey inspections. The Social Worker explained that maintaining those documents and making them available was important because families and individuals who considered placement in the facility could review the facility's survey history to determine whether there is a pattern of deficient care, neglect, or abuse. She stated the information allowed prospective residents and their families to make informed decisions regarding placement. In an interview conducted 07/09/2026, at 3:20 PM, the Receptionist stated she had only worked at the facility for a month. She stated she had not been trained on the survey binder. She stated she was scheduled for some training on the upcoming weekend. The receptionist stated she knew they were working on updating the binder for 2026.In an interview conducted 07/09/2026, at 3:24 PM, the Administrator stated that he had been employed by the facility since April 21, 2026, and officially assumed responsibility for the facility on May 1, 2026. He stated that he had been an administrator for five years. The Administrator stated that it was his responsibility to maintain the survey results binder. He stated that the binder should include the previous year's annual survey results and the plan of correction. The Administrator acknowledged that survey results were required to be accessible to everyone for review. The Administrator stated he was going to change the area where the survey binder was to be more accessible and he was going to place a sign indicating the survey results. He stated that the survey results binder was important because it allowed residents and their families to know what is occurring in their home.The facility policy on Survey Results was requested from DON and Administrator on 7/09/2026 at 3:00 PM, no policy received at exit.

Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive care plan that describes the services that are to be furnished to maintain the resident's highest practicable physical, mental, and psychosocial well-being for one resident (Resident #1) of 9 reviewed, in that: The facility failed to ensure Resident #1's Comprehensive Care Plan reflected a plan of care for all of her fall interventions. Resident #1 was ordered to have a Geri-chair or tilt back wheelchair on 04/17/2026 after she experienced a fall on 04/16/2026 her care plan was not updated to include the intervention of the Geri-chair. This failure could place residents with falls at risk for injury.Findings included: Review of Resident #1's face sheet dated 07/01/2026 reflected a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), osteoarthritis (A condition when bone strength weakens and is susceptible to fracture. It usually affects hip, wrist, or spine.), and diabetes mellitus (A condition results from insufficient production of insulin, causing high blood sugar.). Review of Resident #1's quarterly MDS dated [DATE] reflected she was assessed to have a BIMS score of three indicating she has severe cognitive impairment. Resident #1 was assessed to have falls and was assessed to have one fall without injury. Observation and interview on 07/01/2026 at 11:30 am Resident #1 was observed in a Geri-chair in the TV area. She answered questions appropriately. She stated she liked the Geri-chair and she was comfortable in it. Review of Resident #1's physician orders reflected an order dated 04/17/2026 monitor safety devices: low bed; Fall Matt; Geri-chair or tilt back w/c (wheelchair). Review of Resident #1's fall incident report dated 04/16/2026 reflected Resident #1 experienced a witnessed fall from her wheelchair in the TV area. Review of Resident #1's comprehensive care plan reflected I am at risk for falls r/t debility, advanced age, behaviors Date Initiated: 11/29/2025. Interventions included: 1/17/26 Low bed with fall mat, Date Initiated: 01/17/2026; 1/19/26 tilt back WC, Date Initiated: 01/19/2026; 1/31/26 Educate staff on not leaving the resident in a wheelchair unattended in the Room; 4/7/26 ensure correct positioning in chair, Date Initiated: 04/07/2026; 5/17/26 add nonskid tape under fall mat to prevent sliding of mat, Date Initiated: 05/17/2026; Educate me on use of my call light, Date Initiated: 12/01/2025: Monitor for changes in my condition that may warrant increased supervision/assistance and notify the physician) pommel cushion (a cushion to prevent sliding) added to chair 4/16/26, Date Initiated: 04/16/2026. The care plan did not include the intervention of her Geri-Chair. In an interview on 07/01/2026 at 12:02 pm the MDS Coordinator stated after looking at Resident #1's care plan she stated in regard to updating interventions for falls that they look at the root cause of the fall and develop a plan based on the individual's needs. She state the facility has a PIP (performance improvement plan) in place that they have identified that the care plans are generic and need to be updated. She stated she has seen Resident #1 in the Geri-chair but has not yet updated her care plan She stated the facility keeps switching the MDS coordinators back and forth as to who is doing MCR and long term care plans. She stated she has only had Resident #1 for about a week. She stated the facility has identified that the care plans need to be updated but we can't do them all in one day stated she can only work through as they come due. In an interview on 07/01/2026 at 2:21 pm the DON stated they were trying to even out the workload with the Medicare and long term care, but whoever had her should have seen the order for the Geri-chair and update Resident #1's care plan Review of the facility's policy Care planning policy and procedures (not dated) reflected To provide a comprehensive plan of care addressing resident's needs, strengths, goals, and approaches. Each resident's care plan will remain current and inform staff of resident's needs, strengths, goals, and approaches. A Comprehensive Care plan will be completed according to the RAI manual upon admission, annual, significant change and as needed. These Policies and Procedures are intended only as a guide to our staff and should not be applied blindly across the board. These policies and procedures should be considered along with the experiences of staff and sound reasoning. Our Policies and Procedures must be flexible to the extent that the care provided to our residents meets the individualized needs of each resident. Regardless of the Policies and Procedures, care provided by staff must be specific to the individual needs of each resident so as toachieve the most desirable results for the resident.

Based on observation, interview, and record review, the facility failed to develop a baseline care plan that included instructions needed to provide effective and person-centered care of the residents, for 1 of 4 residents (Resident #1) reviewed for baseline care plans. The facility failed to ensure a baseline care plan was completed within 48 hours of admission that addressed the care needs of newly admitted Resident #1. This failure could place residents at risk of not receiving necessary care and services. The findings included: Record Review of Resident #1's face sheet dated 02/05/2026 reflected a [AGE] year-old female admitted on [DATE] with the following diagnoses frontal lobe and executive function deficit following cerebral infarction ( damage in the brain's frontal region, causing impairments with planning, organizing, initiating tasks, decision-making, emotional control, and behaviors), PSOAS- a long, ribbon-shaped muscle in your back- abscess ( a rare, severe collection of pus within the muscle compartment, often causing fever, back, hip, and thigh pain.), and aphasia ( a language disorder caused by brain damage (often from a stroke or head injury) that impairs the ability to speak, understand, read, or write, affecting communication skills but not intelligence).Review of Resident #1's MDS assessment dated [DATE]indicate the assessment was incomplete.Review of Resident #1's EMR for a base line care plan on 02/05/2026 reflected no base line care plan was completed.In an interview on 02/05/2026 at 8:55 am the DON stated, there should be a baseline care plan completed within 48 hours after a resident is admitted to the facility. She stated the MDS Coordinator was responsible for completing baseline care plans. The DON stated it was very important for baseline care plan to be completed within 48 hours to ensure the residents received the appropriate care. She stated the information from the baseline care plan was derived to the Kardex for the CNAs to know what type of care to give to the residents. The DON stated Resident #1 did not have a baseline care plan. She stated she did not know at this time why Resident #1's baseline care plan was not completed. In an interview on 02/05/2026 at 1:05 pm the MDS Coordinator LVN A stated she was responsible for baseline care plans. MDS Coordinator LVN A stated a resident could be at risk of not receiving the care needed if the baseline care plan was not completed. She stated the expectations was to complete baseline care plan within 48 hours of the resident's admission to the facility. She stated she did not know why Resident #1's baseline care plan was missed. She stated the baseline care plans are important for staff to follow when there was a new admission. MDS Coordinator LVN A stated if a CNA needed to know the care a resident required, they were expected to ask the nurse supervisor. Review of the facility's policy Care Planning Policy and Procedure not dated reflected To provide a comprehensive plan of care addressing resident's needs, strengths, goals, and approaches.Policy:Each resident's care plan will remain current and inform staff of resident's needs, strengths, goals, andapproaches.Procedure:1. A base line care plan will be completed within 48 hours of admission.

Based on interviews and record review, the facility failed to ensure residents who were trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 resident (Resident #2) of 9 residents reviewed for trauma-informed care. The facility failed to ensure Resident #2 had a trauma screening that identified possible triggers when Resident #2 had a history of trauma. This failure could place residents at an increased risk for psychological distress due to re-traumatization and decreased quality of life. Findings included: Review of Resident # 2's Face sheet dated 02/05/2026 at 11:34 AM reflected an [AGE] year-old male, admitted on [DATE] with the following diagnoses: dementia and altered mental status (when a person exhibits symptoms like confusion or disorientation) Review of Resident #2's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 3 to indicate severe cognitive impairment. Resident Mood interview reflected Resident #2 was feeling down, depressed or hopeless nearly every day. The medication section of the MDS reflects Resident #2 takes an antidepressant medication. Review of Resident #2's care plan printed on 02/04/2026 revealed no focus area or interventions for Resident #2's trauma history, behaviors and triggers. Review of Resident #2's nursing progress note dated 01/31/2026 at 12:50 reflected .Resident displayed inappropriate verbal comments after medication was administered. Review of Resident #2's EMR dated 02/04/2026 revealed Resident #2 did not have a trauma screening assessment in his medical record. Review of Resident #2's social service progress note dated 01/30/2026 at 11:51 AM reflected .Res continues to think other residents are out to get him. Thinks someone has a gun and feels they are following him. Accuses staff of showing him naked old women res. Truly believes these allegations even though none show any credibility. Psych notified. [family member A] states res has been like this a long time. This is not new behavior for him and has often interfered with his personal relationships. Res refused to speak to psychologist. She's tried several times and he is mean to her. Monitor. Review of Resident #2's nursing progress note dated 01/06/2026 at 8:43 PM reflected took CNA with me into room to administer HS meds. again, when he saw this nurse i used to respect you but your wrong in taking my med away at night he continued with how i did certain things on certain days, and i was not working on some of these days. for instance this past weekend, I was off, but he swears i was here and refusing to bring his meds. again i said that i have never not brought his meds. then i quit talking and just let him go on ranting etc. he took his med and again threw the cup against the wall and said do not pick that up, i threw it and I will pick it up. In an interview with Resident # 2 on 02/04/2026 at 4:16 PM, Resident #2 reported that his former roommate threatened to set Resident #2's privacy curtain on fire and repeatedly threatened to kill him. He reported that the facility staff moved the roommate to a room on a different hall three weeks ago. He reported that the former roommate walks down 100 hallway where Resident #2's room was located. He stated, he came here four to five times a day and I don't feel comfortable around him. [DON] made him stop coming down. Resident #2 reported that a little black lady was in another resident's room while Resident #2 was walking down the 100 hallway when allegedly she stated, [Resident #2], I want to show you something. Resident #2 reported that when he looked inside the room where the staff member was, he stated there was a Mexican resident sitting in a chair naked. He denied knowing the name of the staff member. Resident #2 reported a week ago an LVN with colored hair was giving him medication as he sat on the bed. He reported that she pushed him and got on top of him. He stated, I shoved her off of me. He denied that she touched him sexually while on top of him. He reported that DON was aware of the incident and stated, she moved her to work on another hallway. He stated the night before the incident, the same LVN told him that she was fond of him. He also alleged that this week as he was walking by the nurse's station with his rolling walker, a male staff member kicked his walker which displaced it out of Resident #2's hands causing injuries to the front of his left shin. He stated that he wrote the incident up and gave it to the DON. He reported an incident with a male, homosexual staff member who allegedly ran his finger across Resident #2's back and stuck his finger in Resident #2's ear. He stated when he became upset about what the male staff member did, another female staff member allegedly referred to Resident #2 as a derogatory name. He stated he reported this incident to the DON. Resident #2 reported that he was assistant warden at a [name] prison and stated, I have seen so many bad things. He reported that he disliked men who hurt or killed women and children. IIn a follow-up interview with Resident #2 on 02/05/2026 at 10:00 AM, he reported that the facility social worker was aware of the alleged incidents between him and his former roommate. He reported knowing the name of the male staff member who ran his finger across his back and put his finger in his ear. He reported knowing the name of the male staff member who he allegedly kicked his wheelchair causing injuries to his left shin. In an interview with the Social Services Director on 02/05/2026 at 1:06 PM, she stated that she has been the social services director for 3 years. She said I have not witnessed any of that happening in regard to alleged incidents by Resident #2. She reported when Resident #2 and his former roommate were not getting along, Resident #2 was referred to a psychologist. She stated that Resident #2 would not cooperate with the psychologist. She reported that his [family member A] is a trigger for him. She reported that his [Family member A] will drop things off for Resident #2 in his room while he was not in there. She stated if Resident #2 saw his [Family member A], an argument occurs. She stated the resident's family would not allow Resident #2 to visit his [Family member B] prior to her passing about four months ago because they did not want him to start family drama. She stated that Resident #2 does not like anyone telling him what to do. She reported that Resident #2's former roommate was large in stature and had a deep voice. She stated he was bossy to Resident #2. She stated Resident #2 was fearful of people having guns and believed his former roommate had a gun. She reported that on Thanksgiving Day, Resident #2 and his former roommate had an argument. She reported that his roommate was moved to a room on Hall 200. She reported that Resident #2 told her the former roommate threatens him by going down Resident #2's hallway. She stated she asked the former roommate to avoid Resident #2 by not walking down Hall 100. She stated that resident behaviors are typically put on the care plan. She stated it was necessary to put a resident's behaviors and triggers on a care plan so the team knows about it and can monitor the effectiveness of the interventions. She stated they can check for improvement and try other goals. She stated not having Resident #2's behaviors and triggers addressed in the care plan could make it difficult to monitor progress. She stated staff who were unfamiliar with Resident #2 would not know about his behaviors and triggers. In an interview with MDS Coordinator LPN A on 02/05/2026 at 3:14 PM, she stated she has worked in the MDS Coordinator role since the second week of August 2025. She stated a resident with a history of making allegations against staff and other residents should have the behavior on the care plan. She stated that a resident's triggers should definitely be on the care plan. She stated the way the resident communicates was put on the care plan. She reported the nursing staff have access to the resident care plans. She reported that CNAs typically learn information about the residents by word of mouth or by looking at the Kardex. She reported the Kardex should have the resident's behaviors and triggers on it. She stated that CNAs report resident information that needs to be on the care plan to the nurses. In an interview with MDS Coordinator LPN B on 02/05/2026 at 3:21 PM, she stated she has worked in the MDS Coordinator role since the middle of October 2025. She reported that the nursing admission assessment triggers things on the care plan. She stated the IDT meets to discuss the residents and their care plans. She reported staff from multiple departments make up the IDT including dietary, social services, MDS, nursing, therapy, and laundry services. She stated that auxiliary staff report behaviors and triggers to the social workers and/or nurses. She reported that a resident's behaviors and triggers should be in the care plan so staff will know what to do when they occur. In an interview with the DON on 02/05/2026 at 10:48 AM, she reported a history of Resident #2 making false allegations against staff and other residents. She reported Resident #2 writes things down and reports it to her. She reported that Resident #2 has been moved to different rooms several times due to him not getting along with his roommates. She stated that his former roommate who he alleged threatened him was relocated to another room on a different hall and denied threatening Resident #2. She stated Resident #2 will be housed in a room without a roommate from now on. She reported that anytime he has a problem with a staff member, they will have a different staff member work his hallway. She reported that he alleged a nurse who worked the nightshift was coming on to him. She stated the nurse would bring another employee with her if she interacted with him. The DON stated Resident #2 did not report to her that anyone pushed him or put their hands on him. She reported that he was evaluated by a psychologist but Resident #2 refused to see the psychologist after the evaluation. She stated the male staff member who he allegedly ran his finger across Resident #2's back was a part-time agency CNA who had long hair. She questioned the staff member about the alleged incident, but he did not remember the incident. She stated, he did not even know who I was talking about. She stated she took the staff member off the agency call list anyway. She denied any knowledge or report of the alleged incident regarding the staff member who he alleged told him she wanted to show him something causing him to see an unclothed resident. The DON stated Resident #2's history of making allegations against staff and other residents as well as his fears and triggers should absolutely be in his care plan. She stated that putting these things in his care plan will make other staff members aware of his behavior and triggers. Review of the facility's policy Care Planning Policy and Procedure (not rated) reflected a purpose To provide a comprehensive plan of care addressing resident's needs, strengths, goals, and approaches. Policy: Each resident's care plan will remain current and inform staff of resident's needs, strengths, goals, and approaches. Procedure: 2. A Comprehensive Care plan will be completed according to the RAI manual upon admission, annual, significant change and as needed. 3. Resident's care plan will be updated quarterly and as needed. 4. Resident's care plan will be reviewed with resident, responsible party and interdisciplinary teamquarterly and as needed.

Based on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident #1) reviewed.The facility failed to ensure that Resident #1 received sufficient supervision to avoid the right femur fracture and subsequent hospitalization on 01/11/26. This failure could place the residents at risk for accidents.Findings included:Review of Resident #1's Face Sheet dated 01/15/26 revealed she was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included unspecified fracture of left femur, aftercare following joint replacement surgery, presence of left artificial hip joint, dementia, iron deficiency, hypotension (low blood pressure) and pain.Review of Resident #1's quarterly MDS dated [DATE] revealed her BIMS score was 01 indicating her cognition was severely impaired. The MDS also indicate Resident #1 needed moderate assistance to roll left and right, Sit to lying and Lying to sitting on side of bed. She needed maximum assistance in sitting, standing and Chair/bed-to-chair transfer. It was noted that Resident #1 was fully dependent on toilet transfer and incontinent care.Review of Resident #1's Comprehensive Care Plan dated 01/15/26 revealed Resident #1 was experiencing pain related to a hip fracture with surgical repair. The relevant intervention was administering the pain medication as ordered and observing the worsening of the pain symptoms and report to physician.Record review of the FRI dated 01/12/26 indicated that, on 01/11/26, Resident #1 was transferred to the ER by the NP's order for evaluation of the swelling on the right thigh.Record review of the hospital record dated 01/12/26 reflected Resident #1 had distal Right femur fracture from unwitnessed ground level fall at nursing facility. The radiology results revealed that a Dynamic Hip Crew (DHS) ( an orthopedic implant used for internal fixation of proximal femur fractures ) was present on the right femur and there was a midshaft comminuted impacted angulated spiral fracture (a severe injury where a bone is twisted and shattered into multiple pieces, with fragments driven into one another and bent out of alignment) , that occurred below the DHS.Record review of the EHR on 01/15/26 revealed there was no documentation of the pain and assessment that Resident #1 had when moving her right leg, on 01/08/26.Record review of the January 2026 MAR reflected Resident's pain level on 01/08/26 and 01/11/26 were 5 and 7 respectively on a pain scale of 1 to 10 where 10 was the highest and Acetaminophen Tablet 650 MG was administered on both of the occasions. Her pain level on 01/09/26 in the day shift was 2. It indicated that her pain level was 0 on rest of the days.During an observation conducted on 01/15/26 at 3:30 p.m., Resident #1 was observed lying in bed. An interview was not possible due to her poor cognitive ability.During a telephone interview on 01/15/26 at 2:15 p.m., the RP for Resident #1 reported that on 01/11/26 at 7:36 p.m. she received a call from the facility indicating that Resident #1 required transfer by EMS to a nearby hospital due to significant swelling of the right lower extremity extending from the thigh to the ankle, with an unknown cause. The RP stated that hospital staff indicated the injury might have occurred several hours prior to its discovery based on the extent of swelling. She further reported that Resident #1 was diagnosed with a right femoral fracture requiring surgical intervention. The RP added that the resident had a prior left hip replacement following a fall in October 2025. She stated that facility staff were unable to provide a definitive explanation for the injury and expressed her belief that the fracture might have resulted from a stress injury during repositioning or care.During a telephone interview on 01/15/26 at 3:16 p.m., CNA G stated she provided care to Resident #1 on the afternoon shifts of 01/09/26, 01/10/26, and 01/11/26. She reported no swelling or pain on 01/09/26 and 01/10/26. However, on 01/11/26 at about 4:30pm, she observed the resident moaning and grimacing in severe pain, with significant swelling of the right leg. She stated she immediately reported these findings to LVN H. When the investigator asked her if she was aware Resident #1 had experienced pain on 01/08/26 when moving her right leg, she responded that she did not know about it.On 01/15/26 at 2:45 p.m., a voicemail message was left for LVN H requesting a return call; no response was received.Review of a progress note dated 01/11/26, authored by LVN H, documented that CNA G reported Resident #1 to be in severe pain with significant swelling of the right upper leg between the hip and knee. Assessment revealed marked edema, warmth, and pain with palpation and movement. Tylenol was administered immediately, and the resident was transferred to the emergency department, as per the physician's order. She stated RN D reported to her about the pain Resident #1 had in the afternoon and was under observation.During an interview on 01/15/26 at 12:05 p.m., RN D stated that she worked the day shifts on 01/09/26, 01/10/26, and 01/11/26 and was not aware of Resident #1's complaint of right leg pain on 01/08/26, as the information was not communicated. She stated no pain complaints were reported on 01/09/26 or 01/10/26 though she had not assessed for pain specifically on her right leg. However, on 01/11/26 at approximately 4:30 p.m., CNA E reported that Resident #1 was shivering. Upon assessment, RN D observed signs of pain in the right leg, but no swelling or deformity observed. She administered Tylenol 650 mg as needed, after which the resident stopped shaking and exhibited no further signs of pain. RN D reported that she communicated this information to the oncoming nurse, LVN H, prior to the end of her shift at 6:00pm.During an interview on 01/15/26 at 3:01 p.m., CNA E stated that she worked with Resident #1 on the afternoon shift of 01/08/26 and observed no swelling or pain during incontinence care. She stated that she worked at the facility on 01/10/26 and 01/11/26, however she had not worked with Resident #1 on 01/09/26 or 01/10/26. On 01/11/26, she observed Resident #1 shivering in pain during lunch, while serving lunch to the residents and reported it to RN D. She said later that day she came to know that the resident had been noted to have pain on 01/08/26 through somebody else (unable to remember who that was).During a telephone interview on 01/15/26 at 1:55 p.m., CNA B stated that while working the day shift on 01/08/26, Resident #1 exhibited pain when her right leg was moved during incontinence care. CNA B reported that although the resident was sometimes combative, on that day she was quiet. CNA B stated she informed LVN A of the change in condition; LVN A assessed the resident and administered pain medication. CNA B further stated that later the resident was observed in common areas in her wheelchair without apparent signs of pain or discomfort. CNA B stated she worked again on 01/09/26 and reported being cautious when providing care for the right leg, noting no further signs of pain. She did not work on 01/10/26 or 01/11/26.During a telephone interview on 01/15/26 at 2:05 p.m., LVN A reported that on the morning of 01/08/26, CNA B informed her that Resident #1 complained of pain from her right leg during perineal care. LVN A stated she completed an assessment and noted no abnormalities, deformities, swelling, or redness of the bilateral lower extremities. However, when perineal care was attempted again, the resident moaned when her right leg was grasped. She stated Resident #1 did not have the cognitive ability to express her pain verbally. LVN A stated she specifically assessed the right leg again and found no visible abnormalities. She administered Acetaminophen (Tylenol)325 mg, two tablets, as needed for pain, and the resident did not complain of pain for the remainder of the day. LVN A stated she was not sure if she had communicated about the incident to the incoming nurse, LVN C, during the shift change. She said she did not report the issue to the NP and forgot to document the incident in the EHR. She stated she should have documented the incident as well as report it to NP and LVN C to ensure monitoring and continuity of care.During an interview on 01/15/26 at 2:17 p.m., LVN C stated that he worked the night shift on 01/08/26 and was not informed of Resident #1's complaint of right leg pain during the change of shift by LVN A. He indicated that he did not perform a focused assessment of the right leg during his shift as he was not aware of the issue with Resident #1's right leg.During an interview on 01/15/26 at 2:30 p.m., CNA I stated that she worked the morning shifts on 01/10/26 and 01/11/26 (6:00 a.m. to 2:00 p.m.). She stated she was not aware of the pain from the right leg of Resident #1 with movements and did not find any signs of pain, swelling, or redness in Resident #1's lower extremities while changing her briefs. Resident #1 was combative sometimes and had not checked for any sign of pain while changing her briefs on these days. She stated if she was aware of the concern with her right leg, she would have observed the resident closely for pain with the movements of the affected leg.During an interview on 01/15/26 at 4:15 p.m., the NP stated she received a call on 01/11/26 regarding swelling and pain in Resident #1's right leg and ordered transfer to the emergency department. She reported she was not aware of the pain episode on 01/08/26. The NP stated the resident had a history of left hip fracture and was prescribed Tylenol as needed, with order for pain assessment each shift. She identified severe pain, swelling, deformity, and redness as possible indicators of fracture and stated she could not determine the exact timeframe for the onset of swelling following a fracture. The NP stated she was not sure if the complaint of pain in the right leg of Resident #1 on 01/08/26 was related to the fracture as there was no swelling or deformity observed at that time. She stated that, considering the age and condition of Resident #1, the finding on 01/08/26 should have been communicated with her and continue to assess and monitor Resident #1 for the pain and change of condition originating on the affected leg.During an interview on 01/15/26 at 10:30 a.m., the DON stated that Resident #1 returned from the hospital on [DATE] following surgical repair of the right femur fracture after being admitted to hospital with swelling on her right leg and pain. The DON reported that on 01/08/26 at approximately 9:00 a.m., CNA B noted the resident moaning and grimacing in pain when her right leg was moved and reported this to LVN A, who assessed the resident and administered Tylenol. The DON stated it was unclear whether this information was communicated to subsequent shifts, however there were no reports of pain or swelling until 01/11/26. She stated there was no information available if Resident #1 was assessed for pain from her right leg. Upon review of the incident, the DON said there was no evidence of follow-up assessment or communication regarding Resident #1's pain until the evening of 01/11/26. The DON stated that the exact timing of the fracture could not be determined. She stated Resident #1 had no fall episodes in the month of January 2026. She indicated that although pain was noted with movement of the right leg on 01/08/26, there were no visible signs of fracture at that time. She stated staff should have conducted focused pain assessments and observations for change of condition of the affected extremity. She further stated that there was no documentation of continued assessment or observation following the initial complaint on 01/08/26. However, she noted that interviews with CNAs who worked on 01/09/26 and 01/10/26 revealed no observed signs of pain or swelling during care across shifts. Record review of the facility's undated policy 'Abuse prevention and prohibition reflected: . Injuries of Unknown Origin: An injury should be classified as injury of unknown origin whenBoth of the following criteria are met: The source of the injury was not observed by any person, or the source of injury could not be explained by the resident.A licensed professional nurse will examine the resident for signs of injury and notify the resident'sphysician of any injuries noted.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 3 out of 5 residents reviewed for pharmacy services, in that: The facility failed to administer medications within the required timeframe for 3 residents (Resident #1, Resident #2 and Resident #3) of 5 residents resulting in late medication administration. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, could result in worsening or exacerbation of chronic medical conditions, and hospitalization.Findings included:Resident #1Review of Resident #1's face sheet dated 9/25/2025 reflected an [AGE] year-old male admitted on [DATE] with diagnoses that included: Parkinson's disease (chronic, progressive brain disorder that affects movement), Hemiplegia (paralysis on one side of the body), Dysphagia (difficulty swallowing), Chronic Obstructive Pulmonary Disease (COPD) (progressive lung disease that causes breathing problems), and Dementia (disease process with underlying conditions affect brain function).Review of Resident #1's quarterly MDS assessment dated [DATE] reflected he had a BIMS score of 6 suggesting severe cognitive impairment.Review of Resident #1's orders reflected an order dated 9/27/20222: Carbidopa-Levodopa ER Tablet Extended Release 50-200 MG Give 1 tablet by mouth four times a day related toPARKINSON'S DISEASE WITH DYSKINESIA, WITH FLUCTUATIONS.Review of Resident #1's August 2025 MAR reflected med administrations times for Carbidopa-Levodopa to be 0700, 1100, 1500 and 1900. [7:00 am, 11:00 am, 3:00 pm, 7:00 pm]Review of Resident #1's care plan dated 9/25/2025 reflected the focus: I have Parkinson's Disease with interventions: Administer my Parkinson's medications as ordered.Review of the facility Medication Admin Report dated 9/24/2025 at 2:31 pm, reflected Resident #1 had Carbidopa-Levodopa due:- on 8/20/2025 at 7:00 am with an administration time of 9:31 am- on 8/21/2025 at 7:00 am with an administration time of 8:51 amReview of Resident #1's progress notes revealed there were no notes supporting the late administration of medications on 8/20/2025 and 8/21/2025.Resident #2Review of Resident #2's face sheet dated 9/25/2025 reflected an [AGE] year-old female admitted on [DATE] with diagnoses that included: Parkinson's disease (chronic, progressive brain disorder that affects movement), urinary tract infection (infection of the urinary tract) Hypertension (high blood pressure) and malignant neoplasm of connective and soft tissue of left upper limb, including shoulder (soft tissue cancer).Review of Resident #2's admission MDS assessment dated 9/82025 reflected she had a BIMS score of 15 suggesting no cognitive impairment.Review of Resident #2's orders reflected an order dated 9/27/20222: Carbidopa-Levodopa Tablet 25-100 MG Give 2 tablets by mouth three times a day related to PARKINSON'S DISEASE WITH DYSKINESIA, WITH FLUCTUATIONS. With administration times:7:00 - 8:00 am, 11:30 - 11:30 am, 3:00 pm - 4:00 pm.Review of Resident #2's care plan dated 8/26/2025 with revision on 9/2/2025 reflected the focus: I have Parkinson's Disease with interventions: Administer my Parkinson's medications as ordered.Review of the facility Medication Admin Report dated 9/24/2025 at 2:31 pm, reflected Resident #2 had Carbidopa-Levodopa due: on 8/28/2025 between 7:00 and 8:00 am with an administration time of 9:16 am.Review of Resident #2's progress notes revealed there were no notes supporting the late administration of medications on 8/28/2025.Resident #3Review of Resident #3's face sheet dated 9/24/2025 reflected an [AGE] year-old female admitted on [DATE] with diagnoses that included: Parkinson's disease (chronic, progressive brain disorder that affects movement), anxiety disorder, Hypothyroidism (disorder of the thyroid gland) depression and chronic pain syndrome. Face sheet reflected resident was discharge on [DATE].Review of Resident #3's uncategorized MDS assessment dated [DATE] reflected a BIMS assessment had not been completed yet.Review of Resident #3's orders reflected an order dated 8/19/2025: Carbidopa-Levodopa ER Oral Tablet Extended Release 25-100 MG (Carbidopa-Levodopa) Give 2 tablet by mouth three times a day related toPARKINSONISM, UNSPECIFIED, with administration times of 10:00 am, 2:00 pm, and 6:00 pm.Review of Resident #3's care plan reflected it was blank. Resident admitted [DATE] and discharged [DATE].Review of the facility Medication Admin Report dated 9/24/2025 at 2:31 pm, reflected Resident #3 had Carbidopa-Levodopa due:- on 8/20/2025 at 2:00 pm, with an administration time of 3:06 pm.- on 8/20/2025 at 6:00 pm, with an administration time of 10:18 pm.Review of Resident #3's progress notes revealed there were no notes supporting the late administration of medications on 8/20/2025.During an interview on 9/24/2025 at 2:37 pm MA-A stated the 400 hall was her regular hall and she typically works the 6 am to 6 pm shift as a Med Aide. She stated the facility policy allows staff to give medications an hour before or after the posted time. She stated she was familiar with the medication Carbidopa-Levodopa, and it was used to treat Parkinson's disease. She stated this medications helps controls tremors or shaking in the residents and helps with confusion related to the disease process. She stated if the medications were late, the system doesn't require them to put in a late note, but they have the option to do a MAR progress note. She stated if medications were given late, they were supposed to notify the charge nurse. She said the day shift [6am to 6pm] med aides were responsible for giving 6 pm medications before their shift ends. During an interview on 9/24/2025 at 3:56 pm, the DON stated staff can administer medications and hour before or an hour after the time in the EMR. If a medication is given late or missed, the med aides should notify the charge nurse. The charge nurse can evaluate the situation and consult with the practitioner as needed. She stated the med aide already there on day shift [6am - 6pm] was responsible for giving 6 pm medications. The DON stated their policy does not state the one-hour window before or after the time, but that was the procedure they followed. She stated this included an hour before or after for a specific time, as well as an hour before or after for a block of range of time. During another interview on 9/25/2025 at 12:03 pm, MA- A stated the medications for Resident #1 on 8/20/2025 and Resident #2 on 8/28/25 were late because these residents were her last two residents to give medications to and she just got to them late. She stated she did not recall if she informed the charge nurse, they were late and does not recall if she put in any MAR notes. She stated a concern for late administration of Carbidopa-Levodopa would be an increase in tremors or shaking but she did not remember seeing any symptoms when she was giving the meds late. During an interview on 9/25/2025 at 12:09 pm, MA-B stated they have an hour before and an hour after the stated time in the EMAR to administer medications to residents and any late or missed medication they were supposed to notify the charge nurse. She stated the administration time for Resident #1's Carbidopa-Levodopa medication on 8/21/2025 fell outside the 1-hour window and she was the MA that administered the medication to Resident #1. She does not know why she administered it late stating maybe he was in the bathroom. She stated she did not remember if she had notified the charge nurse, they were late. She stated the Carbidopa-Levodopa medication helps with shaking for the residents. During an interview on 9/25/2025 at 12:34 pm, MA-C stated the facility policy allowed them to give medications an hour before or an hour after the schedule time. She stated she was the MA working on 8/20/25 and gave Resident #3 her Carbidopa-Levodopa that was scheduled at 2:00 pm, late and missed giving the resident her 6:00 pm dose. She stated the 2:00 pm dose was late because she was probably working on the other hall and didn't get to it in time. MA-C did not remember why she didn't give the 6:00 pm dose - she was not sure about that med if it lit up or not indicating the medication could be given. She did not recall if she had mentioned it to the charge nurse or completed a MAR note in the EMR. She stated her concerns with a late or missed medication like that would be more hand shaking, more body movements because the medications was given for Parkinson's Disease. She did not recall if Resident #3 had an increase in symptoms. Calls to Nurse D to interview her about her late medication administration for Resident #3 were attempted on 9/25/2025 at 12:42pm, 1:10 pm and 1:51 pm. Messages were left at each attempt, but no calls were returned. During an interview on 9/25/2025 at 12:49 pm, the hospice Medical Director (HMD) stated his expectations when a facility was given medication orders for a resident is that 1) the medications would be given; 2) the staff would make sure the resident took the medications, and 3) the medication was given at the times ordered - it is an order not a suggestion. The HMD stated he doesn't have any grave concerns for the late administration of the Carbidopa-Levodopa for Resident #3, but it could have caused an increase in symptoms [tremors] and confusion. During an interview on 9/25/2025 at 2:42 pm, the DON stated her expectation on mediations for residents was that the order would be followed through. If the orders could not be followed, staff would notify the nurse who would notify the NP. She stated her concerns with late medications is that the residents could have fallen out of their therapeutic range, and this could have caused an exacerbation of symptoms of their disease process. During an interview on 9/25/2025 at 3:00 pm, the ADM stated his expectation was that medication orders were followed and any reason for meds given outside of that window that the staff would notify clinical minds. The ADM stated his concerns would have been that residents could be chasing symptoms or there could have been a breakthrough in the disease process, and it would be harder to get it in control. Depending on how late the medication was, it could also have been too much if the late dose is given too close to the next dose and the therapeutic level could be off. During an interview on 9/25/2025 at 4:08 pm, the NP stated her expectation on medications orders would be that the orders were carried out and if there were any questions, the facility would call her in case she wanted to do something different for that resident. She stated she was not aware of the late medication administrations for Resident #1, Resident #2 or Resident #3. She stated her expectation on the timing of medication of Carbidopa-Levodopa was that most residents are admitted on the medication and the facility will get as close as possible to the scheduled time. She stated some residents would get symptomatic and have an increase in tremors or shaking if they did not get it when scheduled. She stated she was not aware of any adverse reactions due to the late medications. Review of facility Medication Admin Audit Report dated 9/24/2025 reflected Resident #1, Resident #2 and Resident #3 had Carbidopa-Levodopa medications administered late as reflected above. Review of undated facility policy Medication Administration Policy and Procedure revealed: PurposeThe purpose of this procedure is to provide guidelines for the safe administration of medications.PolicyThe facility shall provide medications as ordered by the physician.Procedure:1. Medications shall be administered only upon the order of physicians, dentists, or podiatrists.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #5) out of 5 residents reviewed for infection control. The facility failed to clean up blood splatters on the floor of Resident #5's room after IV therapy.These failures placed residents at risk of transmission and/or spread of blood borne pathogens including infections or contagious diseases which could lead to infections and hospitalization.Findings included:Review of Resident #5's face sheet dated 9/25/2025 reflected resident was an [AGE] year-old female admitted on [DATE] with diagnoses: metabolic encephalopathy, hypertension (high blood pressure), atrial fibrillation (heart rhythm disorder), hypothyroidism (thyroid disorder), vitamin deficiency. Review of Resident #5's progress notes dated 9/22/2025 reflected .MD informed who ordered Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML q6hr x5 days, Mucinex Oral Tablet Extended Release 12 Hour 600 MG (Guaifenesin) x5 days, Sodium Chloride Intravenous Solution 0.9 % (Sodium Chloride) 100ml @ 75ml/hr and Cefepime HCl Solution 1 GM/50ML x7 days, IV inserted into L forearm x1 attempt w/ 22g cath. Review of Resident #5's orders reflected an order dated 9/23/2025: IV to left arm Monitoring: Observe and record signs and symptoms of infection every 8 hours: 0- dressing dry and intact. No signs of redness, swelling or tenderness. 1 - redness 2 - swelling 3- tenderness 4 - Other: document findings in notes and notify MD/NP if signs or symptoms of infection occur. During an observation on 9/24/2025 at 12:55 pm, Resident #5 was in her room with a FM present, and several areas of dark red/brown fluid splatters were noted on the floor about resident's bed area. During an interview on 9/24/2025 at 12:57 pm Resident #5 stated the spots on the floor were blood from the day before when they gave her an IV. She stated she had to be careful when moving around her room in her wheelchair, so she didn't track the blood everywhere. During an interview on 9/24/2025 at 1:00 pm, the FM stated she noticed the blood splatters on the floor when she came in to visit Resident #5 and asked resident about them. Resident informed her they came from her IV the day before. The FM stated she had concerns about the cleaning of Resident #5's room and the possibility of something being spread around with the blood on the floor. During an interview on 9/25/2025 at 2:14 pm, the Housekeeping Supervisor stated resident rooms were cleaned daily. She was never notified of the dried blood on Resident # 5's floor. She stated she would have concerns about blood borne pathogens and the resident falling or slipping on the liquid and it getting tracked around into other places. She said if it was not cleaned up, it would be an infection control issue and potential for the spread of germs. She stated her expectations about blood spills were: 1) clean it up right away and 2) let her or housekeeping staff know so they can go clean and disinfect the area. She stated they got an in-service on blood spills yesterday that everyone was responsible for cleaning up spills and notifying housekeeping. During an interview on 9/25/2025 at 2:42 pm, the DON stated it was her expectation that blood spills be cleaned up immediately at the time of the incident, or the second someone sees it, they clean it up and notify housekeeping. She stated her concerns would be the fluid could cause a slip, trip or fall hazard as well as an infection control concern with exposure to blood borne pathogens. She stated they completed in services yesterday with staff and informed them to clean it up immediately, report to the charge nurse so the nurse could notify housekeeping immediately. During an interview on 9/25/2025 at 3:00 pm, the ADM stated his expectations on blood spills was that it has to be cleaned up right away, it's a biohazard. He stated the clinical staff has been trained on how to clean up biohazards and this should have been cleaned up. The ADM stated his concerns were that someone could have been infected by it, a resident, family or staff and it's a dignity issue and a blood pathogen. Review of the undated facility policy Blood/Body Fluids-cleaning up spills/splashes Policy and Procedure revealed: Purpose:All spills or splashes of blood or other body fluids will be cleaned up and the spill or splash area will bedecontaminated as soon as practical. Procedure:1. Surfaces and equipment contaminated with spills or splashes of blood or body fluids must be cleanedup and disinfected as soon as practical.2. All employees must wear gloves when cleaning up spills or splashes of blood or body fluids. (Note:Other protective equipment (e.g., gowns, masks, and goggles) may be necessary if splashing of bloodor body fluids into the eyes, nose, or mouth, or soiling of clothing is likely. Shoe coverings will benecessary if there are large amounts of blood on the floor.)3. After cleaning up spills or splashes of blood or body fluids, the contaminated area must be disinfectedwith one of the following:4. Chemical germicides that are approved for use as hospital disinfectants and are tuberculocidal whenused at recommended dilutions.5. Products registered by the Environmental Protection Agency (EPA) as being effective against HIV withan accepted HIV (AIDS) virus label; or6. A solution of 5.25% sodium hypochlorite (household bleach) diluted between 1:10 and 1:100 withwater.7. On small spill or splash areas and on skin surfaces, a 70% isopropyl alcohol pledge may be used todisinfect the area.8. Hands must be washed as soon as practical after an exposure to blood or body fluids.9. All residents' blood and body fluids should be considered potentially infectious.10. Any exposure to a resident's blood or body fluids should be reported to the infection controlcoordinator.

Based on interview and record review the facility failed to incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning and transitions of care for one of four residents (Resident #1)reviewed for PASRR services . The facility failed to submit a NFSS request form for PASRR Specialized Services within 20 business days after PASRR Comprehensive Service IDT Meeting on 12/23/2024. This failure could place residents at risk of not receiving needed individualized care, and specialized services to meet their needs. Findings include: Record review of Resident #1's face sheet, dated 06/11/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included Parkinson's disease without dyskinesia, and without mention of fluctuations (did not experience involuntary, erratic movements and there are no documented variations in the severity of their symptoms) and , autistic disorder (a neurodevelopment condition characterized by persistent challenges in social communication and interaction, along with restricted, repetitive patterns of behavior, interests, or activities). Record review of Resident #1's MDS , dated 02/15/2025, reflected Resident #1 had a BIMS score of 15, which indicated his cognition was intact. Resident #1 was independent with eating, oral hygiene, toileting, upper and lower body dressing, and personal hygiene. He required supervision with showers. Record review of Resident #1's MDS , dated 04/15/2025, reflected Resident #1 had a BIMS score of 15, which indicated his cognition was intact. Resident #1 was independent with eating, oral hygiene, toileting, upper and lower body dressing, and personal hygiene. He required supervision with showers. Record review of Resident #1's Comprehensive Care Plan, with revision date 12/18/2024 , reflected Resident #1 was PASRR positive. Interventions, revised on 12/18/2024: Provide specialized physical therapy. Provide specialized speech therapy. Provide specialized occupational therapy. Record review of Resident #1's PASRR Comprehensive Service Plan Form, dated 12/23/2024, reflected evaluation for PT and OT was needed. The following was in attendance of the Meeting: Resident #1, PASRR Coordinator, Social Worker, MDS Coordinator and Director of Therapy. Requested Resident #1's PASRR Comprehensive Quarterly Service plan form, due on March 2025 via email to PASRR Coordinator and it was not provided at time of exit. Record review of Email from PASRR QM to the DON and Administrator, dated 04/17/2025, reflected The reason for this email is to notify you that according to our records, an Interdisciplinary Team meeting (IDT) was held and entered the Long-Term Care Online Portal for one or more of your residents. During the IDT meeting nursing facility specialized services were recommended and agreed upon for the resident in your facility. For your facility to be in compliance with the 26 Texas Administrative Code (TAC), Chapter 554, Subchapter BB, section §554.2704(i)(7), a nursing facility must .initiate nursing facility specialized services within 20 business days following the date that the services are agreed to in the IDT meeting . Currently, your nursing facility is out of compliance as per this TAC Rule. If the resident is still in your nursing facility, you must submit a request for the PASRR specialized services agreed to during the IDT meeting within 3 business days for therapies of receiving this email. (This was referring to Resident #1 ). Interview on 06/11/2025 at 10:30 AM, the Director of Therapy stated she attended a meeting in December 2024 with the PASRR Coordinator concerning Resident #1. She stated the IDT (Social Worker, MDS Coordinator, PASRR Coordinator, Director of Therapy) during the meeting decided Resident #1 would benefit from Occupational and Physical therapy to build his endurance. She stated Resident #1 did not receive OT or PT until 05/01/2025 . She stated there was a possibility if a resident did not receive therapy from December 2024 until May 2025, the resident may have a decline in ADLS. She stated Resident #1 was at his baseline with his ADLs and did not have a decline from December 2024 until he began therapy May 2025. The Director of Therapy stated she did ask the PASRR Coordinator if the therapy had been approved prior to April 2025. She did not recall the exact date. The Director of Therapy stated she was aware paperwork was required to be completed for approval with PASRR . She stated she did not recall if she discussed Resident #1's approval for therapy with anyone at the facility. Interview on 06/11/2025 at 10:50 AM, the MDS Coordinator stated the IDT team had an Annual meeting with Resident #1 and the PASRR Coordinator on 12/23/2024 discussing his care. She stated PT and OT was discussed during this meeting and the IDT team decided Resident #1 would benefit from therapy (PT and OT). The MDS Coordinator stated Resident #1's Responsible Party was on the phone during the meeting and was included in the PASRR meeting. She stated the PASRR Comprehensive Service Plan was submitted to Simple LTC (electronic medical record for PASRR information). The MDS Coordinator stated she was not aware of NFSS forms and believed this was the only step she was required to do when requesting services from PASRR. She stated she consulted with the PASRR Coordinator with any updates on Resident #1's approval for PT and OT. The MDS Coordinator stated she did not recall the date she spoke to the PASRR Coordinator. She stated the DON forwarded her an email dated April 2025 with information on Resident #1's therapy from the PASRR office. The MDS Coordinator stated she was not aware of the NFSS forms to be filled out and submitted to PASRR. She stated the DON instructed her how the process of filling out the NFSS forms and to submit these forms in the Simple electronic system for PASRR. She stated she spoke with the Director of Therapy, and they filled out the forms between 05/01/2025 and 05/03/2025. She stated the therapy department completed PT and OT assessments on Resident #1 to be submitted with the NFSS forms. The MDS Coordinator stated Resident #1 began therapy the first week of May 2025. She stated she did not receive training on NFSS forms and the process of submitting all the paperwork to PASRR when requested services for a resident. Attempted interview on 06/11/2025 at 11:35 AM with PASRR Coordinator via phone was unsuccessful. She did not return the phone call. Interview on 06/11/2025 at 11:45 AM, the Director of Nurses stated the protocol after a PASRR Comprehensive Plan meeting, if it was determined a resident needed therapy services or medical equipment was to complete all evaluations required and to document on the NFSS forms. She stated this information was required to be submitted within 20 days of the PASRR Comprehensive Plan Meeting to Simple LTC. The Director of Nurses stated if the NFSS was not completed the resident would not receive services or equipment. She stated Resident #1 PASRR Comprehensive Plan meeting was held on 12/23/2025 and the team during the meeting decided Resident #1 needed PT and OT. She stated the NFSS was not submitted, and she did not follow up to ensure all the paperwork was submitted for Resident #1 to receive these services. The Director of Nurses stated she did not have any paper work showing the MDS Coordinator received training on the process of NFSS and how to submit the appropriate documentation for approval from PASRR. She stated she was not the MDS department supervisor, and it was not her responsibility. She stated the Administrator was MDS supervisor. The Director of Nurses stated the MDS Coordinator began working at the facility in November 2024. The Director of Nurses stated she did not read the email sent to her on 04/17/2025 by the PASRR QM until approximately 2 weeks later. She stated when she did read the email, she did not read the information where it stated the NFSS paper work was expected to be completed within 3 days of receiving the email. She stated she forward the email to the MDS Coordinator, and she explained to the MDS Coordinator what forms were required to be completed by her and the Director of Therapy. She stated the forms were filled out and the MD signed the forms and Resident #1 began his therapy the first week in May 2025. The Director of Nurses stated Resident #1 did not have a decline in his ADLs from December 2024 until he began therapy in May 2025. She stated he was at his baseline. She stated there was a potential if a resident needed OT and PT services and did not receive these services, a resident ADLS may decline. The Director of Nurses stated the facility did not have a policy or protocol for PASRR. Interview on 06/10/2025 at 12:30 PM, Resident #1, stated he was feeling great, and he completed care without assistance except with showers and he needed someone to help him gathering all the things he needed to take a shower. He stated he had not had any changes in doing anything for himself. Interview on 06/10/2025 at 12:50 PM, the Administrator stated the MDS Coordinator was responsible to complete all documents for any services for PASRR. He stated if a resident waited from December 2024 until May 2025 to receive PT and OT, there was a possibility the resident may decline in his ADLS and physical mobility. He stated he did expect the DON to read emails and follow up with the appropriate staff to ensure all the information in the email was completed. The Administrator stated he was the MDS Coordinator supervisor, and he did not know how the paper work on Resident #1 was missed. Interview on 06/10/2025 at 1:25 PM, CNA A stated she had worked at the facility approximately two years. She stated she had been assigned to Resident #1 several times per week from December 2024 until May 2025. CNA A stated his ADL performance was at his baseline during those months. She stated there were no changes in his ADLs. Interview on 06/10/2025 at 1:40 PM, CNA B stated she had been assigned to Resident #1 numerous times per month from December 2024 until May 2025. She stated Resident #1 was independent with his ADL care except he needed supervision with his showers. She stated Resident #1's ADLs had not declined from December 2024 until May 2025. CNA B stated Resident #1 remained at his baseline. Interview on 06/10/2025 at 9:35 AM The DON stated the facility did not have a PASRR policy.

Based on interview and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for two (Resident #1 and Resident #2) of four resident reviewed for catheters. 1. The facility failed to ensure Resident #1 had catheter care orders from 04/02/2025 to 05/07/2025. 2. The facility failed to ensure Resident #2 had catheter care orders from 05/09/2025 to 05/13/2025. These failures could place residents who required incontinent care at risk for development of new or worsening urinary tract infections or pain. Findings included: Review of Resident #1's face sheet dated 05/14/2025 revealed an [AGE] year-old man admitted on [DATE] with diagnoses of obstructive and reflux uropathy (blockage in urinary tract that prevents normal urine flow), dehydration, dysphagia (difficulty swallowing), and other acute osteomyelitis, right ankle and foot. Review of Resident #1's admission MDS dated [DATE] reflected a BIMS score of 12 which indicated a moderate cognitive impairment. Further review revealed Resident #1 was always incontinent. Review of Resident #1's nursing admission assessment completed by LVN A dated 04/02/2025 reflected Resident #1 was admitted from another facility with foley catheter and it was in place at the time of admission. Further review reflected indwelling catheter was selected as present but catheter care option was not selected. Review of Resident #1's care plan dated 05/07/2025 reflected Resident #1 used an indwelling catheter. Interventions included to change tubing and bag as appropriate, provide catheter care every shift and watch for acute behavioral changes. Review of Resident #1's physician orders reflected order with start date of 05/07/2025 input by LVN B an order for a urethra catheter for obstructive uropathy and included orders to monitor that catheter was intact, check for catheter bag, tubing was secure, bag was below level of bladder and assess for pain or discomfort every shift. Further review of discontinued orders from 04/02/2025 to 05/07/2025 reflected no orders for catheter care between admission and 05/07/2025. Review of Resident #1's May 2025 MAR reflected there was no pain indicated related to urinary catheter. Further review reflected catheter care was provided daily and started on 05/07/2025 with no documented concerns or issues. Review of Resident #1's April 2025 MAR reflected there were no orders included for catheter care. Further review reflected pain was monitored in April 2025 and Resident #1 indicated no pain. Review of Resident #1's transfer / discharge report dated 04/02/2025 reflected a medication review report dated 04/02/2025 and included orders to change foley catheter monthly and as needed and provide catheter care every shift and as needed. Review of Resident #1's urology appointment note dated 04/15/2025 reflected catheterization was performed and Resident #1 tolerated procedure well. Review of Resident #1's POC response for last 30 days reflected dates of 05/07/2025 to 05/14/2025 reflected care was provided between these days and included to empty bag, document color of urine, ensure dignity covers were present and tubing was secured. No issues were noted in these responses. Review of Resident #2's face sheet dated 05/14/2025 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of metabolic encephalopathy (a condition where the brain's function is impaired due to an imbalance in the body's metabolism), acute respiratory failure with hypoxia (a condition where the body's tissues are not getting enough oxygen), retention of urine (inability to completely empty the bladder when urinating), and anxiety disorder (excessive fear and worry that interfere with daily life). Review of Resident #2's nursing admission assessment completed by LVN C dated 05/09/2025 reflected Resident #2 was incontinent of bowel and bladder upon admission and had a foley catheter. Further review reflected indwelling catheter option was not selected and catheter care was also not selected. Review of Resident #2's care plan dated 5/12/2025 reflected he was on EBP for an indwelling medical device with interventions for staff to wear PPE during high contact activities (bathing, showering). Review of Resident #2's physician orders reflected an order with a start date of 05/13/2025 included orders to monitor that catheter was intact, check for catheter bag, tubing was secure, bag was below level of bladder and assess for pain or discomfort every shift and as needed. Review of Resident #2's May 2025 MAR reflected catheter care / monitoring began 05/13/2025 with no documented concerns. Review of Resident #2's POC response for last 30 days reflected dates of 05/13/2025 and 05/14/2025 reflected care was provided between these days and included to empty bag, document color of urine, ensure dignity covers were present and tubing was secured. No issues were noted in these responses. During an interview on 05/14/2025 at 1:21 PM, Resident #2 stated he had no concerns or issues with his catheter. Resident #2 stated he had no pain or burning and that he received catheter care at least once a day. During an interview on 05/14/2025 at 12:42 PM, CNA E stated catheter care was performed every time the resident's brief was changed. She stated she also had to wear PPE because the resident had EBP. CNA E stated even if catheter care was not trigger in the resident's POC catheter care was required because it was part of her job. CNA E stated it was obvious that a resident had a catheter. CNA E stated that on the POC she was supposed to document the resident's output, empty the bag at the start and end of her shift. CNA E stated any change was supposed to be reported to the nurse. CNA E stated changes could have been cloudy urine. During an interview on 05/14/2025 at 12:50 PM, CNA F stated that for catheter care she was required to empty the bag, clean around the resident's private area, document color and output. CNA F stated this was documented under the ADLs tab in the resident's POC. CNA F stated that she looked for redness, discoloration of urine and smell. CNA F stated that catheter care was provided daily and at least every shift or every time a resident's brief was changed. CNA F stated if any changes were noted she would have reported it to the nurse right away. During an interview on 05/14/2025 at 1:36 PM, LVN C stated that residents with catheters were checked twice a shift and that the nurse was aware to check because an order popped up on the MAR. LVN C stated that he checks catheters when he arrives for his shift and at the end of his shift. LVN C stated that he worked 12 hours shifts at the facility. LVN C stated that checking catheters included checking for drainage and that it was not backed up, asking for pain in the abdominal area, ensure that the tubing was clasped in the correct spot, the bag was hanging for proper flow and a privacy cover was on. LVN C stated that abnormal findings would be blood, clogging, white mucus (which indicated infection), and pain in abdomen. LVN C stated anything abnormal would be reported to the NP. LVN C stated that there was a batch order that was put in for any resident that admitted with a catheter. LVN C stated the batch orders included to check the catheter, drainage, monitor and check for any pain. LVN C stated order should have been put in upon admission as long as the NP or MD did not discontinue them. LVN C stated that the catheter care orders were only discontinued if the catheter had been removed. LVN C stated if a resident had a catheter but no orders there was a risk for infection, discomfort for the resident. LVN C stated normally the charge nurse put orders in but if it was missed then administration would check. During an interview on 05/14/2025 at 2:17 PM, the MD stated that she does provide orders when a resident admitted for catheter care and if a resident admitted with a catheter they should have had routine catheter care completed. The MD stated this included for staff to monitor for signs and symptoms of infection. The MD stated that she believed the catheter was changed every four weeks. The MD stated she thought the it would be common sense and that a staff would have noticed there were not orders. The MD stated the catheter was changed and monitored to reduce risk of infection. During an interview on 05/14/2025 at 3:00 PM, LVN A stated she was aware what orders a resident had in place on admission based on the resident's hospital orders. LVN A stated that if a resident came from another facility they usually arrived with orders. LVN A stated if a resident admitted with a peg or catheter there was usually a standing order that was put in. LVN A stated if there was not an order the nurse could have asked the MD or NP. LVN A stated that Resident #1 admitted with a catheter and she did not recall what orders were put in for his catheter. LVN A stated that the standing orders usually included to look that the catheter was intact, monitor for pain, and ensure the bag was in the right place (hanging below the bladder). LVN A stated Resident #1 came with orders from another facility but was unsure if he came with orders for his catheter. LVN A stated it was important to monitor a resident with a catheter because the resident could get an infection and staff needed to check how the urine was draining, color and if there was any sediment. LVN A stated any pain, fever, cloudy urine, foul smelling urine or swelling (depending on the placement) would be reported to the NP. During an interview on 05/14/2025 at 3:11 PM, LVN B stated that he was the unit manager for the facility. He stated he put in catheter care orders for Resident #1 because it was noticed during an order review that he had a foley but no orders for catheter care. LVN B stated that when a resident admitted with a catheter, ideally all orders would be included in the admission orders, but the facility had a batch order that was received from the physician that the charge nurse would use for catheter care. LVN B stated that the facility tried to review new admissions the following day and orders were generally reviewed every morning and all physician orders were reviewed from the previous day. LVN B stated that CNAs were trained on day-to-day care when they provided incontinent care, but the responsibility fell on the nurses. LVN B stated that nurses were aware to check or perform catheter care because of the initial head-to-toe admission assessment. LVN B stated it was important to monitor to ensure that the resident was not dealing with an infection and to ensure the resident was draining and observe the urine and ensure there were not renal issues or bleeding. During an interview on 05/14/2025 at 3:29 PM, CNA D stated that during catheter care she wore a gown, and gloves because the resident was on EBP. CNA D stated that she had to clean the catheter itself, clean the resident's private area, and look for signs of breakdown, discharge, discoloration in the tubing, redness. CNA D stated if she noticed any of the mentioned changes or concerns she would have notified the nurse right away. During an interview on 05/14/2025 at 4:35 PM, the DON stated that the charge nurse was responsible to ensure catheter care orders were entered at the time of admission. The DON stated within 24 hours the unit managers reviewed admissions. The DON stated that there were two unit managers that split the building. The DON stated that the 24 hour period did not include weekends. The DON stated that the facility had an RN supervisor over the weekend so she reviewed orders and stated nursing administration rotated on-call. The DON stated that she believed staff were in-serviced on admission orders and treatments on 05/12/2025. The DON stated that the facility had batch orders for catheter care orders and that included daily monitoring, daily monitoring of signs or symptoms of infection and tubing placement. The DON stated that if a resident's catheter was not being monitored or checked by the nurse they were at risk for infection. The DON stated if there was no order the charge nurse was still required to round multiple times a day. The DON stated that it was found Resident #1 did not have order but she was unsure why and stated she guessed it was something the facility missed. The DON stated it was found and a QAPI meeting was conducted and an audit on catheters was completed. The DON stated the audit was completed on 05/07/2025. The DON stated there were no additional residents found in the audit and going forward the unit managers were required to go lay eyes on the residents after the admission. The DON stated she was not aware that Resident #2 did not have catheter care orders until yesterday 05/13/2025. Review of facility in-service dated 05/12/2025 reflected purpose of training was PCC- ADT (Admit, Discharge, and Transfer) and Admit, Return, Discharge and Transfer Documentation. In-service reviewed documentation and charting guidelines and reflected catheter care should include, type of procedure and who performed it, date and time procedure was perform, type and size of catheter, changes in resident's condition, urine output and other pertinent data as necessary. Review of undated facility policy titled Catheter care, Indwelling Catheter Policy and Procedure reflected purpose of catheter care was to prevent infection and reduce irritation. Further review reflected catheter care should be provided daily or as needed.

Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 1 of 3 residents (Resident #48) reviewed for ADL's. The facility failed to ensure assistance was provided for repositioning and incontinent care every 2 hours for Resident #48 when he was observed to be left in his Geri-chair on 05/05/2025 from 7:00 AM until 4:00 PM. (9 hours). This failure could place residents at risk of not being provided care and assistance when needed. Findings Included: Review of Resident #48's face sheet dated 05/06/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses intracranial injury (head injury), spastic hemiplegia affecting dominant side (Hemiplegia is a symptom that involves one-sided paralysis.), contracture of left hand (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in range of motion.) Review of Resident #48's quarterly MDS assessment dated [DATE] reflected he was assessed to have a BIMS score of 8 indicating moderate cognitive impairment. Resident #48 was assessed to not have behaviors or refuse care. Resident #48 was further assessed to be dependent on staff for transferring, bed mobility and toileting and was assessed to be incontinent of bowel and bladder. Review of Resident #48's comprehensive care plan reflected a problem dated 07/11/2023 I am at risk for skin break down related to impaired and/or decreased mobility; psoriasis and seborrheic dermatitis. Interventions included .I may need pillow or other supportive/ protective devices to assist with positioning .Keep my skin clean and dry and avoid shearing/friction .Reposition me as appropriate . Further review of Resident #48's comprehensive care plan reflected a problem dated 07/11/2024 I am incontinent of urine. Interventions included Assist me with perineal cleansing as needed. Observe my skin daily for irritation and redness . Observation on 05/05/2025 at 7:00 AM revealed Resident #48 up in Geri-chair sitting outside the dining room in the TV area. Observation on 05/05/2025 at 7:30 AM revealed Resident #48 up in Geri-chair eating breakfast with assist in the dining room. Observation on 05/05/2025 at 11:50 AM revealed Resident #48 up in Geri-chair sitting outside the dining room in the TV area. Resident #48 was observed to be in the same pants and shirt since breakfast. Both his pants and shirt had eggs on them. Observation on 05/05/2025 at 2:51 PM revealed Resident #48 up in Geri-chair sitting outside the dining room in the TV area. Resident #48 was observed to be in the same pants and shirt with clothing more soiled since lunch. In an interview on 05/05/2025 at 3:50 PM Resident #48 was asked if he had been up all day. Resident #48 stated yes. Resident #48 was asked by surveyor if he would mind lying down in the bed so the surveyor could check his skin. Resident #48 stated he did not mind and stated his bottom was sore. Observation on 05/05/2025 at 3:55 PM revealed CNA F and CNA G mechanical lifting Resident #48 into bed. CNA F removed Resident #48's brief in the front to reveal a saturated brief and strong urine odor. Resident #48 was observed with slight redness to his front peri area. CNA F and CNA G then turned Resident #48 onto his side to reveal the saturated brief also contained BM. Resident #48's skin was slightly red and blanchable . In an interview on 05/05/2025 at 4:10 PM the CNA staffer stated CNA H worked Resident #48's hall from 6:00 AM until 2:00 PM then was replaced by CNA G. In an interview on 05/05/2025 at 4:12 PM CNA G stated he had not gotten to Resident #48 yet that when he came in at 2:00 PM he started his rounds at the front of the hall and had not made it to Resident #48 who was at the end of the hall. In an interview on 05/05/2025 at 4:15 PM LVN C stated she was the nurse assigned to Resident #48's hall. LVN C stated she was supposed to round on her residents every 2 hours. LVN C stated she did not today (05/05/2025) because she got distracted. She stated that sometimes Resident #48 will refuse to go to bed. LVN C she stated no one came to her today and told her that Resident #48 refused care and if he had refused care the CNA should have let her know if a resident was refusing care so they could intervene. LVN C stated she was supposed to monitor the CNAs to ensure resident care was being performed; she stated she just got distracted and did not round. In an interview on 05/05/2025 at 5:17 PM CNA H stated she did not put Resident #48 to bed or perform incontinent care for him because he refused to go to bed. She stated she did not report to his nurse LVN C that he refused care. She stated she did not report his behaviors and should have. She stated she should have repositioned him throughout the day and did not. When asked why she did not provide Resident #48 care through out the day she did not answer. CNA H stated they usually put a pillow under his neck because the way it is contracted. She stated they had three CNAs on the hall, so she had help for a two person mechanical lift transfer. CNA H stated she is supposed to make rounds and perform incontinent care every two hours. In an interview on 05/08/2025 at 12:05 PM the DON stated it was her expectation that nurses make rounds every 2 hours to ensure CNAs are making rounds every two hours and that residents are provided incontinent care every two hours. The DON stated even if the resident does not want to go to bed, she stated they still needed incontinent care and to be repositioned every 2 hours. The DON stated if resident refuses care the CNA should tell the nurse and the care plan should reflect the behavior and the behavior should be monitored by the nurses. She stated Resident #48 to her knowledge did not usually refuse care. Review of the facility's undated policy Incontinence Care reflected Purpose: 1. To keep skin clean, dry, free of irritation and odor. 2. To identify skin problems as soon as possible so treatment can be started. 3. To prevent skin breakdown. 4. To prevent infection . The facility policy did not address how often incontinent care should be provided. No other policies related to resident rounds or repositioning of residents requested on 05/07/2025 and 05/08/2025 were provided.

Based on observations, interviews, and record review the facility failed to ensure pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 3 (Resident #150, and Residents #85) residents reviewed for pain management. A) The facility failed to ensure Resident #150 effective pain management by not evaluating effectiveness of current pain medications and not having her current pain medications available for administration. B) The facility failed to ensure that Resident #85 received at least daily assessments of pain for 34 of 49 days. This failure could place resident at risk for increased pain causing undo suffering. Findings included: A) Review of Resident #150 face sheet dated 05/06/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses chronic pain syndrome, and other specified disorder of bone density and structure, multiple sites. Review of Resident #150 EMR reflected the only MDS completed was her entry MDS dated [DATE]. Review of her nursing admission assessment dated [DATE] completed by LVN E reflected she was assessed for pain on admission with the pain level of 4/10. Review of LVN E's documented note reflected Pt. was medicated prior to leaving last facility . Review of Resident #150 physician orders reflected an order dated 05/02/2025 Monitor for pain every shift; Fentanyl patch 75mcg /hr. replace every 72 hours; Baclofen 5mg two times daily and oxycodone HCL 5mg one tablet every 4 hours as needed for severe pain related to chronic pain syndrome. In an interview on 05/05/2025 at 9:10 AM Resident #150's FM stated she was concerned about Resident #150's pain medication. She stated the facility has not gotten it right since her admission on 05/02/2025. The FM stated Resident #150's oxycodone should be routine instead of PRN. She stated Resident #150 was having too much breakthrough pain. In an interview and observation on 05/06/2025 at 11:22 AM Resident #150 stated she was in pain that her neck was hurting, and she needed her pain medication. Resident #150 stated it had been an hour since she asked for pain medication and still had not gotten it and it was an hour late. Resident #150 began crying stating she was really hurting. Review of Resident #150's base line care plan reflected no entries related to pain or pain management. In a follow up interview on 05/06/2025 at 12:10 PM Resident #150 stated she got her pain medication at 12:00 noon. She stated she had neck pain that was severe which came from a fused vertebra in her neck. She stated they took off her Fentanyl patch on 05/05/2025 and did not put another one on because they did not have any and it needed to be ordered. She stated she wanted her oxycodone to be put routine instead of PRN because they take too long to bring it when it is PRN . Resident #150 further stated she will refuse to take her Baclofen sometimes because it makes her to sleepy and stated she has told them she only wants to take it at night, but they keep trying to give it to her during the day. In an interview on 05/06/2025 at 1:30 PM LVN D stated Resident #150 MD had to reorder her Fentanyl patch due to the triplicate needed. He stated the admitting nurse should have reached out to Resident #150's MD to order the Fentanyl on admission. LVN D stated the medication would be delivered this evening. LVN D stated if the medication had been ordered on the day of her admission she would not have run out. LVN D further stated he was told earlier today right before lunch that she needed pain medication. LVN D further stated he took the medication right to Resident #150 . Review of Resident #150's MAR reflected she was administered her oxycodone HCL 5mg on 05/06/2025 at 7:02 AM and 11:56 AM. (4 hours and 56 min apart) Further review of Resident #150 MAR reflected her pain level was documented at an 8 out 10 at 11:56 AM. In an interview on 05/06/2025 at 5:30 PM LVN E stated when Resident #150 was admitted she had a Fentanyl patch on. LVN E stated she ordered all her medication from the pharmacy but called the NP regarding the fentanyl patch since she could not order it. LVN E further stated the order had to come from the doctor and the NP told her she would call Resident #150's MD to get the order for the Fentanyl. Review of Resident #150's MAR dated May 2025 reflected an entry that Resident #150's Fentanyl patch was removed at 4:34 PM on 05/05/2025. Review of Resident #150's nursing progress note reflected an entry dated 05/05/2025 at 4:34 PM related to order to apply Fentanyl patch documented awaiting drug arrival. Further review reflected an entry dated 05/06/2025 at 2:08 PM This nurse spoke with pharmacist to have fentanyl patch and oxycodone mediation STAT delivered at this time. Pending delivery from pharmacy. Review of nursing progress notes reflected an entry on 05/06/2025 at 5:53 PM Fentanyl patch 75mcg/hr. dose administered at 5:45 PM to right chest. In an interview on 05/07/2025 at 9:35 AM Resident #150 stated her pain was ok this morning she stated she just got her oxycodone and they put her pain patch (Fentanyl) on last night. In an interview on 05/07/2025 at 12:05 PM Resident #150's NP stated she could not order Fentanyl from the pharmacy that the medication had to be ordered by Resident #150's MD. Resident #150's MS stated she has told the nurses in the past and has been reiterating with them that they need to call the MD when they have orders for Fentanyl and to follow up as needed if the medication is not delivered. She stated Residents should have their pain medications on hand to ensure their pain was under control to prevent mood changes and increased anxiety. In an interview on 05/07/2025 at 3:36 PM MDS Coordinator B stated Resident #150 should have a base line plan of care within 48 hours of admission. She further stated Resident #150 should have had a plan of care for her pain. She stated Resident #150 not having one could lead to staff not knowing what to do for the resident to manage her pain. In an interview on 05/08/2025 at 12:05 PM the DON stated the base line care plan should be completed within 48 hours and should cover the residents' immediate needs. She stated with Resident #150's pain which was a big issue with her and should have been on her base line care. She stated failure of the staff not putting all the residents care needs on the base line care plan could lead to staff not knowing what care to provide the resident. In an interview on 05/08/2025 at 12:05 PM the DON stated it was the admitting nurse's job to ensure medications were ordered on admission. She stated with Resident #150, LVN E was new and did not know that she was supposed to follow up with the MD. She stated it was a training issue and she was going to provide training to her to ensure she understood it was not the NP responsibility to follow up with the MD but her responsibility to follow and make sure the medications are ordered ensure the residents care needs are met and residents do not experience pain. B) Review of face sheet dated 05/06/2025 for Resident #85 reflected a [AGE] year-old male, admitted on [DATE], with diagnoses including Metabolic encephalopathy (a group of conditions that cause brain dysfunction), Dementia, Pain, Primary osteoarthritis of the right shoulder (a joint disease that causes breakdown of cartilage and bone), Depression. Review of MDS for Resident #85 dated 02/20/2025 reflected a BIMS score of 11 (moderate cognitive impairment). Review of Physician progress note dated 02/27/2025 reflected a history of Right shoulder surgery. Review of Physician Orders for Resident #85 on 05/06/2025 reflected that there was no order for pain monitoring. Review of Care plan for Resident #85 reflected a focus area dated 02/19/2025 of I am experiencing the presence of pain (Rt Shoulder) with interventions including to Evaluate my pain using a 1-10 scale and Watch me for worsening of my pain symptoms and report to my physician. There are no interventions stating how often to check for pain. Assessments for pain reflected there were no entries for 03/20/2025, 03/25/2025, 03/28/2025, 03/29/2025, 03/30/2025, 03/31/2025, 4/2/2025, 04/03/2025, 04/04/2025, 04/05/2025, 04/06/2025, 04/07/2025, 04/08/2025, 04/09/2025, 04/10/2025, 04/11/2025, 04/12/2025, 04/13/2025, 04/14/2025, 04/15/2025, 04/16/2025, 04/17/2025, 04/18/2025, 04/19/2025, 04/20/2025, 04/21/2025, 04/22/2025, 04/23/2025, 04/24/2025, 04/25/2025, 04/26/2025, 04/27/2025, 04/28/2025, 04/29/2025, 04/30/2025, 05/01/2025, 05/02/2025, 05/03/2025, 05/04/2025, 05/05/2025, 05/06/2025. This is 34 of the last 49 days where pain was not assessed for this resident. Review of Progress notes for Resident #85 reflected there were no progress notes documenting pain on a 1-10 scale for the days not listed between 04/01/2025 to 05/06/2025. There are no narrative style progress notes with assessments of pain levels from 1-10 for the dates not documented on in the pain assessments. Observation on 05/05/25 at 9:13 AM revealed Resident #85 in room. Resident was standing in front of a chest of drawers, leaning on his elbows with his head in his hands. Resident cannot recall the words for the location of the pain, but indicated he had pain to his back on the right side, under his right shoulder blade. Stated that he asks the nurses for medication and his is given what he can take. Stated the pain medications do not help enough. Resident knows where he is but was unable to recall the details of the conversation for more than a few moments. Interview with RN on 05/07/2025 at 10:30 AM stated that Resident #85 had been to orthopedic surgeon twice for steroid injections related to pain. Stated that recent medication added for the resident's pain have been ineffective. State he has an appointment in June for another steroid injection and the facility is going to consult pain management. RN states she was knowledgeable of his unresolved pain condition. Stated there are times that he does not complain of pain. Surveyor requested that RN show where pain is charted. She indicated that her documentation would be in the TAR. RN confirmed that there is no order for pain monitoring. Stated that if there is not a place to document in the TAR, she had not been documenting pain for this resident. She stated that a resident with chronic pain should have orders to monitor for pain at least once a shift. She stated that she does monitor for pain with rounds for her patients. Stated she would add the order to monitor for pain. Stated that unresolved pain can lead to depression, anxiety, agitation, increase in behaviors, and high blood pressure. Interview on 05/07/2025 at 10:38AM with NP stated that the nurses should be monitoring pain every day for Resident #85. Stated it should be recorded with vital signs or in progress notes. Observation on 05/07/2025 at 11:42 AM revealed Resident #85 sitting at the table in the dining room, leaning on his elbows with his head in his hands. Stated he was having pain. Stated his pain was 5/10 to the right side of his back under his right shoulder blade. Stated he asked for pain medications today. Stated he does not recall who he told about the pain. In an interview on 05/8/2025 at 01:52 PM DON stated they should be monitoring pain every day for Resident #85. Stated that her expectation for monitoring pain in residents with chronic or unresolved pain is that they bed assessed every shift, prior to PRN medications, and after medications to assess for effectiveness. Stated that resident #85 should have orders to monitor for pain. Stated his pain should be documented at least daily. Stated that if we do not monitor for pain and document the pain levels they will not know if he has had any pain. Review of facility undated Pain Management Policy and Procedure reflected: Purpose: To maintain the resident as pain free as possible with the least amount of medication required. Policy: Resident pain is to be assessed and addressed to meet individual needs. Procedure: 1. Resident is to be assessed for pain every shift and as needed. a) Pain scale 0-10 utilized for verbal and facial. 2. Nurse to be notified of any resident having pain. Pain medication is to be utilized as ordered by the physician and as indicated. 4. PRN pain medication is to be administered as applicable. 5. The nurse is to document effectiveness of pain medications administered. 6. A non-pharmacological pain intervention is to be provided to assist in pain management . 51511

Based on interview and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for one (Resident #1) reviewed for quality of care. The facility failed to ensure: LVN C obtained physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN C did not inform the DON or PCP when the Life Vest placed on Resident #1 by the Cardiologist's team while she was on duty. The RN/MDS Nurse E failed to ensure orders, monitoring and instructions for charging and care of the Life Vest were in the chart and a Care Plan was updated for Resident # 1. CNA H was not in-serviced in the care of a resident with a Life Vest and gave Resident # 1 two bed baths with the Life Vest still on which could potentially result in the resident and the staff receiving an electric shock. An Immediate Jeopardy (IJ) was identified on 12/03/2021 at 6:31 p.m. While the IJ was removed on 12/06/2021 at 12:24 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy, due to the facility's continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents requiring specialized medical equipment at risk of decreased quality of life, hospitalization or death. The findings include: Review of Resident # 1's Face Sheet reflected he is a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 1's Quarterly MDS dated [DATE] reflected he had a BIMS score of 5 indicating severe cognitive impairment. His active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . (kidney failure) Review of Resident # 1's care plan initiated on 06/11/2021 and revised on 06/18/2021 revealed the resident had oxygen therapy related to congestive heart failure, shortness of breath with difficulty lying flat, shortness of breath on exertion,. The care plan did not address Resident #1's life vest. Review of a Care Plan dated 7/12/2021 by the RN, MDS Nurse E for Resident # 1 reflected Resident to wear life vest as ordered. No other instructions were noted in the Care Plan. Review of a nurse Progress note dated 7/12/2021 at 4:56 PM by LVN C reflected Staff here from (Dr D's) office and placed life vest on Resident # 1 for tracing and to d-fib (defibrillate - a shock treatment to restore the heart to a normal rhythm) - will wear for 3 months. Review of an article dated January, 2014 from nih.gov reflected The Life Vest is a personal defibrillator worn by a patient at risk for sudden [CONDITION(S)]. It monitors the patient's heart continuously and if a patient goes into a life-threatening arrhythmia, the Life Vest delivers a shock treatment to restore the heart to normal rhythm. In an interview on 11/16/2021 at 1:45 PM, the Social Worker for the [CONDITION(S)] clinic for Resident # 1 stated, What I've been told is (Resident # 1) has a life vest, he comes to [CONDITION(S)] with the battery dead or about to die. We do have it documented and have spoken with the facility multiple times about the life vest needing to be charged or bring the charger. He has appeared the last month disoriented and confused which is not his baseline. We sent him to the hospital this morning because he was unresponsive, and his life vest was dead. Review of a Progress note dated 11/16/2021 at 11:35 AM, written by LVN C reflected Resident #1 returned from the ER and the nurse reported They didn't really find anything. They performed a CT of the head (and lab work) They indicated this has become the resident's new baseline and he has a pending order for a hospice consult. Review of Resident #1's [CONDITION(S)] clinical records dated 11/13/2021 and 11/16/2021 reflected he was sent to [CONDITION(S)] with the battery of the life vest being almost dead or dead. In an interview on 12/02/2021 at 11:01 AM, the RN Charge Nurse at the local [CONDITION(S)] center stated, when one Patient or Resident is having a problem, they are made aware. She also stated most of the time Resident #1 gets to the [CONDITION(S)] center with his life vest battery being dead or almost dead. She stated she was made aware one of her staff has called the nursing facility twice for replacement battery due to Resident #1's life vest battery being dead. She also stated, on one of those times, it took the facility up to 4 hours to provide the replacement battery. In an interview on 12/02/2021 at 11:27 AM, PCT A stated she have worked with Resident #1 few times. She also stated she has witnessed Resident #1's life vest battery being dead while at [CONDITION(S)] and the nurse had to call the nursing facility for the backup battery. In an interview on 12/02/2021 at 11:29 AM, PCT B stated she work on 11/16/2021 and Resident #1 was sent to the local hospital emergency department. She stated, Resident #1's life vest battery was dead on that day and there were other times when Resident #1's life vest battery was dead, and they had to call the facility for the backup battery. In an interview on 12/02/2021 at 9:52 AM, the transportation staff stated she always took Resident #1 to [CONDITION(S)] on Tuesdays, Thursdays, and Saturdays at 5:30 pm and all doctors' appointments. She also stated she was aware of Resident #1 having a Life vest and was never in-serviced on Resident #1's life vest. She stated she was called by [CONDITION(S)] on 2 different occasions, on 10/30/2021 and 11/13/2021 requesting the backup battery for Resident #1's life vest. She stated both days were Saturdays, and she asked the Maintenance Director to take the life vest battery to the [CONDITION(S)] center. She also stated she notified the DON after the weekend of 11/13/2021 after being notified by the [CONDITION(S)] center that Health and Human Services will be notified. In an interview on 12/02/2021 at 10:22 AM, the Maintenance Director stated he sometimes help with transportation at the facility. He stated he was asked by the transportation staff to take Resident #1's life vest battery to the [CONDITION(S)] center once, or maybe twice. He also stated he asked the assigned nurse for the life vest battery on the days he had to take it to the [CONDITION(S)] center. He also stated he could not remember who the nurses were. In an interview on 11/17/2021 at 11:40 AM, LVN C, the nurse on duty at the time Resident # 1 received his life vest, stated, I would think I would have documented it. I would make sure that it was in working order. I don't think I notified the DON or doctor. I guess I should have gotten an order for [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview on 12/02/2021 at 3:23 PM, LVN C stated everyone knew about the life vest but where I failed is not asking about the orders I did not think outside the box. She then stated, there was no training done when Resident #1 got the life vest. She stated she was not aware of Resident #1 going to [CONDITION(S)] with his life vest battery being dead. In an interview on 11/17/2021 at 12:00 PM, RN/MDS Nurse E stated, I don't see an order in the chart. We went through the paper chart and couldn't find one either. I assumed there was an order. She looked through the paper chart again with surveyor, but no order was found. During an interview on 12/02/2021 at 4:18 PM, RN/MDS Nurse E stated, I did not talk with any nurse regarding Resident #1's life vest, I just put it on the care plan that it was initiated on 07/12/2021. I do not know when I heard about the life vest, whether it was the same week or the same day. There should have been a system in place for monitoring the life vest. The staff should have been trained. The company should have done an in-service. Any administrative nurse should have in-serviced the staff. We have been in-serviced, it would have been helpful before it was discontinued. In an interview on 11/17/2021 at 1:13 PM, LVN I from the physician's office was asked if a life vest was placed on Resident # 1 at the facility, she stated Correct. The life vest was ordered for the patient (Resident #1) on 7/7/2021 but we didn't get a call from the nursing home asking for an order. We don't know where they live. If I had known it was a nursing home, I would have sent it. In an interview on 11/17/2021 at 1:49 PM, CNA H stated, I was never given any in-services on the life vest. I gave him a bed bath both days this weekend, but I know not to get it wet. In an interview on 11/17/2021 at 2:29 PM, LVN G stated There was no in-service regarding it on the days I was here and there wasn't any notice posted about it to come in for one. I didn't see anything in the chart to check off on it. He would change out his battery sometimes or he would turn on the call light if it needed to be changed. In an interview on 12/02/2021 at 3:02 PM, LVN G stated she worked on 10/30/2021 and 11/13/2021 from 6:00 AM to 6:00 PM and she remembered the Maintenance Director asking her for Resident #1's life vest backup battery on one of those days but she did not ask him where he was taking it. She stated Resident #1 was not in the facility and in her care at the moment, he was at [CONDITION(S)], so she didn't think she had to ask. In an interview on 11/17/2021 at 1:00 PM, the DON who when informed the RN/MDS Nurse E had put Resident to wear life vest as ordered. in a Care Plan dated 7/12/2021, stated, The nurse who observed them putting the vest on him should have gotten an order and relayed that to Dr. F, notified the family and passed it on to the other nurses on the 24-hour report with the upcoming shift. The nurse should have made proper notifications to the PCP (Dr. F) and the DON. LVN C was the nurse on duty that day. If it had been me, I would have put something in the chart about the diagnosis, the instructions, how to operate the life vest and charge it. In an interview on 12/02/2021 at 2:04 PM, CNA J stated she was aware of Resident #1 having a life vest. She also stated she was not trained or in-serviced on what to look for on a resident with life vest. She stated Resident #1 was the one caring for his life vest and changing the battery. In an interview on 12/02/2021 at 2:30 PM, CNA K stated Resident #1 was in the position to take care of his life vest when she worked with him. She stated no one told her about the life vest, she was about to shower Resident #1 when she saw it, she called LVN C to find out LVN C told her what it was. She stated she was never trained or in-serviced on the function of a life vest. In an interview on 12/02/2021 at 2:40 PM LVN L, the nurse who worked the night of 11/12/2021 to 11/13/2021 from 6:00 PM to 6:00 AM. She stated she usually worked with Resident #1 and would get him ready in the morning for [CONDITION(S)]. She stated, I don't remember receiving any in-services on the life vest, no formal in-services. I was changing the batteries. I probably missed documenting about it a couple of times. I'm not sure, don't remember if I had to document on the life vest or not. On 11/12/2021 I remember someone said it was dead. I remember I had to change the battery because it started beeping up at the TV by the nurse's station where he was sitting. When asked the purpose of a life vest, she was unable to answer. In an interview on 12/02/2021 at 2:54 PM, CNA M stated she had never been in-served or trained on the care of a resident with a life vest. In an interview on 12/02/2021 at 3:35 PM, LVN N the nurse who worked the night of 11/15/2021 to 11/16/2021, 6:00 AM to 6:00PM stated we usually get Resident #1 ready for [CONDITION(S)] in the morning. She stated we make sure the battery of the life vest is fully charge before leaving, make sure the light is not blinking, the aides were able to check it also. The last day he went to the [CONDITION(S)], I remember checking the battery but I am not sure if I check it before he left that day. I did not get a call. No training or in-service on the care of the life vest. I did not document anything on his life vest, if there was a problem, I would check. Interview on 12/02/2021 at 6:10 PM, LVN O stated she worked the night of 10/29/2021 from 6:00 PM through 10/30/2021 6:00 AM and she sent Resident #1 to [CONDITION(S)] that morning. She sated, He wore his life vest all the time 24/7, there was one battery charging while the other one was in the vest. If he was assigned to me, I changed the battery out before he went to [CONDITION(S)]. I'd make sure the life vest was on properly, change out the battery. When you put a new battery in it will say battery full and it gives you a green or yellow, I can't remember. There was a computerized window. I'd always change the battery out and put in a fresh battery. On his wheelchair he had a carrying case for his portable oxygen tank, so I'd make sure it was full. I picked up the phone one time at the nurse's station, I don't remember the date, and it was [CONDITION(S)] saying someone needed to bring a new battery. I called our driver, and she came up and took a new battery to them. I would document in the progress notes sometimes about the life vest. I would write a communication note that would go with him. There was an In-service on the life vest and how we should be monitoring it. I don't remember off the top of my head when we were in-serviced or when I documented. That was a long time ago. In an interview on 11/17/2021 at 10:30 AM, the DON stated Resident # 1 came to the facility in June and was given the life vest in July. There is no documentation of it being charged. I got a call from [CONDITION(S)] yesterday and put an order in to charge it yesterday. There was never an order to charge it before. The order should have been in place to monitor it each shift, but they weren't documenting it. The first time they told me about it was yesterday. The [CONDITION(S)] director called and said the last couple of times he was there the battery wasn't charged. She said he had a syncopal ([CONDITION(S)] or passing out) episode, he's unresponsive, was sent to the hospital and we need to send an extra battery or charger. We had a charger. The nurses said they were checking it, but they were never given an order in the computer for them to sign off on it. There was no order for the life vest. Dr. D is his Cardiologist. What the nurses said is it (life vest) came from Dr. D's office. In an interview on 12/02/2021 at 4:39 PM, the DON stated she had not been able to in-service all the nurses regarding care of a resident with a life vest. She also stated she did not in-service the CNAs on the care of a resident with a life vest. She stated, I found out about Resident #1's life vest sometime in August and I went down and looked at the device to make sure it was functioning properly. I talked to the nurses and to make sure they knew he had it. At the time he was charging the battery himself. I did not talk to the CNAs. I should have spoken to the CNAs to listen for the alarm and notify the nurse because they were assisting him of bathing. By the time I found out about the life vest I was under the impression the CNAs were aware because they were working directly under the nurses. It ultimately falls under me . It was not documented, it was informal. They should have been signing off on it in the computer, on the MARs/TARs that it was being monitor. The nurse who was here when he got the life vest should have put the order in computer. I assume the nurses was signing off on it, that is our policy to sign off on it. I assume if there is an order it should be monitored. I should not have assumed I guess because a Life Vest is a defibrillator to regulate the heart if there is a problem. If it was not charged it wouldn't work. If it is not monitored you will not know if it is working. If it is not documented it is not done. In an interview on 11/17/2021 at 1:10 PM, the Administrator stated, Nurses should notify the attending Dr. and let the DON and the MDS nurse know about it. If they don't know how to operate it or charge it there should have been an in-service. Review of facility's in-service dated 11/18/2021 titled external Life-sustaining equipment reflected there were Five (5) out of twelve (12) nurses and zero (0) out of twenty-two (22) CNAs in-serviced on how to monitor and document on a resident with a Life Vest. All nursing staff were not trained on nursing implications regarding Life Vest maintenance. Review of an undated facility policy titled Life Vest Policy and Procedure reflected: -the facility is to monitor the placement of a Life Vest in applicable residents to ensure compliance and safety of the resident. -to maintain functionality of the life vest, the battery will be charged daily and the nurse will ensure that the life vest is on and functioning each shift. -To maintain compliance, the nurse will sign the TAR each shift indicating such. -The life vest will be monitored on each shift and as needed to make sure that the Life Vest is appropriately donned. -The garment is to be worn all day except when bathing and showering. Review of an undated facility Change of condition Policy and Procedure reflected Purpose: To ensure the person's involved in the resident care are made aware of any changes to the resident. The Charge Nurse shall be responsible for notifying the attendant physician when a change occurs. These changes shall include significant changes in the physical, mental or psychosocial status and or the addition of new orders including changes to existing orders. An Immediate Jeopardy was identified on 12/03/2021 at 6:31 PM, due to the above failures. The Administrator was notified of the Immediate Jeopardy and the IJ template was provided on 12/03/2021 at 6:31 PM. The Administrator expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. The Plan of Removal was accepted on 12/04/2021 at 12:24 PM Record review of the facility's Plan of Removal reflected the following: Plan of Removal for Legacy Health and Rehabilitation 12.6.21 QUALITY OF CARE 1. On December 3, 2021, administrative nurses in-serviced nursing staff present at the facility and called nursing staff at home to in-service on the standards of practice for the quality of care regarding life-vest monitoring, charging batteries, maintenance of life-vest, precautions and implications related to safety for direct care staff that may be present when the response button on the life vest is activated. This button should only be activated by the resident. Staff was educated on the importance of not touching the resident when there are loud two-tone sirens broadcasting from the life vest WCD as the resident may be in the process of being shocked and they can be shocked if they are touching the resident. In-service started on 12.3.21 and will be completed on 12.4.21. On-going in-services will continue for future nursing employees during orientation. On 12.3.21 DON and ADON both were in-serviced from corporate nurse on standards of practice and quality of care for monitoring the life-vest. Administrator was in-serviced by corporate nurse on 12.6.21. 2. Charge Nurse Will document resident's status prior to their leaving the facility. By having this system in place it shall ensure prevention of this deficient practice from recurring. Documentation shall include a check list for mechanical devices specifically for each individual resident leaving the facility. This check list will be signed by the transportation driver and the assigned nurse prior to the resident leaving the building for his or her appointment. This binder will be kept at the nurse's station in addition to this practice beginning on Monday 12.6.21 as no appointments are scheduled on 12.5.21. DON in-serviced all charge nurses and transportation driver on 12.4.2021. On 12.3.21 DON and ADON both were in-serviced by corporate Nurse on this process. On 12.6.21 Administrator was in-serviced by corporate nurse on new process. 3. ADON will audit documentation via electronic signage in the resident's electronic chart for residents with external equipment. This process will begin on 12.4.21. DON or ADON along with MDS will meet with charge nurses daily during the clinical meeting to review orders from previous day and care plan as needed. To ensure failure to initiate an order does not occur again: DON or designee will audit daily new orders three times a week beginning 12.4.21. 4. Procedures for implementing: Revision of the policy and procedure for life vest, This is a change to the current policy revised and dated on 12.3.21, The DON and administrative RNs delivered the in-services. The policy was revised to reflect information on activation, safety precautions for individuals in the presence of the resident when the life vest is activated and monitoring for proper donning and care of the life vest garment as the previous policy did not have this information. Quarterly education/training and in-services regarding monitoring, care/function and education related to the life-vest will be implemented by the DON, ADON and administrative nurses. DON will ensure compliance; this will begin on 12.3.21. On-going training will take place for new hires during orientation and in the event that a life vest is initiated for a resident. On 12.3.2021 charge nurses were in-serviced regarding communicating orders to DON and Responsible party when life sustaining equipment such as a life-vest is initiated. DON reviewed educational information and training videos on the [NAME] Medical website regarding use, care and managing life vest (WCD). The effective date of revision of the existing policy is 12.3.21. We currently do not have any residents with a life-vest. In the event that a resident is admitted with a life vest, a review of the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON will ensure compliance. 5. Completion date: 12.6.21 6. DON reviewed concerns with facility Medical Director and completed fishbone/ root cause analysis on 12.4.2021 DON and or ADON will continue to in-service staff regarding the policy and procedure for residents with a life-vest each time a life vest is initiated for a resident. DON monitor this process on an on-going basis for quality assurance. In-services for direct care staff began 12.3.21 and were completed 12.4.21 at approximately 2015 hours. 7. Administrator will be responsible for POR. Resident neglect: 1. Immediate action during survey: A. In-service the nursing staff present at facility and staff at home over the phone started on 12.3.21, completion date 12.4.21. Ongoing training and in-servicing will be provided for new nursing employees during orientation. On 12.3.21 DON and ADON were both in-serviced from corporate nurse and on 12.6.21 corporate nurse in-serviced administrator over the phone. Abuse and Neglect Importance of life-vest How to charge life-vest How to care for and monitor life-vest Communication of new orders Documentation of new orders Entering new orders 2. Long term actions to prevent deficient practice from recurring: A. Will perform quarterly competency check offs and in-service staff beginning 12.3.21 with competency check off when a life-vest initiated. DON or designee will be responsible for competency check offs. We currently do not have a patient with a life-vest. We will perform a verbal competency, in the event we receive an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Monitoring and caring for life-vest, charging of batteries Communication and documentation of new orders and entering orders. 3. Plan for improving process A. Will monitor placement and proper functioning of life-vest including charging of batteries each shift. Monitoring will be documented each shift. DON or designee will ensure orders are entered when a life vest is initiated. This will start on the day the life vest is place (unable to give a start date because no one has a life vest) DON or designee will monitor compliance. DON and ADON will review NMAR and progress notes of any resident that receives a life vest to ensure assigned nurses are documenting their monitoring of the vest each shift, this will begin the day the life vest is placed B. Will QAPI immediately and quarterly when life-vest is present and in use. Addressed with medical director and fishbone/ root cause analysis completed. This included how to monitor life-vest and pre-cautions related to individuals wearing a life-vest. C. In-service quarterly and as needed. DON or administrative nurse will complete in-services. DON will ensure compliance. Educating all nursing staff regarding the use, monitoring, removal, cleaning, and activation of life-vest, in addition to charging of the battery and spare battery daily. Educating resident and staff regarding the safety and use of response button. 4. Procedure for implementing and monitoring In the event that a life vest is in use, the DON or designee will perform weekly audits in MAR to ensure documentation and monitoring is in place. This will start upon admission of a resident with a life-vest. We currently do not have a patient with a life-vest. 5. Administrator responsible for POR 6. Date of completion 12.6.21 Monitoring of the plan of removal was completed from 12/4/2021 through 12/6/2021. Interviews with LVN P, CMA Q, LVN N and LVN R all reflected they had been educated regarding the life vest. They stated they knew not to touch the life vest if the alarm was sounding as it would mean the resident was being shocked. They stated the nurses were in charge of confirming the safety and functionality of the life vest at least once per shift. They stated they were educated to check the batteries to ensure they were charged at least once per shift. They stated these checks by CNAs and LVNs were documented in the EMR. In an interview on 12/4/2021 at 6:00 PM, the DON stated she had completed the in-services with the staff regarding the monitoring and safety checks for the life vest. She stated if a resident was admitted /readmitted with a life vest the orders would be entered into the EMR by herself or the ADON and all staff would be notified. She stated it would also be discussed at the daily stand up meeting. In an interview on 12/6/2021at 9:40 AM, the ADM stated there was not a resident currently at the facility using a life vest. She stated all staff were in serviced as well as herself and the DON on the care of the life vest, safety precautions and monitoring of residents who were required to wear one. Review of facility's Outgoing Binder, undated kept at the nurses' station reflected an additional checklist for residents with mechanical devices to be reviewed prior to a resident leaving the facility. Review of facility's Life Vest policy revised 12/3/2021 reflected instructions, care and monitoring of the life vest. On 12/6/2021 at 12:24 PM, the administrator was notified that the IJ was removed. However, the facility remained out of compliance at a severity level of no actual harm that is not immediate jeopardy with a scope of isolated due to the facility need to evaluate the effectiveness of the corrective system.

Based on observation, interviews and records review the facility failed to prevent infection for 40 of 84 Residents reviewed for Infection Control and exposure to Covid-19. The facility failed to designate staff for each cohort of Residents Hot (tested positive for infection), Warm (on Isolation precautions) and Cold (Residents who tested negative and displayed no signs or symptoms of infection) zones. Staff were observed working in both the warm and cold areas. The facility failed to appropriately screen essential caregivers on entry. The facility failed to ensure PPE was utilized correctly in Isolation rooms by having isolation gowns hanging in isolation rooms with the doors open and used gowns on the floor of resident rooms. The facility failed to ensure high touch areas were cleaned frequently and with the appropriate sanitizing agent. An Immediate Jeopardy was identified on [DATE] at 5:30 PM. While the IJ was lowered on [DATE] at 12:00 PM the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not IJ identified as pattern due to the facility's need to evaluate the effectiveness of their Plan of Removal. The facility was provided the IJ Template on [DATE]. These failures placed residents at risk of exposure to COVID 19, which could result in illness, hospitalization and death. Findings include: In an interview on [DATE] at 8:42 am the Administrator A stated the facility continued weekly COVID-19 testing she stated on [DATE] a total of 14 Residents and four staff tested positive for COVID. The Administrator stated another eight Residents tested positive on [DATE]. Three of those had recovered and one recovered and was discharged home. For a total 19 Residents still considered positive in the facility. On [DATE] at 9:20 am observation of 400 Hall revealed five Residents were on Droplet precautions and full PPE was needed to enter the room. These Residents received care from staff who also provided care to negative Residents not on droplet precautions. On [DATE] at 9:23 am observation of 100 Hall revealed seven Residents were on Droplet precautions and required full PPE to enter the rooms. These Residents received care from staff who also provided care to negative Residents not on droplet precautions. On [DATE] at 9:30 am observation of 200 Hall revealed three Residents were on Droplet precautions and required full PPE to enter the rooms. These Residents received care from staff who also provided care to negative Residents not on droplet precautions. On [DATE] at 9:35 am observation of the front entrance of 300 hall revealed a plastic barrier was in place and notices were posted reflecting no entry was allowed at this time. In an interview on [DATE] at 3:40 p.m. Resident #2 stated she felt fine. She was observed to have oxygen in place via nasal cannula at 2 L/min. Resident #2 stated she sometimes feels short of breath when she coughs. Resident #2 passed away in hospital on [DATE] and had tested positive for COVID-19. In an interview on [DATE] at 11:45 am the Administrator stated the facility had closed up the majority of Hall 200 as a second COVID Isolation Unit. She stated after testing on Monday [DATE] more Residents were identified as positive. The Resident total for Positives was now 36. Total in Hospital was now 5. One Resident had died - Resident #15 who was receiving hospice care and who was positive for COVID-19. Two more staff members were now positive. In an interview on [DATE] at 2:35 p.m. the Administrator A stated the facility had attempted to contact trace the COVID-19 positive staff and Residents, but were unable to pinpoint a source. Administrator A stated the first positive reported was a staff member (LVN E) on [DATE]. She stated the first Positive Resident was #12 on [DATE], she stated the incident was over 7 days apart. Administrator A stated RN G also reported a positive test on [DATE] but was outside the facility on vacation at the time, believed last in facility on ,[DATE] or ,[DATE]. The Administrator stated the next identified Positive tests were received on [DATE]. She stated 8 Residents were positive for COVID-19 and no staff. She stated on [DATE] a total of 14 additional Residents tested positive. Four staff at the facility tested positive and one who had been on Rehab leave tested positive. Review of screening logs dated [DATE] and [DATE] reflected temperature and symptoms were not recorded for five essential caregiver. During an interview on [DATE] at 12:34 p.m., SCR C stated he knew the visitors were screened and did not have a fever because he screened them and just didn't write it down. He could not remember what the actual temperature was. He stated he knew that they were supposed to write in the temperature and answer the symptoms questions themselves but did not do so. Observation on [DATE] at 12:39 p.m. revealed half of the 300 hall was behind plastic sheeting and had been converted to a COVID-19 unit. The other half was a mix of rooms housing residents on droplet precautions (Warm Zone) and those not (Cold Zone). All doors on hall 300 were open, regardless of whether there were droplet precautions signs on the doors of the rooms. Disposable isolation gowns were seen hanging near the doors, inside of the rooms (rooms 304 Resident #23, 305 Resident #24, and 306 Resident #25), with droplet precautions signs on them. There was an isolation gown on the floor of room [ROOM NUMBER] Resident #22 (Warm Zone). During an interview on [DATE] at 12:50 p.m., CNA R stated she doesn't know where to find the posters to indicate that residents are on droplet precautions, but she had asked the HKS for them. She stated that the residents on Hall 300 who are on droplet precautions are on them due to having roommates who tested positive for COVID-19. Observation on [DATE] at 1:06 p.m. revealed that hall 100 was a mix of rooms housing residents on droplet precautions (Warm Zone) and those not (Cold Zone). All doors on hall 100 were open, regardless of whether there were droplet precautions signs on the doors of the rooms. The following rooms of residents on droplet precautions were observed open: 105 (Resident #7), 112 (Resident #9), 114 (Resident #16), 116 (Resident #8), and 117 (Resident #13). Observation on [DATE] at 1:37 p.m. revealed CNA Q helping Resident #12 into bathroom, wearing a face shield, N95 mask, and gloves. CNA Q helped Resident #12 to the bathroom and onto the toilet, and she then exited his bathroom and went across the hall wearing the same gloves into another resident's bathroom to assist the LVN J, who was already in with the resident. CNA Q touched several surfaces, including the bathroom doorknob, the sink counter, and a package of disposable wipes, which she handed to LVN J. Without changing gloves, she then re-entered Resident #12's bathroom, assisted him into a chair in his room, and began pulling sheets off of his bed. She emptied his bathroom trash can and bagged a soiled brief and wipes, carried the soiled linens in one bag and the soiled trash in another, and disposed of them both in the soiled linens closet. Only then did she doff her gloves and perform hand hygiene. Observation on [DATE] at 2:17 p.m. revealed a HK staff member was cleaning room [ROOM NUMBER], a room indicated to have a resident on droplet precautions. She was observed working without wearing a gown or gloves. Observation revealed was a gown on her cart outside the room. The ADM walked by and spoke to this HK but did not mention the isolation precautions or the lack of PPE use in the room. The HK then swept the floor in the doorway and just outside of room [ROOM NUMBER], replaced her broom and dustpan without sanitizing it, and washed her hands in the resident sink for exactly six seconds. She then donned gloves and entered another resident room that did not have droplet precaution status [REDACTED]. Observation in the courtyard on [DATE] at 2:35 p.m. revealed that CNA T exited the 300 hall COVID isolation unit into the courtyard in full PPE (Tyvek jumpsuit, shoe covers, head cover, N95 mask, and face shield) and purchased a soda from the vending machine that is right outside of the non-COVID portion of the 300 hall. During an interview on [DATE] at 2:35 p.m., CNA T stated she had exited the isolation unit to use the machine before and that a couple of the other staff members from the isolation unit also occasionally come out and use the vending machine. In an interview on [DATE] at 2:53 p.m. the DON stated she saw the staff from the COVID unit come out and use the vending machine, and that is big no-no. She stated that the staff should be disinfecting high touch surfaces such as doorknobs, hand rails, and computers once an hour if they can. She stated that they are supposed to use the yellow disinfectant in spray bottles and the purple-topped wiipes for this. She stated that the resident doors on isolation should be closed if the residents will allow it. She stated she went through closing the doors and some residents yelled, and so she cracked open these doors but ensured the doors of those residents who did not mind them being closed were closed. During an interview on [DATE] at 1:08 p.m., Resident #8 stated that he did not care if his door was open or shut. During an interview on [DATE] at 1:11 p.m., Resident #16 stated that she did not prefer her door open and would be fine with it shut. Observation on [DATE] at 3:00 p.m. revealed room [ROOM NUMBER] on isolation precautions Resident #8's door is still open said it doesn't make any difference to him if his door is closed or open. All isolation doors on Hall 100 seen still open. Observation on [DATE] at 3:04 p.m. revealed no spray bottles of disinfectant visible anywhere on the halls. There was one canister of purple topped wipes at the nurse's station that had some wipes left in it. Another canister was sitting on the top of an isolation PPE cart outside the room of a resident on 200 hall with droplet precautions in place. That canister was completely empty. In an interview on [DATE] at 3:04 p.m. LVN J stated she was the charge nurse for the 100 hall, but she was from a staffing agency and did not normally work at the facility. She stated she had been looking for more wipes and didn't know where the disinfecting spray was. In an interview on [DATE] at 3:07 p.m. a surveyor asked DON where they keep the yellow spray for disinfecting, DON said she would have to ask the nurse where they keep the yellow spray, when told that the nurse didn't know about the yellow spray, she said that they usually use the purple top wipes, and yellow spray is more for housekeeping. When asked where the purple topped wipes are kept, she said in the administrator's office. When asked how staff gets them during the weekends, she stated she makes sure they are stocked before she leaves for the weekend. When asked to ensure all wipes are restocked, it was observed the DON could not find a key to unlock at least three carts. Observation on [DATE] from 12:35 p.m. to 3:55 p.m. revealed no high touch surface disinfection was conducted on Hall 100 during the observation period. During an interview on [DATE] at 3:15 p.m., when LVN K was asked what she was using to disinfect her equipment if the purple top wipes were unavailable, she said she had the personal disinfecting wipes. Asked to see the personal disinfectant, she stated they were in her bag (which was behind the counter at the nurses' station down the hall). She retrieved a canister of name brand disinfecting wipes with ammonium chloride as the active ingredient. Observation on [DATE] at 4:02 p.m. revealed CNA AA went into room [ROOM NUMBER] (Resident #9), the door of which indicated droplet precautions, without donning a face shield, gown, or gloves. The CNA AA gave Resident #9 a pair of scissors, washed her hands for exactly four seconds, and cleaned up the sink counter. She then turned back to the resident, bent over her, and assisted her with something in her lap that was out of view. CNA AA then asked CNA Q if she needed help, and CNA Q said she needed help to reposition a resident. CNA AA went into the other resident's room and closed the door without donning gloves or performing hand hygiene prior to entering. In an interview on [DATE] at 4:15 p.m. LVN I stated she does not ask residents to wear a mask while providing care and asked if she should. In an interview on [DATE] at 4:18 p.m. Med Aide U stated she doesn't have any screening she needs to do now. The nurses do the COVID screening; she just does vitals. She uses the bleach wipes on the portable vital sign machine. She doesn't know the exact dry time. Reading the canister, she determines the dry time for all organisms is three minutes. She stated if she's being honest she can't wait three minutes for the dry time on the bleach wipes in between each resident and still stay caught up with her work. She has never discussed this with her supervisors. In an interview on [DATE] at 4:25 p.m. the DON stated they are not asking residents to mask up during care. She stated they monitor for COVID signs each shift, and there are two shifts, so they monitor twice a day. She stated that seems like enough. She stated she does have the emergency rules for nursing facilities. Observation on [DATE] at 4:30 p.m. revealed the following on the COVID unit: outside 300 hall there is no PPE station. CNA T comes out and grants entrance. She says she is restocking the PPE and points out hand hygiene on the pillar just on the inside of the door. CNA T walks the surveyor across the lobby in between Halls 300 and 400 just past the rehab gym and says this is how we get back and forth between the halls, we do not have to go around. Other staff observed walking through the pathway. As the surveyor entered a large room where all staff are congregated with medications and supplies were observed on the table. A plastic sheeting with zipper goes into resident hall. PPE donning station observed on the outside of end of hall door with no hand hygiene opportunity. No hand hygiene was observed inside the door anywhere. LVN N confirmed that there was no hand hygiene opportunity available at the doffing area and stated she would go find some. Observation revealed the doffing is just a couple barrels at the end of the hallway right inside the door. No specific doffing station was observed. Review of staffing sheets for the facility reflected that CNA W was scheduled in the hall 300 covid unit for the first four hours of the evening shift on [DATE] and in hall 100 for the second four hours of that shift. In an interview on [DATE] at 8:20 am, CNA W stated on [DATE] he worked COVID unit (on Hall 300), and then ,[DATE] he worked Hall 100 (the Cold or negative Unit), and then after that he has worked COVID ever since. CNA W stated it was his opinion the Covid infections started happening right after they started letting visitors in the building a couple at a time. He stated Resident #12 (first positive resident) didn't have visitors but he often had treats (packaged snacks from outside the facility) delivered by his family members. Observations on [DATE] at 12:15 p.m. of the Hall 400 COVID-19 Isolation unit revealed the majority of doors on the hall were open, rooms 400, 402, 404, 411, 413, 414 and other were observed to be open. In an interview on [DATE] at 5:30 p.m. Acting Administrator B was notified an IJ/Immediate Jeopardy situation existed due to above failures. The Acting Administrator was given a copy of the IJ template and a POR was requested. The first POR was submitted [DATE] at 2:49 PM and was not accepted. The final accepted POR was submitted [DATE] at 9:52 AM. Review of Infection Control Policies and Procedures dated [DATE] reflected the facility goal was to establish a safe and sanitary environment to prevent the development and transmission of communicable disease and infections (both Nosocomial and Community acquired). The three page document did not refer specifically to COVID-19. Review of the COVID-19 Policy and Procedures received on [DATE] from the administrator reflected the facility policy was to follow State Department of Health guidelines related to COVID-19. The policy included screening of all who enter, Hand Hygiene, face masks, social distancing, signage and cleaning and frequently disinfecting high traffic surfaces (such as counters and handrails). The POR was as follows: Legacy Nursing and Rehabilitation Plan of Correction [DATE] We were notified of the IJ on [DATE] at 5:30pm. 1. Infection Control - Staff and residents that have been exposed to a positive or suspected positive person will be quarantined according to CDC recommendations. Residents under quarantine will be established in a designated area of the facility with dedicated staff to provide care. We have adjusted staff assignments effective [DATE] to represent this change. Staff will continue to be screened upon entry of the facility. Any staff indicating exposure will be sent home to quarantine according to the latest CDC recommendations. This practice is currently in effect. Staff will encourage residents to keep their doors closed throughout the facility, particularly on the Warm and Hot zone areas. The Administrator and DON will instruct the administrative nurses and charge nurses to address this matter with floor staff as well as residents to keep doors closed. Staff were instructed on [DATE] regarding this matter. The Charge Nurses will monitor this matter upon making rounds on their respective halls. The electronic monitoring assessments were adjusted to que nurses to check resident temperatures and monitor for signs/symptoms of COVID residents three times per day. This que was implemented on [DATE] by the DON and is currently in effect. 2. Cohorting of Residents - Legacy has designated three zones within the facility. The Hot Zone is our COVID Unit for active positive residents. The Warm Zone is for residents under quarantine due to potential exposure, being out the hospital or new admission. The Cold Zone is for residents that have tested negative and remain asymptomatic. Completed [DATE]. We have designated staff working in each of these zones for consistency and continuity. Staff are directed to work within their zone during their entire shift. Completed [DATE]. The Staffing Coordinator will complete the staffing assignments for each shift according to the zones established within the facility. The Administrator and DON or their designee will monitor these assignment sheets daily to ensure compliance. This process was implemented [DATE]. 3. Handwashing and Other Infection Control matters - The DON, Housekeeping Supervisor provided additional training on [DATE] to droplet precautions including donning / doffing PPE, hand washing, disinfection product utilization and set times. The training information and materials were provided by our Corporate Nurse via policy and procedure based on CDC, CMS and HHSC requirements and recommendations. Housekeeping information was based on manufacturer recommendations. Staff competencies related these items will be conducted and documented for all present staff on [DATE] by the DON and ADON. Remaining active staff will complete competencies upon returning to work for their next rotation and as part of the new hire orientation process by the DON, ADON or administrative nurse designee. Hand sanitizing stations are setup at the entrance of 400 Hall along with a hand washing station in the safe zone. Staff are directed to sanitize, don PPE, enter safe zone and wash hands. This was completed [DATE]. The Charge Nurses working the COVID unit were educated on this practice and signs have been posted with these directions. The Administrator, DON or their designee will periodically monitor the entrance at shift change to ensure adherence to this practice. Hard surface and high traffic areas are disinfected at least three times per day (morning, afternoon, evening/night). Please see the attached log to be used to document cleaning times. While housekeeping has been cleaning these surfaces multiple times per day, we implemented the form to document these times on [DATE]. The Housekeeping Supervisor will monitor the forms daily and maintain a copy for review consistent with the QA program. 4. Actions of the Facility - The facility will implement a Quality Assurance Program to monitor and ensure the implementation of the items listed above for a period of six weeks. Implemented [DATE] for six weeks ([DATE]). The Administrator and Director of Nursing or designated supervisor will review staffing assignments for proper assignment given the Zones determined within the facility daily for a period of 6 weeks. Residents room assignment will be reviewed and discussed daily to ensure proper assignment according to the dedicate Zone. The Housekeeping Supervisor will provide a copy of the cleaning log to the Administrator, Director of Nursing or designee daily for monitoring and collection for QA. Hand hygiene and PPE application will be monitored by DON, ADON and designated administrative nurses at least once daily on various shifts as part of the QA. Monitoring for the POR began on [DATE] at 8:15 am. Observation of the facility on [DATE] at 8:15 am revealed adequate staffing was in place for Cold, Warm and Hot zones at the facility. The administrator stated a total of 23 Residents positive for Covid-19 were now in the Isolation units. He stated 32 Residents had recovered from Covid-19 on [DATE] and had been moved to the negative unit on Hall 100. Observation of the facility on [DATE] at 8:25 am revealed all residents were moved off 300 Hall and the Hot Zone remained on 400 Hall. A Warm Zone was in operation with designated staff on 200 Hall. Observation of 100 Hall revealed no Residents on Isolation or Droplet precautions. In an interview on [DATE] at 8:40 the DON stated staff had been inserviced on Staffing assignments (copy of schedule provided), Housekeeping logs (copy of monitoring log provided), and inservice and skills checkoffs for Handwashing were completed by DON. The DON stated she would be monitoring PPE useage and conducting spot checks daily and provided a report form to be utilized when other designated staff conducted spot checks. In an interview on [DATE] at 8:45 am LVN E stated she had been inserviced on Policy changes by the DON. She stated she had been provided a choice of N95 masks (after a skin reaction to green N95), she stated she had been asked to demonstrate skills such as donning and doffing PPE and handwashing. LVN E stated she had been educated on reinforcing handwashing for Residents. LVN E was observed obtaining PPE supplies from a supply station on Hall 200, sanitizing her hands and donning the PPE in the correct order. In an interview on [DATE] at 8:55 am CNA R stated she had been inserviced on Policy updates for Covid-19, separation of Warm, Cold, and Hot Residents, Handwashing and PPE. She stated she had performed a skills check off for Donning and Doffing and Hand washing. She stated all staff had been asked to reinforce handwashing with Residents. CNA R was observed washing her hands, donning PPE in the correct order on Hall 200. CNA R was observed disposing of PPE in the red disposal bin before exiting room [ROOM NUMBER]. In an interview on [DATE] at 10:25 am RN D stated she had received updated education on facility policies for PPE, Infection Control and Covid-19. RN D stated she was an agency nurse and felt she had been given a good orientation to working on 400 Hall the Covid positive unit. Review of Updated Policies for Infection Control dated [DATE] reflected dedicated staff were scheduled for each Cohort of Residents, Cold/Negative, Warm/unknown status and Hot/Covid-19 positive. Staffing changes effective on [DATE]. Policy on screening staff as they enter the facility reflected the screener must monitor to ensure all questions are answered and instruct staff to complete all questions. The DON was to conduct spot checks for accuracy. While the IJ was lowered on [DATE] at 12:00 PM the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not IJ identified as pattern due to the facility's need to evaluate the effectiveness of their Plan of Removal.

Based on observation, interviews and records review the facility failed to prevent infection for 40 Residents reviewed for Infection Control. The facility failed to designate staff for each cohort of Residents Hot (tested positive for infection), Warm (on Isolation precautions) and Cold (Residents who tested negative and displayed no signs or symptoms of infection) zones. Staff were observed working in both the warm and cold areas. The facility failed to appropriately screen essential caregivers on entry. The facility failed to store and dispose of PPE appropriately by having isolation gowns hanging in isolation rooms with the doors open and used gowns on the floor of resident rooms and to ensure staff wore PPE in the isolation rooms. The facility failed to ensure high touch areas were cleaned frequently and with the appropriate sanitizing agent. An Immediate Jeopardy was identified on [DATE] at 5:30 PM. While the IJ was lowered on [DATE] at 12:00 PM the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not IJ identified as pattern due to the facility's need to evaluate the effectiveness of their Plan of Removal. the facility was provided the IJ Template on [DATE]. These failures placed residents at risk of exposure to COVID 19, which could result in illness, hospitalization and death. Findings include: In an interview on [DATE] at 8:42 am the Administrator A stated the facility continued weekly COVID-19 testing she stated on [DATE] a total of 14 Residents and 4 staff tested positive for COVID. The Administrator stated another 8 Residents tested positive on [DATE]. Three of those had recovered and one recovered and was discharged home. For a total 19 Residents still considered positive in the facility. On [DATE] at 9:20 am observation of 400 Hall revealed five Residents were on Droplet precautions and full PPE was needed to enter the room. These Residents received care from staff who also provided care to negative Residents not on droplet precautions. On [DATE] at 9:23 am observation of 100 Hall revealed seven Residents were on Droplet precautions and required full PPE to enter the rooms. These Residents received care from staff who also provided care to negative Residents not on droplet precautions. On [DATE] at 9:30 am observation of 200 Hall revealed three Residents were on Droplet precautions and required full PPE to enter the rooms. These Residents received care from staff who also provided care to negative Residents not on droplet precautions. On [DATE] at 9:35 am observation of the front entrance of 300 hall revealed a plastic barrier was in place and notices were posted reflecting no entry was allowed at this time. In an interview on [DATE] at 3:40 p.m. Resident #2 stated she felt fine. She was observed to have oxygen in place via nasal cannula at 2 L/min. Resident #2 stated she sometimes feels short of breath when she coughs. Resident #2 passed away in hospital on [DATE] and had tested positive for COVID-19. In an interview on [DATE] at 11:45 am the Administrator stated the facility had closed up the majority of Hall 200 as a second COVID Isolation Unit. She stated after testing on Monday [DATE] more Residents were identified as positive. The Resident total for Positives was now 36. Total in Hospital was now 5. One Resident had died - Resident #15 who was receiving hospice care and who was positive for COVID-19. Two more staff members were now positive. In an interview on [DATE] at 2:25 p.m. the Medical Director stated they have re-organized things. 400 Hall now COVID isolation with 32 Residents 300 Hall terminally cleaned and disinfected by disinfection sprayer -hall 300 had one resident under observation she has tested negative twice. 100 hall had some residents under observation, the Medical Director stated all have tested negative, she stated one was a new admission. Hall 200 had some Residents before quarantine barrier, past a set of double doors (the former quarantine area) is locked and cleaning is continuing right now, no Residents past double doors. In an interview on [DATE] at 2:35 p.m. the Administrator A stated the facility had attempted to contact trace the COVID-19 positive staff and Residents, but were unable to pinpoint a source. Administrator A stated the first positive reported was a staff member (LVN E) on [DATE]. She stated the first Positive Resident was #12 on [DATE], she stated the incident was over 7 days apart. Administrator A stated RN G also reported a positive test on [DATE] but was outside the facility on vacation at the time, believed last in facility on ,[DATE] or ,[DATE]. The Administrator stated the next identified Positive tests were received on [DATE]. She stated 8 Residents were positive for COVID-19 and no staff. She stated on [DATE] a total of 14 additional Residents tested positive. Four staff at the facility tested positive and one who had been on Rehab leave tested positive. In an interview on [DATE] at 2:40 p.m. the Medical Director stated all Residents have been reviewed for appropriate placement in Hot, Warm and Cold zones. She stated all Residents housed in isolation had positive test results for COVID-19. She stated the remaining Residents housed in the facility could all be considered Cold as all had tested negative for COVID-19. She stated the Residents under observation were quarantined in their rooms per guidance for hospital visits or new admissions but were negative in repeated testing for COVID-19. Review of screening logs dated [DATE] and [DATE] reflected temperature and symptoms were not recorded for five essential caregiver. During an interview on [DATE] at 12:34 p.m., SCR C stated he knew the visitors were screened and did not have a fever because he screened them and just didn't write it down. He could not remember what the actual temperature was. He stated he knew that they were supposed to write in the temperature and answer the symptoms questions themselves but did not do so. Observation on [DATE] at 12:39 p.m. revealed half of the 300 hall was behind plastic sheeting and had been converted to a COVID-19 unit. The other half was a mix of rooms housing residents on droplet precautions (Warm Zone) and those not (Cold Zone). All doors on hall 300 were open, regardless of whether there were droplet precautions signs on the doors of the rooms. Disposable isolation gowns were seen hanging near the doors, inside of the rooms, with droplet precautions signs on them. There was an isolation gown on the floor of room [ROOM NUMBER] (Warm Zone). During an interview on [DATE] at 12:50 p.m., CNA R stated she doesn't know where to find the posters to indicate that residents are on droplet precautions, but she had asked the HKS for them. She stated that the residents on this hall who are on droplet precautions are on them due to having roommates who tested positive for COVID-19. Observation on [DATE] at 1:06 p.m. revealed that hall 100 was a mix of rooms housing residents on droplet precautions (Warm Zone) and those not (Cold Zone). All doors on hall 100 were open, regardless of whether there were droplet precautions signs on the doors of the rooms. The following rooms of residents on droplet precautions were observed open: 105 (Resident #7), 112 (Resident #9), 114 (Resident #16), 116 (Resident #8), and 117 (Resident #13). During an interview on [DATE] at 1:08 p.m., Resident #8 stated that he did not care if his door was open or shut. During an interview on [DATE] at 1:11 p.m., Resident #16 stated that she did not prefer her door open and would be fine with it shut. Observation on [DATE] at 1:37 p.m. revealed CNA Q helping Resident #12 into bathroom, wearing a face shield, N95 mask, and gloves. CNA Q helped Resident #12 to the bathroom and onto the toilet, and she then exited his bathroom and went across the hall wearing the same gloves into another resident's bathroom to assist the LVN J, who was already in with the resident. She touched several surfaces, including the bathroom doorknob, the sink counter, and a package of disposable wipes, which she handed to LVN J. Without changing gloves, she then re-entered Resident #12's bathroom, assisted him into a chair in his room, and began pulling sheets off of his bed. She emptied his bathroom trash can and bagged a soiled brief and wipes, carried the soiled linens in one bag and the soiled trash in another, and disposed of them both in the soiled linens closet. Only then did she doff her gloves and perform hand hygiene. Observation on [DATE] at 1:42 p.m. revealed LVN J sets up Resident #12, washes hands. She was observed helping resident wash her hands and coaches for quite some time. LVN J was observed using her jacket to grab door handle. LVN J was observed adjusting her mask and N95 was not over her chin. Observation on [DATE] at 2:17 p.m. revealed a HK staff member was cleaning room [ROOM NUMBER], a room indicated to have a resident on droplet precautions. She was observed working without wearing a gown or gloves. Observation revealed was a gown on her cart outside the room. The ADM walked by and spoke to this HK but did not mention the isolation precautions or the lack of PPE use in the room. The HK then swept the floor in the doorway and just outside of room [ROOM NUMBER], replaced her broom and dustpan without sanitizing it, and washed her hands in the resident sink for exactly six seconds. She then donned gloves and entered another resident room that did not have droplet precaution status [REDACTED]. During an interview on [DATE] at 2:25 p.m., the DON stated that both the 300 and 400 halls were designated for COVID-19 positive residents, and those halls began with the plastic sheeting. She stated she thought that therapy staff were not seeing any residents in the therapy gym, and all therapy is happening in the rooms. Observation in the courtyard on [DATE] at 2:35 p.m. revealed that CNA T exited the 300 hall COVID isolation unit into the courtyard in full PPE (Tyvek jumpsuit, shoe covers, head cover, N95 mask, and face shield) and purchased a soda from the vending machine that is right outside of the non-COVID portion of the 300 hall. During an interview on [DATE] at 2:35 p.m., CNA T stated she has exited the isolation unit to use the machine before and that a couple of the other staff members from the isolation unit also occasionally come out and use the vending machine. In an interview on [DATE] at 2:53 p.m. the DON stated she saw the staff from the COVID unit come out and use the vending machine, and that is big no-no. She stated she is having the vending machine disinfected now. the resident doors on isolation should be closed if the residents will allow it. She stated she went through closing the doors and some residents yelled, and so she cracked these doors. But the other doors should be closed. They do high touch surface cleaning they try to do it hourly. They use the yellow spray bottles and the purple top wipes. Nursing staff use both. Observation on [DATE] at 2:57 p.m. revealed HK staff disinfecting vending machine. Observation on [DATE] at 3:00 p.m. revealed room [ROOM NUMBER] on isolation precautions Resident #8's door is still open said it doesn't make any difference to him if his door is closed or open. All isolation doors on Hall 100 seen still open. Observation on [DATE] at 3:04 p.m. revealed no spray bottles of disinfectant visible anywhere on the halls. There was one canister of purple topped wipes at the nurse's station that had some wipes left in it. Another canister was sitting on the top of an isolation PPE cart outside the room of a resident on 200 hall with droplet precautions in place. That canister was completely empty. In an interview on [DATE] at 3:04 p.m. LVN J stated she was the charge nurse for the 100 hall, but she was from a staffing agency and did not normally work at the facility. She stated she had been looking for more wipes and didn't know where the disinfecting spray was. The staff was unable to demonstrate knowledge of cleaning procedures or location of cleaning supplies. In an interview on [DATE] at 3:07 p.m. a surveyor asked DON where they keep the yellow spray for disinfecting, DON said she would have to ask the nurse where they keep the yellow spray, when told that the nurse didn't know about the yellow spray, she said that they usually use the purple top wipes, and yellow spray is more for housekeeping. When asked where the purple topped wipes are kept, she said in the administrator's office. When asked how staff gets them during the weekends, she stated she makes sure they are stocked before she leaves for the weekend. When asked to ensure all wipes are restocked, it was observed the Administator could not get into at least three carts. Observation on [DATE] at 3:09 pm revealed no high touch surface disinfection had been conducted on 100 Hall. During an interview on [DATE] at 3:15 p.m., when LVN K was asked what she was using to disinfect her equipment if the purple top wipes were unavailable, she said she had the personal disinfecting wipes. Asked to see the personal disinfectant, she stated they were in her bag. She retrieved a canister of name brand disinfecting wipes with ammonium chloride as the active ingredient. Observation on [DATE] at 4:02 p.m. revealed CNA Alpha went into room [ROOM NUMBER] (Resident #9), the door of which indicated droplet precautions, without donning a face shield, gown, or gloves. The CNA Alpha gave Resident #9 a pair of scissors, washed her hands for exactly four seconds, and cleaned up the sink counter. She then turned back to the resident, bent over her, and assisted her with something in her lap that was out of view. CNA Alpha then asked CNA Q if she needed help, and CNA Q said she needed help to reposition a resident. CNA Alpha went into the other resident's room and closed the door without donning gloves or performing hand hygiene prior to entering. In an interview on [DATE] at 4:15 p.m. LVN I She does not ask residents to wear a mask while providing care and asked if she should. In an interview on [DATE] at 4:18 p.m. Med Aide U stated she doesn't have any screening she needs to do now. The nurses do the COVID screening; she just does vitals. She uses the bleach wipes on the portable vital sign machine. She doesn't know the exact dry time. Reading the canister, she determines the dry time for all organisms is three minutes. She stated if she's being honest she can't wait three minutes for the dry time on the bleach wipes in between each resident and still stay caught up with her work. She has never discussed this with her supervisors. In an interview on [DATE] at 4:25 p.m. the DON stated they are not asking residents to mask up during care. She stated they monitor for COVID signs each shift, and there are two shifts, so they monitor twice a day. She stated that seems like enough. She stated she does have the emergency rules for nursing facilities. Observation on [DATE] at 4:30 p.m. revealed the following on the COVID unit: outside 300 hall there is no PPE station. CNA T comes out and grants entrance. She says she is restocking the PPE and points out hand hygiene on the pillar just on the inside of the door. CNA T walks the surveyor across the lobby in between Halls 300 and 400 just past the rehab gym and says this is how we get back and forth between the halls, we do not have to go around. Other staff observed walking through the pathway. As the surveyor entered a large room where all staff are congregated with medications and supplies were observed on the table. A plastic sheeting with zipper goes into resident hall. PPE donning station observed on the outside of end of hall door with no hand hygiene opportunity. No hand hygiene was observed inside the door anywhere. The surveyor asked staff, LVN N if she missed any hand hygiene station, and she stated no she will get some now. Observation revealed the doffing is just a couple barrels at the end of the hallway right inside the door. No specific doffing station was observed. Resident #19 was observed standing in doorway trying to tell LVN N she has a spot on her arm that hurts. It looks like a half moon, dark scab that is slightly red and inflamed around it. She says it hurts. LVN N informed the resident her she is going to get a bandaid. When asked if she has assessed the skin tear or reported it to the NP, she says no. She says it looks like it has been there for a while. When asked if it looked like it needed treatment beyond just a bandaid, she said yes, probably. In an interview on [DATE] at 8:20 am, CNA W stated on [DATE] he worked COVID unit (on Hall 300), and then ,[DATE] he worked Hall 100 (the Cold or negative Unit), and then after that he has worked COVID ever since. CNA W stated it was his opinion the Covid infections started happening right after they started letting visitors in the building a couple at a time. He stated Resident #12 (first positive resident) didn't have visitors but he often had treats (packaged snacks from outside the facility) delivered by his family members. Observations on [DATE] at 12:15 p.m. of the Hall 400 COVID-19 Isolation unit revealed adequate numbers of staff in place. In an interview LVN H stated she felt the one nurse and 4 aides was adequate to provide care for Residents on the Isolation hall. Observation revealed the majority of doors on the hall were open, rooms 400, 402, 404, 411, 413, 414 and other were observed to be open. Cleaning equipment was observed stationed in the hallway. In an interview CNA V stated the staff had been instructed not to leave PPE in the halls by a state surveyor in the facility this weekend. In an interview on [DATE] at 5:30 p.m. Acting Administrator B was notified an IJ/Immediate Jeopardy situation existed due to above failures. The first POR was submitted [DATE] at 2:49 PM and was not accepted. The final accepted POR was submitted [DATE] at 9:52 AM. In an interview on [DATE] at 8:20 am Acting Administrator B stated the facility had re-organized Residents and created Hot, Warm and Cold Zones to appropriately cohort those affected by COVID-19. Administrator B stated the facility had re-educated or in-serviced staff on Infection Control and Donning and Doffing procedures. Observation of the facility on [DATE] at 8:35 am revealed the Hot zones on hall 400 and half of hall 300 remained in place. DON stated the second half of Hall 300 was a Cold Zone housing only negative Residents, she stated two remained on the hall outside the Hot area. DON stated Hall 200 was the warm zone and contained Residents on 14 day quarantine or Isolation precautions. She pointed out the family of one Resident (Resident #23) in room [ROOM NUMBER] had refused to transfer him to another room. DON stated 100 hall was the Cold Zone with all Residents now negative. She stated Residents in room [ROOM NUMBER] (#8) and 117 (#13) had passed the 14 day mark and were coming off quarantine today. DON stated she had designated staff to work in each zone and the staff would not be asked to work in a different area. The DON supplied the schedule of designated staff. Observation on [DATE] at 8:43 am of the entrance to the 400 Hall Hot zone or COVID-Isolation unit (on the exterior of the facility) revealed a gallon jug of hand sanitizer was available at the donning station outside the door. No sink was visible in the area. Observation on [DATE] at 8:47 am of the entrance to the 300 Hall Isolation Unit or Hot Zone (outside the facility) revealed no hand sanitizer or handwashing station was available. Supplies of PPE (gowns, coveralls, face shields, N 95 masks and gloves) were observed. Observation on [DATE] at 9:40 am revealed a member of housekeeping staff was wiping off door handles and railings. In an interview Housekeeper X stated he had been wiping down the hard surfaces every hour or so. He stated he was utilizing the facility supplied disinfectant (a yellow liquid in spray bottle). He stated he sprayed the surfaces, let it dry 6 minutes or more and then wiped the surfaces off. Review of the in-service for Disinfecting sprays (on [DATE]) reflected the yellow spray was to have a drying time of up to 10 minutes Review of Infection Control Policies and Procedures dated [DATE] reflected the facility goal was to establish a safe and sanitary environment to prevent the development and transmission of communicable disease and infections (both Nosocomial and Community acquired). The three page document did not refer specifically to COVID-19. Review of the COVID-19 Policy and Procedures received on [DATE] from the administrator reflected the facility policy was to follow State Department of Health guidelines related to COVID-19. The policy included screening of all who enter, Hand Hygiene, face masks, social distancing, signage and cleaning and frequently disinfecting high traffic surfaces (such as counters and handrails). The POR was as follows: Legacy Nursing and Rehabilitation Plan of Correction [DATE] We were notified of the IJ on [DATE] at 5:30pm. 1. Infection Control - Staff and residents that have been exposed to a positive or suspected positive person will be quarantined according to CDC recommendations. Residents under quarantine will be established in a designated area of the facility with dedicated staff to provide care. We have adjusted staff assignments effective [DATE] to represent this change. Staff will continue to be screened upon entry of the facility. Any staff indicating exposure will be sent home to quarantine according to the latest CDC recommendations. This practice is currently in effect. Staff will encourage residents to keep their doors closed throughout the facility, particularly on the Warm and Hot zone areas. The Administrator and DON will instruct the administrative nurses and charge nurses to address this matter with floor staff as well as residents to keep doors closed. Staff were instructed on [DATE] regarding this matter. The Charge Nurses will monitor this matter upon making rounds on their respective halls. The electronic monitoring assessments were adjusted to que nurses to check resident temperatures and monitor for signs/symptoms of COVID residents three times per day. This que was implemented on [DATE] by the DON and is currently in effect. 2. Cohorting of Residents - Legacy has designated three zones within the facility. The Hot Zone is our COVID Unit for active positive residents. The Warm Zone is for residents under quarantine due to potential exposure, being out the hospital or new admission. The Cold Zone is for residents that have tested negative and remain asymptomatic. Completed [DATE]. We have designated staff working in each of these zones for consistency and continuity. Staff are directed to work within their zone during their entire shift. Completed [DATE]. The Staffing Coordinator will complete the staffing assignments for each shift according to the zones established within the facility. The Administrator and DON or their designee will monitor these assignment sheets daily to ensure compliance. This process was implemented [DATE]. 3. Handwashing and Other Infection Control matters - The DON, Housekeeping Supervisor provided additional training on [DATE] to droplet precautions including donning / doffing PPE, hand washing, disinfection product utilization and set times. The training information and materials were provided by our Corporate Nurse via policy and procedure based on CDC, CMS and HHSC requirements and recommendations. Housekeeping information was based on manufacturer recommendations. Staff competencies related these items will be conducted and documented for all present staff on [DATE] by the DON and ADON. Remaining active staff will complete competencies upon returning to work for their next rotation and as part of the new hire orientation process by the DON, ADON or administrative nurse designee. Hand sanitizing stations are setup at the entrance of 400 Hall along with a hand washing station in the safe zone. Staff are directed to sanitize, don PPE, enter safe zone and wash hands. This was completed [DATE]. The Charge Nurses working the COVID unit were educated on this practice and signs have been posted with these directions. The Administrator, DON or their designee will periodically monitor the entrance at shift change to ensure adherence to this practice. Hard surface and high traffic areas are disinfected at least three times per day (morning, afternoon, evening/night). Please see the attached log to be used to document cleaning times. While housekeeping has been cleaning these surfaces multiple times per day, we implemented the form to document these times on [DATE]. The Housekeeping Supervisor will monitor the forms daily and maintain a copy for review consistent with the QA program. 4. Actions of the Facility - The facility will implement a Quality Assurance Program to monitor and ensure the implementation of the items listed above for a period of six weeks. Implemented [DATE] for six weeks ([DATE]). The Administrator and Director of Nursing or designated supervisor will review staffing assignments for proper assignment given the Zones determined within the facility daily for a period of 6 weeks. Residents room assignment will be reviewed and discussed daily to ensure proper assignment according to the dedicate Zone. The Housekeeping Supervisor will provide a copy of the cleaning log to the Administrator, Director of Nursing or designee daily for monitoring and collection for QA. Hand hygiene and PPE application will be monitored by DON, ADON and designated administrative nurses at least once daily on various shifts as part of the QA. Monitoring for the POR Observation of the facility on [DATE] at 8:15 am revealed adequate staffing was in place for Cold, Warm and Hot zones at the facility. The administrator stated a total of 23 Residents positive for Covid-19 were now in the Isolation units. He stated 32 Residents had recovered from Covid-19 on [DATE] and had been moved to the negative unit on Hall 100. Observation of the facility on [DATE] at 8:25 am revealed all residents were moved off 300 Hall and the Hot Zone remained on 400 Hall. A Warm Zone was in operation with designated staff on 200 Hall. Observation of 100 Hall revealed no Residents on Isolation or Droplet precautions. In an interview on [DATE] at 8:40 the DON stated staff had been inserviced on Staffing assignments (copy of schedule provided), Housekeeping logs (copy of monitoring log provided), and inservice and skills checkoffs for Handwashing were completed by DON. The DON stated she would be monitoring PPE useage and conducting spot checks daily and provided a report form to be utilized when other designated staff conducted spot checks. In an interview on [DATE] at 8:45 am LVN E stated she had been inserviced on Policy changes by the DON. She stated she had been provided a choice of N95 masks (after a skin reaction to green N95), she stated she had been asked to demonstrate skills such as donning and doffing PPE and handwashing. LVN E stated she had been educated on reinforcing handwashing for Residents. In an interview on [DATE] at 8:55 am CNA R stated she had been inserviced on Policy updates for Covid-19, separation of Warm, Cold, and Hot Residents, Handwashing and PPE. She stated she had performed a skills check off for Donning and Doffing and Hand washing. She stated all staff had been asked to reinforce handwashing with Residents. In an interview on [DATE] at 10:25 am RN D stated she had received updated education on facility policies for PPE, Infection Control and Covid-19. RN D stated she was an agency nurse and felt she had been given a good orientation to working on 400 Hall the Covid positive unit. Review of Updated Policies for Infection Control dated [DATE] reflected dedicated staff were scheduled for each Cohort of Residents, Cold/Negative, Warm/unknown status and Hot/Covid-19 positive. Staffing changes effective on [DATE]. Policy on screening staff as they enter the facility reflected the screener must monitor to ensure all questions are answered and instruct staff to complete all questions. The DON was to conduct spot checks for accuracy. The IJ was lowered at the time of exit on [DATE] at 12:00 PM.

Based on observation, interview, and record review the facility failed to consult with the resident's physician regarding a need to alter treatment significantly for one (1) of two (2) residents (Resident # 5) with a decline in wound status when: The facility failed to notify Resident # 5's physician at the Wound Care Clinic of a decline in the condition of pressure sores from 02/04/2015 until 02/17/2015 regarding his Left Ischial, Left hip, Right hip, Right Ischial and the Upper Sacrum, which became, larger, deeper or worsen from a Stage III to unstageable. This deficient practice placed four (4) residents with pressure sores at risk for the development of new pressure sores, infection, and worsening of current pressure sores. Findings include: Review of Resident # 5's Face Sheet reflected a [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with the following Diagnosis: [REDACTED]. Review of the readmission assessment dated [DATE] reflected the following: Left Ischial-Stage IV-6 cm x 5.3 cm, unable to determine depth-bone could be felt when touched, Small amount serosanguineous exudate, wound bed red and yellow. Left Hip-Stage IV-5 x 5.5 cm, 1 cm depth, undermining from 5 to 7 o'clock up to 2 cm, and from 10-12 o'clock up to 2.4 cm, moderate amount of Serosanguineous exudate, wound bed red. Right Hip-Stage IV-2.5 x 6 cm, 1.5 cm depth, undermining from 11-2 o'clock up to 3.7 cm, moderate amount of serosanguineous exudate, wound bed red. Right Ischial-Stage III-6 x 5 cm, unable to determine depth, small amount of serosanguineous exudate, wound be red and yellow. Upper Sacrum-Stage III- 2 x 1 cm, no depth, scant amount of serosanguineous exudate, with a red and yellow wound bed. Review of Resident # 5's most recent significant change in status MDS assessment dated [DATE] reflected Resident # 5 had a BIMS score of 9 which indicated moderate cognitive impairment. The assessment reflected Resident # 5 had one (1) Stage II Pressure Sore (Partial thickness loss of dermis presenting as a shallow open sore with a red pink wound bed without slough), three (3) Stage III Pressure Sores (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present, but does not obscure the depth of tissue loss. May include undermining), and three (3) Stage IV Pressure Sores (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining.) with the current sore treatments of a pressure reducing device for the chair and bed, nutrition or hydration intervention to manage skin problems, and pressure sore care. Review of Resident # 5's Comprehensive Care Plan dated 01/22/2015 reflected Resident # 5 was readmitted to the facility on [DATE] with multiple pressure sores, and interventions which included: Treatments as ordered by the physician. The Care Plan was updated 02/05/2015 with interventions including new treatment orders from the Wound Care Clinic for the pressure sores, notify the physician and family as needed, medications as ordered for pain, and notify the physician if pain is uncontrolled. Observation on 02/27/2015 at 2:45 PM revealed Resident # 5 was admitted to the hospital. During the observation Resident # 5 did not respond when asked questions by the surveyor. Resident # 5 was on a speciality bed and had 4 [DEVICE] (vacuum and speciality dressing at the wound site that helps to remove infectious materials and actively promote granulation) in place. In an interview on 02/27/2015 at 2:50 PM the Hospital Wound Care Specialist Nurse stated, Resident # 5 had a wound vac applied on 02/26/2015 after debridement was done to the following areas: right hip, right ischeal, left hip and left ischeal. Review of Resident # 5's readmission physicians orders with a start date of 01/22/2015 reflected the following treatment for [REDACTED]. An additional order received on 01/21/2015 for Resident # 5 to have a referral to the wound care clinic. Review of the nurses notes dated 01/28/2015 at 3:42 PM reflected Resident # 5 had returned from the wound care clinic (initial visit), without treatment orders. Further review of Resident # 5's nurses notes revealed no documentation the wound care clinic had been called to obtain treatment orders after Resident # 5 was evaluated at the Wound Care Clinic. In an interview on 02/26/2015 at 4:00 PM, the Treatment Nurse stated she had called the Wound Care Clinic on 01/30/2015 ( two days after the appointment) to obtain treatment orders for Resident # 5's pressure sores. She stated she was told by a Wound Care Clinic employee the orders were not ready and would be sent out as soon as the physician had written the orders. The Treatment Nurse stated she did not make any other attempts to obtain treatment orders from the Wound Care Clinic or notify the Primary Physician of her inability to obtain wound care orders for Resident # 5. The Treatment Nurse stated she did not receive new treatment orders from the Wound Care Clinic until 02/04/2015. The Treatment Nurse stated since the wounds had already been treated on 02/04/2015, the new orders were not initiated by the Treatment Nurse until 02/05/2015 (8 days after the initial Wound Care Clinic appointment). Review of the wound care clinic orders dated 01/28/2015 were noted as received by the Wound Care Clinic nurse on 02/02/2015 at 8:05 AM fax, reflected the following orders: Irrigate and cleanse (no specific solution to irrigate and clean) the right hip, sacral and left trochanteric pressure sores and apply [MEDICATION NAME] AG every day; Irrigate and cleanse (no specific solution to irrigate and clean) the left ischial pressure sore and apply Santyl and gauze daily; All dressing changes to be performed daily after cleansing and irrigation; Clinitron bed for treatment of [REDACTED]. Review of the telephone orders transcribed by the Treatment Nurse, 02/05/2015 and signed by Resident # 5's primary physician did not include the Wound Care Clinic physician's orders [REDACTED]. In an interview on 02/27/2015 at 2:15 PM, a Wound Care Clinic employee stated after reviewing their records the treatment orders from the initial visit on 01/28/2015 were faxed to the facility on [DATE] at 12:29 PM. The Wound Care Clinic employee stated the nursing home had called one time (01/30/2015) requesting new treatment orders. She also stated since 01/30/2015 the wound care clinic has not received any telephone calls from the nursing home regarding Resident # 5 with any concerns including wounds worsening. In an interview on 02/27/2015 at, at 3:45 PM, the Treatment Nurse stated she had found the orders from the Wound Care Clinic attached to a clip board on the treatment cart on 02/04/2015 for Resident # 5. The Treatment Nurse stated she wrote the orders for treatment, but since she had already completed treatments for the day, the new orders were not initiated until 02/05/2015. The Treatment Nurse stated after reviewing the orders from the Wound Care Clinic she had failed to write to irrigate each wound prior to applying the new dressing. The Treatment Nurse stated, I just missed that part of the order. The Treatment Nurse stated she cleansed the wounds with would cleanser, but did not irrigate the wounds. Review of the Weekly Pressure sore Record reflected the facility failed to document any skin assessment until 02/04/2015 (14 days after the initial assessment) with the following assessment: Left Ischial-Stage IV, 6 x 7 cm, unable to determine depth, with a large amount of exudate (no type documented), red and yellow bed, no mention of bone. (wound had declined) Physician was not notified and the new orders from 02/02/2015 had not been implemented. Left Hip-Stage IV, 4 x 3 cm, 1 cm depth with no description of type/amount of exudate, condition of the wound bed or measurement of the undermining. (incomplete assessment). Right hip-Stage IV, 2 x 3.5 cm, 1.5 cm in depth with no description of type/amount of exudate, condition of the wound bed or measurement of the undermining. (incomplete assessment) Right Ischial-Stage III, 4 x 6 cm, and 1 cm in depth with no description of type/amount of exudate, condition of the wound bed (incomplete assessment) Upper Sacrum-Stage III, 1.0 x 1.0 and no depth, with no description of type/amount of exudate, or condition of the wound bed. (incomplete assessment) <http://www.hopkinsmedicine.org.gec/series/wound_care.html reflected, An assessment of the wound should be done weekly and be used to drive treatment decisions. Wound assessment includes: location, class/stage, base tissues, exudates, odor, edge/perimeter, pain and an evaluation for infection. Review of the Weekly Pressure sore Record dated 02/11/2015 reflected the following: Left Ischial-Stage IV, 6.5 x 5.5 cm, unable to determine depth, with no assessment of type or amount of exudate, condition of the wound bed or mention of the bone. (incomplete assessment) Left Hip-Stage IV, 3.5 x 4.5, 1.5 cm depth, underming up to 3.5 cm, with no assessment of type or amount of exudate, or the condition of the wound bed. (wound had declined - increase in undermining). The Physician was not notified and the wound care was not changed. Right Hip-Stage IV, 2 x 4 cm, 1.5 cm depth, undermining up to 3.5 cm with no assessment of type or amount of exudate, or the condition of the wound bed (wound had declined). The Physician was not notified and the wound care was not changed. Right Ischial-Stage IV, 7 x 8 cm, 1.0 cm depth, with no assessment of type or amount of exudate or the condition of the wound bed (wound had declined). The Physician was not notified and the wound care was not changed. Upper Sacrum-Stage III, did not include measurements only assessment read changed to unstageable. Review of the Facility Weekly Pressure sore Log dated 02/17/2015 reflected the following measurements: Left Ischial-Stage IV, 6.5 x 5.5 cm, unable to determine depth, with an odor and drainage.(incomplete assessment) Left Hip-Stage IV, 3.5 x 4.5 cm, 1.5 cm depth, with drainage and no odor. (incomplete assessment) Right Hip-Stage IV, 2 x 4 cm, 1.5 cm depth, with drainage. (incomplete assessment) Right Ischial-Stage IV, 7 x 8 cm, 1.0 cm depth, with drainage. (incomplete assessment) Upper Sacrum-Stage III, no measurements, no documentation of drainage or odor. (incomplete assessment) Review of the Weekly sore Record revealed Resident # 5 was seen at the wound care clinic on 02/18/2015. No documentation of measurements were found in Client # 5's clinical record. In an interview on 03/02/2015 at 8:45 AM, the DON stated the facility had not received any measurements of wounds being treated by the wound care clinic since Resident # 5 had started going to the wound care clinic on 01/28/2015. No other measurements were documented on the Weekly Pressure sore Record from 02/11/2015 until Resident # 5 was discharged to the hospital on [DATE]. Review of notes dated 03/12/2015, written by the MDS Coordinator during the Weekly Pressure Sore Meeting, reflected Resident # 5 had a Stage III Pressure Sore to the Sacrum which measured 2.5cm x 2.5 cm (no depth, drainage or odor documented). In an interview on 03/02/2014 at 3:40 PM, the Treatment Nurse stated she did not call the Wound Care Clinic when Resident # 5's pressure sores increased in size, since he was being seen by the physician at the Wound Care Clinic. She also stated she did not measure and document undermining in the wounds, the type/amount of exudate, or the condition of the wound bed, stating she knew the Wound Care Clinic was seeing Resident # 5. Review of nurses notes dated 02/23/2015 at 2:44 PM reflected Resident was transferred to the hospital for treatment related to osteomylitis (Bone Infection). Review of the initial skin assessment conducted at the hospital on [DATE] at 3:23 PM by the hospital Wound Care Nurse reflected the following: Left Ischial-Stage IV, Full Thickness, 8 x 7.5 cm, 3 cm depth, with Moderate amount of Serosanguineous drainage with a mild odor, with a yellow, gray slough and bone visible. (Wound had declined since last facility assessment on 02/17/2015) Left hip-Stage IV, 13 x 8 cm, 2.5 cm depth, wound bed yellow gray slough 20% , undermining 2-12 cm, large amount purulent (containing pus) serosanguineous drainage. (wound had declined - wound had increased in size from 6.5 x 5.5 cm and now has undermining around wound) Right Hip-Stage IV, 8 x 7 cm, 2 cm depth, wound bed slough (50%), undermining from 1 to 11 cm, large amount of purulent Serosanguineous fluid. (wound had declined - wound had increased from 2 cm x 4 cm and from no undermining documented on 02/17/2015 to 1cm to 11 cm around the wound). Right Ischial-Stage IV, 5 x 2.5 cm, 1 cm depth yellow gray slough 50 %, with moderate serosanguineous drainage. (wound had declined - no slough documented on 02/17/2015 assessment) Upper Sacrum-Stage IV, 5 x 7 cm, 0.3 depth, 100% yellow gray slough, large mount of purulent serosanguineous drainage. (wound had declined - area previously measured at 2.5 x 2.5 cm) In an interview on 03/02/2015 at 8:45 AM, the DON stated she expected the Treatment Nurse to perform a complete assessment of every resident with a pressure sore, at least weekly, to include, the length, width and depth in the wound, measurement of any undermining, the condition of the wound bed, and the type and amount of exudate. The DON stated she also expected the Treatment Nurse to notify her if the wounds were getting worse so an RN could reassess the wound, and to notify the physician of any decline in wound status. She also stated that she expected the Treatment Nurse to call the Wound Care Clinic daily after a visit until new orders are received. Review of the facility Skin Assessment Policy revised 6/11 reflected the following: Weekly Monitoring .5. The treatment nurse will administer daily wound care Monday thru Friday to all residents that have wounds. The charge nurses will administer treatments on the weekend. 6. Physicians will be notified of pressure sore changes and improvements as needed by the treatment nurse. After 2 weeks of daily wound care, with no noted improvement to the wound, the physician will be notified, and a change of treatment will be requested. After 7 days of daily wound care, if there is a decline in the resident's wound, the physician will be notified as well . Regardless of resident's risk for pressure sore status, all residents will have weekly skin assessments done . The facility provided a list of three (3) current residents with pressure sores.

Based on observation, interview, and record review the facility failed to implement policies and procedures to prohibit neglect for one (1) of ten (10) residents (Resident # 5) reviewed for neglect when: The Treatment Nurse failed to perform complete weekly wound assessments and notify the physician of a decline in wound status between 02/04/2015 and 02/23/2015, so that new orders could be received and implemented to promote healing. The Treatment Nurse failed to follow up with the Wound Care Clinic to obtain treatment orders when the facility had not received orders for treating Stage III and Stage IV Pressure Sores from 01/28/2015 to 02/04/2015. The Treatment Nurse failed to accurately transcribe orders dated 02/04/2015, which were sent to the facility on [DATE] by the Wound Care Clinic, which resulted in the facility staff failing to irrigate Stage III pressure ulcers to the Right Ischial (buttocks), and the Upper Sacrum (upper buttocks) and Stage IV wounds to the Left Ischial, Left Hip and the Right hip. This deficient practice placed three (3) current residents with pressure sores at risk for the development of new pressure sores, infection, and worsening of current pressure sores. Findings Include: Review of Resident # 5's Face Sheet reflected a [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with the following Diagnosis: [REDACTED]. Review of the readmission assessment dated [DATE] reflected the following: Left Ischial-Stage IV-6 cm x 5.3 cm, unable to determine depth-bone could be felt when touched, Small amount serosanguineous exudate, wound bed red and yellow. Left Hip-Stage IV-5 x 5.5 cm, 1 cm depth, undermining from 5 to 7 o'clock up to 2 cm, and from 10-12 o'clock up to 2.4 cm, moderate amount of Serosanguineous exudate, wound bed red. Right Hip-Stage IV-2.5 x 6 cm, 1.5 cm depth, undermining from 11-2 o'clock up to 3.7 cm, moderate amount of serosanguineous exudate, wound bed red. Right Ischial-Stage III-6 x 5 cm, unable to determine depth, small amount of serosanguineous exudate, wound be red and yellow. Upper Sacrum-Stage III- 2 x 1 cm, no depth, scant amount of serosanguineous exudate, with a red and yellow wound bed. Review of Resident # 5's most recent significant change in status MDS assessment dated [DATE] reflected Resident # 5 had a BIMS score of 9 which indicated moderate cognitive impairment. The assessment reflected Resident # 5 had one (1) Stage II Pressure Sore (Partial thickness loss of dermis presenting as a shallow open sore with a red pink wound bed without slough), three (3) Stage III Pressure Sores (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present, but does not obscure the depth of tissue loss. May include undermining), and three (3) Stage IV Pressure Sores (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining.) with the current pressure sore treatments of a pressure reducing device for the chair and bed, nutrition or hydration intervention to manage skin problems, and pressure sore care. Review of Resident # 5's Comprehensive Care Plan dated 01/22/2015 reflected Resident # 5 was readmitted to the facility on [DATE] with multiple pressure sores, and interventions which included: Treatments as ordered by the physician. The Care Plan was updated 02/05/2015 with interventions including new treatment orders from the Wound Care Clinic for the pressure sores, notify the physician and family as needed, medications as ordered for pain, and notify the physician if pain is uncontrolled. Observation on 02/27/2015 at 2:45 PM revealed Resident # 5 was admitted to the hospital. During the observation Resident # 5 did not respond when asked questions by the surveyor. Resident # 5 was on a speciality bed and had 4 [DEVICE] (vacuum and speciality dressing at the wound site that helps to remove infectious materials and actively promote granulation) in place. In an interview on 02/27/2015 at 2:50 PM the Hospital Wound Care Specialist Nurse stated, Resident # 5 had a wound vac applied on 02/26/2015 after debridement was done to the following areas: right hip, right ischeal, left hip and left ischeal. Review of Resident # 5's readmission physicians orders with a start date of 01/22/2015 reflected the following treatment for [REDACTED]. An additional order received on 01/21/2015 for Resident # 5 to have a referral to the wound care clinic. Review of the nurses notes dated 01/28/2015 at 3:42 PM reflected Resident # 5 had returned from the wound care clinic (initial visit), without treatment orders. Further review of Resident # 5's nurses notes revealed no documentation the wound care clinic had been called to obtain treatment orders after Resident # 5 was evaluated at the Wound Care Clinic. In an interview on 02/26/2015 at 4:00 PM, the Treatment Nurse stated she had called the Wound Care Clinic on 01/30/2015 ( two days after the appointment) to obtain treatment orders for Resident # 5's pressure sores. She stated she was told by a Wound Care Clinic employee the orders were not ready and would be sent out as soon as the physician had written the orders. The Treatment Nurse stated she did not make any other attempts to obtain treatment orders from the Wound Care Clinic or notify the Primary Physician of her inability to obtain wound care orders for Resident # 5. The Treatment Nurse stated she did not receive new treatment orders from the Wound Care Clinic until 02/04/2015. The Treatment Nurse stated since the wounds had already been treated on 02/04/2015, the new orders were not initiated by the Treatment Nurse until 02/05/2015 (8 days after the initial Wound Care Clinic appointment). Review of the wound care clinic orders dated 01/28/2015 were noted as received by the Wound Care Clinic nurse on 02/02/2015 at 8:05 AM fax, reflected the following orders: Irrigate and cleanse (no specific solution to irrigate and clean) the right hip, sacral and left trochanteric pressure sores and apply [MEDICATION NAME] AG every day; Irrigate and cleanse (no specific solution to irrigate and clean) the left ischial pressure sore and apply Santyl and gauze daily; All dressing changes to be performed daily after cleansing and irrigation; Clinitron bed for treatment of [REDACTED]. Review of the telephone orders transcribed by the Treatment Nurse, 02/05/2015 and signed by Resident # 5's primary physician did not include the Wound Care Clinic physician's orders [REDACTED]. In an interview on 02/27/2015 at 2:15 PM, a Wound Care Clinic employee stated after reviewing their records the treatment orders from the initial visit on 01/28/2015 were faxed to the facility on [DATE] at 12:29 PM. The Wound Care Clinic employee stated the nursing home had called one time (01/30/2015) requesting new treatment orders. She also stated since 01/30/2015 the wound care clinic has not received any telephone calls from the nursing home regarding Resident # 5 with any concerns including wounds worsening. In an interview on 02/27/2015 at, at 3:45 PM, the Treatment Nurse stated she had found the orders from the Wound Care Clinic attached to a clip board on the treatment cart on 02/04/2015 for Resident # 5. The Treatment Nurse stated she wrote the orders for treatment, but since she had already completed treatments for the day, the new orders were not initiated until 02/05/2015. The Treatment Nurse stated after reviewing the orders from the Wound Care Clinic she had failed to write to irrigate each wound prior to applying the new dressing. The Treatment Nurse stated, I just missed that part of the order. The Treatment Nurse stated she cleansed the wounds with would cleanser, but did not irrigate the wounds. Review of the Weekly Pressure Ulcer Record reflected the facility failed to document any skin assessment until 02/04/2015 (14 days after the initial assessment) with the following assessment: Left Ischial-Stage IV, 6 x 7 cm, unable to determine depth, with a large amount of exudate (no type documented), red and yellow bed, no mention of bone. (wound had declined) Physician was not notified and the new orders from 02/02/2015 had not been implemented. Left Hip-Stage IV, 4 x 3 cm, 1 cm depth with no description of type/amount of exudate, condition of the wound bed or measurement of the undermining. (incomplete assessment). Right hip-Stage IV, 2 x 3.5 cm, 1.5 cm in depth with no description of type/amount of exudate, condition of the wound bed or measurement of the undermining. (incomplete assessment) Right Ischial-Stage III, 4 x 6 cm, and 1 cm in depth with no description of type/amount of exudate, condition of the wound bed (incomplete assessment) Upper Sacrum-Stage III, 1.0 x 1.0 and no depth, with no description of type/amount of exudate, or condition of the wound bed. (incomplete assessment) <http://www.hopkinsmedicine.org.gec/series/wound_care.html reflected, An assessment of the wound should be done weekly and be used to drive treatment decisions. Wound assessment includes: location, class/stage, base tissues, exudates, odor, edge/perimeter, pain and an evaluation for infection. Review of the Weekly Pressure Ulcer Record dated 02/11/2015 reflected the following: Left Ischial-Stage IV, 6.5 x 5.5 cm, unable to determine depth, with no assessment of type or amount of exudate, condition of the wound bed or mention of the bone. (incomplete assessment) Left Hip-Stage IV, 3.5 x 4.5, 1.5 cm depth, underming up to 3.5 cm, with no assessment of type or amount of exudate, or the condition of the wound bed. (wound had declined; there was an increase in undermining). The Physician was not notified and the wound care was not changed. Right Hip-Stage IV, 2 x 4 cm, 1.5 cm depth, undermining up to 3.5 cm with no assessment of type or amount of exudate, or the condition of the wound bed (wound had declined.) The Physician was not notified and the wound care was not changed. Right Ischial-Stage IV, 7 x 8 cm, 1.0 cm depth, with no assessment of type or amount of exudate or the condition of the wound bed (wound had declined). The Physician was not notified and the wound care was not changed. Upper Sacrum-Stage III, did not include measurements only assessment read changed to unstageable. Review of the Facility Weekly Pressure Ulcer Log dated 02/17/2015 reflected the following measurements: Left Ischial-Stage IV, 6.5 x 5.5 cm, unable to determine depth, with an odor and drainage.(incomplete assessment) Left Hip-Stage IV, 3.5 x 4.5 cm, 1.5 cm depth, with drainage and no odor. (incomplete assessment) Right Hip-Stage IV, 2 x 4 cm, 1.5 cm depth, with drainage. (incomplete assessment) Right Ischial-Stage IV, 7 x 8 cm, 1.0 cm depth, with drainage. (incomplete assessment) Upper Sacrum-Stage III, no measurements, no documentation of drainage or odor. (incomplete assessment) Review of the Weekly Ulcer Record revealed Resident # 5 was seen at the wound care clinic on 02/18/2015. No documentation of measurements were found in Client # 5's clinical record. In an interview on 03/02/2015 at 8:45 AM, the DON stated the facility had not received any measurements of wounds being treated by the wound care clinic since Resident # 5 had started going to the wound care clinic on 01/28/2015. No other measurements were documented on the Weekly Pressure Ulcer Record from 02/11/2015 until Resident # 5 was discharged to the hospital on [DATE]. Review of notes dated 03/12/2015, written by the MDS Coordinator during the Weekly Pressure Sore Meeting, reflected Resident # 5 had a Stage III Pressure Sore to the Sacrum which measured 2.5cm x 2.5 cm (no depth, drainage or odor documented). In an interview on 03/02/2014 at 3:40 PM, the Treatment Nurse stated did not call the Wound Care Clinic when Resident # 5's pressure sores increased in size, since he was being seen by the physician at the Wound Care Clinic. She also stated she did not measure and document undermining in the wounds, the type/amount of exudate, or the condition of the wound bed, stating she knew the Wound Care Clinic was seeing Resident # 5. Review of nurses notes dated 02/23/2015 at 2:44 PM reflected Resident was transferred to the hospital for treatment related to osteomylitis (Bone Infection). Review of the initial skin assessment conducted at the hospital on [DATE] at 3:23 PM by the hospital Wound Care Nurse reflected the following: Left Ischial-Stage IV, Full Thickness, 8 x 7.5 cm, 3 cm depth, with Moderate amount of Serosanguineous drainage with a mild odor, with a yellow, gray slough and bone visible. (Wound had declined since last facility assessment on 02/17/2015) Left hip-Stage IV, 13 x 8 cm, 2.5 cm depth, wound bed yellow gray slough 20% , undermining 2-12 cm, large amount purulent (containing pus) serosanguineous drainage. (wound had declined, wound has increased in size from 6.5 x 5.5 cm and now has undermining around wound) Right Hip-Stage IV, 8 x 7 cm, 2 cm depth, wound bed slough (50%), undermining from 1 to 11 cm, large amount of purulent Serosanguineous fluid. (wound had declined, wound has increased from 2 cm x 4 cm and from no undermining documented on 02/17/2015 to 1cm to 11 cm around the wound). Right Ischial-Stage IV, 5 x 2.5 cm, 1 cm depth yellow gray slough 50 %, with moderate serosanguineous drainage. (wound had declined - no slough documented on 02/17/2015 assessment) Upper Sacrum-Stage IV, 5 x 7 cm, 0.3 depth, 100% yellow gray slough, large mount of purulent serosanguineous drainage. (wound had declined - area previously measured at 2.5 x 2.5 cm) In an interview on 03/02/2015 at 8:45 AM, the DON stated she expected the Treatment Nurse to perform a complete assessment of every resident with a pressure sore, at least weekly, to include, the length, width and depth in the wound, measurement of any undermining, the condition of the wound bed, and the type and amount of exudate. The DON stated she also expected the Treatment Nurse to notify her if the wounds were getting worse so an RN could reassess the wound, and to notify the physician of any decline in wound status. She also stated that she expected the Treatment Nurse to call the Wound Care Clinic daily after a visit until new orders are received. Review of the facility Skin Assessment Policy revised 6/11 reflected the following: Weekly Monitoring .5. The treatment nurse will administer daily wound care Monday thru Friday to all residents that have wounds. The charge nurses will administer treatments on the weekend. 6. Physicians will be notified of pressure ulcer changes and improvements as needed by the treatment nurse. After 2 weeks of daily wound care, with no noted improvement to the wound, the physician will be notified, and a change of treatment will be requested. After 7 days of daily wound care, if there is a decline in the resident's wound, the physician will be notified as well . Regardless of resident's risk for pressure ulcer status, all residents will have weekly skin assessments done . Review of the facility's policy Abuse and Neglect Prohibition Policy reviewed 12/10, reflected, Policy Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of personal property. Definitions .Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness .4. Identification A. The facility Quality Assurance Team will investigate occurrences, patterns and trends that may indicate the presence of abuse, neglect or misappropriation of resident property and to determine the direction of the investiagion/intervention through analysis of systems, audits and reports . The facility provided a list of three (3) current residents with pressure sores.

Based on observation, interview, and record review the facility failed to implement written policies and procedures that prohibit neglect for one (1) of ten (10) residents (Resident # 5) reviewed for neglect when: The Treatment Nurse failed to perform complete weekly wound assessments and notify the physician of a decline in wound status between 02/04/2015 and 02/23/2015, so that new orders could be received and implemented to promote healing. The Treatment Nurse failed to follow up with the Wound Care Clinic to obtain treatment orders when the facility had not received orders for treating Stage III and Stage IV Pressure Sores from 01/28/2015 to 02/04/2015. The Treatment Nurse failed to accurately transcribe orders dated 02/04/2015, which were sent to the facility on [DATE] by the Wound Care Clinic, which resulted in the facility staff failing to irrigate Stage III pressure ulcers to the Right Ischial (buttocks), and the Upper Sacrum (upper buttocks) and Stage IV wounds to the Left Ischial, Left Hip and the Right hip. This deficient practice placed three (3) current residents with pressure sores at risk for the development of new pressure sores, infection, and worsening of current pressure sores. Findings Include: Review of the facility's policy Abuse and Neglect Prohibition Policy reviewed 12/10, reflected, Policy Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of personal property. Definitions .Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness .4. Identification A. The facility Quality Assurance Team will investigate occurrences, patterns and trends that may indicate the presence of abuse, neglect or misappropriation of resident property and to determine the direction of the investiagion/intervention through analysis of systems, audits and reports . Review of the facility Skin Assessment Policy revised 6/11 reflected the following: Weekly Monitoring .5. The treatment nurse will administer daily wound care Monday thru Friday to all residents that have wounds. The charge nurses will administer treatments on the weekend. 6. Physicians will be notified of pressure ulcer changes and improvements as needed by the treatment nurse. After 2 weeks of daily wound care, with no noted improvement to the wound, the physician will be notified, and a change of treatment will be requested. After 7 days of daily wound care, if there is a decline in the resident's wound, the physician will be notified as well . Regardless of resident's risk for pressure ulcer status, all residents will have weekly skin assessments done . Review of Resident # 5's Face Sheet reflected a [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with the following Diagnosis: [REDACTED]. Review of the readmission assessment dated [DATE] reflected the following: Left Ischial-Stage IV-6 cm x 5.3 cm, unable to determine depth-bone could be felt when touched, Small amount serosanguineous exudate, wound bed red and yellow. Left Hip-Stage IV-5 x 5.5 cm, 1 cm depth, undermining from 5 to 7 o'clock up to 2 cm, and from 10-12 o'clock up to 2.4 cm, moderate amount of Serosanguineous exudate, wound bed red. Right Hip-Stage IV-2.5 x 6 cm, 1.5 cm depth, undermining from 11-2 o'clock up to 3.7 cm, moderate amount of serosanguineous exudate, wound bed red. Right Ischial-Stage III-6 x 5 cm, unable to determine depth, small amount of serosanguineous exudate, wound be red and yellow. Upper Sacrum-Stage III- 2 x 1 cm, no depth, scant amount of serosanguineous exudate, with a red and yellow wound bed. Review of Resident # 5's most recent significant change in status MDS assessment dated [DATE] reflected Resident # 5 had a BIMS score of 9 which indicated moderate cognitive impairment. The assessment reflected Resident # 5 had one (1) Stage II Pressure Sore (Partial thickness loss of dermis presenting as a shallow open sore with a red pink wound bed without slough), three (3) Stage III Pressure Sores (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present, but does not obscure the depth of tissue loss. May include undermining), and three (3) Stage IV Pressure Sores (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining.) with the current pressure sore treatments of a pressure reducing device for the chair and bed, nutrition or hydration intervention to manage skin problems, and pressure sore care. Review of Resident # 5's Comprehensive Care Plan dated 01/22/2015 reflected Resident # 5 was readmitted to the facility on [DATE] with multiple pressure sores, and interventions which included: Treatments as ordered by the physician. The Care Plan was updated 02/05/2015 with interventions including new treatment orders from the Wound Care Clinic for the pressure sores, notify the physician and family as needed, medications as ordered for pain, and notify the physician if pain is uncontrolled. Observation on 02/27/2015 at 2:45 PM revealed Resident # 5 was admitted to the hospital. During the observation Resident # 5 did not respond when asked questions by the surveyor. Resident # 5 was on a speciality bed and had 4 [DEVICE] (vacuum and speciality dressing at the wound site that helps to remove infectious materials and actively promote granulation) in place. In an interview on 02/27/2015 at 2:50 PM the Hospital Wound Care Specialist Nurse stated, Resident # 5 had a wound vac applied on 02/26/2015 after debridement was done to the following areas: right hip, right ischeal, left hip and left ischeal. Review of Resident # 5's readmission physicians orders with a start date of 01/22/2015 reflected the following treatment for [REDACTED]. An additional order received on 01/21/2015 for Resident # 5 to have a referral to the wound care clinic. Review of the nurses notes dated 01/28/2015 at 3:42 PM reflected Resident # 5 had returned from the wound care clinic (initial visit), without treatment orders. Further review of Resident # 5's nurses notes revealed no documentation the wound care clinic had been called to obtain treatment orders after Resident # 5 was evaluated at the Wound Care Clinic. In an interview on 02/26/2015 at 4:00 PM, the Treatment Nurse stated she had called the Wound Care Clinic on 01/30/2015 ( two days after the appointment) to obtain treatment orders for Resident # 5's pressure sores. She stated she was told by a Wound Care Clinic employee the orders were not ready and would be sent out as soon as the physician had written the orders. The Treatment Nurse stated she did not make any other attempts to obtain treatment orders from the Wound Care Clinic or notify the Primary Physician of her inability to obtain wound care orders for Resident # 5. The Treatment Nurse stated she did not receive new treatment orders from the Wound Care Clinic until 02/04/2015. The Treatment Nurse stated since the wounds had already been treated on 02/04/2015, the new orders were not initiated by the Treatment Nurse until 02/05/2015 (8 days after the initial Wound Care Clinic appointment). Review of the wound care clinic orders dated 01/28/2015 were noted as received by the Wound Care Clinic nurse on 02/02/2015 at 8:05 AM fax, reflected the following orders: Irrigate and cleanse (no specific solution to irrigate and clean) the right hip, sacral and left trochanteric pressure sores and apply [MEDICATION NAME] AG every day; Irrigate and cleanse (no specific solution to irrigate and clean) the left ischial pressure sore and apply Santyl and gauze daily; All dressing changes to be performed daily after cleansing and irrigation; Clinitron bed for treatment of [REDACTED]. Review of the telephone orders transcribed by the Treatment Nurse, 02/05/2015 and signed by Resident # 5's primary physician did not include the Wound Care Clinic physician's orders [REDACTED]. In an interview on 02/27/2015 at 2:15 PM, a Wound Care Clinic employee stated after reviewing their records the treatment orders from the initial visit on 01/28/2015 were faxed to the facility on [DATE] at 12:29 PM. The Wound Care Clinic employee stated the nursing home had called one time (01/30/2015) requesting new treatment orders. She also stated since 01/30/2015 the wound care clinic has not received any telephone calls from the nursing home regarding Resident # 5 with any concerns including wounds worsening. In an interview on 02/27/2015 at, at 3:45 PM, the Treatment Nurse stated she had found the orders from the Wound Care Clinic attached to a clip board on the treatment cart on 02/04/2015 for Resident # 5. The Treatment Nurse stated she wrote the orders for treatment, but since she had already completed treatments for the day, the new orders were not initiated until 02/05/2015. The Treatment Nurse stated after reviewing the orders from the Wound Care Clinic she had failed to write to irrigate each wound prior to applying the new dressing. The Treatment Nurse stated, I just missed that part of the order. The Treatment Nurse stated she cleansed the wounds with would cleanser, but did not irrigate the wounds. Review of the Weekly Pressure Ulcer Record reflected the facility failed to document any skin assessment until 02/04/2015 (14 days after the initial assessment) with the following assessment: Left Ischial-Stage IV, 6 x 7 cm, unable to determine depth, with a large amount of exudate (no type documented), red and yellow bed, no mention of bone. (wound had declined) Physician was not notified and the new orders from 02/02/2015 had not been implemented. Left Hip-Stage IV, 4 x 3 cm, 1 cm depth with no description of type/amount of exudate, condition of the wound bed or measurement of the undermining. (incomplete assessment). Right hip-Stage IV, 2 x 3.5 cm, 1.5 cm in depth with no description of type/amount of exudate, condition of the wound bed or measurement of the undermining. (incomplete assessment) Right Ischial-Stage III, 4 x 6 cm, and 1 cm in depth with no description of type/amount of exudate, condition of the wound bed (incomplete assessment) Upper Sacrum-Stage III, 1.0 x 1.0 and no depth, with no description of type/amount of exudate, or condition of the wound bed. (incomplete assessment) <http://www.hopkinsmedicine.org.gec/series/wound_care.html reflected, An assessment of the wound should be done weekly and be used to drive treatment decisions. Wound assessment includes: location, class/stage, base tissues, exudates, odor, edge/perimeter, pain and an evaluation for infection. Review of the Weekly Pressure Ulcer Record dated 02/11/2015 reflected the following: Left Ischial-Stage IV, 6.5 x 5.5 cm, unable to determine depth, with no assessment of type or amount of exudate, condition of the wound bed or mention of the bone. (incomplete assessment) Left Hip-Stage IV, 3.5 x 4.5, 1.5 cm depth, underming up to 3.5 cm, with no assessment of type or amount of exudate, or the condition of the wound bed. (wound had declined; there was an increase in undermining). The Physician was not notified and the wound care was not changed. Right Hip-Stage IV, 2 x 4 cm, 1.5 cm depth, undermining up to 3.5 cm with no assessment of type or amount of exudate, or the condition of the wound bed (wound had declined.) The Physician was not notified and the wound care was not changed. Right Ischial-Stage IV, 7 x 8 cm, 1.0 cm depth, with no assessment of type or amount of exudate or the condition of the wound bed (wound had declined). The Physician was not notified and the wound care was not changed. Upper Sacrum-Stage III, did not include measurements only assessment read changed to unstageable. Review of the Facility Weekly Pressure Ulcer Log dated 02/17/2015 reflected the following measurements: Left Ischial-Stage IV, 6.5 x 5.5 cm, unable to determine depth, with an odor and drainage.(incomplete assessment) Left Hip-Stage IV, 3.5 x 4.5 cm, 1.5 cm depth, with drainage and no odor. (incomplete assessment) Right Hip-Stage IV, 2 x 4 cm, 1.5 cm depth, with drainage. (incomplete assessment) Right Ischial-Stage IV, 7 x 8 cm, 1.0 cm depth, with drainage. (incomplete assessment) Upper Sacrum-Stage III, no measurements, no documentation of drainage or odor. (incomplete assessment) Review of the Weekly Ulcer Record revealed Resident # 5 was seen at the wound care clinic on 02/18/2015. No documentation of measurements were found in Client # 5's clinical record. In an interview on 03/02/2015 at 8:45 AM, the DON stated the facility had not received any measurements of wounds being treated by the wound care clinic since Resident # 5 had started going to the wound care clinic on 01/28/2015. No other measurements were documented on the Weekly Pressure Ulcer Record from 02/11/2015 until Resident # 5 was discharged to the hospital on [DATE]. Review of notes dated 03/12/2015, written by the MDS Coordinator during the Weekly Pressure Sore Meeting, reflected Resident # 5 had a Stage III Pressure Sore to the Sacrum which measured 2.5cm x 2.5 cm (no depth, drainage or odor documented). In an interview on 03/02/2014 at 3:40 PM, the Treatment Nurse stated did not call the Wound Care Clinic when Resident # 5's pressure sores increased in size, since he was being seen by the physician at the Wound Care Clinic. She also stated she did not measure and document undermining in the wounds, the type/amount of exudate, or the condition of the wound bed, stating she knew the Wound Care Clinic was seeing Resident # 5. Review of nurses notes dated 02/23/2015 at 2:44 PM reflected Resident was transferred to the hospital for treatment related to osteomylitis (Bone Infection). Review of the initial skin assessment conducted at the hospital on [DATE] at 3:23 PM by the hospital Wound Care Nurse reflected the following: Left Ischial-Stage IV, Full Thickness, 8 x 7.5 cm, 3 cm depth, with Moderate amount of Serosanguineous drainage with a mild odor, with a yellow, gray slough and bone visible. (Wound had declined since last facility assessment on 02/17/2015) Left hip-Stage IV, 13 x 8 cm, 2.5 cm depth, wound bed yellow gray slough 20% , undermining 2-12 cm, large amount purulent (containing pus) serosanguineous drainage. (wound had declined, wound has increased in size from 6.5 x 5.5 cm and now has undermining around wound) Right Hip-Stage IV, 8 x 7 cm, 2 cm depth, wound bed slough (50%), undermining from 1 to 11 cm, large amount of purulent Serosanguineous fluid. (wound had declined, wound has increased from 2 cm x 4 cm and from no undermining documented on 02/17/2015 to 1cm to 11 cm around the wound). Right Ischial-Stage IV, 5 x 2.5 cm, 1 cm depth yellow gray slough 50 %, with moderate serosanguineous drainage. (wound had declined - no slough documented on 02/17/2015 assessment) Upper Sacrum-Stage IV, 5 x 7 cm, 0.3 depth, 100% yellow gray slough, large mount of purulent serosanguineous drainage. (wound had declined - area previously measured at 2.5 x 2.5 cm) In an interview on 03/02/2015 at 8:45 AM, the DON stated she expected the Treatment Nurse to perform a complete assessment of every resident with a pressure sore, at least weekly, to include, the length, width and depth in the wound, measurement of any undermining, the condition of the wound bed, and the type and amount of exudate. The DON stated she also expected the Treatment Nurse to notify her if the wounds were getting worse so an RN could reassess the wound, and to notify the physician of any decline in wound status. She also stated that she expected the Treatment Nurse to call the Wound Care Clinic daily after a visit until new orders are received. The facility provided a list of three (3) current residents with pressure sores.

Based on observation, interview, and record review, the facility failed to provide services that meet professional standards of quality for one (1) of one (1) Treatment Nurse reviewed for wound care for one (1) of five (5) residents (Resident # 5) reviewed for pressure sores when: The Treatment Nurse failed to perform complete weekly wound assessments and notify the physician of a decline in wound status between 02/04/2015 and 02/23/2015, so that new orders could be received and implemented to promote healing. The Treatment Nurse failed to follow up with the Wound Care Clinic to obtain treatment orders when the facility had not received orders for treating Stage III and Stage IV Pressure Sores from 01/28/2015 to 02/04/2015. The Treatment Nurse failed to accurately implement the wound care orders sent from the Wound Care Clinic on 02/02/2015 which resulted in the Treatment Nurse and the weekend licensed nurses failing to irrigate Stage III pressure sores to the Right Ischial (buttocks), and the Upper Sacrum (upper buttocks) and Stage IV wounds to the Left Ischial, Left Hip and the Right hip. This deficient practice placed the current (3) residents with pressure sores at risk for the development of new pressure sores, infection, and worsening of current pressure sores. Findings Include: Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.11 Standards of Nursing Practice (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status; (G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices; (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications; (O) Implement measures to prevent exposure to infectious pathogens and communicable conditions; (P) Collaborate with the client, members of the health care team and, when appropriate, the client's significant other(s) in the interest of the client's health care; (2) Standards Specific to Vocational Nurses. The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician's assistant, physician, podiatrist, or dentist. Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity. The licensed vocational nurse shall assist in the determination of predictable healthcare needs of clients within healthcare settings and: (A) Shall utilize a systematic approach to provide individualized, goal-directed nursing care by: (i) collecting data and performing focused nursing assessments; iii) participating in the development and modification of the comprehensive nursing care plan for assigned clients; (iv) implementing appropriate aspects of care within the LVN's scope of practice; and (v) assisting in the evaluation of the client's responses to nursing interventions and the identification of client needs; (B) Shall assign specific tasks, activities and functions to unlicensed personnel commensurate with the educational preparation, experience, knowledge, and physical and emotional ability of the person to whom the assignments are made and shall maintain appropriate supervision of unlicensed personnel. Review of Resident # 5's Face Sheet reflected a [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with the following Diagnosis: [REDACTED]. Review of the readmission assessment dated [DATE] reflected the following: Left Ischial-Stage IV-6 cm x 5.3 cm, unable to determine depth-bone could be felt when touched, Small amount serosanguineous exudate, wound bed red and yellow. Left Hip-Stage IV-5 x 5.5 cm, 1 cm depth, undermining from 5 to 7 o'clock up to 2 cm, and from 10-12 o'clock up to 2.4 cm, moderate amount of Serosanguineous exudate, wound bed red. Right Hip-Stage IV-2.5 x 6 cm, 1.5 cm depth, undermining from 11-2 o'clock up to 3.7 cm, moderate amount of serosanguineous exudate, wound bed red. Right Ischial-Stage III-6 x 5 cm, unable to determine depth, small amount of serosanguineous exudate, wound be red and yellow. Upper Sacrum-Stage III- 2 x 1 cm, no depth, scant amount of serosanguineous exudate, with a red and yellow wound bed. Review of Resident # 5's most recent significant change in status MDS assessment dated [DATE] reflected Resident # 5 had a BIMS score of 9 which indicated moderate cognitive impairment. The assessment reflected Resident # 5 had one (1) Stage II Pressure Sore (Partial thickness loss of dermis presenting as a shallow open sore with a red pink wound bed without slough), three (3) Stage III Pressure Sores (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present, but does not obscure the depth of tissue loss. May include undermining), and three (3) Stage IV Pressure Sores (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining.) with the current sore treatments of a pressure reducing device for the chair and bed, nutrition or hydration intervention to manage skin problems, and pressure sore care. Review of Resident # 5's Comprehensive Care Plan dated 01/22/2015 reflected Resident # 5 was readmitted to the facility on [DATE] with multiple pressure sores, and interventions which included: Treatments as ordered by the physician. The Care Plan was updated 02/05/2015 with interventions including new treatment orders from the Wound Care Clinic for the pressure sores, notify the physician and family as needed, medications as ordered for pain, and notify the physician if pain is uncontrolled. Observation on 02/27/2015 at 2:45 PM revealed Resident # 5 was admitted to the hospital. During the observation Resident # 5 did not respond when asked questions by the surveyor. Resident # 5 was on a speciality bed and had 4 [DEVICE] (vacuum and speciality dressing at the wound site that helps to remove infectious materials and actively promote granulation) in place. In an interview on 02/27/2015 at 2:50 PM the Hospital Wound Care Specialist Nurse stated, Resident # 5 had a wound vac applied on 02/26/2015 after debridement was done to the following areas: right hip, right ischeal, left hip and left ischeal. Review of Resident # 5's readmission physicians orders with a start date of 01/22/2015 reflected the following treatment for [REDACTED]. An additional order received on 01/21/2015 for Resident # 5 to have a referral to the wound care clinic. Review of the nurses notes dated 01/28/2015 at 3:42 PM reflected Resident # 5 had returned from the wound care clinic (initial visit), without treatment orders. Further review of Resident # 5's nurses notes revealed no documentation the wound care clinic had been called to obtain treatment orders after Resident # 5 was evaluated at the Wound Care Clinic. In an interview on 02/26/2015 at 4:00 PM, the Treatment Nurse stated she had called the Wound Care Clinic on 01/30/2015 ( two days after the appointment) to obtain treatment orders for Resident # 5's pressure sores. She stated she was told by a Wound Care Clinic employee the orders were not ready and would be sent out as soon as the physician had written the orders. The Treatment Nurse stated she did not make any other attempts to obtain treatment orders from the Wound Care Clinic or notify the Primary Physician of her inability to obtain wound care orders for Resident # 5. The Treatment Nurse stated she did not receive new treatment orders from the Wound Care Clinic until 02/04/2015. The Treatment Nurse stated since the wounds had already been treated on 02/04/2015, the new orders were not initiated by the Treatment Nurse until 02/05/2015 (8 days after the initial Wound Care Clinic appointment). Review of the wound care clinic orders dated 01/28/2015 were noted as received by the Wound Care Clinic nurse on 02/02/2015 at 8:05 AM fax, reflected the following orders: Irrigate and cleanse (no specific solution to irrigate and clean) the right hip, sacral and left trochanteric pressure sores and apply [MEDICATION NAME] AG every day; Irrigate and cleanse (no specific solution to irrigate and clean) the left ischial pressure sore and apply Santyl and gauze daily; All dressing changes to be performed daily after cleansing and irrigation; Clinitron bed for treatment of [REDACTED]. Review of the telephone orders transcribed by the Treatment Nurse, 02/05/2015 and signed by Resident # 5's primary physician did not include the Wound Care Clinic physician's orders [REDACTED]. In an interview on 02/27/2015 at 2:15 PM, a Wound Care Clinic employee stated after reviewing their records the treatment orders from the initial visit on 01/28/2015 were faxed to the facility on [DATE] at 12:29 PM. The Wound Care Clinic employee stated the nursing home had called one time (01/30/2015) requesting new treatment orders. She also stated since 01/30/2015 the wound care clinic has not received any telephone calls from the nursing home regarding Resident # 5 with any concerns including wounds worsening. In an interview on 02/27/2015 at, at 3:45 PM, the Treatment Nurse stated she had found the orders from the Wound Care Clinic attached to a clip board on the treatment cart on 02/04/2015 for Resident # 5. The Treatment Nurse stated she wrote the orders for treatment, but since she had already completed treatments for the day, the new orders were not initiated until 02/05/2015. The Treatment Nurse stated after reviewing the orders from the Wound Care Clinic she had failed to write to irrigate each wound prior to applying the new dressing. The Treatment Nurse stated, I just missed that part of the order. The Treatment Nurse stated she cleansed the wounds with would cleanser, but did not irrigate the wounds. Review of the Weekly Pressure sore Record reflected the facility failed to document any skin assessment until 02/04/2015 (14 days after the initial assessment) with the following assessment: Left Ischial-Stage IV, 6 x 7 cm, unable to determine depth, with a large amount of exudate (no type documented), red and yellow bed, no mention of bone. (wound had declined) Physician was not notified and the new orders from 02/02/2015 had not been implemented. Left Hip-Stage IV, 4 x 3 cm, 1 cm depth with no description of type/amount of exudate, condition of the wound bed or measurement of the undermining. (incomplete assessment). Right hip-Stage IV, 2 x 3.5 cm, 1.5 cm in depth with no description of type/amount of exudate, condition of the wound bed or measurement of the undermining. (incomplete assessment) Right Ischial-Stage III, 4 x 6 cm, and 1 cm in depth with no description of type/amount of exudate, condition of the wound bed (incomplete assessment) Upper Sacrum-Stage III, 1.0 x 1.0 and no depth, with no description of type/amount of exudate, or condition of the wound bed. (incomplete assessment) <http://www.hopkinsmedicine.org.gec/series/wound_care.html reflected, An assessment of the wound should be done weekly and be used to drive treatment decisions. Wound assessment includes: location, class/stage, base tissues, exudates, odor, edge/perimeter, pain and an evaluation for infection. Review of the Weekly Pressure sore Record dated 02/11/2015 reflected the following: Left Ischial-Stage IV, 6.5 x 5.5 cm, unable to determine depth, with no assessment of type or amount of exudate, condition of the wound bed or mention of the bone. (incomplete assessment) Left Hip-Stage IV, 3.5 x 4.5, 1.5 cm depth, underming up to 3.5 cm, with no assessment of type or amount of exudate, or the condition of the wound bed. (wound had declined - increase in undermining). The Physician was not notified and the wound care was not changed. Right Hip-Stage IV, 2 x 4 cm, 1.5 cm depth, undermining up to 3.5 cm with no assessment of type or amount of exudate, or the condition of the wound bed (wound had declined). The Physician was not notified and the wound care was not changed. Right Ischial-Stage IV, 7 x 8 cm, 1.0 cm depth, with no assessment of type or amount of exudate or the condition of the wound bed (wound had declined). The Physician was not notified and the wound care was not changed. Upper Sacrum-Stage III, did not include measurements only assessment read changed to unstageable. Review of the Facility Weekly Pressure sore Log dated 02/17/2015 reflected the following measurements: Left Ischial-Stage IV, 6.5 x 5.5 cm, unable to determine depth, with an odor and drainage.(incomplete assessment) Left Hip-Stage IV, 3.5 x 4.5 cm, 1.5 cm depth, with drainage and no odor. (incomplete assessment) Right Hip-Stage IV, 2 x 4 cm, 1.5 cm depth, with drainage. (incomplete assessment) Right Ischial-Stage IV, 7 x 8 cm, 1.0 cm depth, with drainage. (incomplete assessment) Upper Sacrum-Stage III, no measurements, no documentation of drainage or odor. (incomplete assessment) Review of the Weekly sore Record revealed Resident # 5 was seen at the wound care clinic on 02/18/2015. No documentation of measurements were found in Client # 5's clinical record. In an interview on 03/02/2015 at 8:45 AM, the DON stated the facility had not received any measurements of wounds being treated by the wound care clinic since Resident # 5 had started going to the wound care clinic on 01/28/2015. No other measurements were documented on the Weekly Pressure sore Record from 02/11/2015 until Resident # 5 was discharged to the hospital on [DATE]. Review of notes dated 03/12/2015, written by the MDS Coordinator during the Weekly Pressure Sore Meeting, reflected Resident # 5 had a Stage III Pressure Sore to the Sacrum which measured 2.5cm x 2.5 cm (no depth, drainage or odor documented). In an interview on 03/02/2014 at 3:40 PM, the Treatment Nurse stated she did not call the Wound Care Clinic when Resident # 5's pressure sores increased in size, since he was being seen by the physician at the Wound Care Clinic. She also stated she did not measure and document undermining in the wounds, the type/amount of exudate, or the condition of the wound bed, stating she knew the Wound Care Clinic was seeing Resident # 5. Review of nurses notes dated 02/23/2015 at 2:44 PM reflected Resident was transferred to the hospital for treatment related to osteomylitis (Bone Infection). Review of the initial skin assessment conducted at the hospital on [DATE] at 3:23 PM by the hospital Wound Care Nurse reflected the following: Left Ischial-Stage IV, Full Thickness, 8 x 7.5 cm, 3 cm depth, with Moderate amount of Serosanguineous drainage with a mild odor, with a yellow, gray slough and bone visible. (Decline since last facility assessment on 02/17/2015) Left hip-Stage IV, 13 x 8 cm, 2.5 cm depth, wound bed yellow gray slough 20% , undermining 2-12 cm, large amount purulent (containing pus) serosanguineous drainage. (decline, wound has increased in size from 6.5 x 5.5 cm and now has undermining around wound) Right Hip-Stage IV, 8 x 7 cm, 2 cm depth, wound bed slough (50%), undermining from 1 to 11 cm, large amount of purulent Serosanguineous fluid. (decline, wound has increased from 2 cm x 4 cm and from no undermining documented on 02/17/2015 to 1cm to 11 cm around the wound). Right Ischial-Stage IV, 5 x 2.5 cm, 1 cm depth yellow gray slough 50 %, with moderate serosanguineous drainage. (decline no slough documented on 02/17/2015 assessment) Upper Sacrum-Stage IV, 5 x 7 cm, 0.3 depth, 100% yellow gray slough, large mount of purulent serosanguineous drainage. (decline, area previously measured at 2.5 x 2.5 cm) In an interview on 03/02/2015 at 8:45 AM, the DON stated she expected the Treatment Nurse to perform a complete assessment of every resident with a pressure sore, at least weekly, to include, the length, width and depth in the wound, measurement of any undermining, the condition of the wound bed, and the type and amount of exudate. The DON stated she also expected the Treatment Nurse to notify her if the wounds were getting worse so an RN could reassess the wound, and to notify the physician of any decline in wound status. She also stated that she expected the Treatment Nurse to call the Wound Care Clinic daily after a visit until new orders are received. Review of the facility Skin Assessment Policy revised 6/11 reflected the following: Weekly Monitoring .5. The treatment nurse will administer daily wound care Monday thru Friday to all residents that have wounds. The charge nurses will administer treatments on the weekend. 6. Physicians will be notified of pressure sore changes and improvements as needed by the treatment nurse. After 2 weeks of daily wound care, with no noted improvement to the wound, the physician will be notified, and a change of treatment will be requested. After 7 days of daily wound care, if there is a decline in the resident's wound, the physician will be notified as well . Regardless of resident's risk for pressure sore status, all residents will have weekly skin assessments done . The facility provided a list of three (3) current residents with pressure sores.

Based on observation, interview and record review the facility failed to ensure that a resident having pressure sores received necessary treatment and services to promote healing and prevent the further decline of pressure sores for one (1) of one (1) residents (Resident # 5) receiving services from the Wound Care Clinic when: The Treatment Nurse failed to perform complete weekly wound assessments and notify the physician of a decline in Resident # 5's wound status between 02/04/2015 and 02/17/2015, so that new orders could be received and implemented to promote healing. Resident # 5's Left Ischial pressure sore was increasing in size from 6 cm x 5.3 cm to 6 cm x 7 cm and increasing from a small to large amount of exudate, the Left hip increased in depth from 1.0 cm to 1.5 cm, the Right Ischial increased from 5 cm x 6 cm to 7 cm x 8 cm, and the upper sacrum went from a Stage III pressure sore to being unstageable. The Treatment Nurse failed to follow up with the Wound Care Clinic to obtain treatment orders when the facility had not received orders for treating Stage III and Stage IV Pressure Sores from 01/28/2015 to 02/04/2015, which resulted in a decline of Resident # 5's Left Ischial increasing in size from 6 cm x 5.3 cm to 6 cm x 7 cm and going from a small amount of serosanguinesous exudate, to a large amount of exudate. The Treatment Nurse failed to accurately transcribe orders dated 02/04/2015, which were sent to the facility on [DATE] by the Wound Care Clinic, which resulted in the facility staff failing to implement the order to irrigate Stage III pressure sores to the Right Ischial (buttocks), and the Upper Sacrum (upper buttocks) and Stage IV pressure sores to the Left Ischial, Left Hip and the Right hip. From 02/04/2015 until his hospitalization [DATE], Resident # 5's Stage III wound to Right Ischial declined to a Stage IV, a Stage III to the upper sacrum declined to a Stage IV, and a Stage IV wound to the Left Ischial depth declined from being able to feel bone, to bone being exposed This deficient practice placed three (3) current residents with pressure sores at risk for the development of new pressure sores, infection, and worsening of current pressure sores. Findings Include: Review of Resident # 5's Face Sheet reflected a [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with the following Diagnosis: [REDACTED]. Review of the readmission assessment dated [DATE] reflected the following: Left Ischial-Stage IV-6 cm x 5.3 cm, unable to determine depth-bone could be felt when touched, Small amount serosanguineous exudate, wound bed red and yellow. Left Hip-Stage IV-5 x 5.5 cm, 1 cm depth, undermining from 5 to 7 o'clock up to 2 cm, and from 10-12 o'clock up to 2.4 cm, moderate amount of Serosanguineous exudate, wound bed red. Right Hip-Stage IV-2.5 x 6 cm, 1.5 cm depth, undermining from 11-2 o'clock up to 3.7 cm, moderate amount of serosanguineous exudate, wound bed red. Right Ischial-Stage III-6 x 5 cm, unable to determine depth, small amount of serosanguineous exudate, wound be red and yellow. Upper Sacrum-Stage III- 2 x 1 cm, no depth, scant amount of serosanguineous exudate, with a red and yellow wound bed. Review of Resident # 5's most recent significant change in status MDS assessment dated [DATE] reflected Resident # 5 had a BIMS score of 9 which indicated moderate cognitive impairment. The assessment reflected Resident # 5 had one (1) Stage II Pressure Sore (Partial thickness loss of dermis presenting as a shallow open sore with a red pink wound bed without slough), three (3) Stage III Pressure Sores (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present, but does not obscure the depth of tissue loss. May include undermining), and three (3) Stage IV Pressure Sores (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining.) with the current pressure sore treatments of a pressure reducing device for the chair and bed, nutrition or hydration intervention to manage skin problems, and pressure sore care. Review of Resident # 5's Comprehensive Care Plan dated 01/22/2015 reflected Resident # 5 was readmitted to the facility on [DATE] with multiple pressure sores, and interventions which included: Treatments as ordered by the physician. The Care Plan was updated 02/05/2015 with interventions including new treatment orders from the Wound Care Clinic for the pressure sores, notify the physician and family as needed, medications as ordered for pain, and notify the physician if pain is uncontrolled. Observation on 02/27/2015 at 2:45 PM revealed Resident # 5 was admitted to the hospital. During the observation Resident # 5 did not respond when asked questions by the surveyor. Resident # 5 was on a speciality bed and had 4 [DEVICE] (vacuum and speciality dressing at the wound site that helps to remove infectious materials and actively promote granulation) in place. In an interview on 02/27/2015 at 2:50 PM the Hospital Wound Care Specialist Nurse stated, Resident # 5 had a wound vac applied on 02/26/2015 after debridement was done to the following areas: right hip, right ischeal, left hip and left ischeal. Review of Resident # 5's readmission physicians orders with a start date of 01/22/2015 reflected the following treatment for [REDACTED]. An additional order received on 01/21/2015 for Resident # 5 to have a referral to the wound care clinic. Review of the nurses notes dated 01/28/2015 at 3:42 PM reflected Resident # 5 had returned from the wound care clinic (initial visit), without treatment orders. Further review of Resident # 5's nurses notes revealed no documentation the wound care clinic had been called to obtain treatment orders after Resident # 5 was evaluated at the Wound Care Clinic. In an interview on 02/26/2015 at 4:00 PM, the Treatment Nurse stated she had called the Wound Care Clinic on 01/30/2015 ( two days after the appointment) to obtain treatment orders for Resident # 5's pressure sores. She stated she was told by a Wound Care Clinic employee the orders were not ready and would be sent out as soon as the physician had written the orders. The Treatment Nurse stated she did not make any other attempts to obtain treatment orders from the Wound Care Clinic or notify the Primary Physician of her inability to obtain wound care orders for Resident # 5. The Treatment Nurse stated she did not receive new treatment orders from the Wound Care Clinic until 02/04/2015. The Treatment Nurse stated since the wounds had already been treated on 02/04/2015, the new orders were not initiated by the Treatment Nurse until 02/05/2015 (8 days after the initial Wound Care Clinic appointment). Review of the wound care clinic orders dated 01/28/2015 were noted as received by the Wound Care Clinic nurse on 02/02/2015 at 8:05 AM fax, reflected the following orders: Irrigate and cleanse (no specific solution to irrigate and clean) the right hip, sacral and left trochanteric pressure sores and apply [MEDICATION NAME] AG every day; Irrigate and cleanse (no specific solution to irrigate and clean) the left ischial pressure sore and apply Santyl and gauze daily; All dressing changes to be performed daily after cleansing and irrigation; Clinitron bed for treatment of [REDACTED]. Review of the telephone orders transcribed by the Treatment Nurse, 02/05/2015 and signed by Resident # 5's primary physician did not include the Wound Care Clinic physician's orders [REDACTED]. In an interview on 02/27/2015 at 2:15 PM, a Wound Care Clinic employee stated after reviewing their records the treatment orders from the initial visit on 01/28/2015 were faxed to the facility on [DATE] at 12:29 PM. The Wound Care Clinic employee stated the nursing home had called one time (01/30/2015) requesting new treatment orders. She also stated since 01/30/2015 the wound care clinic has not received any telephone calls from the nursing home regarding Resident # 5 with any concerns including wounds worsening. In an interview on 02/27/2015 at, at 3:45 PM, the Treatment Nurse stated she had found the orders from the Wound Care Clinic attached to a clip board on the treatment cart on 02/04/2015 for Resident # 5. The Treatment Nurse stated she wrote the orders for treatment, but since she had already completed treatments for the day, the new orders were not initiated until 02/05/2015. The Treatment Nurse stated after reviewing the orders from the Wound Care Clinic she had failed to write to irrigate each wound prior to applying the new dressing. The Treatment Nurse stated, I just missed that part of the order. The Treatment Nurse stated she cleansed the wounds with would cleanser, but did not irrigate the wounds. Review of the Weekly Pressure Ulcer Record reflected the facility failed to document any skin assessment until 02/04/2015 (14 days after the initial assessment) with the following assessment: Left Ischial-Stage IV, 6 x 7 cm, unable to determine depth, with a large amount of exudate (no type documented), red and yellow bed, no mention of bone. (wound had declined) Physician was not notified and the new orders from 02/02/2015 had not been implemented. Left Hip-Stage IV, 4 x 3 cm, 1 cm depth with no description of type/amount of exudate, condition of the wound bed or measurement of the undermining. (incomplete assessment). Right hip-Stage IV, 2 x 3.5 cm, 1.5 cm in depth with no description of type/amount of exudate, condition of the wound bed or measurement of the undermining. (incomplete assessment) Right Ischial-Stage III, 4 x 6 cm, and 1 cm in depth with no description of type/amount of exudate, condition of the wound bed (incomplete assessment) Upper Sacrum-Stage III, 1.0 x 1.0 and no depth, with no description of type/amount of exudate, or condition of the wound bed. (incomplete assessment) <http://www.hopkinsmedicine.org.gec/series/wound_care.html reflected, An assessment of the wound should be done weekly and be used to drive treatment decisions. Wound assessment includes: location, class/stage, base tissues, exudates, odor, edge/perimeter, pain and an evaluation for infection. Review of the Weekly Pressure Ulcer Record dated 02/11/2015 reflected the following: Left Ischial-Stage IV, 6.5 x 5.5 cm, unable to determine depth, with no assessment of type or amount of exudate, condition of the wound bed or mention of the bone. (incomplete assessment) Left Hip-Stage IV, 3.5 x 4.5, 1.5 cm depth, underming up to 3.5 cm, with no assessment of type or amount of exudate, or the condition of the wound bed. (wound had declined; there was an increase in undermining). The Physician was not notified and the wound care was not changed. Right Hip-Stage IV, 2 x 4 cm, 1.5 cm depth, undermining up to 3.5 cm with no assessment of type or amount of exudate, or the condition of the wound bed (wound had declined.) The Physician was not notified and the wound care was not changed. Right Ischial-Stage IV, 7 x 8 cm, 1.0 cm depth, with no assessment of type or amount of exudate or the condition of the wound bed (wound had declined). The Physician was not notified and the wound care was not changed. Upper Sacrum-Stage III, did not include measurements only assessment read changed to unstageable. Review of the Facility Weekly Pressure Ulcer Log dated 02/17/2015 reflected the following measurements: Left Ischial-Stage IV, 6.5 x 5.5 cm, unable to determine depth, with an odor and drainage.(incomplete assessment) Left Hip-Stage IV, 3.5 x 4.5 cm, 1.5 cm depth, with drainage and no odor. (incomplete assessment) Right Hip-Stage IV, 2 x 4 cm, 1.5 cm depth, with drainage. (incomplete assessment) Right Ischial-Stage IV, 7 x 8 cm, 1.0 cm depth, with drainage. (incomplete assessment) Upper Sacrum-Stage III, no measurements, no documentation of drainage or odor. (incomplete assessment) Review of the Weekly Ulcer Record revealed Resident # 5 was seen at the wound care clinic on 02/18/2015. No documentation of measurements were found in Client # 5's clinical record. In an interview on 03/02/2015 at 8:45 AM, the DON stated the facility had not received any measurements of wounds being treated by the wound care clinic since Resident # 5 had started going to the wound care clinic on 01/28/2015. No other measurements were documented on the Weekly Pressure Ulcer Record from 02/11/2015 until Resident # 5 was discharged to the hospital on [DATE]. Review of notes dated 03/12/2015, written by the MDS Coordinator during the Weekly Pressure Sore Meeting, reflected Resident # 5 had a Stage III Pressure Sore to the Sacrum which measured 2.5cm x 2.5 cm (no depth, drainage or odor documented). In an interview on 03/02/2014 at 3:40 PM, the Treatment Nurse stated did not call the Wound Care Clinic when Resident # 5's pressure sores increased in size, since he was being seen by the physician at the Wound Care Clinic. She also stated she did not measure and document undermining in the wounds, the type/amount of exudate, or the condition of the wound bed, stating she knew the Wound Care Clinic was seeing Resident # 5. Review of nurses notes dated 02/23/2015 at 2:44 PM reflected Resident was transferred to the hospital for treatment related to osteomylitis (Bone Infection). Review of the initial skin assessment conducted at the hospital on [DATE] at 3:23 PM by the hospital Wound Care Nurse reflected the following: Left Ischial-Stage IV, Full Thickness, 8 x 7.5 cm, 3 cm depth, with Moderate amount of Serosanguineous drainage with a mild odor, with a yellow, gray slough and bone visible. (Wound had declined since last facility assessment on 02/17/2015) Left hip-Stage IV, 13 x 8 cm, 2.5 cm depth, wound bed yellow gray slough 20% , undermining 2-12 cm, large amount purulent (containing pus) serosanguineous drainage. (wound had declined, wound has increased in size from 6.5 x 5.5 cm and now has undermining around wound) Right Hip-Stage IV, 8 x 7 cm, 2 cm depth, wound bed slough (50%), undermining from 1 to 11 cm, large amount of purulent Serosanguineous fluid. (wound had declined, wound has increased from 2 cm x 4 cm and from no undermining documented on 02/17/2015 to 1cm to 11 cm around the wound). Right Ischial-Stage IV, 5 x 2.5 cm, 1 cm depth yellow gray slough 50 %, with moderate serosanguineous drainage. (wound had declined - no slough documented on 02/17/2015 assessment) Upper Sacrum-Stage IV, 5 x 7 cm, 0.3 depth, 100% yellow gray slough, large mount of purulent serosanguineous drainage. (wound had declined - area previously measured at 2.5 x 2.5 cm) In an interview on 03/02/2015 at 8:45 AM, the DON stated she expected the Treatment Nurse to perform a complete assessment of every resident with a pressure sore, at least weekly, to include, the length, width and depth in the wound, measurement of any undermining, the condition of the wound bed, and the type and amount of exudate. The DON stated she also expected the Treatment Nurse to notify her if the wounds were getting worse so an RN could reassess the wound, and to notify the physician of any decline in wound status. She also stated that she expected the Treatment Nurse to call the Wound Care Clinic daily after a visit until new orders are received. Review of the facility Skin Assessment Policy revised 6/11 reflected the following: Weekly Monitoring .5. The treatment nurse will administer daily wound care Monday thru Friday to all residents that have wounds. The charge nurses will administer treatments on the weekend. 6. Physicians will be notified of pressure ulcer changes and improvements as needed by the treatment nurse. After 2 weeks of daily wound care, with no noted improvement to the wound, the physician will be notified, and a change of treatment will be requested. After 7 days of daily wound care, if there is a decline in the resident's wound, the physician will be notified as well . Regardless of resident's risk for pressure ulcer status, all residents will have weekly skin assessments done . The facility provided a list of three (3) current residents with pressure sores.

Based on observation, interview and record review, the facility failed to promptly notify or consult the physician when there was a significant change in the Resident's physical, mental or psychosocial status and of a need to alter treatment significantly for one (1) of three (3) residents (Resident #1) reviewed for indwelling catheters. B.) Resident #1 received a tear to his urethral meatus and bruising to his penis. Resident #1's Physician was not notified immediately resulting in worsening of the urethral tear causing urethral erosion to the base of his penis. This deficient practice five (5) residents at risk for urethral erosion, urethral pressure sores, infection,[MEDICAL CONDITION], surgical repair and pain. Findings Include: Review of Resident #1's Face Sheet reflected a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #1's Significant Change Minimum Data Set (MDS) dated 11/18/2013 reflected Resident #1's Brief Interview for Mental Status (BIMS) score was three (3) out of 15 indicating Resident #1 was had severe cognitive impairment. Resident #1 was coded to not have any behaviors. Resident #1 was coded to require extensive one (1) person physical assist with bed mobility, locomotion, and eating. Resident #1 was coded to require total dependence of two (2) staff for transfers. Resident #1 was coded to require total dependence of one (1) staff for dressing and personal hygiene. Resident #1 was coded to have an indwelling urinary catheter. Resident #1 was coded to be at risk for developing pressure ulcers and was coded to have one Unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan gray, green or brown) and/or eschar (tan, brown or black) in the wound bed pressure ulcer measuring 4.5 centimeters (cm) length by 2.7 cm width, with tissue type coded as eschar. B.) Review of Resident #1's Comprehensive Care Plan dated07/31/2013 and revised 08/20/2013 reflected "Has indwelling catheter d/t (due to) dx (diagnosis) benign blockage of prostrate and is prone to leakage and plugging. Resident Foley Catheter noted leaking prior to admission. 11/11/2013 Resident has tear and bleeding at the urethral meatus. Cause noted as "undetermined" with potential to be from Foley catheter ...Resident's tear to urethral meatus to resolve without complications x 14 days. Resident will not have further complications from Foley catheter positioning x 90 days." Resident #1's Comprehensive Care Plan further reflected Resident #1 required total assistance with transfers with assist of two staff plus stand up lift. Review of Resident #1's Consolidated Physician Orders dated 12/03/2013 reflected "Foley Cath. care every shift and as needed. Start date 07/30/2013. "Change Foley Cath. 18 French 5 milliliters every two (2) weeks (sterile insertion tray and change drainage bag). Start date 11/20/2013." "Use cath secure as needed to prevent further urethral erosion. Start date 11/11/2013." Observation on 12/3/2013 at 9:25 AM revealed Resident #1 up in a wheelchair. Resident #1 was noted to have a urinary catheter extending out of the leg of his pants and hanging in a privacy bag on the back of his wheelchair. Resident #1 was alert but unable to answer questions. In an interview on 12/3/2013 at 9:30 AM during initial tour the Administrator stated Resident #1 had a meatus tear from pulling on his Foley. The Administrator further stated the only behavior Resident #1 had was yelling out at times. The Administrator stated Resident #1 was transferred with mechanical lift with assist of two staff members. Review of Resident #1's Patient Progress Notes dated 11/10/2013 at 3:00 PM reflected " Penis meatus split d/t (due to) pulling of Foley catheter, noted bloody small drainage. Wife informed. Area clean with soap and water and dried well, denies pain or discomfort. WCTM (will continue to monitor). " Note was signed by LVN E. In an interview on 12/5/2013 at 10:15 AM Resident #1's Nurse Practitioner (NP) stated she was made aware of Resident #1's urethral meatus tear on Monday 11/11/2013 and was not aware how the injury happened. Resident #1's NP stated she expected the nurses to call her immediately with such an injury. Review of Resident #1's NP Progress Notes dated 11/11/2013 at 3:47 PM reflected "seen today at the request of the patient's wife for evaluation of his urethral meatus. Staff reports that over the weekend, he was noted to have bleeding and a tear at the urethral meatus. Cause is undetermined, but presumed likely to Foley catheter. The patient has not verbalized any pain, though his dementia is quite advanced. Brief was opened, and a small amount of blood noted. The penis shows a urethral tear down to the base of the penis. Bruising noted. Tenderness noted to palpation. Foul odor noted. A/P (Assessment/ Plan): Urethral tear. Urology is able to get him in immediately, therefore, will make arrangements for him to be transferred there for further evaluation." Review of Resident #1's Incident and Accident Reports for November reflected no incident/ accident report for 11/10/2013 or 11/11/2013 regarding Resident #1's urethral meatus tear. Review of Resident #1's Urology Progress Note, no date, reflected "Pt. (patient) with cath here today for evaluation d/t (due to) urethral erosion ... urethral erosion to base of penis. Mild. Blood oozing. No foul drainage or discharge. Urethral erosion secondary to Foley cath. Use cath secure to reduce pressure from Foley, change cath q (every) two (2) weeks." Review of Resident #1's Urology Progress Note dated 11/12/2013 at 6:23 AM reflected "Patient appears to have experienced trauma to cath site. I recommended cath secure device be used to avoid further pulling on catheter. I warned against use of constrictive securing devices. I also ordered cath change every two weeks." Review of the website: <http://www.ncbi.nlm.nih.gov/pubmed/ 992> reflected "Medical devices often are overlooked as a potential cause of pressure ulcers. Indwelling urinary catheters have been described as a cause of urethral erosion. In men, the resultant partial-thickness or full-thickness wound can involve a small area of the glans penis or cleave the glans or penile shaft, requiring reconstructive surgery or urinary diversion. This complication can be prevented by securing the Foley to the patient with tape, ensuring that the drainage system is properly supported, and by attention to patient position." Review of Resident #1's NP Progress note dated 11/14/2013 at 10:20 AM "Brief was opened, and a small amount of blood noted. The penis shows a urethral tear down to the base of the penis. Bruising improved. Torn area without significant redness. Assessment/ Plan : Monitor for infection. He has been evaluated by urology." In an interview on 12/4/2013 at 11:10 AM Resident #1's Wife stated she comes to see her husband everyday around lunch time. Resident #1's Wife stated Resident #1 does not pull on his Foley. Resident #1's Wife stated she did not know what happened but she stated Resident #1 did not pull on his Foley. Observation on 12/05/2013 at 2:45 PM revealed Resident #1 would not let surveyor observe urethral tear. In an interview on 12/05/2013 at 1:25 PM LVN E stated Resident #1's urethral tear happened during a transfer on 11/10/2013. LVN E stated the aides called her to the room to evaluate Resident #1 after the incident. LVN E further stated she did not call the Physician because the split was small. LVN E further stated that the tear had increased by the next day and was bigger. LVN E stated she did not do an incident report or report the incident on 11/10/2013. In an interview with the Administrator on 12/5/2013 at 2:30 PM the Administrator stated the incident regarding Resident #1's urethral tear should have been investigated related to the undermined ethology of the tear. The Administrator stated she was unaware Resident #1's urethral tear occurred during a transfer. The Administrator stated it was " tragic " that the incident happened. Review of the Facility Policy Catheter Care (Indwelling Catheter), no date indicated, reflected "Basic Responsibility: Licensed Nurse. Purpose: To prevent infection. To reduce irritation. General Documentation Guidelines: condition of the perineum and catherter insertion site, any unusal condition or change in condition, color, amount, consistency and odor of urine. Notification of the physician of any condition change." The facility provided CMS Form 672 that reflected five (5) residents with pressure sores and CMS Form 802 that reflected five (5) male residents with indwelling urinary catheters.

Based on observation, interview and record review the facility failed to ensure one (1) of six (6) Residents (Resident #1) reviewed for pressure sores received necessary treatment and services to promote healing, and once developed, failed to ensure necessary treatment and services to promote healing. Resident #1 developed a pressure sore to his left heel on 09/25/2013. Resident #1's Physician was not notified and treatment was not initiated till 10/28/2013 and Resident #1 had dietary recommendations for would healing not carried out for 16 days resulting in worsening of Resident #1's left heel pressure sore. This deficient practice affected one (1) resident and placed five (5) residents at risk for developing new or worsening pressure sores, [MEDICAL CONDITION] (skin infection), [DIAGNOSES REDACTED] (infection of the bone),[MEDICAL CONDITION] (infection of the blood), severe pain and death. Findings Include: Review of Resident #1's Face Sheet reflected a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #1's Significant Change Minimum Data Set (MDS) dated 11/18/2013 reflected Resident #1's Brief Interview for Mental Status (BIMS) score was three (3) out of 15 indicating Resident #1 was had severe cognitive impairment. Resident #1 was coded to not have any behaviors. Resident #1 was coded to require extensive one (1) person physical assist with bed mobility, locomotion, and eating. Resident #1 was coded to require total dependence of two (2) staff for transfers. Resident #1 was coded to require total dependence of one (1) staff for dressing and personal hygiene. Resident #1 was coded to be at risk for developing pressure ulcers and was coded to have one Unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan gray, green or brown) and/or eschar (tan, brown or black) in the wound bed pressure ulcer measuring 4.5 centimeters (cm) length by 2.7 cm width, with tissue type coded as eschar. Review of Resident #1's Comprehensive Care Plan dated 07/31/2012 and revised 11/26/2013 reflected "Potential for skin breakdown related to impaired mobility, impaired cognition, DX. (Diagnosis) CAD ([MEDICAL CONDITION]), DX. A fib ([MEDICAL CONDITION] Fibrillation), incontinence of bowel and bladder, history of pressure ulcers ...10/28/2013 Stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling) to left heel ... 1.4 cm length x 1.2 cm width x 0.2 cm depth. 11/18/2013 Resident and wife preferred use of shoe that fit foot tightly complicating decubitus ulcer on left heel. Noted moderate amount of yellow drainage with measurement 6.5 cm length x 4.5 cm width." Tissue described as "dark and necrotic with macerated edges. Redness and increased warmth are noted to the medial aspect near the ankle... Presence of [MEDICAL CONDITION]." Handwritten on the care plan "Left heel now noted as unstageable. 11/26/2013 unstageable pressure ulcer to the left heel measures 6.0 cm x 4.0 cm x UTD (undetermined depth)." Review of Resident #1's Braden Score (Pressure Ulcer Risk Score, a score of 16 or less indicated high risk for pressure sore development and interventions should be put into place) was 18 on 09/15/2012 and indicated the Resident was not at high risk for pressure sores. Resident #1's Braden Score was 14 on 08/11/2013 and indicated the Resident was at high risk or pressure sore development. Observation on 12/3/2013 at 9:25 AM revealed Resident #1 up in wheelchair. Resident #1's left foot was observed to be in a Multi Podus boot (Multi podus boots are sometimes spelled Mulit podis boots. These boots are used primarily for decubitus ulcer healing, wound care, contracture management and ankle/foot stabilization.). Resident #1 was alert but unable to answer questions. Review of Resident #1's Consolidated Physician order [REDACTED]. Start date 11/18/2013." "Heel protectors on at HS (hour of sleep) start date 10/28/2013." "Apply Multi Podus boot to left foot at all times. Start date 11/18/2013." Review of Resident #1's Consolidated Physician order [REDACTED]. Review of Resident #1's Nursing Skin Report dated 09/25/2013 reflected "left heel with yellow slough 1 cm x 0.5 cm" no depth or stage was indicated. Report was signed by Registered Nurse (RN) B. Review of the <http://www.medleague.com/blog/2013/11/14/key-points-for-pressure-ulcer-staging-and-documentation/> ; website reflected "Slough and eschar (types of dead tissue) will only form in full thickness wounds, not partial thickness wounds, indicating a Stage III or IV." In an interview on 12/05/2013 at 9:20 AM RN B stated there was a pressure sore to Resident #1's left heel as indicated by the Nursing Skin Report dated 09/25/2013. RN B stated she did not call the physician because she came in late in the evening to get caught up with the weekly skin checks. RN B stated she told the charge nurse when she found a new skin condition so the charge nurse could put the information on the 24 hour report sheet. RN B further stated "I guess" when asked if she reported Resident #1's left heel on 09/25/2013. In an interview on 12/05/2013 at 9:25 AM the Director of Nursing (DON) stated the charge nurse on 09/25/2013 was Licensed Vocational Nurse (LVN) D. In an interview on 12/5/2013 at 2:15 PM LVN D stated the person who fills out the skin sheet is responsible for notifying the physician, getting orders and initiating treatment for [REDACTED].#1's area to his left heel. Review of the 24 hour report sheets for 09/25/2013 and 09/26/2013 reflected no documentation for Resident #1's left heel pressure sore. Review of Resident #1's Physician Telephone orders from 09/25/2013 through 10/28/2013 reflected no orders for treatment for [REDACTED]. Review of Resident #1's Treatment Administration Record (TAR) for September 2013 reflected a hand written entry "Heel Protectors on while in bed" dated 09/26/2013. Review of Resident #1's TAR for October 2013 reflected no entry for heel protectors while in bed. Review of the Skin Meeting dated 10/02/2013 reflected an entry for Resident #1 "Left heel yellow slough will recheck." Skin Meeting was signed by the DON, MDS Coordinator, RN C and LVN E. Review of Resident #1's Nursing Skin Report from 10/04/2013 through 10/25/2013 reflected no documentation of Resident #1's left heel pressure sore. Review of Resident #1's Nursing Skin Report for week of 11/04/2013 reflected an entry dated 10/28/2013 for a Stage III pressure sore to Resident #1's left heel. Review of Resident #1's Weekly Pressure Ulcer Record dated 10/28/2013 reflected an entry dated 10/28/2013 for a Stage III pressure sore "1.4 cm length by 1.2 cm width and 0.3 cm depth, with purulent exudate with a yellow wound bed. The evaluation was checked as an initial evaluation with a handwritten entry "small open ulcer... thin yellow tissue..." The assessment was signed by LVN E. Review of Resident #1's Physician Telephone orders dated 10/28/2013 no time indicated reflected "Heel protectors at HS, Stage III left heel, Clean with wc (wound cleanser), pat dry, apply santyl oint, foam, kerlix and secure." Review of Resident #1's Weekly Pressure Ulcer Record dated 11/05/2013 reflected an assessment of Resident #1's left heel pressure sore "Stage III 1.5 cm by 1.5 cm by UTD (undetermined depth) with senosanguineous exudate with a red/ yellow wound bed and white/gray pallor for surrounding skin color, full thickness, 70% red tissue, 30 % slough." The assessment was signed by LVN E. Review of Resident #1's Nutritional assessment dated [DATE] reflected "Wt. (weight) down 7.2 lbs. Then update with weight down 12.1 lbs. for the quarter and significant at 8.1 % and also notified of a recent Stage III on Left heel 10/29/2013 [MEDICATION NAME] WNL (within normal limits) with H &H (hemoglobin and hematocrit) down. Is on shakes TID, Vitamin C, B12 and [MEDICATION NAME]. Will request to give super cereal at breakfast, a multivitamin and Juven (Juven is a unique blend of 3 key ingredients: ReVigor (a source of HMB) and the conditionally-essential amino acids [MEDICATION NAME], and [MEDICATION NAME]. These ingredients help build lean body mass to support healing) one packet with 6 oz (ounce) water BID (twice daily) for two (2) wks. (weeks)." Assessment signed by the RD (Registered Dietician) Review of Resident #1's Weight Change Notification to Resident #1's Physician dated 11/06/2013 reflected "Weight 8/2013 149.3lb, Weight 11/2013 137.2 lb. Weight down.. and Stage III Decub (decubitus) may we: 1.) give super cereal at breakfast. 2.) A Multivitamin with minerals 3.) Juven one packet with 6 oz. H20 (water) BID times two (2) weeks." Resident #1's Physician responded on Weight change Notification "ok" dated 11/14/2013. The facility signed the notification as received 11/22/2013. Notification was signed by the RD. Review of Resident #1's Physician Telephone Orders from 11/06/2013 to 11/22/2013 reflected an order written [REDACTED]. water BID times two (2) weeks. Review of Resident #1's MAR (Medication Administration Record) for November 2013 reflected the Physician orders [REDACTED]. Review of Resident #1's Weekly Pressure Ulcer Record dated 11/12/2013 reflected left heel pressure sore was checked as unstageable with measurements: 2.7 cm by 4.5 cm with UTD. An handwritten entry on the assessment reflected "Area that was macerated now open, wound larger ...80% yellow slough, 20% red dark tissue." Date physician notified was documented on the assessment as 11/8/2013. The assessment was signed by LVN E. Review of Resident #1's Progress Note dated 11/14/2013 at 10:04 AM reflected Resident #1 seen for worsening decubitus ulcer and poor intake. "His wife reports that the patient doesn' t like the food his is served... Nutritionist has been consulted. " Review of Resident #1's Physician Telephone order dated 11/14/2013 reflected "Refer to Dr. (wound care physician) for Stage III decubitus to heel. Prostate AWC ( A wound care supplement.) 30 ml (milliliters) PO (by mouth) daily for decub (decubitus), Zinc 220 mg one PO daily." Review of Resident #1's Progress Note dated 11/18/2013 at 10:29 AM reflected "seen today to follow up on decubitus ulcer to left heel. The patient has not complained of pain, but his dementia is quite advanced, and he rarely complains ... The dressing was removed from the left heel and showed a moderate amount of yellow discharge. The wound to heel is significantly worse than three days ago, and now measures approximately 6.5 cm x 4.5 cm. The tissue is dark and necrotic with macerated edges. There is redness and increased warmth to the medical aspect near the ankle. Decubitus ulcer, unstageable, with [MEDICAL CONDITION]: worsening. Appointment is scheduled with podiatry this afternoon for further evaluation." Progress Note was signed by NP. Review of Resident #1's Physician Telephone order dated 11/18/2013 at 3:00 PM reflected "wash with soap and water daily, rinse, and dry left foot wound. Apply [MEDICATION NAME] to ulcer left foot, apply dry dressing (gauze and kerlix), Apply Multi Podus boot to left foot at all times." Ordered signed by the Podiatrist. In an interview on 12/04/2013 at 11:10 AM Resident #1's wife stated he went to see a Podiatrist about his sore on his left heel. Resident #1's Wife stated the sore on Resident #1's heel just keeps getting worse. Observation on 12/04/2013 at 3:00 PM revealed Resident #1 up in wheelchair. LVN E removed Resident #1's multi-podus boot to left foot. Resident #1 had an unstageable pressure sore to his left heel approximately 7 cm by 5 cm area of black eschar with 1 cm of white/gray macerated peri-wound. LVN E wiped Resident #1's left heel with normal saline then applied [MEDICATION NAME] solution to area and applied gauze dressing and wrapped with kerlix. Approximation made by surveyor. In an interview on 12/05/2013 at 9:30 AM the DON stated LVN E stages all pressure sores in the facility and the pressure sores are reviewed in the weekly skin meetings. The DON did not recall if Resident #1's left heel pressure sore was reported to her on 09/25/2013. In an interview on 12/05/2013 at 10:00 AM Resident #1's Nurse Practitioner (NP) stated she was not made aware of Resident #1's left heel pressure sore till 10/28/013. The NP further stated Resident #1 had rapid progression of the left heel pressure sore and was sent to a Podiatrist for follow up. The NP stated it would have been nice to know about the pressure sore when it first developed. The NP further stated she should have been made aware right away. In an interview on 12/05/2013 at 1:25 PM LVN E stated she did not see Resident #1's left heel pressure sore when doing weekly skin checks from 10/04/2013 through 10/25/2013. LVN E stated she first noted Resident #1's left heel pressure sore and it was open with slough in the wound when it was found. LVN E stated "It was bad". LVN E stated she staged all pressure sores when she is at the facility. She stated she tells the DON during the weekly skin meeting and the DON will look at the wounds. In an interview on 12/05/2013 at 2:30 PM the Administrator stated she expected the nurses to notify the physician immediately when a resident has a change of condition. In an interview on 12/05/2013 at 4:23 PM the DON stated she did not have an assessment of Resident #1's left heel pressure sore completed during weekly skin meeting. The DON stated "I guess I blew it, I should have done an assessment on 10/02/2013 during the skin meeting." Review of the Facilities Policy Pressure ulcer Preventive Measures Policy "Residents at risk for the development of pressure ulcers (score of 18 or less on the Braden Scale section of the Resident Data Set) receive interventions to reduce the risk of pressure ulcers, and a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the resident's clinical condition demonstrates that they are unavoidable; and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and reduce the risk of new pressure ulcers developing ... A Licensed Nurse will assess each resident from head to toe weekly to identify any new pressure ulcers ...The physician and family must be notified ...The physician must be notified every two (2) weeks of the status of the wound or immediately in the event of a decline." The facility provided 672 reflected five (5) residents with pressure sores.

Based on observation, interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for one (1) of three (3) residents (Resident #1) reviewed for indwelling urinary catheters. Resident #1 received a tear to his urethral meatus and bruising to his penis. Resident #1's Physician was not notified immediately resulting in urethral erosion to the base of his penis. This deficient practice placed five (5) residents at risk for urethral erosion, urethral pressure sores, infection, sepsis, surgical repair and pain. Findings Include: Review of Resident #1's Face Sheet reflected a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #1's Significant Change Minimum Data Set (MDS) dated 11/18/2013 reflected Resident #1's Brief Interview for Mental Status (BIMS) score was three (3) out of 15 indicating Resident #1 was had severe cognitive impairment. Resident #1 was coded to not have any behaviors. Resident #1 was coded to require extensive one (1) person physical assist with bed mobility, locomotion, and eating. Resident #1 was coded to require total dependence of two (2) staff for transfers. Resident #1 was coded to require total dependence of one (1) staff for dressing and personal hygiene. Resident #1 was coded to have an indwelling urinary catheter. Review of Resident #1's Comprehensive Care Plan dated07/31/2013 and revised 08/20/2013 reflected "Has indwelling catheter d/t (due to) dx (diagnosis) benign blockage of prostrate and is prone to leakage and plugging. Resident Foley Catheter noted leaking prior to admission. 11/11/2013 Resident has tear and bleeding at the urethral meatus. Cause noted as "undetermined" with potential to be from Foley catheter ...Resident's tear to urethral meatus to resolve without complications x 14 days. Resident will not have further complications from Foley catheter positioning x 90 days." Resident #1's Comprehensive Care Plan further reflected Resident #1 required total assistance with transfers with assist of two staff plus stand up lift. Review of Resident #1's Consolidated Physician Orders dated 12/03/2013 reflected "Foley Cath. care every shift and as needed. Start date 07/30/2013. "Change Foley Cath. 18 French 5 milliliters every two (2) weeks (sterile insertion tray and change drainage bag). Start date 11/20/2013." "Use cath secure as needed to prevent further urethral erosion. Start date 11/11/2013." Observation on 12/3/2013 at 9:25 AM revealed Resident #1 up in a wheelchair. Resident #1 was noted to have a urinary catheter extending out of the leg of his pants and hanging in a privacy bag on the back of his wheelchair. Resident #1 was alert but unable to answer questions. In an interview on 12/3/2013 at 9:30 AM the Administrator stated Resident #1 had a meatus tear from pulling on his Foley. The Administrator further stated the only behavior Resident #1 had was yelling out at times. The Administrator stated Resident #1 was transferred with mechanical lift with assist of two staff members. Review of Resident #1's Patient Progress Notes dated 11/10/2013 at 3:00 PM reflected " Penis meatus split d/t (due to) pulling of Foley catheter, noted bloody small drainage. Wife informed. Area clean with soap and water and dried well, denies pain or discomfort. WCTM (will continue to monitor). " Note was signed by Licensed Vocational Nurse (LVN) E. In an interview on 12/5/2013 at 10:15 AM Resident #1's Nurse Practitioner (NP) stated she was made aware of Resident #1's urethral meatus tear on Monday 11/11/2013 and was not aware how the injury happened. Resident #1's NP stated she expected the nurses to call her immediately with such an injury. Review of Resident #1's NP Progress Notes dated 11/11/2013 at 3:47 PM reflected "seen today at the request of the patient's wife for evaluation of his urethral meatus. Staff reports that over the weekend, he was noted to have bleeding and a tear at the urethral meatus. Cause is undetermined, but presumed likely to Foley catheter. The patient has not verbalized any pain, though his dementia is quite advanced. Brief was opened, and a small amount of blood noted. The penis shows a urethral tear down to the base of the penis. Bruising noted. Tenderness noted to palpation. Foul odor noted. A/P (Assessment/ Plan): Urethral tear. Urology is able to get him in immediately, therefore, will make arrangements for him to be transferred there for further evaluation." Review of Resident #1's Incident and Accident Reports for November reflected no incident/ accident report for 11/10/2013 or 11/11/2013 regarding Resident #1's urethral meatus tear. Review of Resident #1's Urology Progress Note, no date, reflected "Pt. (patient) with cath here today for evaluation d/t (due to) urethral erosion ... urethral erosion to base of penis. Mild. Blood oozing. No foul drainage or discharge. Urethral erosion secondary to Foley cath. Use cath secure to reduce pressure from Foley, change cath q (every) two (2) weeks." Review of Resident #1's Urology Progress Note dated 11/12/2013 at 6:23 AM reflected "Patient appears to have experienced trauma to cath site. I recommended cath secure device be used to avoid further pulling on catheter. I warned against use of constrictive securing devices. I also ordered cath change every two weeks." Review of the website: <http://www.ncbi.nlm.nih.gov/pubmed/ 992> reflected "Medical devices often are overlooked as a potential cause of pressure ulcers. Indwelling urinary catheters have been described as a cause of urethral erosion. In men, the resultant partial-thickness or full-thickness wound can involve a small area of the glans penis or cleave the glans or penile shaft, requiring reconstructive surgery or urinary diversion. This complication can be prevented by securing the Foley to the patient with tape, ensuring that the drainage system is properly supported, and by attention to patient position." Review of Resident #1's NP Progress note dated 11/14/2013 at 10:20 AM "Brief was opened, and a small amount of blood noted. The penis shows a urethral tear down to the base of the penis. Bruising improved. Torn area without significant redness. Assessment/ Plan : Monitor for infection. He has been evaluated by urology." In an interview on 12/4/2013 at 11:10 AM Resident #1's Wife stated she comes to see her husband everyday around lunch time. Resident #1's Wife stated Resident #1 does not pull on his Foley. Resident #1's Wife stated she did not know what happened but she stated Resident #1 did not pull on his Foley. Observation on 12/05/2013 at 2:45 PM revealed Resident #1 would not let surveyor observe urethral tear. In an interview on 12/05/2013 at 1:25 PM LVN E stated Resident #1's urethral tear happened during a transfer on 11/10/2013. LVN E stated the aides called her to the room to evaluate Resident #1 after the incident. LVN E further stated she did not call the Physician because the split was small. LVN E further stated that the tear had increased by the next day and was bigger. LVN E stated she did not do an incident report or report the incident on 11/10/2013. In an interview with the Administrator on 12/5/2013 at 2:30 PM the Administrator stated the incident regarding Resident #1's urethral tear should have been investigated related to the undermined ethology of the tear. The Administrator stated she was unaware Resident #1's urethral tear occurred during a transfer. The Administrator stated it was " tragic " that the incident happened. Review of the Facility Policy Catheter Care (Indwelling Catheter), no date indicated, reflected "Basic Responsibility: Licensed Nurse. Purpose: To prevent infection. To reduce irritation. General Documentation Guidelines: condition of the perineum and catherter insertion site, any unusal condition or change in condition, color, amount, consistency and odor of urine. Notification of the physician of any condition change." Review of the Facility Policy Abuse and Neglect Prohibition Policy dated 12/2010 reflected " Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of personal property ... All reports of resident abuse, neglect, misappropriation of resident property, and injuries of an unknown source shall be promptly and thoroughly investigated ...When an in incident or suspected incident of resident abuse, neglect, misappropriation of resident property, or injury of an unknown source is reported, the administrator will appoint a staff member to investigate the incident.. The investigation shall consist of: (a) A review of the completed resident abuse report form; (b) An interview with the person(s) reporting the incident; (c) Interviews with any witnesses to the incident; (d) An interview with the resident if he/she is able to be interviewed; (e) A review of the resident's medical record; (f) An interview with staff members (if applicable) having contact with the resident during the period of the alleged incident; (g) Interviews with the resident's roommate, family members, and visitors; (i) A review of all circumstances surrounding the incident; (h) Interviews with other residents to which the accused employee provides care or service. Abuse Reporting: All personnel must promptly report any incident or suspected incident of resident abuse, including injuries of an unknown source ... Any alleged violations involving mistreatment, neglect or abuse, including injuries of an unknown source and misappropriation of resident property, must be reported to the Administrator, the Director of Nursing or the Director of Social Services." The facility provided CMS Form 672 that reflected five (5) residents with indwelling urinary catheters.

Based on observation, interview and record review the faclity, based on a Resident's comprehensive assessment, failed to ensure each resident maintained acceptable parameters of nutritional status and received a therapeutic diet when there was a nutritional problem for one (1) of four (4) residents (Resident #1) reviewed for unplanned weight loss or gain. Resident #1 had 8.1% weight loss in three (3) months and the facility did not ensure dietary recommendations were put into place for Resident #1 for 16 days. This deficient practice placed six (6) residents at risk of further weight loss or gain, increased risk of pressure ulcers and an overall decline in their physical and psychosocial condition. Findings Include: Review of Resident #1's Face Sheet reflected a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #1's Significant Change Minimum Data Set ((MDS) dated [DATE] reflected Resident #1's Brief Interview for Mental Status (BIMS) score was three (3) out of 15 indicating Resident #1 was had severe cognitive impairment. Resident #1 was coded to not have any behaviors. Resident #1 was coded to require extensive one (1) person physical assist with bed mobility, locomotion, and eating. Resident #1 was coded to require total dependence of two (2) staff for transfers. Resident #1 was coded to require total dependence of one (1) staff for dressing and personal hygiene. Resident #1 was coded to be at risk for developing pressure ulcers and was coded to have one Unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan gray, green or brown) and/or eschar (tan, brown or black) in the wound bed pressure ulcer measuring 4.5 centimeters (cm) length by 2.7 cm width, with tissue type coded as eschar. Resident #1 was not coded to have weight loss. Resident #1 was coded to be on a mechanically altered, therapeutic diet. Review of Resident #1's Comprehensive Care Plan dated 07/31/2012 and revised 11/18/2013 reflected "Resident is at nutritional risk with a potential for weight fluctuations ... Resident eats in restorative dining for noon time meal ... Resident weight significantly decreases with several diet changes. Resident is now on pureed diet with shakes TID (three times daily) ... "Hand written on the Comprehensive Care Plan was an entry "11/18/2013 significant wt. (weight) loss x 3 months. 137.2 lbs. (pounds) wife assist with most meals. " Observation on 12/04/2013 at 12:30 PM revealed Resident #1 was up in a wheelchair in the Cypress Dinning room. Resident #1 was sitting with his Wife who was assisting him with his meal. Observation on 12/04/2013 at 1:00 PM revealed Resident # 1 ate approximately 20% of his lunch meal. Review of Resident #1's Weight listing reflected 8/05/2013: 149.3 lbs., 9/04/2013 144.4 lbs., 10/04/2013 141.4 lbs., and 11/3/2013 137.2 lbs. (8.1%). Review of Resident #1's Nutritional assessment dated [DATE] reflected "Wt. (weight) down 7.2 lbs. Then update with weight down 12.1 lbs. for the quarter and significant at 8.1 % and also notified of a recent Stage III on Left heel 10/29/2013 [MEDICATION NAME] WNL (within normal limits) with H &H (hemoglobin and hematocrit) down. Is on shakes TID, Vitamin C, B12 and [MEDICATION NAME]. Will request to give super cereal at breakfast, a multivitamin and Juven (Juven is a unique blend of 3 key ingredients: ReVigor (a source of HMB) and the conditionally-essential amino acids [MEDICATION NAME], and [MEDICATION NAME]. These ingredients help build lean body mass to support healing) one packet with 6 oz (ounce) water BID (twice daily) for two (2) wks. (weeks)." Assessment signed by the RD (Registered Dietician) Review of Resident #1's Weight Change Notification to Resident #1's Physician dated 11/06/2013 reflected "Weight 8/2013 149.3lb, Weight 11/2013 137.2 lb. Weight down.. and Stage III Decub (decubitus) may we: 1.) give super cereal at breakfast. 2.) A Multivitamin with minerals 3.) Juven one packet with 6 oz. H20 (water) BID times two (2) weeks." Resident #1's Physician responded on Weight change Notification "ok" dated 11/14/2013. The facility signed the notification as received 11/22/2013. Notification was signed by the RD. Review of Resident #1's Physician Telephone Orders from 11/06/2013 to 11/22/2013 reflected an order written [REDACTED]. water BID times two (2) weeks. Review of Resident #1's MAR (Medication Administration Record) for November 2013 reflected the Physician orders [REDACTED]. Observation on 12/05/2013 at 2:30 PM revealed Resident # 1 weighed and the current weight was 140.2. Resident # 1 had gained 3.0 lbs since supplements began. In an interview on 12/05/2013 at 9:15 AM the Director of Nursing (DON) stated she was responsible for the follow up of dietary recommendation. The DON stated she was having problems receiving the recommendations from the physicians in a timely manner. The DON further stated it was "not OK" for a resident with weight loss to wait 16 days for dietary recommendations to be carried out. In an interview on 12/05/2013 at 10:15 AM Resident #1's Nurse Practitioner (NP) stated she is at the facility weekly and was not notified of the RD recommendations. Resident #1's NP further stated she could have signed off on the recommendations while in the facility and expedited the orders being carried out. Resident #1's NP further stated the 16 days from the time the facility received the RD recommendations and the recommendations being carried out was not appropriate. In an interview on 12/5/2013 at 2:45 PM the Administrator stated the system for follow up on dietary recommendations was not efficient and a new system was being put in place. Review of the Facilities Policy on When to Call the Doctor, no date indicated, reflected the policy did not address weight loss or follow up on dietary recommendations. The facility provided MS Form 802 that reflected six (6) residents identified with weight loss or gain

Based on observations, interview and record review, the facility failed to maintain acceptable parameters of nutritional status for 1 of 4 residents reviewed for weight loss (Resident # 11). Resident #11 had a severe (5.77%) weight loss from 08/22/11 to 09/07/11. She was not weighed in accordance with the physician's orders [REDACTED]. This deficiency could place all 7 residents designated by the facility as being at risk for undetected weight loss. Findings include: Review of the History and Physical dated 08/23/11 reflected Resident #11 is an [AGE] year old female with a [DIAGNOSES REDACTED]. She was admitted to the facility on [DATE] with a weight of 97 pounds. A Review of the Resident's Care Plan dated 09/05/11 reflected the resident was care planned for being at " nutritional risk with a potential for weight loss .... " Interventions per the care plan included: "Provide diet as ordered:; Provide assistance with meals and attempt to redirect when leaving meal table; Involve family; Provide Root Beer sodas per resident request; Dietary consult as indicated; Honor resident preferences; Offer substitutes when intake is less than 50%; Weigh monthly and as ordered." An observation on 09/06/11 at 12:00 PM revealed Resident #11 in the Cypress Dining Room (for residents that need assistance in dining) not eating her regular diet. An alternative diet was obtained and Resident #11 refused that diet as well. An observation on 09/07/11 at 8:00 AM revealed Resident #11 in the Cypress Dining Room refusing her breakfast. She also refused the alternative. She did drink her juice independently but ignored staff when they tried to interact with her. An interview on 09/07/11 at 12:15 PM, Certified Nursing Assistant (CNA) 2 stated that Resident #11 often refuses food and has done so since she was admitted on [DATE]. She further stated that they had tried what was reported to be her preferences, but the resident still refused. She said resident will sometimes just spit the food out. Review of a Nutritional assessment dated [DATE] reflected the resident's appetite as good with a meal completion average of 50-75%. Review of the Meals Intake Log kept in the Cypress Dining Room on 09/07/11 at 11:45 AM, reflected CNA's document the percentage of diet eaten daily at each meal. The log reflected Resident # 11's intake to be from 0-20% for August and September. Review of Resident #11's physician's orders [REDACTED]. Review of a Weight Report printed 09/07/11 at 11:57 AM reflected a weight of 97 pounds on 08/22/11 and weight of 91.4 pounds on 09/07/11 for Resident #11. Further review of Resident #11's clinical record revealed no other documentation was available to show that the resident was weighed weekly as ordered. In an interview on 09/07/11 at 5:50 PM, the Director of Nurses (DON) stated it is the facility's policy to weigh all new admissions every week times 4 weeks. She also states an established resident is weighed per doctor's order or monthly. In an interview on 09/08/11 at 1:30 PM Resident #11's son stated his mother was "anorexic" before admission to the facility. The son states both he and the facility have tried everything to get his mother to eat. Review of the Dietary Progress Note dated 08/29/11 reflects the "resident with weight < IBN range. Poor intake. Diet order regular. Will offer shakes at meals in hopes of increasing intake. Attempted to obtain food preferences; resident gave no response when questioned." Review of Nurse's Notes dated 08/24/11 through 09/06/11 reflected there was no documentation of Resident #11's poor intake or that the physician had been notified of the poor intake and weight loss. Review of the facility's Weight and Length Measurement policy on 09/07/11 at 4:30 PM says the purpose is " (1) To obtain accurate weight of each resident; (2) To maintain constant control of weight changes; (3) To assess nutrition and status of resident. NOTE: Residents are weighed on admission and monthly unless otherwise ordered by nursing order or the attending physician to monitor the resident ' s condition " . A review of the facility ' s policy titled Weight Loss System on 09/07/11 at 4:45 PM reflects " weekly weights are done on residents determined to be at risk of weight loss and weights are done for 4 weeks or as deemed necessary by ...physician, on all new admits " and the "physician and family are to be notified of weight loss". The CMS 672 reflected the facility census was 82. There were 7 residents with unplanned significant weight loss/gain identified by the facility.