Every finding on record at Legend Oaks Healthcare and Rehabilitation - Fort W

Based on interview and record review, the facility failed to allow a resident to remain in the facility when a resident exercises his or her right to appeal a transfer or discharge notice from the facility while the appeal is pending for 1 (Resident # 1) of 3 residents. The facility refused to allow Resident #1 to remain in the facility after her discharge date of 06/19/26 when they were notified on 06/15/26 that an appeal had been filed on her behalf. This failure could place residents at risk of not getting the opportunity to remain in a familiar homelike environment, getting the care and services required. Findings included: Record review of Resident #1's Discharge MDS assessment dated [DATE], revealed she was a [AGE] year-old female who was admitted to the facility on [DATE], and discharged on 06/19/26. Resident #1 had diagnoses that included: Diabetes Mellitus (high blood sugar), Morbid Obesity (overweight), Cerebral Infarction (stroke), Dysphagia (motor speech disorder), Muscle Wasting and Atrophy (loss of muscle mass and strength), Unspecified Sequelae of Cerebral Infarction (a range of long-term effects and complications that can significantly impact daily life requiring ongoing rehabilitation and support). Resident #1 had a BIMS score of 15, indicating her cognition was intact. Resident #1 required setup with eating and substantial/maximal assistance with oral hygiene, upper body dressing, personal hygiene, roll left and right, sit to lying and lying to sitting. Resident #1 had not completed walking. Record review of resident roster dated 06/30/26 revealed Resident #1 was not residing in the facility. Record review of Resident #1's discharge notice dated 05/20/26 reflected the following: Dear [Resident #1], It is with regret that we inform you of our need to discharge you from [Facility Name] no later than June 19, 2026, which is thirty (30) days from the above date. The decision to suggest alternate placement is based on your failure to pay the for your stay at the facility, following reasonable and appropriate notice of your payment obligations and the amount of said balance. Accordingly, we are exercising our option to discharge you to the address referenced above or address of your choice in accordance with the terms and provisions of 42 CFR Section 483.15(c)(1) and Texas Administrative Code, Chapter 19, Subchapter F, Rule S19.502: (5) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Should you identify alternative placement in advance of June 19, 2026, we will be happy to accommodate an earlier transfer. Otherwise, we plan to transfer [Resident #1] to an accepting facility on or before June 19, 2026. A facility discharge care plan meeting is scheduled for Wednesday May 27, 2026@ 2:30 p.m. for location discussion. Please plan to attend. Please be advised that you have the right to appeal our decision to discharge to file a discharge appeal, fax the request to [phone number] and/or email it to [email]. If you have any other questions related to your transfer out of the Facility; contact information for the Ombudsman is as follows. Record review of Discharge Summary and Post-Discharge Plan of Care dated 06/19/26 revealed:Reason for admission: Custodial/Long-term Care ServicesTreatment Provided: Skilled Nursing - medication management, nursing assessments, monitoring conditions, assistance with activities of daily living, care planning, and ongoing evaluation of health status throughout the stay. Progress: Resident remained stable during stay with nursing needs address as ordered. Resident demonstrated no significant complication and was discharged with appropriate services, medication and follow up care. Resident does not meet medical necessity for a continued stay in skilled nursing facility. Reason for discharge: Resident's heal has improved sufficiently, resident no longer needs the services of the facility. Planned discharge date : [DATE]Final Diagnosis: Cerebral Infarction, Unspecified, Discharge instructions provided to Resident/Resident Representative regarding Diagnosis Final Summary of Resident statusCognitive Status: Able to make needs known. Any psychosocial adjustment difficulty behavior: Adjustment Disorder with Depressed Mood other recurrent Depression Delirium due to known Physiological Condition. Labs in discharge packet. Physical Function:Ambulatory with assistive device. Wheelchair. Activities of Daily Living Performances: Needs assistance with Activities of Daily LivingExtensive assistance-resident involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance. Factors affecting mobility: NoneMost Recent Pain Level: 0 06/18/26 7:40 PMTherapy Services: Muscle weakness (generalized) Difficulty in walking, lack of coordination, Cognitive communication deficit. Nutritional Status: Height 66.0, Weight 364.6 Hoyer Scale 06/02/26; All natural teeth. Record review of Nursing Home Relocation Narrative to Confidential Resource revealed:Dated 04/21/26Met with consumer at Nurse Facility and follow up email to Nurse Facility Social Worker: I also spoke with [Resident #1]. She said she has had a decline but still wants to work toward moving out of the nursing home. Dated 04/24/26Reply from Nurse Facility Social Worker: Thank you so much for the update![Resident #1] loses her Medicaid eligibility on 5/1/26. She does not meet medical necessity. We have torelocate her ASAP but I don't know where to? Any and all support and advice is greatlyappreciated in her case. Dated 05/13/26monthly update: significant decline Dated 06/09/26Phone Call with Ombudsman who met with [Resident #1] and spoke with nursing facility staff. No one could locate a letter denying medical necessity and Ombudsman stated they could not force a transfer.Ombudsman is working with [Resident #1] and will keep [Confidential Resource] posted on progress/process ofrelocation. Dated 06/15/26forwarding email from Nursing Home Social Worker: What is the status of theMoney Follow Person? [Resident #1] is set to discharge to a group home on 6/19/26. Will her benefits transfer? Phone call with Ombudsman who stated consumer's daughter has letter stating issue of medicalnecessity that was just located and the date of letter was 5-19-26. Ombudsman isappealing today and will forward info to [Confidential Resource]. Email to Nursing Home Social Worker: Good morning, Social Worker,[Unknown] forwarded me your email about [Resident #1's] discharge scheduled for 6-19. I just got off the phone with the Ombudsman, who stated she has been in contact with [Resident #1's] daughterand did locate a letter about her not meeting medical necessity dated 5-19 whichstates that she has 90 days from the date of the letter to appeal.The Ombudsman submitted the appeal this morning which will allow us time to complete the process if [Resident #1] approves of the group home you have located. Can you provide theaddress/contact for the home? I will come by this week to speak with [Resident #1] about the grouphome and her options.Thank you for your assistance. Nursing Home Social Worker reply: Here is the address, she needs to sign the lease to move in on 6/19/2026 or she will lose the space that I worked so hard to find for her. I made hundreds of calls in order to find her a good safe place. Please help! Reply from Executive Director of Nursing Facility: I have attached a copy of the discharge notice provided to [Resident #1] today. Date 06/16/26Phone Call with Ombudsman that appeal had been filed. Discussed that [Resident #1] doesn't want to move to Dallas and discharge will be on hold until appeal process is heard/determined. Date 06/17/26Spoke with Nursing Facility Social Worker and expressed concern about how [Resident #1] could not meet medical necessity. SW stated, Being overweight does not automatically qualify medical necessity. She did this to herself. She was walking when she came in here and kept ordering take out. [Confidential Resource]expressed that Minimum Data Set can be subjective and Social Worker stated they submitted several different ways attempting to get her qualified.[Resident #1] stated she does not want to be there but doesn't want to go to Dallas either as it istoo far from her daughter. Record review of notification of appeal in an email from the Ombudsman to the Administrator dated 06/15/26 revealed: Good morning [Administrator], This resident has filed an appeal. Thank you, . During interview on 06/30/26 at 10:30 AM with Confidential Resource revealed she was notified that as of 06/01/026 Resident #1 would be discharged from the facility on 06/19/26. Confidential Resource explained that a discharge with that short notice would not allow Resident #1 to be a safe discharge to include reasonable location, a caregiver or durable medical equipment in place. Confidential Resource further expressed the facility was notified that Resident #1 had an appeal filed on 06/15/26, which should have granted her the opportunity to remain in the facility while the appeal was being heard. The Confidential Resource stated Resident #1 was discharged to an unwanted location outside of the county away from family, with no bed, mechanical lift, or durable medical equipment in place. She stated upon Resident #1's arrival to a group home that she did not agree to go, she required the fire department's assistance to enter the home due to not having a mechanical lift, no medical bed leaving her to sleep painfully in a regular bed, and since then first month's rent, a 1200.00 check that had bounced. According to the Confidential Resource the facility was responsible for allowing Resident #1 to remain in the facility until a decision was made on her appeal, not doing so placed Resident #1 at risk of not being able to find a suitable location to discharge to. An attempt to interview Resident #1 on 06/30/26 was unsuccessful. During interview on 06/30/26 at 11:08 AM with Family Member revealed she had been notified Resident #1 was provided a discharge notice around the end of May 2026 for discharge date of 06/19/26 due to being behind on rent payment. The Family Member stated an appeal was completed on Resident #1's behalf on 06/15/26, however Resident #1 was discharged anyway. During interview on 06/30/26 at 11:30 AM with the Social Worker revealed that as of January 2026, Resident #1 was no longer medically necessary to remain in the facility, relocation meeting was set to take place on January 5, 2026, to begin her discharge planning. The Social Worker stated Resident #1 was doing well, then had a sudden decline, extending her coverage until May 1, 2026. The Social Worker stated Resident #1's coverage ended in April 2026, however the facility honored May 1st, 2026, coverage date allowing Resident #1 to become a private payer starting May 1, 2026. The Social Worker stated she and the Business Office Manager delivered the Medicaid denial notification letter and May 2026 billing to Resident #1 on May 06, 2026, and explained that no other nursing home would accept her without a payer source. The Social Worker stated due to her finances the contacted the group home, worked out a good deal for Resident #1 to relocate for 1200.00 monthly to include 3 hot meals, assistance with her activities of daily living, and medications. According to the Social Worker Resident #1's discharge meeting was completed May 26, 2026, and there was no request for an appeal. The Social Worker stated she does not get a direct notice if a resident requests an appeal, I believe the Ombudsman helped with an appeal and notified the facility. Residents have 90 days from the discharge letter to file an appeal. Residents could still be discharged for non-payment during the appeal process and if they win the appeal and would allow them to return. According to the Social Worker Resident #1 was not placed at risk being discharged prior to her appeal process; and resident did not want to be there. The Social Worker stated she ordered the durable medical equipment on 06/19/26 the day of the discharge. During interview on 06/30/26 at 12:20 PM with the Medical Director, she revealed she was aware Resident #1 was discharging the facility on 06/19/26. The Medical Director stated she visited with Resident #1 during her stay in the facility and Resident #1 has told her several times they are trying to get rid of me. The Medical Director stated she explained to Resident #1 she was doing well and there was no reason for her to remain in the facility. During interview on 06/30/26 at 12:47 PM, the Administrator revealed Resident #1 lost medical necessity to remain in the facility as of April 1. 2026, this led to failure to pay resulting in a discharge notice for nonpayment on May 20, 2026. According to the Administrator Resident #1 had made it very clear she did not want to remain in the facility, therefore her applied income was not taken in the hopes for her to have adequate funding to relocate to a group home found by the Social Worker. The Administrator stated, it was not until June 14, 2026, 5 days prior to Resident #1's discharge date that we were notified of an appeal, and according to provider letter if she had not made a payment 60 days prior the facility had the right to continue with the discharge. According to the Administrator, if Resident #1 won her appeal, the facility would be an option for Resident #1 to relocate. The Administrator was asked why Resident #1 was discharged after the facility was notified of her appeal, and she responded, we looked into her financials, asked her if she had the ability to pay, contacted family to negotiate payment however there was no response was provided. Follow-up interview on 06/30/26 at 4:01 PM with the Administrator revealed she was not aware of the appeal process, or that she was required to allow Resident #1 to remain in the facility during the appeal process. The Administrator stated that she followed the provider letter which stated unless: the resident has failed, after reasonable and appropriate notice, topay for (or to have paid under Medicare or Medicaid) a stay at thefacility. Nonpayment applies if the resident does not submit thenecessary paperwork for third party payment or after the thirdparty, including Medicare or Medicaid, denies the claim and theresident refuses to pay for the resident's stay; The Administrator stated Resident #1 was not placed at risk being discharged , she was healthy, the group home was a safe place for her to discharge to, and she had her durable medical equipment delivered the following day. During interview on 06/30/26 at 1:11 PM, the Nurse Practitioner stated she aware that Resident #1 was being discharged on 06/19/26. The Nurse Practitioner stated Resident #1 was being discharged because she no longer had medical necessity to remain in the facility. The Nurse Practitioner stated was present during Resident #1's discharge on [DATE], Resident #1's vitals were stable, and there were no current issues to allow her to remain in the facility. The Nurse Practitioner stated Resident #1 had been seen walking, had a decline that now required a mechanical lift for transfers, other than that she was ok to relocate. During interview on 06/30/26 at 1:56 PM with Group Home Representative stated she had worked with the Social Worker so that Resident #1 to relocate to her group home in Dallas County. According to the Group Home Representative she had agreed to house Resident #1 in her group home for 1200.00 per month and a link was provided to the Social Worker so that Resident #1 could sign the lease. The Group Home Representative stated she received a call on 06/19/26 asking if Resident #1 could enter the group home a day early on 06/19/26, Group Home Representative stated that she refused the transfer because there had not been any durable medical equipment delivered or available for Resident #1. According to the Group Home Representative Resident #1 arrived on 06/19/26, when Resident #1 arrived emergency services had to be called to transfer Resident #1 into the home, there was no mechanical lift, no bed, or wheelchair delivered prior to her arrival. The Group Home Representative stated, they just dumped her here, she now has the equipment which was delivered a day or two after her arrival, the least has not been signed, and the check from the facility of 1200.00 has bounced. During interview on 07/06/26 at 10:49 AM with the Ombudsman revealed she was aware Resident #1 received a discharge notice in May 2026, however there was nothing indicating where Resident #1 would be relocating to, no address or anything, they were trying to just mover her. According to the Ombudsman, Resident #1 was to relocate to a group home located in Dallas County, no lease had been signed. Resident #1 did not want to remain in the facility any longer, however she did not agree with moving to Dallas, because that was too far away from her family. The Ombudsman stated when she attempted to discuss Resident #1's move, the facility was not able to provide her with any documentation to reveal Resident #1 was no longer medically necessary to remain in the facility. The Ombudsman stated the facility made it seem like Resident #1 was not paying, however the facility was her representative payee, and she had trust account there, so she had funds coming in. The facility was supposed to work with Resident #1 to ensure she was properly discharged , they were not supposed to discharge her once I notified them on June 15, 2026, that an appeal was filed. The facility was responsible for allowing her to remain in the facility during the appeal process, discharging her placed her at risk of unsafe discharge. The Administrator provided Provider Letter PL 2022-25. Record review of facility policy revised April 2025 titled Criteria for Transfer and Discharge revealed the following: It is the policy of this Facility that each resident will remain in the Facility and not be transferred or discharged unless the discharge or transfer is appropriate as per the existing criteria. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the Facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. The Facility shall permit each resident to remain in the Facility and not transfer or discharge the resident from the Facility unless: If the resident (and/or their representative) exercises their right to appeal a transfer or discharge notice, the Facility shall not transfer or discharge the resident while the appeal is pending.

Based on observation, interview, and record review, the facility failed to ensure the storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. for 10 Rooms (Rooms 103, 108, 204, 213, 302,303, 305, 403, 408, and 616) of 20 rooms reviewed for safe food storage. The facility failed to monitor resident personal refrigerators in Rooms 103, 108, 204, 213, 302, 303, 305, 403, 408, and 616 to ensure they were clean, sanitary, and the temperature was monitored.This failure could place residents at risk of consuming unsanitary foods. Findings included: Observation on 06/23/26 at 9:25 A.M., the personal refrigerator located in room [ROOM NUMBER] revealed there was no log documenting the daily temperature checks of the refrigerator. Observation on 06/23/26 at 9:35 A.M., the personal refrigerator located in room [ROOM NUMBER] revealed there was no internal thermometer and no log posted documenting the daily temperature checks of the refrigerator. Observation and on 06/23/26 at 9:40 A.M., the personal refrigerator located in room [ROOM NUMBER] had a brown fluid spilled in the bottom of the refrigerator, there was no internal thermometer and there was no log posted documenting the daily temperature checks of the refrigerator. Observation on 06/23/26 at 9:48 A.M., the personal refrigerator located in room [ROOM NUMBER] was sitting on the floor of the room, there was a brown liquid spilled on the bottom of the refrigerator and there was no log posted documenting the daily temperature checks of the refrigerator. Observation on 06/23/26 at 9:53 A.M., the personal refrigerator located in room [ROOM NUMBER] revealed there was no internal thermometer and there was no log documenting the daily temperature checks of the refrigerator. Observation on 06/23/26 at 9:56 A.M., the personal refrigerator located in room [ROOM NUMBER] revealed there was no internal thermometer and the log documenting the daily temperature checks of the refrigerator revealed the last temperature documented was on 03/05/26. Observation on 06/23/26 at 10:00 A.M., the personal refrigerator located in room [ROOM NUMBER] revealed there was no internal thermometer and the log documenting the daily temperature checks of the refrigerator revealed the last temperature documented was on 03/05/26. Observation on 06/23/26 at 10:08 A.M., the personal refrigerator located in room [ROOM NUMBER] revealed there was no internal thermometer and there was no log documenting the daily temperature checks of the refrigerator. Observation on 06/23/26 at 10:11 A.M., the personal refrigerator for room [ROOM NUMBER] revealed the log documenting the daily temperature checks of the refrigerator revealed the last documented temperature was in December 2025. Observation on 06/23/26 at 10:18 A.M., the personal refrigerator located in room [ROOM NUMBER] revealed there was no internal thermometer and there was no log documenting the daily temperature checks of the refrigerator. In an interview on 06/23/26 at 1:16 PM, CNA-A stated the residents or their family were responsible for keeping resident refrigerators clean. He stated maintenance was responsible for monitoring the temperatures of the refrigerators. In an interview on 06/23/26 at 1:33 PM, the Maintenance Director stated Housekeeping was responsible for checking the residents' refrigerators and keeping them clean. He stated no one had told him about monitoring the refrigerators. In an interview on 06/23/26 at 1:41 PM, CNA-B stated they thought maintenance was responsible for checking the refrigerator temperatures in the residents' rooms. They thought dietary was supposed to check the food in the refrigerators. In an interview on 06/23/26 at 1:47 PM, CNA-C stated they thought housekeeping was responsible for keeping the resident refrigerators clean, but they did not know who checked the temperatures.In an interview on 06/23/26 at 1:58 PM, CNA-D stated they thought housekeeping was responsible for cleaning the residents' refrigerators when they cleaned the rooms, but she was not sure.In an interview on 06/23/26 at 2:23 PM, LVN-E stated they were unsure who was responsible for cleaning the resident refrigerators. They stated possibly housekeeping cleaned them when they cleaned the rooms. They stated if the resident had spoiled food in the refrigerator, it could cause them to become sick.In an interview on 06/23/26 at 2:45 PM, RN-F stated the nurses usually checked the temperatures on the refrigerators in the resident rooms, and logging the temperature. Temperatures were usually checked by the night shift. She stated food had to be monitored to ensure there was no spoilage.In an interview on 06/23/26 at 2:56 PM, RN-G stated the nursing staff was responsible for checking the refrigerators in the resident rooms, usually done on night shift. They stated if residents were to eat spoiled food, they could become sick.In an interview on 06/23/26 at 3:05 PM, the ADON stated previously housekeeping and maintenance were responsible for the residents' refrigerators. Maintenance monitored the temperatures and housekeeping kept them clean, but somewhere along the way the process stopped. She stated the nursing staff should be checking any food that comes out of the refrigerators was not spoiled before the residents consumed it, to prevent the residents from getting sick. She did not know if staff were formally trained on the process or if it was just something passed on during on-the-job training. Record review of the facility's policy titled, Resident Personal Food Storage, dated April 2025, reflected: Food or beverage brought in from outside sources for storage in facility pantries, refrigeration units, or personal/resident room refrigeration units will be monitored by designated facility staff for food safety .4. Refrigerator units will have internal thermometers to monitor for safe food storage temperatures.5. Staff will monitor and document unit refrigerator temperatures.

Based on observation, interview and record review, the facility failed to ensure each resident was free of any significant medication errors for 1 of 6 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure Resident #1, who was diagnosed with Stage 4 renal carcinoma (kidney cancer), was administered his physician ordered oral chemotherapy medication, axitinib 3 mg bid, to treat his advanced kidney cancer. On 05/27/26 a computed tomography (CT) scan showed a 2 mm increase in the mass on Resident #1's right kidney. An Immediate Jeopardy (IJ) was identified on 06/12/26 at 4:16 p.m. and an IJ Template was provided to the Administrator at 4:50 p.m. While the IJ was removed on 06/13/26, the facility remained out of compliance at a scope of pattern with the severity level of no actual harm with potential for more than minimal harm that was not an immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving therapeutic dosages of medication as ordered by the physician, which could cause serious harm, worsening of condition, or death.Findings included:Record review of Resident #1's Quarterly MDS Assessment, dated 05/11/26, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. The MDS Assessment under Section C-Cognitive Patterns reflected Resident #1 had a BIMS score of 0, which indicated severe cognitive impairment or irresponsiveness. The MDS Assessment under Section GG-Functional Abilities reflected Resident #1 did not have limited range of motion or require any mobility devices. The MDS Assessment under Section GG-Functional Abilities (mobility devices) reflected Resident #1 required a wheelchair for mobility. The MDS Assessment under Section GG-Functional Abilities (self-care) reflected Resident #1 substantial assistance with most ADLs. The MDS Assessment under Section I-Active Diagnoses reflected Resident #1's active diagnoses included: cerebral infarction (stroke), aphasia (communication disorder), delirium (sudden, severe stated of confusion), hemiplegia and hemiparesis (weakness and paralysis that affects one side of the body), and cancer. Record review of Resident #1's care plan, revised 10/20/25, reflected the resident had chemotherapy related to renal cell carcinoma (cancer). The care plan interventions included: giving medications and treatments as ordered, monitoring and documenting for side effects, activities to divert attention from effect of chemotherapy, keeping environment clean to prevent risk of infection, monitoring nutritional status and intervening as indicated, and reporting any side effects or complications to the MD. Record review of Resident #1's progress notes, dated 04/01/26-06/11/26, reflected the following: 04/21/26 at 8:34 p.m. - RN D wrote: [RN D] called to [family] regarding a refill for Axitinib Oral Tablet 1 MG 3 tablet by mouth two times a day for renal cell carcinoma, for a total of 3mg. The [family] stated she will bring the medication this morning. Further review of this document reflected there were no other notes regarding requests or deliveries for axitinib medication. Record review of Resident #1's Out on pass sign out sheets, dates April 2026-June 2026, reflected the resident spent five days with family that required medication administration outside of the facility. Record review of Resident #1's April 2026 MAR reflected axitinib was administered as follows: 04/01/26-04/02/26 - 7:00 a.m. and 7:00 p.m. doses administered; 04/03/26 - 7:00 a.m. dose administered; 04/03/26 - 7:00 p.m. dose coded as 9 which indicated resident was away from facility with medications; 04/04/26 - 7:00 a.m. and 7:00 p.m. doses coded as 9 which indicated resident was away from facility with medications;04/05/26 - 7:00 a.m. dose coded as 9 which indicated resident was away from facility with medications; 04/06/26-04/09/26 - 7:00 a.m. and 7:00 p.m. doses administered; 04/10/26 - 7:00 a.m. dose administered; 04/10/26 -7:00 p.m. dose coded as 9 which indicated resident was away from facility with medications; 04/11/26 - 7:00 a.m. and 7:00 p.m. doses coded as 9 which indicated resident was away from facility with medications; 04/12/26 -7:00 a.m. dose coded as 9 which indicated resident was away from facility with medications; 04/12/26 - 7:00 p.m. dose administered; 04/13/26-04/16/26 - 7:00 a.m. and 7:00 p.m. doses administered; 04/17/26- 7:00 a.m. dose administered; 04/17/26 - 7:00 p.m. dose coded as 9 which indicated resident was away from facility with medications; 04/18/26 - 7:00 a.m. dose coded as 8 which indicated resident was absent from facility; 04/18/26 - 7:00 p.m. dose coded as 9 which indicated resident was away from facility with medications; 04/19/26 - 7:00 a.m. dose coded as 9 which indicated resident was away from facility with medications; 04/19/26- 7:00 p.m. dose administered; 04/20/26-04/24/26- 7:00 a.m. and 7:00 p.m. doses administered; 04/25/26 - 7:00 a.m. dose administered; 04/25/26 - 7:00 p.m. dose coded as 9 which indicated resident was away from facility with medications; 04/26/26 - 7:00 a.m. dose coded as 9 which indicated resident was away from facility with medications; 04/26/26 - 7:00 p.m. dose administered;04/27/26 - 7:00 a.m. dose coded as 9 which indicated resident was away from facility with medications; 04/27/26 - 7:00 p.m. dose administered; and 04/28/26-04/30/26 - 7:00 a.m. and 7:00 p.m. doses administered. Record review of Resident #1's May 2026 MAR reflected axitinib was administered as follows: 05/01/26-05/07/26 - 7:00 a.m. and 7:00 p.m. doses administered; 05/08/26 - 7:00 a.m. dose administered; 05/08/26 - 7:00 p.m. dose coded as 9 which indicated resident was away from facility with medications; 05/09/26 - 7:00 a.m. and 7:00 p.m. doses coded as 9 which indicated resident was away from facility with medications; 05/10/26 - 7:00 a.m. dose coded as 9 which indicated resident was away from facility with medications; 05/10/26 - 7:00 p.m. dose administered; and 05/11/26-05/31/26 - 7:00 a.m. and 7:00 p.m. doses administered. Record review of Resident #1's MAR, dated June 2026, reflected axitinib was administered as follows: 06/01/26-06/11/26 - 7:00 a.m. and 7:00 p.m. doses administered; and 06/12/26 - 7:00 a.m. dose administered. Record review of Resident #1's order summary report, dated 06/12/26, reflected in part the following order: Axitinib oral tablet 1 mg-give 3 tablets by mouth two times a day for renal cell carcinoma, total of 3 mg. Start Date: 01/01/26 Further review of the order summary report reflected Resident #1 was not ordered any other medications or treatments for renal cell carcinoma. Record review of Resident #1's clinical chart-after visit summary, dated 5/29/26, reflected in part the following: CT chest abdomen pelvis scan with contrast collected on 5/27/26:Impression:Slight interval increase in size of the exophytic right renal mass invading the right abdominal wall.Slight interval increase in size of adjacent soft tissue metastasis.Mildly enlarged para-aortic lymph nodes.Stable pulmonary nodules likely representing metastatic disease.Assessment and Plan:Metastatic renal cell carcinoma-with renal mass and nodules.Status post 24 months of Keytruda, last October CT scan shows few mm increase (6mm to 8mm) in the mass.Per [RP], [Resident #1] might have missed several doses at the nursing home. Continue on axitinib 3 mg bid Plan to continue until progression or intolerance. Emphasized that [Resident #1] needs to get his medication regulated. In an interview on 06/12/26 at 10:02 a.m., Resident #1's Family Member AA stated Resident #1 was diagnosed with kidney cancer in 2003 that progressed over the years and was currently Stage 4. She stated Resident #1 started axitinib for treatment of his cancer about three years ago, and it was helping to slow the disease. Family Member AA stated Resident #1's tumor was stable for 3-4 months prior to his most recent oncology appointment on 05/29/26 when a CT scan showed a growth of what she initially thought was 1 mm but the lab report showed 2 mm. Family Member AA stated she had ongoing concerns that the facility was not administering Resident #1's axitinib as ordered. She stated there were multiple times the facility had medication remaining when it was time for a refill. She stated LVN A called her on 05/13/26 and informed her that Resident #1 only had six pills remaining and would be completely out at the end of the day. Family Member AA stated Resident #1's most recent bottle of axitinib was delivered to her home on [DATE], and she took it to the facility on [DATE]. She stated she visited the facility about every other day, and the nurses would allow her to count the pills when she requested. Family Member AA stated she counted Resident #1's axitinib on 06/08/26, and he still had approximately 97 pills remaining in the bottle that was provided to the facility on [DATE], which indicated that some doses were missed. Family Member AA stated the facility had not notified her of any issues with the medication, and they denied missing any doses when she inquired about the extra pills remaining. Resident #1's Family Member AA stated since she recently moved, Resident #1 had not been able to spend many nights away from the facility with her, but when he did, she administered his medications as scheduled. She stated Resident #1 had not been away from the facility overnight in about a month. Family Member AA stated she noticed Resident #1 was weaker and more fatigued, but she could not completely contribute it to the missed doses of medication. In an observation on 06/12/26 at 10:15 a.m., LVN A completed a count of Resident #1's axitinib medication, and there were a total of 72 tablets remaining in the bottle. The label reflected a fill date of 05/07/26 with a quantity of 180 tablets. Further observation reflected that there was not a documented date of when the bottle was opened. With order for the resident to receive a total of 6 tablets per day, 72 tablets remaining on 06/12/26 indicated a surplus and significant medication error. In an interview on 06/12/26 at 10:26 a.m., LVN A stated she worked at the facility for a year and worked on the hall with Resident #1. LVN A stated Resident #1 received axitinib as chemotherapy treatment for his cancer, and the medication was provided to the facility by the resident's family. LVN A stated she would notify the family when Resident #1 was down to his last few doses, and the family would bring in a new, unopened bottle. LVN A stated she was the nurse who received Resident #1's current bottle of medication but she could not remember the exact date. She stated it was around the end of May 2026. LVN A stated she just remembered calling the family and informed that he only had 6 pills remaining and a new bottle was brought in the following day. LVN A stated the medication was always available and Resident #1 never missed a dose on her shift. LVN A stated Resident #1 had not complained or shown any signs of being unwell. She stated he enjoyed sitting outside in the sun and had not changed his routine. In an observation and interview on 06/12/26 at 10:40 a.m., Resident #1 was observed sitting on an enclosed patio with his sunglasses and hat. Resident #1 was unable to complete a full interview due to aphasia; however, he could understand others and gesture to answer Yes and No questions. When asked if he felt well, Resident #1 shook his head Yes and gave the surveyor a fist-bump. When asked if he had missed any medications, Resident #1 shrugged and indicated that he did not know. In an interview on 06/12/26 at 11:24 a.m. with the Administrator and Clinical Resource, the Administrator described Resident #1's family dynamic as conflicted; however, they were involved in his care. The Administrator stated the family was responsible for delivering Resident #1's chemotherapy medication (axitinib) to the facility and staff would let them know when it was time for a refill. The Administrator stated the facility did not have a process in place to track and inventory the medication as it was brought in to prevent any errors. She stated she could see how implementing a process would benefit the residents and the facility, so she would start an in-service with staff. The Administrator stated there should already be log of when Resident #1's medications left the facility when the resident was out on pass; however, the log was never provided. An attempted interview on 06/12/26 at 1:53 p.m. with Resident #1's oncologist was unsuccessful due to the doctor being unavailable. In an interview on 06/12/26 at 2:00 p.m., the MD stated she did not manage Resident #1's cancer treatment; however, it was her medical opinion that missing multiple doses of axitinib had the potential to cause progression of the tumor. The MD stated she managed Resident #1's general health and there had been no reports of the resident showing any signs or symptoms of being unwell. The MD stated she also saw Resident #1 weekly and did not have any significant concerns. In an interview on 06/13/26 at 10:00 a.m., RN D stated he worked at the facility for over a year. RN D stated he worked with Resident #1 and administered the resident's medication. He stated Resident #1 received axitinib that was provided by his family. RN D stated he never received the medication from Resident #1's family and it was always available in the cart during his shift. RN D stated he received medications from the families of other residents in the past and there was no policy or procedure for the nurses to count and document the medications unless it was a narcotic. In an interview on 06/13/26 at 11:05 a.m., the Pharmacy Representative stated Resident #1's account reflected the axitinib was a last dispensed on 05/07/26 and delivered to the family's address on 05/08/26 at 1:28 p.m. The Pharmacy Representative stated Family Member AA called on 05/05/26 and reported that the nursing facility still had 7 days' worth of medication left over, so the pharmacy advised them to start the new bottle on 05/12/26. The Pharmacy Representative stated the family should have needed a new bottle by 06/12/26; however, there was a note on the account that stated the refill needed to be delayed until 06/22/26 because Family Member AA called the pharmacy again on 06/10/26 and stated the facility still had 16 days' worth of medication remaining. The Pharmacy Representative stated Resident #1's account had an adverse event due to the number of times the medication refill was put on hold as it indicated that the medication was not being administered as scheduled. The Pharmacy Representative stated a pharmacist would have to provide any additional information needed regarding the medication. In an interview on 06/13/26 at 11:20 a.m., the Pharmacist stated an adverse event was placed on Resident #1's account each time the refill was held due to a surplus of medication. The Pharmacist stated all adverse events were reported to the prescriber for them to determine course of action. The Pharmacist stated Family Member AA called the pharmacy and reported concerns that the nursing facility was not administering Resident #1's axitinib correctly, and it caused the resident's tumor to grow. The Pharmacist stated the Oncologist was made aware of the concern reported. The Pharmacist stated the original fill date for Resident #1's axitinib was on 10/30/24 and had been ongoing since then. The Pharmacist stated the refills were consistent with no documented adverse events until approximately two months ago, except for one adverse event documented in October 2025. In an interview on 06/13/26 at 11:51 a.m., Resident #1's Family Member BB stated the facility had not reported any recent issues with the resident's medications; however, she recalled about a year ago when the facility admitted they made an error by overlooking the axitinib because it was stored in a top drawer and Resident #1 missed some doses. Family Member BB stated she sometimes received Resident #1's axitinib at her home and the nurses would tell her to hold it when there was medication left over. Family Member BB stated in May 2026 the facility informed her that they still had about 2 weeks' worth of medication remaining, and they did not need the new bottle. She stated Family Member AA usually dealt with the medication, so she did not think too much of it. Family Member BB stated Family Member AA believed the axitinib was keeping Resident #1 alive, so she was very adamant about the medication being administered as ordered. Review of the facility's policy titled Medication Administration, revised May 2025, reflected in part the following: Policy: It is the policy of this facility to accurately prepare, administer and document oral medications.Further review of this document reflected it did not address managing medication inventory. On 06/12/26 at 12:06 p.m., the Administrator was asked to provide a policy regarding management of medication inventory for non-narcotic medications brought to the facility from an outside pharmacy and/or family. The Administrator revealed the facility did not have this policy. An Immediate Jeopardy (IJ) was identified on 06/12/26 at 4:16 p.m. The Administrator was notified of an Immediate Jeopardy (IJ) on 06/12/26 at 4:45 p.m., due to the above failures and the IJ template was provided at 4:50 p.m. A Plan of Removal was requested. In an interview on 06/12/26 at 6:58 p.m., the Administrator stated she had just completed her own investigation and did not agree that Resident #1 had a significant medication error. The Administrator now had documents and provided the following information: - A statement from LVN A that an unopened bottle of Resident #1's axitinib with 180 tablets was delivered to the facility on [DATE], and the nurse continued to administer the medication as ordered. - An interview with the pharmacy that revealed Resident #1's axitinib was delivered and signed for by the resident's family on dates: 01/07/26, 02/16/26, 03/11/26, 04/09/26, and 05/08/26. - Statements from LVN A, LVN B, LVN C, RN D, LVN E, LVN L, and LVN M verifying that Resident #1's axitinib was available in the cart and all doses were administered as reflected on the MAR. - A progress note, dated 04/21/26, from RN D stating Resident #1's family was notified that a refill for axitinib was needed. - The 24-hour working report that reflected the axitinib was delivered to the facility by family on 04/22/26, the facility requested a refill on 05/23/26, and the family delivered another bottle of axitinib on 05/24/26. Further review of the additional information provided by the Administrator did not reflect when the bottles of axitinib were opened. There also was no documentation provided to show if the new bottles were used immediately upon delivery or if the nurses continued administering medications that remained from the previous bottle. The facility's Plan of Removal (POR) was accepted on 06/12/26 at 9:05 p.m. and included: Plan of Removal June 12, 2026 Version 2 F760 Significant Medication Errors Per the information provided in the IJ Template given on 6/12/2026, the facility allegedly failed to ensure Resident #1 was free of a significant medication error potentially resulting in worsening of the resident's condition and placed him at risk of serious harm or death. The Medical Director was notified of alleged IJ on 6/12/2026 at 5:00 p.m.An audit was completed on June 12, 2026 for residents that have medications that are provided by their family/responsible party. Medications were counted and match the eMAR administration.Education was initiated with Nurses on 6/12/2026 and will be completed for all Nurses by 6/13/26 by the DON, ADONs or Clinical Resource. The training is to include medication brought in by family/responsible parties, documenting the date of receipt and count of those medications, documentation of medication administration of the eMAR.This education may be in-person or over the phone with the DON, ADONs or Clinical Resource.This education will also be included in the new hire orientation and will be included for agency/PRN nursing staff. All education will be completed prior to the employee's start of their next shift; no staff will be allowed to work unless they have had the training.An ad hoc meeting regarding items in IJ template was completed on 6/12/2026 at 5pm. Attendees included the Administrator, DON, ADON, Medical Director and Clinical Resource. The Plan of Removal items and interventions were developed, reviewed, and agreed upon.The DON or designee will monitor to ensure medication that is provided by family/responsible parties is counted and documented when they are delivered to the nurses. These meds will be counted and verified with eMAR weekly to ensure accurate administration.The DON and ADON will verify nurse knowledge on medications brought in by family/responsible parties with 3 nurses weekly using a knowledge check form.These medications will be reviewed during the weekly clinical meeting, and the Medical Director will be consulted for any recommendations or suggestions, as necessary.9. Knowledge checks will be completed with 3 nurses weekly and will be on-going throughout the Quality Assurance process, reported weekly to the QAPI committee meeting for 4 weeks or until substantial compliance is established and then monthly for 90 days.10. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance is established and continue monthly for 90 days to ensure ongoing compliance. QAPI meetings content will include laboratory orders and results.11. Follow up on IJ Plan of Removal and monitoring will be verified by the DON and the Administrator by review of medication count orders, the weekly clinical meeting, review of nurse knowledge checks obtained throughout the week, and the weekly QAPI meeting.Alleged date of compliance 6/12/2026[Administrator][Nursing Facility] In an interview on 06/13/26 at 2:44 p.m. with the Clinical Resource and Administrator, the Administrator stated the expectation was for the clinical staff to follow a process that validates the amount of medication in the building to ensure it was available and administered as ordered. The Clinical Resource stated medication errors could place residents at risk of all sorts of issues including a change in condition depending on the medication and existing issues. Monitoring of the facility's implementation of the Plan of Removal on 06/13/26 from 9:45 a.m.- 4:30 p.m. revealed the following: Record review of an in-service, dated 06/12/26, reflected nurses were educated by the ADON prior to the start of the shift on the facility's updated procedures on verifying, counting and documenting all medications brought into the facility from outside pharmacies and families. Record review of Residents #1, #2, #3, #4, #5, and #6, who all received medication from outside pharmacies and/or families, MARs and medication logs reflected that all medications were verified with an accurate quantity. Record review of a document provided by the Administrator, dated 06/12/26, reflected a medication audit was completed on all residents who had medications brought in by family/RPs. Record review of a document provided by the Administrator, dated 06/12/26, reflected a QAPI meeting was held to discuss the correction plan for the facility's deficiency in pharmacy services. Interviews on 06/13/26 from 10:20 a.m.-11:00 a.m. with the RPs of Residents #1, #2, #3, #4, and #6, revealed no concerns regarding delivery and administration of medications. Resident #5's RP was unavailable for an interview. Interviews on 06/13/26 from 9:45 a.m.-3:25 p.m. conducted with the Administrator, Clinical Resource, and nurses: LVN A (day shift), LVN B ( day shift), LVN C (night shift), RN D ( night shift), LVN E ( day shift), LVN F (day shift), RN G (day shift), RN H (day shift), RN I (night shift), LVN J (night shift), LVN K (night shift), indicated they all participated in an in-service regarding the facility's updated procedures on medication reconciliation for medications brought in from outside pharmacies and/or families. All nurses were able to state medications brought into the facility from an outside pharmacy or family member would be verified against the order, counted, and documented on a log and the MAR to include date of receipt. All nurses were also able to state that all medications sent on pass with residents would be counted and documented on a log upon the resident leaving and returning to the facility to ensure that all doses were administered according to the physician's order. All nurses stated any discrepancies with the medication would be reported to the DON or Clinical Resource immediately. The Clinical Resource and Administrator understood that management was responsible for monitoring medication reconciliation and ensuring that staff remained in compliance with procedures. An Immediate Jeopardy (IJ) was identified on 06/12/26 at 4:16 p.m. and an IJ Template was provided to the Administrator at 4:50 p.m. While the Administrator was informed on 06/13/26 at 4:58 p.m. that the IJ was removed, the facility remained out of compliance at a scope of pattern with the severity level of no actual harm with potential for more than minimal harm that was not an immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents.The facility failed to address the root cause of Resident #1's multiple falls, failed to implement therapy recommendations, and failed to implement interventions to prevent the resident from falling from his wheelchair from November 2025 to February 2026. On 12/02/25, Resident #1 fell from his wheelchair and sustained a laceration to the top of his left eyebrow and required four sutures on 02/07/26 when Resident #1 again fell from wheelchair and sustained an abrasion to the forehead and a hematoma of the scalp and during a scan Resident #1 was also found to have a subacute (condition that falls between sudden and long term/persistent) to chronic appearing nonunion fracture (broken bone that fails to heal) of the posterior left 11th rib. This failure could place residents at risk for serious injury or harm, decline in health, and decreased quality of life. Findings included:Review of Resident #1 quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease, non-Alzheimer's dementia, seizure disorder, anxiety disorder, difficulty walking, cognitive communication deficit, , and muscle weakness. The MDS reflected Resident #1 had unclear speech and usually understood others and had a BIMS of 0 which indicated his cognition was severely impaired. The MDS also reflected that the resident was in a manual wheelchair and was dependent for all ADLs. The MDS further reflected Resident #1 had 2 or more falls since admission. Review of Resident #1's care plan revised on 02/16/26 reflected the resident had actual falls related to poor balance and unsteady gait. 11/09/25 - Actual fall no injury11/14/25 - Actual fall no injury 12/02/25 - Actual fall with laceration to top of left eye12/06/25 - Actual fall with no injury 12/31/25 - Actual fall with laceration to left upper eyebrow01/24/26 - No injury01/25/26 - No injury02/07/26 - No injury 02/14/26 - No injuryInterventions included:- Staff to provide resident with activities - Staff to assist resident back to bed after breakfast- Staff to proper reposition resident in wheelchair at the table during lunch- Staff to provide resident with fidget blanket while sitting up in wheelchair in dining room - Staff to assist resident back to bed after lunch- Bed in lowest position - Floor mat- Staff to ensure resident is properly positioned in bed during rounds- Therapy consult for strength and mobilityReview of Resident #1's Fall Risk Evaluation dated 10/23/25 reflected the resident was high fall risk. Review of Resident #1's incident reports from November 2025 to February 2026 reflected:*11/09/25 documented by RN A - Resident fell down from the chair in the dining room.This nurse did head to toe assessment and no injuries were noted and was put back safely in bed. *11/14/25 documented the Previous DON - Resident had a fall in the dining room, was assessed and no injuries noted.*12/02/25 - documented by LVN B - nurse observed the resident on the floor in prone position, wheelchair behind him, his head on the table. Head to toe assessment done and skin laceration to top of the left eye noted. The resident was sent to the ER for further evaluation. The resident was unable to give description. *12/06/25 - documented by LVN C - called into the front lobby and the resident was observed in a sitting position on the floor in front of the wheelchair. Staff observed him slide out of the wheelchair during an activity. Assessed for injury and was able to move all extremities. The resident was assisted back into bed. *12/31/25 - documented by LVN D - Resident was seen sliding out of his wheelchair to the floor of the dining room. Resident was laying on the floor on his left side when the nurse assessed him. The resident was unable to give description and head-to-toe assessment was completed and no injuries were noted. Resident rested comfortably in the wheelchair at that time. *01/24/26 - documented by LVN E - Upon entering the dining room the resident was observed laying on the floor in front of his wheelchair. The nurse assessed the resident for injuries and was transferred back to the wheelchair. The resident was unable to give description. *01/25/26 - documented by RN A - Resident had an unwitnessed fall in the dining room and was found on the floor. The resident was assisted back to the wheelchair and head to toe assessment was done and there were no injuries noted. Encouraged the resident not to get up without assistance and press call light when needed. *02/07/26 - documented by LVN F - Resident was found on the floor lying on his right side with a cut noted to the right side of his head. The resident was sent out to the hospital for evaluation and treatment. *02/14/26 - documented by LVN G - The patient was found lying on the left side near the head of the bed. No injuries were noted. Review of Resident #1's hospital dated 12/02/25 reflected the following: .pt fell forward out of wheelchair and hit head onto tile floor.Laceration noted to L eyebrow.Number of sutures: 4. Review of Resident #1's hospital records dated 02/07/26 reflected the following: .Abrasion to forehead.Fall from wheelchair.Hematoma of scalp.Subacute to chronic appearing nonunion fracture of the posterior left 11th rib.Review of Resident #1's progress notes dated 02/19/26 documented by the Social Worker revealed hospice delivered a wheelchair that was not appropriate for the resident. Observation on 04/16/26 at 9:43 AM revealed Resident #1 was in the activity room in a padded reclining wheelchair with one of his legs over the right side of the chair and the chair was next to the Activity Director. Resident #1 appeared to try to lean forward and touch his shoe, but body stayed in an upright position and there were no concerns of a fall. Observation and interview on 04/16/26 at 12:03 PM revealed Resident #1 was in the dining room sitting in his padded high back reclining wheelchair being fed by his family. Resident #1's family said they were very happy about the resident's current reclining chair and felt the resident would be safer in it. The resident's family said she had been told by the MDS Nurse that the reclining chair that was provided by hospice was a restraint, but the family said they were worried about the resident's safety more than the wheelchair being a restraint. Resident #1 was spoken to, but he did not make long eye contact and when he tried to speak, his words were not coherent. Interview on 04/16/26 at 12:54 PM with CNA H revealed she worked with Resident #1, and she was told the resident had a history of frequent falls out of his manual wheelchair. The resident fell in the dining room a couple times when she worked but did not recall the dates but said Resident #1 had not sustained any injuries. CNA H said she was told Resident # should be put to bed after every meal and other interventions included to keep an eye on him and reposition the resident in his wheelchair. CNA H further stated the resident had recently been put in a new reclining wheelchair from hospice and Resident #1 was doing much better and had not had recent falls. Interview on 04/15/26 at 1:16 PM with RN A revealed she worked with Resident #1 when he had a few of his falls but did not recall the dates. RN A said the resident was in a regular wheelchair that he would slide out of and/or fall forward from because Resident #1 was not able to hold himself for more than 5 to 10 minutes. RN A said they would try to reposition the resident in his wheelchair but there were no other interventions put in place until the resident recently got his new reclining wheelchair from hospice. RN A further stated the new chair was much better for Resident #1 because it kept him from leaning forward and he had not had recent falls.Interview on 04/16/26 at 2:23 PM with the OT revealed Resident #1 was put on therapy caseload on 10/14/25 and per the PT notes, the resident's goals were to reduce his falls from reaching forward and to improve trunk control. The OT said Resident #1 was not aware or capable of alertness processing due to his cognition. The OT said that because of his lack of awareness and poor trunk control staff were to frequently reposition the resident in his wheelchair to try to prevent falls. The OT further stated she did not recall any other intervention put in place other than repositioning Resident #1 to prevent falls. Interview on 04/16/26 at 3:35 PM with the MDS Nurse revealed Resident #1 has frequent falls and his mattress was changed and he was put in a low bed. The MDS Nurse stated she was under the impression that a reclining Broda chair was a restraint and due to her years of experience in the field, management at the time trusted her opinion of a reclining wheelchair. The MDS Nurse said Resident #1's family brought the idea of a reclining wheelchair to her attention, but the MDS Nurse had told the family the same thing about it being a restraint. The MDS Nurse further stated the hospice company had brought the resident a new padded reclining wheelchair and he appeared to be doing well in it although there were times the resident would try to swing his legs over it therefore required increased supervision. The MDS Nurse said, moving forward, they would take a resident's condition and cognition during a safety assessment for the need of a reclining wheelchair.Interview on 04/17/26 at 10:19 PM with the Director of Rehab revealed they worked with Resident #1 on balance with the resident because he could not be educated on safety awareness or take verbal cues due to his impaired cognition. The Director of Rehab said the resident was able to sit up for 5 minutes at a time, but that length decreased as time went by due to his lack of trunk control. The Director of Rehab was aware of Resident #1's frequent falls and normally they would attempt a different type of cushion or drop the seat of the wheelchair, but she was told that would be a restraint for the resident because that would prevent him from attempting to get up. The Director of Rehab said she reviewed Resident #1's records and there were no other inventions put in place to try and prevent his falls. The Director of Rehab said moving forward they would take a resident's condition and cognition during a safety assessment for the need of a reclining wheelchair.Interview on 04/17/26 at 1:36 PM with LVN B revealed Resident #1 had a couple falls during her shift in the dining room but she did not recall the dates. LVN B said the resident would be in his wheelchair one minute and the next he was on the floor. LVN B said the resident's falls were because of his condition had declined and he always tried to lean his head forward or on the dining room table. Resident #1 had to be frequently watched and reposition to try to avoid falls but since hospice had brought the new reclining wheelchair, the resident had not had any falls. Interview on 04/17/26 at 1:49 PM with CNA I revealed Resident #1 appeared to have some drastic body movements due to his cognition. CNA I said that no matter how much or often the resident was repositioned in the wheelchair he would lean to the side or forward. CNA I said the only interventions they were told to help reduce his falls were to try to lay him down after meals and continue to reposition and monitor as often as they could. CNA I further stated Resident #1 continued to have frequent falls until hospice brought in the padded reclining wheelchair because the resident was no longer able to move forward. Interview on 04/17/26 at 2:19 PM with the Previous DON revealed she no longer worked at the facility therefore did not recall all the interventions that were put in place for Resident #1's falls. The Previous DON recalled Resident #1 was put to bed after meals because most of the falls had occurred in the dining room and when the resident was admitted to hospice, he was given a high back reclining wheelchair. The Previous DON further stated staff were to reposition the resident in his chair to try and prevent falls. Interview on 04/17/26 at 3:39 PM with the Current DON revealed she began working at the facility on 03/23/26. The Current DON said they would implement a root cause to each resident and add appropriate interventions to each incident report and update the resident care plans to try and prevent resident falls. Review of other residents who were a high fall risk were in an appropriate wheelchair conducive to their needs and the rooms were equipped with low beds, scoop mattresses, and fall mats in place.Review of the facility's policy titled Fall Management System revised on 12/2003 reflected the following: Policy It is the policy of this facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs.7. The QAA Committee will analyze trends related to falls and will determine if further intervention is needed.

Based on interviews, and record reviews, the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1 of 5 residents (Resident #1) reviewed for pressure ulcers. The facility failed to ensure Resident #1 did not develop a pressure wound to his left heel. This failure could place residents at risk of infection or a deterioration of their health.Findings included:Record review of Resident #1's admission MDS assessment , dated 02/06/26, reflected he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included fracture of left upper arm, stroke affecting his left side, muscle weakness, and history of falls. He was discharged home on [DATE]. Resident #1's BIMS score was 14, indicating he was cognitively intact. His Functional Abilities assessment indicated he walked with the assistance of a walker, had impairment of the left arm, and required some assistance with his ADLs. Record review of Resident #1's care plan, dated 02/03/26, reflected he was admitted with a wound to his left elbow, and then developed a pressure ulcer to his left heel . He also had impaired physical mobility, and at risk of decreased tissue circulation. Record review of Resident #1's Braden Scale for predicting pressure ulcer risk evaluation date 02/03/26 reflected a score of 14 which made him a Moderate Risk. Record review of Resident #1's admission Assessment, completed 02/03/26 by RN-A, reflected he had a skin issue to his right inner forearm that was present on admission. RN-A documented in her admission note Skin/wound assessment: Fracture in humerus to the left hand, wear a sling. Record review of Resident #1's physician orders reflected the following orders: 02/11/26 - Cleanse left heel with wound cleanser, pat dry with 4x4 gauze, apply dry dressing every day shift every Mon, Wed, Fri02/25/26 - keep left heel on bunny boot at all times, to prevent heel from rubbing against surface and promote healing. every shift for wound Record review of Resident #1's Therapy notes reflected that the resident was seen in the gym by Physical, Occupational, and Speech therapies daily from 02/03/26 to 02/26/26 for several hours a day, except on the weekends. Record review of Resident #1's skin note on 02/06/26 by the Wound Care Nurse documented a bruise to the right inner forearm and a traumatic wound to the left elbow. Record review of Resident #1's skin note on 02/10/26 by RN-B documented new wound on Resident #1's left heel, which was described as an open blister that was acquired in-house. The note reflected that the skin on the left heel was partially intact and degloved (skin torn away from the body, resembling a glove being stripped off). No other notes describing the blister were found.Record review of Resident #1's hospital records for admission on [DATE] revealed he had suffered a fall at home resulting in a fracture to his left upper arm and a wound to his left elbow. No issues noted with the right arm. Record review of Resident #1's hospital records from admission on [DATE] revealed the resident had been brought to the hospital from home by his family. He was diagnosed with a stage III pressure ulcer to his left heel measuring 6cm x 6cm (pg. 23) In an interview on 03/25/26 at 2:05 PM, Resident #1's family member stated the resident was admitted to the facility after suffering a fall at home and injuring his left arm. The family member stated therapy staff were the only ones who would get the resident out of bed, and he spent the rest of his time in bed. The Family Member stated she visited Resident #1 daily, and he was always in his bed. The Family Member stated staff told her the resident was too unsteady to be out of bed, and it was safer for him to be in bed or in a wheelchair. The Family Member stated Resident #1 had been living independently previously and would not use a wheelchair, preferring to keep using his walker. The family member stated the facility did not put any offloading or other preventative measures in place until after the wound to his heel developed. The resident was at another facility and doing better with therapy. In an interview on 03/26/26 at 11:00 AM, the Wound Care Nurse stated Resident #1 was admitted with the injury to his left elbow but the wound to his left heel was acquired in the facility. She stated the most likely cause was his lack of mobility and friction from the bed and sheets. She stated she was alerted to the wound on 02/11/26, and after assessing it she contacted the Wound Care Physician for treatment orders. She stated when the resident was admitted they did not start off-loading practices because he was reported to be ambulatory and able to move about. After the wound on the resident's heel developed, she placed the foam boot for padding and protection of the heel. She stated the wound measured 5.5 cm X 5 cm on her first assessment. In an interview on 03/26/26 at 12:30 PM, the Director of Rehabilitation stated Resident #1 had made minimal progress in his mobility after working with Physical Therapy. The resident remained unsteady and continued using his walker when out of bed. In an interview on 03/26/26 at 1:27 PM, LVN-C stated Resident #1 was confused at times, he would get out of bed without assistance to go to the bathroom. The resident was unsteady when using his walker, and he was encouraged to remain in bed so he would not fall. The resident did not want to participate in activities, and he spent most of his time in bed except when he was working with therapy. LVN-C stated she could not recall when the preventative measures were put in place but did know it was not until after he had the wound on his heel. She stated since he was able to turn himself, and he was getting out of bed, they would not have necessarily implemented any precautionary measures. She did not know what his Braden score was without being able to review his chart, but she did not think he was very high risk.In an interview on 03/26/26 at 2:00 PM, the Physician stated Resident #1 had a history of vascular issues and other medical problems that would have made him prone to pressure ulcers, but she could not say what caused the wound to develop. In an interview on 03/26/26 at 3:30 PM following the exit conference, the Administrator and the DON returned with the Physician on the phone. The Physician stated Resident #1's pressure ulcer was unavoidable due to his vascular issues and his medical condition. The DON stated with the resident being ambulatory, staff would not have placed heel protection boots on him. The DON was unable to state if the resident's Braden Scale, scoring him as a moderate risk for pressure ulcers was accurate without reviewing it .

Based on observation, interviews and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.The facility failed to ensure items were properly covered and labeled in the walk in fridge, and fans used in the kitchen were free of grease and dust. These failures could place residents at risk of foodborne illness. Findings included: Observation on 03/03/26 at 8:48 AM in the kitchen revealed that a floor fan near the sink was running and pointed towards the steam table. Grease and dust were accumulated on the front grille of the fan. Observation on 03/03/26 at 8:53 AM in the walk in refrigerator, revealed the following:- one medium sized square container not covered completely. The plastic wrap was labeled and dated pudding 2/28- one medium sized square container not covered completely, holding an unknown item that looked like cheese sauce. The plastic wrap was dated 3/2 and had no label. Interview on 03/03/26 at 8:53 AM, the Dietary Manager said the containers should be covered and labeled. The Dietary Manager proceeded to remove the containers from the refrigerator. Observation on 03/04/26 at 10:54 AM, revealed the same fan was observed near the sink running and pointed towards the steam table, with grease and dust accumulated on the front grille of the fanObservation on 03/04/26 at 10:59 AM, revealed another floor fan was observed near the dishwashing area, running and pointed towards the dish machine. Dust was accumulated on the front grille of the fan. Interview on 03/05/26 at 2:22 PM, the Dietary Manager stated opened food stored in the refrigerator should be completely covered to keep any contaminants out. She said the fans should be cleaned as needed. She said not cleaning the fans could cause contaminants to blow into the food. She stated the risk would be food borne illnesses. Interview on 03/05/26 at 4:02 PM, the Administrator stated opened food stored in the refrigerator should be covered and labeled. She said the fans should be cleaned as needed. She said the risk would be cross contamination. Record review of the facility policy titled Infection Control Policy / Procedure revised 05/2010, revealed It is the policy of this facility to promote a sanitary environment.Thorough scrubbing will be used for all environmental surfaces that are being cleaned.Record review of the facility Meals and Food policy, dated June 2017, reflected: .8. Food purchased, stored, and served in this facility is labeled and dated according to all applicable food service regulations.Record review of the U.S. FDA Food Code 2022 reflected: Section 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by:(1) Except as specified in (1)(d) below or when combined as ingredients, separating raw animal FOODS during storage, preparation, holding, and display from:(a) Raw READY-TO-EAT FOOD including other raw animal FOOD such as FISH for sushi or MOLLUSCAN SHELLFISH, or other raw READY-TO-EAT FOOD such as fruits and vegetables, (b) Cooked READY-TO-EAT FOOD,. and Section 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers.(B) Label information shall include:(1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; .

Based on observation and interview, the facility failed to dispose of garbage and refuse properly for 2 of 2 dumpsters. (Dumpsters #1 and #2).1. The facility failed to ensure the lids and doors were completely shut on both dumpsters. 2. The facility failed to ensure trash, including used incontinent briefs and other garbage was not near dumpster #1.These failures could place residents at risk of an unsanitary environment and could attract pests, rodents and other animals. Findings included:Observation of the dumpster area on 03/03/26 at 8:58 AM revealed the following:- doors open on dumpster #1 and #2 exposing trash, - the lids on both dumpsters were open,- a clear trash bag with soiled incontinent briefs and other trash was lying partially underneath dumpster #1.Interview on 03/03/26 at 8:58 AM, the Dietary Manager stated the doors and lids should be closed, and trash picked up to keep rodents and bugs away. Interview on 03/03/26 at 2:16 PM, the Corporate Nurse stated she spoke with the Maintenance Supervisor who said he and housekeeping were responsible for maintaining the areas around the dumpster. She said the reason the trash bag was lying there was because the container was on top of it. She said the doors and lids should be closed. Interview on 03/05/26 at 4:02 PM, the Administrator stated the trash should be picked up and doors and lids closed on the dumpsters. The Administrator stated the facility did not have a policy for outside garbage and refuse disposal.

Based on observation, interviews and record reviews, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, maintaining medical records on each resident that are complete and accurately documented for 1 of 6 (Resident #3) residents reviewed for clinical records.The facility failed to ensure Resident #3's TAR accurately indicated treatment provided or refusals on 01/06/26, 01/10/26, 01/20/26, 01/22/26, 01/24/26, and 01/27/26. This failure could place residents at risk of not receiving treatments and inaccuracy of their medical records. Findings included:Record review of Resident #3's Quarterly MDS assessment, dated 05/05/25, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #3's diagnoses included Diabetes Mellitus (a disease that occurs when the body does not respond properly to insulin leading to high blood sugar levels), Peripheral vascular disease (slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel), and Cerebrovascular Accident (stroke). Resident #3's BIMS score was 15, indicating intact cognition.Record review of Resident #3's care plan revealed the following: - Has nutritional problem or potential nutritional problem r/t non-pressure chronic ulcer to left ankle, overweight, DMII, date initiated 10/03/24- Resistive to care r/t [family member] impedes care, date initiated 06/10/25- Has Diabetic Ulcer to left Achilles tendon r/t Vascular insufficiency, date initiated 08/19/25Record review of Resident #3's January 2025 TAR revealed blanks for 01/06/26, 01/10/26 and 01/20/26 for the following treatment:- Cleanse Venous wound to left Achilles tendon with Vasha (wound cleanser), pat dry, Alginate calcium with Silver apply once daily, dress with gauze, Kling and Coban (types of self-adhering wraps) compression change every 48 hours and as needed; if saturated, soiled or dislodged. Every 48 hours for wound healing - Start date 07/30/25 - DC date 01/21/26. Further review of Resident #3's January 2025 TAR revealed blanks for 01/22/26, 01/24/26 and 01/27/26 for the following treatments:- Cleanse Venous wound to left Achilles tendon with Vasha, then pat dry, apply collagen sheet and cover with dry dressing three times a week and PRN if dressing become soiled or dislodged until further instructions every day shift every Tue, Thu, Sat for wound healing -Start Date- 01/22/2026 - D/C Date- 01/29/2026. - Diabetic Ulcer to R Great toe: cleanse with Vasha then pat dry apply collagen sheet and cover with dry dressing three times a week and PRN if dressing become soiled or dislodged until further instructions every day shift every Tue, Th, Sat for wound healing - Start date 01/22/26 D/C date 01/29/26.Observation and interview on 03/03/26 at 10:57 AM revealed Resident #3 appeared well groomed and dressed and was sitting up in his wheelchair. Resident #3 had a heel protector on the right heel. He stated dressings had not been changed every other day in January . Interview on 03/05/26 at 12:10 PM, the DON stated the wound care nurse was responsible for wound care and if she was not there the nurse on the floor was responsible. She stated the previous wound care nurse was no longer employed at the facility. A telephone interview was attempted on 03/05/26 at 12:18 PM with LVN D, but the attempt was unsuccessful. Interview on 03/05/26 at 12:20 PM, RN B stated if there was no wound care nurse, she would do wound care. She stated the first shift nurse did Bed A, and the second shift nurse did Bed B. She said when a treatment was done it was supposed to be marked off on the TAR. She stated if there was a blank it could mean the nurse forgot or the treatment could have been missed. She said it was important to document treatment was administered to show it was done. Interview on 03/05/26 at 2:01 PM, by phone with LVN E, revealed she had worked on 01/22/26 and did provide the wound treatment for Resident #3. She stated she had worked on that hall on 01/27/26 and remembered that Resident #3 had refused the dressing change on one of the Tuesdays she worked but did not remember what date. She said it was supposed to be signed off, but sometimes they (staff) do forget. She stated she was supposed to document refusals. Interview on 03/05/26 at 4:02 PM, the Administrator stated she expected staff to sign off on the TAR to validate the treatment was given. She stated she expected staff to document if residents refused care. She stated the risk would be not knowing if the treatment was given or not. Interview on 03/05/26 at 4:19 PM, the DON stated the TAR should have been signed off for wound care and if a resident refused it should be documented. She stated the risk would be that the resident did not get wound care and inaccuracy of records. Record review of the facility's policy titled Recording and Maintenance of MAR dated July 2017, reflected: .Procedure: .8. The resident's MAR is initialed by the person administering the medication in the space provided under the date and on the line for that specific medication. Initials on the MAR are verified with a full signature on the signature sheet (or, if electronic, per facility policy for electronic MARs and Signatures).9. If a dose of regularly scheduled medication is refused by the resident, the initials of the person attempting administration will be circled and the reason for refusal will be documented on the backside of the MAR (or, if electronic, per facility policy for annotation of refusals).

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 2 medication rooms (Station 2 medication room) reviewed for pharmacy services. The facility failed to remove expired medications from the Station 2 Medication Room, which included Famotidine, with an expiration date of 02/25, and Benzocaine 20% and Glucosamine, with an expiration date of 01/26. This failure could place residents at risk of receiving medications that were ineffective.Findings included: Observation on 03/04/26 at 12:36 PM of the Station 2 medication room with the ADON revealed 2 boxes of Famotidine 10 mg (medication to reduce stomach acid) with an expiration date of 02/25, Benzocaine 20% (topical numbing medication) with an expiration date of 01/26, and Glucosamine 500 mg (dietary supplement used to support joint health) with an expiration date of 01/26. Observation and interview on 03/04/26 at 12:46 PM revealed the ADON opened the boxes of Famotidine to confirm the expiration date. The ADON stated the Famotidine had an expiration date of 02/25, and the Benzocaine and Glucosamine had an expiration date of 01/26. The ADON stated it was her responsibility to ensure there were no expired medications in the storage rooms. The ADON stated she was new to the facility and started on 02/05/26. She stated central supply checked weekly when medications were stocked and the nurses were expected to check the medication room when they pulled medications. The ADON stated she was expected to conduct weekly audits to ensure there were no expired medications but had not done that yet. The ADON stated the risk of having expired medications was residents could receive the medication and not receive the full benefit. Interview on 03/05/26 at 9:50 AM, the DON revealed she expected the ADON to check the medication rooms weekly for expired medications. She stated the ADON was still new, so it was her responsibility to check the medication rooms as well. She stated it was also Central Supply's responsibility to check for expired medications when she was restocking. The DON stated there was a position open for Central supply since 01/26. She stated the previous Central Supply changed to a PRN CNA [CNA A] but still assisted with restocking the medication rooms. She stated the nurses were only responsible for reviewing expired medications on their cart and when administering any medications. The DON stated the nurses were not expected to review the medication rooms for expired medications. The DON stated the risk of having expired medications in the storage rooms was they could be administered to residents and cause an adverse reaction. Interview on 03/05/26 at 1:12 PM, CNA A revealed she was Central Supply until 01/23/26 when she changed to a CNA PRN. She stated she did still assist with restocking the medication rooms. CNA A stated every Thursday she and a nurse would restock the medication rooms and do spot checks for expired medications. She stated the last time it was completed was on 02/26/26. CNA A stated she was unable to recall what nurse was with her, but it could have been the ADON. CNA A stated the medication room gets rearranged frequently and she must have missed the expired medications. She stated the risk of having expired medications in the medication room was they could be administered and make the residents sick. Interview on 03/05/26 at 1:38 PM, RN B revealed it was the ADON and DON who checked the medication rooms for expired medications. RN B stated she was expected to review her medication cart and medications prior to administration for their expiration date. She stated it was the ADON and DON's responsibility to ensure there were no expired medications in the medication rooms. RN B stated the risk of having expired medications was that they could be administered to the residents and it could be ineffective or cause a reaction. Interview on 03/05/26 at 1:42 PM, the Administrator revealed she expected the medication rooms to be reviewed for expired medications weekly when the rooms were restocked. She stated the nurses were also responsible for checking the rooms when they pulled medications. She stated Central Supply usually did the storage rooms restocking, but CNA A was assisting until the position was refilled. The Administrator stated it was all nurses and central supply's responsibility for ensuring there were no expired medications; however, the DON was overall responsible. The Administrator stated the risk of having expired medication in the storage rooms was they could be administered to residents and be less effective. Record review of the facility's Medication Access and Storage/Drug Destruction policy, revised 07/23, reflected the following: .Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order exists.

Based on observation, interview, and record review the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for 1 of 3 residents (Resident #83) reviewed for respiratory care. The facility failed to ensure Resident #83 had a physician order for oxygen treatment. This deficient practice could affect residents who received oxygen therapy from receiving inadequate oxygen support.Findings included:Record review of Resident #83's MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and readmitted [DATE]. Resident #83 had a BIMS of 15 indicating her cognition was intact. Her diagnoses included heart failure (heart muscle is unable to pump enough blood to meet the body's need for blood and oxygen), hypertension (high blood pressure), and chronic obstructive pulmonary disease (progressive lung disease that makes it difficult to breathe). Resident #83 had shortness of breath or trouble breathing when lying flat, however, no indication for use of oxygen .Record review of Resident #83's clinical record reflected there were no physician orders for Resident #83's use of supplemental oxygen. Record review of Resident #83's care plan revealed Resident #83 had COPD (Chronic Obstructive Pulmonary Disease) with potential for Respiratory Decline. Goal: Resident #83 Will display optimal breathing pattern daily. Interventions included Give oxygen therapy as ordered by the physician - resident refuses humidification bottle, Monitor for signs and symptoms of acute respiratory insufficiency: Anxiety, Confusion, Restlessness, Shortness of Breath at rest. Monitor/document/report to physician as needed any signs and symptoms of respiratory infection: Fever, Chills, increase in sputum (thick, slippery fluid produced by the respiratory tract) (document the amount, color, and consistency), chest pain, increased difficulty breathing (Dyspnea), increased coughing, and wheezing.Observation and interview on 03/03/26 at 12:06 PM of Resident #83 revealed she was sitting in her room in a wheelchair. Resident #83 had her nasal cannula in place which was connected to a portable oxygen tank. Resident #83 stated she required the use of the oxygen for some time, and she was on 2 liters of oxygen continuously.Interview on 03/05/26 at 11:45 AM, RN C revealed Resident #83 was on 2 liters of oxygen continuously, and when asked to confirm by the order, RN C stated she was not able to locate the physician order for the oxygen. RN C stated Resident #83 was discharged from the hospital, and the order may have been deleted. RN C stated once Resident #83 returned the admitting nurse was responsible for ensuring Resident #83's use of oxygen was entered. RN C further stated not having an order for the oxygen placed Resident #83 at risk of being administered the incorrect amount of oxygen. Interview on 03/05/2026 at 1:27 PM, the DON revealed she was not aware of Resident #83 not having current oxygen orders. The DON stated it was the responsibility of the admitting nurse to ensure that all orders are entered during admission to the facility. The DON stated it was a group effort of all nursing department heads to ensure all orders were current and updated. The DON stated that not reviewing physician orders for accuracy placed residents at risk of missing treatments or administrating the incorrect amounts of treatment. Record review of the facility's Physician Orders policy, revised May 2007, reflected: It is the policy of this facility that drugs and treatments shall be administered/carried out upon the order of a person duly licensed and authorized to prescribe such drugs and treatments. Orders for medications must include:A. Name and strength of the drug.B. Quantity or specific duration of therapy.C. Dosage and frequency of administration.D. Route of administration if other than oral; and E. Reason or problem for which given.

Based on observation, interview and record review, the facility failed to ensure a resident who is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections based on the resident's comprehensive assessment for 1 of 3 residents (Resident #4) reviewed for urine incontinence/catheters. The facility failed to ensure Resident #4 had a physician order for the use and care of an indwelling catheter. This failure could place residents with catheters at risk of not receiving proper care and infections. Findings included: Record review of Resident #4's MDS assessment, dated 01/07/26, reflected an [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had a BIMS score of 15 indicating his cognition was intact. Resident #4 required supervision or touching assistance with toileting. Resident #4's diagnoses included Benign Prostatic Hyperplasia without lower urinary tract (enlarged prostate) symptoms, Diabetes Mellitus (high blood sugar), anxiety disorder (feelings of fear, dread, or apprehension), bipolar disorder (significant mood swings), and depression (persistent feelings of sadness). Resident #4's assessment did not include the use of a catheter. Record review of Resident #4's undated care plan reflected no use of or care for Resident #4 having an indwelling catheter. Record review of Resident #4's order summary report did not reflect an order for the use of or care for an indwelling catheter.Observation and interview on 03/03/26 at 10:13 AM, Resident #4's catheter bag was hanging low attached to his wheelchair. Resident #4 stated the communication stinks, I have to ask the aides to check my catheter, they will not check it on their own. Resident #4 further expressed he usually emptied the catheter on his own, without the assistance of facility staff. According to Resident #4 he has not had any complications of irritation, burning or pulling with the use of the catheter.Interview and observation on 03/05/26 at 11:46 AM with RN C revealed Resident #4 laying in bed, with the catheter hanging low on his wheelchair. Resident #4's catheter was securely strapped to his right leg. RN C reported she was aware Resident #4 had a catheter; however, she could not identify what size catheter was used. Resident #4 was able to share that he used a French 18. RN C stated aides were responsible for emptying Resident #4's catheter and nurses were responsible for ensuring proper care was provided. Interview on 03/05/2026 at 1:19 PM, RN C revealed during her record review she could not locate an order for Resident #4's catheter use, or care. RN C stated the admitting nurse was responsible to ensure all orders pertaining to Resident #4's catheter use and care were entered. RN C stated not having orders placed Resident #4 at risk of not receiving proper care. Interview on 03/05/26 at 1:27 PM, the ADON revealed she had been notified by RN C that Resident #4 was without catheter orders. The ADON stated Resident #4 had been out in the hospital, and Resident #4's orders should have been entered by the admitting nurse upon his return. The ADON stated they must have orders for use and care, and without the orders Resident #4 was at risk of improper care and infection. Interview on 03/05/26 at 1:54 PM, the DON revealed she was unaware Resident #4 did not have orders for his catheter use or care. The DON stated nurses were responsible for ensuring that all resident orders were entered upon admission. The DON stated Resident #4 not having orders placed him at risk of infection and improper care for his catheter. Record review of the facility's Indwelling Urinary Catheters policy, revised September 2022, reflected: It is the policy of this facility that each resident with an indwelling catheter will receive catheter care to promote hygiene, comfort and decrease the risk of infection.The Attending Physician, Resident, Responsible Party and Nursing will discuss the need for urinary drainage via a catheter. Diagnosis will be obtained and entered into the resident's record. The resident and/or resident's responsible party will be notified of the risk and benefits of a urinary catheter.Orders will be obtained for catheter size, care, monitoring, and when to change the catheter and drainage system.The catheter will be monitored with care given. Catheters will be changed per the physician's order.Leg straps or other devices will be used to support the catheter to prevent pulling on the urethra.

Based on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #4) reviewed for comprehensive care plans.The facility failed to develop a care plan for Resident #4's indwelling catheter.These failures placed residents at risk of infections and not receiving appropriate care.Findings included:Record review of Resident #4's MDS assessment, dated 01/07/26, reflected an [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had a BIMS score of 15 indicating his cognition was intact. Resident #4 required supervision or touching assistance with toileting. Resident #4's diagnoses included Benign Prostatic Hyperplasia without lower urinary tract (enlarged prostate) symptoms, Diabetes Mellitus (high blood sugar), anxiety disorder (feelings of fear, dread, or apprehension), bipolar disorder (significant mood swings), and depression (persistent feelings of sadness). Resident #4's assessment did not include the use of a catheter. Record review of Resident #4's undated care plan reflected no use of or care for Resident #4 having an indwelling catheter. Record review of Resident #4's order summary report did not reflect an order for the use of or care for an indwelling catheter.Observation and interview on 03/03/26 at 10:13 AM, Resident #4's catheter bag was hanging low attached to his wheelchair. Resident #4 stated the communication stinks, I have to ask the aides to check my catheter, they will not check it on their own. Resident #4 further expressed he usually emptied the catheter on his own, without the assistance of facility staff. According to Resident #4 he has not had any complications of irritation, burning or pulling with the use of the catheter.Observation and interview on 03/05/26 at 11:46 AM with RN C revealed Resident #4 lying in bed, and his catheter was hanging low on his wheelchair. Resident #4's catheter was securely strapped to his right leg. RN C reported she was aware Resident #4 had a catheter. According to RN C, care plans were generated upon admission so that nursing staff were able to provide adequate care. RN C stated care plans were updated by the MDS Coordinator.Interview on 03/05/26 at 1:27 PM, the ADON revealed she had been notified by RN C that Resident #4's care plan was not updated with his use or care for a catheter. The ADON stated Resident #4's care plan should have been updated by either the ADON, DON or the MDS Coordinator when there are changes in his condition. The ADON stated the care plan included important information for use and care, without it Resident #4 was at risk for improper care and infection. Interview on 03/05/26 at 1:54 PM, the DON revealed she was unaware Resident #4 did not have his care plan updated with his catheter use or care. The DON stated MDS Coordinators were responsible for ensuring that all resident care areas were entered upon admission. The DON stated Resident #4 not having an updated care plan placed Resident #4 at risk of infection and improper care for his catheter.Interview on 03/05/26 at 4:48 PM, the MDS Coordinator revealed she was not aware that Resident #4's care plan did not include his use of a catheter. The MDS Coordinator said Resident #4 had recently been out to the hospital, (unsure of the dates) with the catheter. The MDS Coordinator stated nurses were responsible for ensuring the order was entered so the care plan could reflect proper care for residents. The MDS Coordinator said the purpose of the care plan was to notify all staff of resident's care needs. The MDS Coordinator said if something was missing from the resident's care plan, it placed residents at risk and there could be miscommunication regarding the resident's care. Record review of the facility's Care Plans, Comprehensive Person-Centered policy, revised January 2022, reflected: It is the policy of this facility that the interdisciplinary team shall develop a comprehensive person-centered care plan for each resident that includes measurable objective and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for supervision. The facility failed to ensure Resident #1, who was a high risk for elopement for which he wore a WanderGuard device, was provided with adequate supervision to prevent him from exiting the building on 07/28/25. Despite the WanderGuard alarm sounding, RN A turned the alarm off without immediately going outside to determine if there was a resident elopement. The resident was found approximately nine hours after he went missing. He was found two miles away from the facility by the local police department following an extensive search. The noncompliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began on 07/28/25 and ended on 07/29/25. The facility had corrected the noncompliance before the survey began.This failure placed residents at risk of harm and/or serious injury. Findings included:Record review of Resident #1's admission MDS assessment, dated 07/03/25, reflected the resident was an [AGE] year-old male, who was admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's Disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline), cerebral ischemia (inadequate blood supply to the brain), hypertension (high blood pressure), muscle weakness (a condition where your muscles cannot work with the expected amount of force). The MDS reflected Resident #1 had severe cognitive impairment with a BIMS score of 00. Resident #1 did not exhibit wandering behaviors. The MDS further reflected Resident #1 had Wander/elopement alarm (bracelet detected near a sensor, the system triggers an alert).Record review of Resident #1's care plan, dated 06/24/25, reflected Focus: Elopement risk/wanderer r/t Impaired safety awareness. Goal: Will not leave facility unattended through the review date. Interventions: Document wandering behavior and attempted diversional interventions. Monitor placement and function of Wander Guard Q Shift Wander Guard to Right ankle expiration date 02/24/26. Record review of Resident #1's Elopement Risk Evaluation, dated 06/29/25, reflected Resident #1 was a high risk for elopement. The evaluation indicated Resident #1 had a diagnosis of dementia and Alzheimer's disease. Ambulation: Ambulates independently or with supervision. Mental status: Disoriented. History of elopement in the last 6 months: Two or more Episodes. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs, outside the facility): 2. Yes, wandering is aimless w/potential to go outside, active exit seeking behavior. Record review of Resident #1's physician orders dated 07/01/25, reflected Wander guard to right ankle every day shift every 90 day(s) for wanderguard.Record review of Resident #1's progress notes dated 07/29/25 at 2:02 AM by RN A reflected: Resident active walking on the hallway upon arrival at 1800 [6:00 PM] appeared happy had a smile on his face and very talkative in Spanish. Tolerated his HS meds. Resident started following this nurse while passing the medicine. Approximate 2000 [8:00PM] this nurse did not see resident in the hallway. The nurse and CNA started looking for him in the rooms of 600 hall, we did not see him. This nurse called for code white alerted all the staff in the facility and we started looking for him in and out of the facility. Family called and left them a message to call the facility. The family called back later and told this nurse they will come over to the facility. Administrator was notified.Record review of Resident #1's progress notes dated 07/29/25 at 4:53 AM by Clinical Market Leader reflected: 4:50am police arrived to facility with resident in back seat. Resident able to stand and transfer to wheelchair and brought into facility for assessment by charge nurse. Family also arrived behind police and notified of return to facility. Police notified this writer that EMS would arrive shortly to assess him as this was their protocol. Resident alert and denies pain, water in hand, assisted to his room by nurse and family.Record review of the facility's Provider Investigation Report, completed by the Administrator on 08/05/25, reflected the following: Incident date: 07/28/25, Time of Incident: 8:00 PMDescription of the Allegation: Resident missing from facility Assessment Date: 07/29/25; Time: 4:55 AM;Charge nurse completed head to toe assessment upon resident return on 7/29/25 @ apprx. 4:55 a.m - no injuries notes, resident mood was pleasant and friendly. EMS arrived at apprx. 5:10 a.m. (per PD policy). Completed assessment as well - no concerns. Vitals within normal limits. Attending physician assessed at apprx. 10:30 a.m. no injuries notes - suggested precautionary CBC - normal results - Skin assessment completed during shower by c.n.a. no issues noted. Provider Response: The facility initiated missing resident protocol. Implementing search efforts to include inside facility, outside the facility and an extensive search of the surrounding area by vehicle, on foot, air search and K9 unit. Facility completed a visual census check of all residents in the facility. The facility informed the medical director-administrator-Interim DON-Family-[Name] PD of missing resident. Family reviewed camera footage to establish at timeline and verify description. Facility initiated interviews with all staff working at the time of the incident. Facility reviewed elopement risk assessments for all residents on 07/28 & 07/29/2025. Interventions and care plans were reviewed and modified as appropriate. Facility initiated education and in servicing related to elopement/missing residents as well as abuse/neglect. Facility conducted on site elopement drills for both shifts. Facility initiated education and implemented documented census reconciliation process to be completed at the onset of each shift and again at 2359. Facility adjusted camera system to provide visual monitoring of the front door at each nurse's station. Facility initiated walking rounds to include lobby area during the 6p-6a shift. Installation of wader guard sound box with flashing lights at each nurse's station in addition to the exiting one at the front door. Facility is in the process of installing a camera outside of the front entrance. Charge nurse was suspended pending investigation later terminated. Upon resident return Head to toe assessment X 2 - no injuries noted. No new orders. Family notified upon exit and return - medical director notified upon exit and return. Resident placed 1-1 observations - resident d/c to another SNF with secure area on 7/29/25. Investigation Summary: After completing staff interviews and reviewing video footage it was determined the res was observed to be on 600 Hall walking along side charge nurse. At apprx. 7:40 p.m. resident walked away from the nurse out of camera view as she continued med pass on 600 hall. At apprx 7:51 p.m. res [resident] was seen to be in the front foyer walking around. At apprx. 7:54 p.m. resident was seen on camera following a Hispanic female out the front door. The nurse stated at apprx. 8:00 p.m., she noticed resident was not in his room or on the 600 Hall. Elopement protocol was initiated search efforts included the inside and outside parameters of the facility as well as an extensive search of the surrounding territory. Facility staff and leadership actively engaged in the search by foot and vehicle utilizing resident photo and description. [Department Name] PD became involved in the search to include foot patrol/vehicle patrol/Helicopter search and K9 (canine) unit as well as social media alerts. Multiple family members were onsite assisting in search efforts as well communicating with facility administration sharing leads and search efforts. Resident was located in the parking lot of a nearby car dealership. [Department Name] PD returned the resident at approximately 4:55 a.m. on 7/29/25. Resident was drinking water and smiling. He appeared to have his normal demeanor. Head to toe assessment completed by charge nurse as well as EMT (per PD protocol). No injuries noted, vitals within normal range. Family arrived within minutes of his return embraced resident and assisted staff with preparing him for bed. Resident went to sleep within moments. Shower offered resident no new findings. Labs requested to be followed up at receiving facility as resident was transferred to [Facility Name] in a secure environment. Labs resulted within normal range with no new orders. During follow up conversation with the family, they agreed to resident likely related the Hispanic female he followed out the door to his spouse as she had visited earlier in the evening. Resident did wander within the facility although he had not made previous attempts to exit the facility. Family expressed gratitude and appreciation for the care that was provided to the resident.Record review of RN A's witness statement, dated 07/28/25, reflected the following: To whom it my concern, approximate @ 1900 [7:00PM] resident noted with wet pant and CNA took him to his room and cleaned him up and dressed him on green top and red pants. After he was changed resident started following this nurse while passing HS meds. At approximate 2000 [8:00PM] I noticed resident was not on hallway. Myself and the CNA started looking for him in all the rooms and bathrooms on 600 Hall. We did not locate him and at that time I called Code White. All staff in the facility started looking for him around the in and out of the facility. Family and administrator was notified. Regards, RN A. Record review of CNA B witness statement, dated 07/29/25, reflected the following: Statement of CNA B 500/600 Hall, around 7PM she noticed his pants was wet & she took him into his room & changed out his pants. When she got finished with him, he went back to the nurses. Around 8 he was with the nurse & I was with another resident that was going out & when I came out the nurse asked about him. And I said that he was with you & she told me she couldn't locate him. So, then we all was looking for him together. We could not find him inside the building, so we went outside the building & still was unable to locate him. Witnessed by CNA B.An attempt was made to contact RN A by phone on 09/11/25 at 11:30 AM; however, there was no answer. Interview on 09/11/25 at 11:36 AM with LVN C revealed she worked the night Resident #1 eloped from the facility on 07/28/25 from 6PM-6AM. She stated she was the nurse assigned to 200 Hall and a little after 7:00PM before 8:00PM she had gone to 600 Hall looking for something and she observed Resident #1 standing behind RN A. She stated at approximately 8:00 PM she was notified of the code white. She stated she stopped what she was doing and checked each of her rooms on 200 Hall before she went over to the 600 Hall. LVN C stated that night there was visitors in the building. She stated no WanderGuard alarms were heard that night. She stated everyone was notified and Resident #1 was found on 07/29/25 at around 5:00 AM. LVN C stated Resident #1 was an elopement risk because he would pace the hallways and follow people around. Interview on 09/11/25 at 2:08 PM with CNA B revealed she was the CNA assigned to Resident #1 when he eloped from the facility on 07/28/25. She stated around 7:00 PM she observed Resident #1 with RN A, she stated Resident #1 needed a brief change, so she took him to his room to change him. Once she was done changing Resident #1, Resident #1 went back to the nurse's station to be with RN A. She stated RN A was passing out medications and Resident #1 was following her. CNA B stated she continued to assist other residents and around 8:00PM RN A was calling for her. She stated RN A told her she had heard the WanderGuard alarms go off at the main entrance but did not see anyone and she turned off the alarm. CNA B stated she did not hear any alarms go off because she was in a resident room. She stated RN A asked her for help on checking on the residents and that was when RN A noticed Resident #1 could not be located. CNA B stated RN A called a code white and everyone began to search for Resident #1 inside and outside the facility. CNA B stated Resident #1 was found the following day on 07/29/25 at around 5:00 AM. She stated Resident #1 was assess and had no injuries. CNA B stated Resident #1 was an elopement risk and had a WanderGuard on. She stated Resident #1 was known to pace the hallways and follow people around the facility. CNA B stated Resident #1 was able to walk without assistance. She stated that night Resident #1 followed a visitor out the facility.Interview on 09/11/25 at 2:59 PM with the DON revealed she was on leave when Resident #1 eloped from the facility. She stated Resident #1 was known to pace the hallways and follow staff around the facility but was easily redirected. She stated she could not recall if Resident #1 would exit seek, but he would come to the front area of the facility. She stated after the elopement the facility inserviced all staff on elopement/missing person, what to do in case of an elopement and abuse and neglect. She stated elopement risk assessments and care plans were reviewed. She stated nurses are expected to print out a census and complete a resident head count at the beginning of each shift. The DON stated they also added a new WanderGuard alarm system on each nurse station with flashing lights. She stated they also added a camera at the main entrance and each nurse station surveillance monitors were added to overlook different areas of the facility. Interview on 09/11/25 at 3:10 PM with the Administrator revealed she was notified of Resident #1's elopement at around 8:40 PM. She stated she reviewed camera footage because there were some inconsistencies with what the resident was wearing. She stated camera footage revealed at 7:51 PM Resident #1 was observed following RN A, then it showed Resident #1 walking away from the nurse. She stated at 7:54 PM a visitor was walking towards the main entrance and Resident #1 can be observed following behind the visitor. The Administrator stated according to RN A she heard the WanderGuard alarms go off and the nurse went to go check but did not observe anyone at the front and deactivate the alarm. She stated RN A went back to her hall and completed a head count of her resident and that was when she noticed Resident #1 missing. She stated a code white was called and everyone began the search. She stated Resident #1 was found at 4:55 AM on 07/29/25 by the police department. She stated Resident #1 was located about 2 miles away from the facility at a local business. The Administrator stated when Resident #1 returned to the facility he was happy, a head-toe assessment was completed, and no injuries were noted. The Administrator stated Resident #1 was an elopement risk and had a WanderGuard because he would walk around the facility. She stated Resident #1 never attempted to open doors or tried to go outside. She stated the day Resident #1 eloped, the visitor he followed behind fit the description of his wife. The Administrator stated Resident #1 was probably thinking he was following his wife out. She stated after the incident all staff were in-service on elopement/missing person, abuse and neglect, completed elopement/missing person drills, a new WanderGuard alarm system was placed at each nurse's station, weekly door/WanderGuard checks completed and at beginning of each shift nurses must print out a census and complete a head count of all residents. She stated a camera was placed outside the main entrance and surveillance monitors were placed at each nurse's station. She stated elopement risk assessments were completed on all residents and care plans were reviewed. The Administrator stated Resident #1 was placed on 1:1 supervisor and then discharged on 07/29/25 to a more appropriate placement.Record review of the facility's Elopement/Unsafe Wandering policy, revised January 2022, reflected the following: It is the policy of this facility to provide a safe environment for all residents through appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement. This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision and diversional programs to prevent unsafe wandering while maintaining the least restrictive environment for those at risk for elopement.This was determined to be a Past Non-Compliance Immediate Jeopardy on 09/11/25 at 4:22 PM. The Administrator and the DON were notified. The Administrator was provided with the Immediate Jeopardy Template on 09/11/25 at 4:25 PM.The facility took the following actions to correct the non-compliance prior to the abbreviated survey:Record review of the facility's Resident frequent Monitoring Tool reflected Resident #1 was placed on 1:1 supervision on 07/29/25 from 5:30 AM until he transferred at 11:30 AM. Record review of Elopement/Wandering Evaluation reflected they were reviewed and completed on Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5 on 07/29/25.Record review of Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5's Care Plans reflected care plans were reviewed on 07/29/25 to reflect them as being at risk for elopements and having WanderGuards.Record review of the facility's Elopement binders located on both nurse's stations and reception reflected pictures of residents who were at elopement risk and contained information regarding the residents.Record review of the facility Elopement Drill Drills reflected a drill was completed on 07/29/25 at 12:00PM.The facility continued to conduct random Missing Person/Elopement drills on the following days: 08/09/25 6:15 PM, 08/14/25 - 8:15 PM, 09/08/25 - 11:05 AM. Record review of facility Emergency Exit Door and Wanderguard Inspection Log forms for all exit doors reflected door checked were completed daily from 07/29/25 through 07/31/25 and then completed once a week from 08/01/25 through 09/06/25 by Maintenance Director. Record review of facility daily Census/Midnight Census print out, start date 07/29/25 through 09/11/25 reflected nursing completing head count of residents. Observation on 09/11/25 at 10:15 AM of nurses' station revealed surveillance monitors were added at each nurses' station that overlook different areas of the facility and outside the main entrance. Observation on 09/11/25 from 2:55 PM through 2:58 PM revealed main entrance WanderGuard alarm was tested with Maintenance Director. Each nurses' station has an alarm for WanderGuard, and the alarm was heard throughout the facility. When alarm goes off flashing light flashes which indicates Code White.Record review of in-services dated 07/28/25 and 07/29/25 reflected all facility staff were in-serviced on: Elopement/Missing Resident, Policy, Procedures, Elopement Book, Abuse and Neglect. Summary of Inservice: Assessment- Residents are assessed upon admission, quarterly and with any changes in condition or elopement attempts. Care Plans are updated for those that are high risk. WanderGuards - WanderGuards must have a physician order and should be changed out every 6 months. Alarms should be responded to immediately in the event a resident is attempting to exit the facility. If a resident is found missing, the employee and team will initiate the missing resident procedures as outlined in the Elopement/Unsafe Wandering Policy and Guidelines (attached) that is located in the elopement. What to do in the event of an Elopement; What to do in the event you are unable to locate your patient; What to do if you hear the alarm going. Elopement Code White, Abuse and Neglect. In-serviced on 08/07/25 reflected Wander guard - New alarm sound/flashing light at nurse's station. [NAME] light flashing and sound possible elopement. When alarm sounds staff will respond accordingly. Wander guard- all staff immediately check foyer/front door area as well outside the door. Interviews on 09/11/25 from 11:36 AM through 5:20 PM with CNA B, LVN C, ADON D, ADON E, Housekeeping F, Housekeeping G, Therapy H, Therapy I, Dietary Supervisor, [NAME] J, CNA K, CNA L, MA O, CNA P, LVN Q, LVN R, LVN S, Social Worker and Maintenance Director who worked the shifts of 6:00 AM-6:00 PM, 6:00 PM-6:00 AM revealed the facility staff were able to verify education was provided to them. Facility staff were able to accurately summarize the elopement/missing person, code white, abuse, and neglect in-service, and where to locate elopement binders. Facility staff were able to indicate new WanderGuard alarm system were added to each nurse's station with flashing lights and elopement/missing person drills were completed. Nursing staff stated a daily/midnight census were printed and head counts were completed before shift, elopement assessment were reviewed/completed (an evaluation to determine any resident at risk of elopement), care plans reviewed for residents who were elopement risk, nurses ensure WanderGuards were checked daily to ensure they were working properly and document on the MAR, and surveillance monitors were added to each nurses station that overlook different areas of the facility. Staff indicated a surveillance camera was also added at the front entrance to provide additional oversight.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 5 residents (Resident #1 and Resident #2) reviewed for abuse. The facility failed to ensure Resident #1 was free from abuse when Resident #2 pulled Resident #1 out of bed and hit him on 01/30/25. The noncompliance was identified as past noncompliance. The noncompliance began on 01/30/25 and ended on 01/30/25. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of being abused. Findings included: Record review of Resident #1's quarterly MDS, dated [DATE], reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included heart failure, diabetes, stroke, and respiratory failure. The resident had a BIMS of 8, which indicated his cognition was moderately impaired. The MDS further reflected Resident #1 did not have any physical or verbal behaviors. Record review of Resident #1's care plan, revised on 08/08/24, reflected the resident had the potential to demonstrate verbally abusive behaviors related to dementia, ineffective coping skills, poor impulse control, and mental illness. Interventions included to analyze key times, places, circumstances, triggers, and what de-escalates behaviors. Record review of Resident #2's quarterly MDS, dated [DATE], reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included end stage renal disease, Huntington's disease (a progressive, inherited neurodegenerative disorder that affects the brain), pain in left leg and cognitive communication deficit. The resident had a BIMS of 13, which indicated his cognition was intact. The MDS further reflected the resident did not have physical or verbal behaviors. Record review of Resident #2's care plan, initiated on 05/07/24, reflected he had the potential to demonstrate physical behaviors resisting treatments and assistance related to anger, and poor impulse control. Interventions included to document observed behaviors and attempted interventions. Record review of the facility's Provider Investigation Report, dated 02/06/25, reflected the following: [Resident 2] and [Resident #1] were roommates in [room]. At approx. 2:10 a.m. [Resident #1] was yelling at resident [Resident #3] to stop 'snotting around' and making all that noise. Apparently this triggered resident [Resident #2] who then became physically aggressive with [Resident #1] pulling him out of the bed while hitting and slapping him. [Resident #1] then engaged physically in the altercation hitting [Resident #2]. Head to toe assessment conducted on both residents-minor lacerations present on [Resident #1]. Treated provided in house. No injuries [sic] notes to [Resident #2]. [Resident #1] then requested to be sent to [hospital] for evaluation of right knee and head pain-No major injuries noted. [Resident #1] returned with no new order. Residents continue to be separated with [Resident #2] being located to a private room No history of prior incident for either resident. Record review of Resident #1's incident report, dated 01/30/25 , documented by LVN A reflected the following: Incident Description This nurse was charting at nurses' station and noticed resident's call light going off. Upon hearing banging coming from the room, I got up to answer the light. I heard both residents yelling and began to jog towards the room. Upon entering, resident was laying on his right side on the floor Resident stated that his roommate attacked him. I asked the roommate if this was true. He was pacing around on his side of the room. He stated 'did! I was fed up with him.' I called to the other nurses and CNAs to assist me in getting him cleaned up and back in bed. 'All day and night he's being doing snot stuff. So I said 'stop doing that nasty stuff.' He came over and started grabbing on my arms swinging at me. He got a hold of one of my arms and pulled me onto the floor. When I was on the floor he was slapping me so I punched him back. He finally backed off .Injuries Observed at Time of Incident Laceration: right lower leg, forehead, left side of neck, right knee, left lower leg, right forearm Record review of the facility's incident/accident report from November 2024 to February 2025 reflected there were no incidents between Resident #1 and Resident #2. Record review of Resident #1 and Resident #2's progress notes from 04/2024 to January 2025 reflected there were no incidents or disagreements between the resident while they were roommates. Observation and interview on 02/26/25 at 10:55 AM revealed Resident #1 was in bed watching his tablet, and he did not have a roommate at the time. There appeared to be some small scabbed areas to his chest, and one on each arm. The resident said he did not get along with his roommate [Resident #2] because he had a habit of having terrible drainage and would not blow his nose and then swallow it. Resident #1 said he would always tell Resident #2 to either blow his nose to stop making those sounds and Resident #2 would go to his side of the bed and says fuck you old man. The night of the incident Resident #1 said he got tired of listening to Resident #2 make his sounds so again he told Resident #2 to blow his nose. Resident #2 then went around to Resident #1's bed and began to threaten him and Resident #1 told Resident #2 to shut the hell up. At that time, Resident #2 began to try to hit him (Resident #1) but he ended up being scratched. Resident #1 said Resident #2 grabbed his right arm and pulled him down to the floor off the bed and when he was on the floor, Resident #1 was able to hit Resident #2 back and that was when Resident #2 said stop stop and he walked over to his side of the room. Resident #1 further stated he began to yell for help and that was when LVN A and other staff entered the room to help him back into bed. Resident #1 further stated he had some scratches on his chest, both arms, and his left shoulder. Observation and interview on 02/26/25 at 3:08 PM of Resident #2 revealed he was in a room by himself on another hall separate from Resident #1. Resident #2 said the staff were very good to him and he liked to be a loner. The resident recalled the incident between him and Resident #1 and he said Resident #1 was complaining saying he (Resident #2) was snoring, which was not true and he got tired of Resident #1 calling him a boy. Resident #2 said he had enough so he went over to Resident #1 and pulled him out of his bed and that was all. Resident #2 said he never told anyone at the facility Resident #1 was calling him a boy. Interview on 02/26/25 at 11:28 AM with RN B revealed she worked with both Residents #1 and #2 and to her knowledge it appeared as both residents got along and neither resident complained to her they did not like each other. RN B said Resident #2 was very quiet and usually stayed to himself and watched TV in the room. RN B said she never heard them argue or threaten each other. Interview on 02/26/25 at 11:31 AM with MA C revealed she passed medications to both Residents #1 and #2 when they were roommates. MA C said both residents stayed to themselves and did not really talk to each other and Resident #2 stayed in the room and watched TV. The MA said she never heard them argue and neither resident ever complained about the other. Interview on 02/26/25 at 11:35 AM with CNA C described Resident #2 as being very calm and not having any behaviors towards others. CNA C said Residents #1 and #2 did not have any issues with each other that she was aware nor did she ever hear them argue. CNA C said Resident #2 told her he was tired of Resident #1 referring to him a boy when he would ask that he turn the TV down. Regarding the incident, CNA C stated Resident #2 said he had enough, so he went over to Resident #1's bed and pulled him down and out of his bed. Interview on 02/26/25 at 1:42 PM with LVN A revealed she was at the nurses' station when she saw the call light on to Resident #1 and #2's room and heard banging. She stated upon entering the room Resident #1 was on the floor, and Resident #2 was standing on his side of the room pacing. She stated Resident #2 appeared to be upset. Resident #1 said he had been attacked by Resident #2. She stated Resident #2 interrupted and said he had enough of being called a little boy, so he went to confront Resident #1. Resident #2 told LVN A Resident #1 swung at him first, so he retaliated and pulled Resident #1 to the floor. LVN A said she noticed Resident #1 had a couple of lacerations on his legs and arms, which looked like he had been scratched. She said some of the scratches had bled a little, but Resident #1 did not want them treated because he was upset. Resident #1 was sent to the hospital to be evaluated because he mentioned he hit his head. She revealed Resident #1 did not have any head injuries after being evaluated at the hospital. LVN A said both residents had been roommates for over 6 months. She stated she recalled a couple months prior they had bickered with each other because Resident #1 said Resident #2 made noises. LVN A stated that was the only time they had a disagreement, but they had not been yelling or cursing and it did not happen again after that. She also said neither resident stated they wanted to change rooms, nor did they say they did not like each other. Interview on 02/26/25 at 1:42 PM with CNA E revealed she cared for Residents #1 and #2 the night of the incident, and she had not noticed anything out of the ordinary between the residents. CNA E said she provided care to Resident #1 and shortly after leaving their room, she was called back into the room because she was told Resident #1 was on the floor because he had been pulled down by Resident #2. She stated upon entering the room both residents had already been separated and Resident #2 was taken to another room. CNA E said she recalled seeing some scratches on Resident #1's legs and one on his nose. CNA E stated she assisted LVN A in getting Resident #1 off the floor and back into bed. CNA A stated during the time she had worked with both residents, she was not aware they did not like each other or that they had ever yelled or cursed at each other. Interview on 02/26/25 at 2:25 PM with CNA F revealed she worked the night of the incident between Residents #1 and #2, and she happened to pass by their room when she noticed a commotion, so she stepped inside to see if the staff already in the room needed help. She was told Resident #2 pulled Resident #1 out of bed, so she went ahead and took Resident #2 to another room. CNA F said she was not able to see any injuries on Resident #1 because there were other staff around him. CNA F further stated she was not aware if Residents #1 and #2 had a history with each other. CNA F said she requested not to care for Resident #1 because he had been very rude to her in the past during care. Interview on 02/26/25 at 2:44 PM with the Social Worker revealed she was told there was an altercation between Residents #1 and #2 because Resident #2 was making some noises Resident #1 did not like, so Resident #2 pulled Resident #1 out of bed. The Social Worker said both residents were roommates for months, and they never had any incidents in the past, so she thought they were doing well. She stated if she had been aware the residents were no getting along she would have looked into moving one to another room. The Social Worker said neither resident complained to her about the other. She stated when she went to check on Resident #1, he was no longer upset and said he was able to defend himself against Resident #2. The Social Worker further stated neither resident was in any distress after the incident and neither resident had a history of physical aggression towards others. Interview on 02/26/25 at 4:07 PM with the ADON revealed she was not aware there were any issues between Resident #1 and Resident #2, and both residents stayed to themselves on their side of the room with the privacy curtain pulled in between. The ADON stated neither resident had ever mentioned to her that they had problems with each other. She stated if they had been made aware, they would have discussed a room change. Interview on 02/26/25 at 4:13 PM with the DON revealed she was not aware of any roommate issues between Residents #1 and #2 prior to the incident. She stated no one ever mentioned anything to her, and it appeared to be an isolated incident. The DON said she was told about the altercation where Resident #2 pulled Resident #1 out of bed because Resident #2 said Resident #1 called him a boy. She stated both residents were interviewable and would have been able to tell staff if they were unhappy being roommates and nothing was ever mentioned or noticed. The DON further stated Resident #1 sustained some skin tears and scratches from the altercation but nothing that required treatment. After the incident, all staff were re-educated on abuse/neglect and what to do if they witnessed any incidents. Interview on 02/26/25 at 4:22 PM with the Administrator revealed Residents #1 and #2 were roommates for a while. She stated they appeared to get along, and she was surprised when she was told they had an altercation. The Administrator said she was told Resident #1 was calling Resident #2 a boy because Resident #2 was making some kind snot noises, so Resident #2 pulled Resident #1 out bed. She stated staff immediately intervened when they became aware and both residents were separated. The Administrator described Resident #2 as being very quiet. She stated he did not engage much with others. She further stated Resident #1 sustained some scratches on his body and neither resident appeared to be in distress from the incident. After the incident, she stated all staff were re-educated on abuse/neglect to ensure they all knew what to do if they ever witness any types of abuse. Record review of the facility's Abuse: Prevention of and Prohibition Against policy, revised December 2023, reflected the following: Policy It is the policy of the Facility that each resident had the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment Observation on 02/26/25 at 10:55 AM and 3:08 PM revealed Residents #1 and #2 were each in their own room with no current roommate on different halls, so they did not have to cross paths. Neither resident was seen out of their room during the day. Record review of the incident/accident logs from November 2024 to February 2025 reflected there were no other resident to resident altercations. Record review of the in-services dated 01/30/25 reflected 40 staff were educated on resident rights and resident to resident abuse. Interview on 02/26/25 from 11:28 PM to 4:22 PM with LVN A, RN B, MA C, CNA D, CNA E, CNA F, CNA G, CNA H, LVN I, and the ADON revealed they were in-serviced on the types of abuse, resident rights and resident to resident abuse. They all said all the residents had the right to be free from abuse and neglect, were able to name the different types of abuse. They were able to describe if they saw resident to resident abuse they were to separate them immediately, assess for injuries, and notify the Abuse Coordinator.

Based on observation, interview, and record review, the facility failed to ensure that residents who received nutrition by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 2 residents (Resident #101) reviewed for enteral feeding. The facility failed to follow physician orders for Resident #101's enteral feeding tube to be flushed with 175 cc (mL) of water every 4 hours. This failure placed residents at risk of dehydration, aspiration pneumonia, and metabolic abnormalities. Findings included: Record review of Resident #101's Admission Record dated 12/19/24 reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #101's quarterly MDS assessment dated [DATE] reflected his diagnoses included non-traumatic intracerebral hemorrhage in brain stem (brain bleed), respiratory failure, dysphasia (difficulty speaking) following other cerebrovascular disease (stroke), aphasia (language disorder), paraplegia (loss muscle function in the lower half of the body), and gastro-esophageal (acid reflux) reflux disease without esophagitis (inflammation). Resident #101 BIMS score was not completed due to resident was rarely/never understood. The MDS further revealed Section K - Swallowing/Nutritional Status indicated resident nutritional approach was feeding tube. Record review of Resident #101's care plan dated 09/17/24 reflected: Requires tube feeding r/t Dysphagia following CVA. Goal: Will maintain adequate nutritional and hydration status aeb weight stable, no s/sx of malnutrition or dehydration through review date. Interventions: Is dependent with tube feeding and water flushes. See MD orders for current feeding orders. Record review of Resident #101's physician orders dated 10/11/24 reflected an order for the resident's feeding tube to be flushed with 175 cc of water every 4 hours. Record review of Resident #101's physician orders dated 10/24/24 reflected an order for the resident to receive Jevity 1.5 at 60 mL per hour for 22 hours a day. Observation on 12/17/24 at 10:41 AM revealed Resident #101 lying in bed. He could not answer questions. Resident #101 was connected to his feeding pump, and the feeding rate was set at 60 mL/hr and the water flush rate was set at 145 mL every 4 hours. The Jevity formula bag was dated 12/17/24 at a rate 60 mL/hr. The water bag was dated 12/17/24 at a rate 145 ml/4 hrs. Observation on 12/17/24 at 2:18 PM revealed Resident #101 lying in bed with his feeding pump connected. The feeding rate was set at 60 mL per hour, and the water flush rate was set at 145 mL every 4 hours. Interview on 12/17/24 at 2:39 PM with RN A revealed she was the nurse assigned to Resident #101. She stated she changed Resident #101's formula bag and water bag. She stated Resident #101's water flush rate was set for 145 mL every 4 hours. She stated when she placed the new formula and water bag, she just turned on the feeding machine. She stated the feeding machine rate amount was already set, and all they had to do was turn it on. RN A reviewed Resident #101's physician orders and stated she was not aware resident water flush order was for 175 mL every 4 hours. She stated she failed to review Resident #101's orders prior to connecting the resident. RN A stated she was unsure how long Resident #101 had been receiving water flushes of 145 mL. She stated the potential risk of not providing Resident #101 with the correct water amount could lead to dehydration. Interview on 12/18/24 at 1:27 PM with the ADON revealed she was made aware of Resident #101 not receiving the correct water flushes. She stated the feeding pump did not have the correct flush amount. She stated her expectation was for the nurses to check physician orders prior to connecting the resident. She stated it was her responsibility to complete spot checks on residents who were on g-tubes to ensure the formula bags were labeled, dated, and the amount rates were correct. She stated the potential risk if nursing staff were not checking physician orders was that it could lead to residents receiving too much or too little water intake and if to little could lead to dehydration. Interview on 12/19/24 at 2:40 PM with the DON revealed she was made aware that Resident #101's feeding pump was set with the incorrect water flush rate amount. She stated her expectation was for her nursing staff to review orders prior to starting the resident feeding. She stated it was the responsibility of all nursing staff to ensure residents received the correct amount. She stated the risk of not receiving the correct amount was that it could lead to weight loss or dehydration. Review of the facility's Quality of Care policy, revised December 2023, reflected the following: It is the policy of this facility to provide proper care and maintenance of gastrostomy tubes. .10. Flushing the Tube: a. To reduce the risk of tube clogs, always flush with lukewarm water. - Every four (4) hours if feeding is continuous, or per physician orders. b. The amount of water used for tube flushing depend on the individual physician orders.

Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice for 1 of 2 residents (Resident #56) reviewed for intravenous fluids. 1. The facility failed to change and maintain the integrity of Resident #56's PICC/central line dressing per professional standards. 2. The facility failed to have physician orders to change Resident #56's PICC/central line dressing, flushing, and to monitor for infection infiltration. These failures could affect residents by placing them at risk for infections and cross-contamination. Findings included: Record review of Resident #56's Admission Record dated 12/19/24 reflected the resident was a [AGE] year-old male who readmitted to the facility on [DATE]. His diagnoses included hemiplegia and hemiparesis (paralysis on one side of the body) following cerebral infraction (stroke) affecting left non-dominant side, non-pressure chronic ulcer of left ankle with necrosis of bone, and peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Record review of Resident #56's clinical record reflected an MDS Assessment had not yet been completed for the resident. Record review of Resident #56's care plan dated 12/12/24 reflected: Focus: Has a Urinary Tract Infection. Goal: Urinary tract infection will resolve without complications by the review date. Interventions: Change IV set as ordered. Flush PICC Line as ordered. Give antibiotic therapy as ordered. Monitor/document for side effects and effectiveness. PICC Line dressing as ordered. Record review of Resident #56's physician order dated 12/10/24 reflected the following order for IV antibiotic therapy: Meropenem Intravenous Solution Reconstituted 1 gm (Meropenem) Use 1000 mg intravenously every 12 hours for bacteremia for 13 Days. There was no order to change the PICC/central line dressing using sterile technique every 7 days, and as needed, no orders for flushing and to monitor for infection and infiltration. Observation and interview on 12/17/24 at 10:45 AM revealed Resident #56's PICC/central ling dressing was not dated on his right upper chest. The PICC/central line insertion site was not open to air, and the dressing was still clean and intact. The site had no obvious signs of infection. Resident #56 stated he admitted to the facility about a week ago. He stated his dressing had not been changed since being admitted . Resident #56 denied any discomfort or pain. Interview on 12/17/24 at 1:37 PM with RN A revealed she was the nurse assigned to Resident #56. She stated Resident #56 had a PICC line and had orders for antibiotics every 12 hours. RN A observed Resident #56's PICC line dressing and stated there was no date on the dressing. She stated the dressing should have a date on it. RN A reviewed Resident #56's physician orders and stated Resident #56 did not have orders to have his PICC/central line dressing changed every 7 days or as needed. Also, Resident #56 did not have orders for flushing the line of for monitoring for infection. She stated the PICC line should be flushed before and after antibiotics were given. She stated the admitting nurse should have called the doctor to obtain orders and should have obtained report from the hospital of when the PICC line dressing was placed. She stated the PICC line dressing should be dated and then changed within 7 days or PRN if the dressing got soiled. She stated the potential risk of not dating the dressing was that it could lead to not knowing when the dressing was last changed and was a risk for infection. She stated it was the responsibility of all nursing staff to ensure orders were obtained. She stated the potential risk of not having physician orders was that it could lead to the PICC line clogging. Interview on 12/18/24 at 1:23 PM with the ADON revealed all staff were expected to obtain physician orders from the doctor that addressed PICC line dressing changes and flushing. She stated she was made aware Resident #56 did not have orders for the PICC line dressing change and flushing. She stated the admitting nurse was responsible for reviewing orders and putting them in the system. She stated if the resident did not have orders, the admitting nurse was responsible for contacting the doctor and obtaining physician orders. She stated during morning meeting she and the DON were responsible for reviewing orders and ensuring orders were obtained. She stated the potential risk would be the PICC line getting occluded (clogged) and infected. She stated the PICC line dressing should always be dated so staff were aware of when the last time the dressing was changed. Interview on 12/19/24 at 2:35 PM with the DON revealed when a resident admitted to the facility with a PICC line, the admitting nurse should complete a full skin assessment, review physician orders, and notify the doctor if any orders were missing. She stated PICC line dressings should be dated, so the nursing staff knew how long the dressing had been on and when it needed to be changed. She stated Resident #56 should have orders for dressing changes, flushes, and monitoring for infection. She stated her nursing staff were flushing Resident #56's PICC line without physician orders. She stated it was the responsibility of the ADON to ensure orders were obtained, and the clinical management team would check if the orders were in place. She stated the potential risk of not dating the PICC line dressing was that it would lead to infection if the dressing was not changed. She stated the potential risk of not having orders to monitor or flush the PICC line was that it could lead to the PICC line clogging. Review of the facility's Physician Orders policy revised October 2022 reflected the following: It is the policy of this facility that drugs and treatments shall be administered/carried out upon the order of a person duly licensed and authorized to prescribe such drugs and treatments. - No drugs or biologicals shall be administered except upon the order of a person lawfully authorized to prescribe for and treat human illnesses. - All drug and biological orders shall be dated and signed by the person lawfully authorized to give such an order. - Verbal orders must be recorded in the resident's chart by the person receiving the order and must include the date and times of the order. - Orders for medications much include: o Name and strength of the drug; o Quantity or specific duration of therapy o Dosage frequency of administration; o Route of administration if other than oral; and o Reason or problem for which given. Review of the facility's PICC Line Dressing Change policy revised July 2023 reflected the following: Central Vascular Access Device - Peripherally Inserted Central Catheter (PICC) Dressing Change Policy: The transparent dressing are changed every 7 days and sooner when it becomes loosened to the point of compromising sterility or presents a risk of accidental dislodgment of the catheter. An accumulation of moisture, fluid, blood, or exudate could also be a criteria for a dressing change .M. Label dressing and discard used supplies appropriately.

Based on observation, interview, and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, for 1 of 2 residents (Resident #260) reviewed for dialysis. The facility failed to ensure pre- and post-dialysis assessments were completed for Resident #260. This failure could place residents at risk of inadequate post-dialysis care. Findings included: Record review of Resident #260's Admission Record dated 12/19/24 reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE] and discharged home on 12/18/24. Record review of Resident #260's Admission MDS assessment dated [DATE] reflected his diagnoses included encounter for orthopedic aftercare following surgical amputation, end-stage renal disease (kidney failure), diabetes mellitus (high blood glucose) and hypertension (high blood pressure). Resident #206 had a BIMS score of 14 indicating resident was cognitively intact. The MDS reflected the resident received dialysis. Record review of Resident #260's care plan dated 12/01/24 reflected: Focus: Needs hemodialysis r/t ESRD Dialysis MWF @ [Dialysis Location] Chair Time 6 AM. Goal: Will have no s/sx of complications from dialysis through the review date. Interventions: Check arteriovenous fistula [surgically created connection between an artery and vein used for hemodialysis treatments] every day for bruit [sound heard using a stethoscope often indicating turbulent blood flow] and thrill [a vibration felt on the skin overlaying an area with turbulent blood flow]. Obtain vital signs and weight. Report significant changes in pulse, respirations and BP immediately. Record review of Resident #260's physician order dated 12/02/24 reflected an order for Resident #260 to receive dialysis every Monday, Wednesday, and Friday at 6:00 AM. Record review of Resident #260's physician order dated 12/03/24 reflected the following order: DIALYSIS EVERY M-W-F 5AM. Please send Dialysis Flow Sheet with a full set of vitals in the morning every Mon, Wed, Fri .Please send full set of vitals. Record review of Resident #260's physician order dated 12/02/24 reflected the following: Dialysis communication form to be completed and filed/scanned in chart on dialysis days every day shift every Mon, Wed, Fri. Record review of Resident #260's Nursing Dialysis Communication Record forms dated 12/02/24, 12/04/24, 12/09/24 reflected there was no information documented on the resident assessment and observation post-dialysis sections. The form dated 12/11/24 had no documented information on the resident assessment and observation or pre-dialysis sections. The facility did not have a form for Resident #260 for Friday, 12/13/24. Interview on 12/17/24 at 11:24 AM with Resident #260 revealed he was a dialysis patient and would go to dialysis three times a week on Monday, Wednesday, and Fridays. He stated his chair time was at 6:00 AM. Resident #260 stated he never missed a treatment. He stated he was provided with a binder when he went to dialysis. He stated staff would check his vitals in the morning before leaving to dialysis treatment, but it was rare for his vitals to be taken when he returned to the facility from dialysis. Interview on 12/19/24 at 12:24 PM with RN B stated when a resident went to dialysis it was the responsibility of the assigned nurse to provide the resident with a dialysis communication form and complete the pre-assessment prior to the resident going to dialysis. He stated when the resident returned the resident's assessment and observation post-dialysis section needed to be completed. He stated Resident #260 received dialysis, but he could not recall if he ever worked with Resident #260 on his dialysis days. He stated if the pre- and post-dialysis assessments did not have information it was because they were not completed. RN B stated the potential risk of not monitoring or documenting pre- and post-dialysis vitals was that it could lead to not knowing if the resident had a change in condition. Interview on 12/19/24 at 2:03 PM with the ADON revealed nursing staff were expected to complete pre- and post-vitals on residents who received dialysis. She stated she reviewed Resident #260's dialysis communication forms and noticed the forms were not fully completed and could not locate a form for 12/13/24. She stated it was the responsibility of Medical Records to inform them if any forms had missing information. She stated Medical Records had not informed her of any missing forms or missing information. She stated the potential risk would be nursing staff missing a change in condition with the resident, and the resident's vitals being low. Interview on 12/19/24 at 2:12 PM with Medical Records revealed it was the responsibility of the nursing staff to ensure pre- and post-dialysis information was filled out. She stated her role was only to upload the files into the residents' medical charts. Interview on 12/19/24 at 2:42 PM with the DON revealed nursing staff were expected to complete pre- and post-dialysis information. She stated she was not aware Resident #260's dialysis communication forms were not being completed. She stated when residents returned from dialysis, the forms were provided to Medical Records. Once the forms were uploaded, the forms were given to the ADON or DON. She stated it was the responsibility of the ADON to review the dialysis communication forms to make sure they were completed. She stated the potential risk of not completing the pre- and post-assessments was that it could lead to missing a change in condition in the resident's health with vitals being low or high. Record review of the facility's Dialysis (Renal), Pre and Post Care policy revised May 2022, reflected the following: Is it the policy of this facility to: - Assist resident in maintaining homeostasis pre- and post-renal dialysis; - Assess and maintain patency of renal dialysis access; and - Assess resident daily for function related to renal dialysis. Pre Dialysis Care: 1. Assess resident's blood pressure (in non-shunt arm) prior to being transported to the dialysis unit. Post Dialysis Care: 1. Dialysis access should be assessed upon return to the facility for patency, and any unusual redness or swelling. Documentation: 1. Assess care given, and condition of renal dialysis access. 2. All assessments, including daily weights and blood pressure to be put in the clinical records. 3. Compliance with care plan approaches and diet order.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 2 residents (Resident #2) reviewed for elopement. The facility failed to provide adequate supervision to Resident #2, who was aphasic and had right-sided hemiplegia, when the resident left the faciity on [DATE] without staff knowledge and made it approximately 1.5 miles from the facility with the assistance of a bystander. The resident was out of the facility for approximately two hours without staff knowledge, and he was located by his family who had placed a tracking device on his shoe. The non-compliance was identified as past non-compliance. The IJ began 09/15/24 and ended on 09/23/24. The facility corrected the non-compliance before surveyor's entrance. This failure placed residents at risk of harm and/or serious injury. Findings included: Record review of Resident #1's admission MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included cancer, hypertension (high blood pressure), aphasia (language disorder that makes it difficult to understand or express language), stroke, and hemiplegia (paralysis or weakness in one side of the body). The MDS further reflected the resident had no speech was but he usually understood others and was also usually understood by others and had memory problems. Record review of Resident #2's care plan created on 06/27/24 reflected the resident was at risk for communication related to aphasia. Interventions included to assist with finding words as needed/appropriate. The care plan further reflected the resident had an ADL deficit performance related to hemiplegia affecting the right dominant side/weakness. Interventions included to monitor/document report to the doctor or as needed of any changes or potential for improvement or declines in function. The care plan did not reflect that Resident #2 was at risk for elopement or wandering. Review of Resident #2's elopement assessments, dated 06/22/24 and 08/03/24, revealed he was a low risk for elopement and wandering. Review of the facility's Provider Investigation Report dated 09/16/24 reflected the following: resident frequently sits outside daily independently or with family. Prior to this incident there have been no attempts to leave the facility property. [Family member] visited with resident on 09/15/24 after this visit at 2:59 p.m. the resident was observed via camera self propelling his wheelchair off facility property. The resident was located near the neighborhood he previously lived in being pushed by an individual unfamiliar to the facility. At apprx 4:30 p.m. the charge nurse and family located the resident via apple tag (that was placed on resident shoe by family). Resident was returned [ sic] him to the facility unharmed. Head to toe assessment and vitals were completed, no injuries or s/s of distress noted Observation and interview on 10/08/24 at 9:16 AM with Resident #2 revealed he was self-propelling his wheelchair out the door to the enclosed courtyard. Resident #2 smiled and greeted the surveyor during the introduction. The resident was not able to complete sentences but was able to answer yes/no questions. The resident was asked if he could write or type his conversation and he shook his head no. Resident #2 was asked if he was doing ok and he said yea and nodded his head. He was asked if he was hurting, and he said no and shook his head. The resident was asked if he sat outside in the front of the building, and he said no and made a circular motion with his hand of the courtyard. He was asked if he only stayed in the courtyard, and he said yes. The resident was asked if he had recently left the facility and he began to laugh and said yes. The resident was asked where he was going but was not able to answer the question and only pointed up. Observation on 10/08/24 at 9:00 AM of the facility revealed there was a shaded patio that extended over the driveway in front of the front entrance. There was a sidewalk that extended around the facility without having to go into the parking lot. Interview on 10/08/24 at 9:39 AM with Resident #2's family member [Family Member #3] revealed the resident admitted to the facility post stroke in June 2024. Family Member #3 stated during the resident's time at the facility, he had never made any attempt to leave. The family said he enjoyed being outdoors. They said the day of the incident, the resident's [Family Member #4] had visited and left the facility sometime after lunch. Later after [Family Member #4's] visit, the resident's [Family #3] arrived at the facility to visit and when he was not found in his regular places the staff began to look for the resident. When he was not found at the facility, they contacted the resident's [Family Member #4] who said she had an air tag on the resident, and she was able to locate the resident. The resident's [Family Member #3] and charge nurse drove to the location and the resident was found, uninjured, and being pushed by a young man. Resident #2's family member stated the resident had let them know he was trying to get back home, and he had been found about 5 blocks from his house. [Family Member #4] stated the reason they had an air tag (tracking device) on the resident was because the nursing home situation was new to them, and it let them know where he was at all times even when he was at doctor appointments and they did not know if the facility staff were aware of the air tag. The resident's [Family Member #4] further stated the resident understood he could not leave the facility and he was not to sit outside in front of the facility anymore and if he wanted to be outside, he had to go to the enclosed courtyard. Interview on 10/08/24 at 1:34 PM with the Social Worker revealed it was difficult to complete a BIMS (a short cognitive screening tool used to assess a patient or resident's cognitive abilities) on Resident #2 because he was non-verbal when he admitted . They called the resident's family to assist with the assessment and when they got to the mood assessment questions, Resident #2 took the sheet and read the questions himself and appropriately answered yes or no or gave a thumbs up or thumbs down. Interview on 10/08/24 at 1:07 PM with LVN F revealed the day of the incident, 09/15/24, he passed medications and saw Resident #2 around 2:00 PM and he was in his room. Later around 4:00 PM, the resident's [Family Member #3] asked him if he had seen Resident #2 because he was not at his usual places, so they began to look for him. While they were looking for the resident, the resident's [Family Member #4] was contacted, and she told them the resident had an air tag on and gave them the location of the resident. The LVN said they were not aware the family had placed an air tag on the resident. He and the other charge nurse and Resident #2's [Family Member #3] went to the location the air tag indicated and he was found by a park being pushed by a young teenager. The resident was assessed, and he was not injured and was taken back to the facility. LVN F said Resident #2's family regularly visited and when they were not visiting, he enjoyed sitting out front of the facility people watching. LVN F said the resident was safe to be outside on his own and he had never tried to leave the facility. LVN F further stated Resident #2 was checked on frequently when he was outside just to make sure he was ok. LVN F also said the front door was locked when there was not receptionist at the front entrance. Interview on 10/08/24 at 3:23 PM with RN G revealed he was Resident #2's charge nurse the day of the incident, 09/15/24. He said that day, Resident #1's [Family Member #4] had visited and left the facility at around 1:30 PM. Resident #2 had a routine where he sat outside in front of the facility, and he had never attempted to leave the premises. RN G said the day of the incident he last saw the resident around 2:30 PM at the nurses' station and sometime after 3:00 PM the resident's [Family Member #3] was looking for the resident. At that time, they began to look for the resident and the resident's [Family Member #4] was called who said she had an air tag on the resident and was able to pull the location of the resident. The RN said he was not aware the family had placed an air tag on the resident when he admitted to the facility. He and the other charge nurse drove to the resident's location and found Resident #2 about 2 miles from the facility. Resident #2 was being pushed by a teenager and upon assessment the resident did not have any injuries. RN G said the resident had been at the facility for a few months, and he had never tried to leave and it was unusual for him to have left that day. Normally when Resident #2 sat outside, the staff checked on him frequently to make sure he didn't need anything. Interview on 10/08/24 at 11:52 PM with CNA H revealed she worked with Resident #2, and he was able to self-propel his wheelchair and only used his call light when he needed to be changed. CNA H said the resident was never exit seeking and only left the facility when he was out on pass with family or he usually sat outside in the front of the facility and they would frequently check on him to see if he needed anything because he did not require supervision to be outside. Interview on 10/08/24 at 2:47 PM with LVN I revealed Resident #2 enjoyed sitting outside and looked at the cars and the visitors coming and going. The resident had never attempted to leave the facility or alluded that he wanted to leave. While Resident #2 was outside staff would make sure to check on him frequently and there were no issues or concerns with elopement. Interview on 10/08/24 at 12:40 PM with the Speech Therapist revealed she had been working with Resident #2 with his expressive speech. He was non-verbal but able to make his needs known with choices and yes and no questions. Based on her assessment the Speech Therapist stated Resident #2 was able to make his needs known. She said the resident would sit outside of the facility and had never alluded that he wanted to leave the facility. Prior to the incident, while the resident was outside, staff knew they were to monitor the resident while he was outside to make sure he was ok, but she felt he was safe to stay outside on his own because he knew to stay on the patio and not go into the driveway or parking lot. Since the incident, the resident was told not to go out the front and instructed to go to the enclosed courtyard if he wanted to be outdoors. The Speech Therapist further stated Resident #2 was able to maneuver his wheelchair pretty well even with having deficits on his right side of his body. Interview on 10/08/24 at 1:17 PM with the Physical Therapist revealed Resident #2 was able to maneuver his wheelchair better now than when he first admitted to the facility. She said it could be challenging to communicate with the resident, but the resident was able to understand what was being told to him and was able to follow instructions and commands. The Physical Therapist further stated she felt like the resident was safe to sit outside alone and he had never tried to leave the facility since he had been at the facility. Staff knew to check on Resident #2 when he was outside due to the summer heat, but the resident mainly sat outside under the shaded patio until his family arrived to visit. Interview on 10/08/24 at 3:48 PM with the DON revealed she was made aware Resident #2 had left the faciity on [DATE]. She was told that through an air tag, the family had placed on the resident , without them knowing, had located the resident around his old neighborhood. The nurses told her the resident had been assessed and there were no injuries noted. The DON said Resident #2 always sat outside in the front and never tried to leave. After the incident, the resident was put on 1:1 for 3 days and elopement assessments were done on the residents and there were no residents identified for elopement. They had elopement in-services and drills to make sure staff knew what to do in case they had an elopement. The DON further stated the front doors were being locked on the weekends or when there was not a receptionist at the entrance. Interview on 10/08/24 at 4:00 PM with the Administrator revealed Resident #2 was alert and oriented and had a history of sitting outside in the front of the facility. The resident enjoyed being outside and would wheel himself sidewalk and at no time had he ever expressed he wanted to leave. The Administrator was made aware the resident had left on 09/15/24 when the resident's wife was not able to locate him in the facility. Resident #2 was located through an air tag that had been placed on the resident by the family, that they were not aware of. Per the family, they asked the resident where he was going, and he told him he was going home. The resident was brought back to the facility unharmed, and they placed a WanderGuard on the resident for safety. The Administrator said they were able to get video footage from the library next door and it captured the resident going by there at 3:17 PM and he was brought back to the facility after 4:00 PM. After the incident the family was told the resident would need to wear a WanderGuard for safety and the front doors would remained locked if there was not a receptionist at the front desk. Resident #2 and his family were told the resident could no longer sit outside unsupervised but could continue to go to the enclosed courtyard if he wanted to be outdoors. There were no other residents identified as being an elopement risk during their assessment. Observation on 10/08/23 at 10:23 AM revealed Resident #2 was sitting with his wife near the front door, and they were asked to get close to the door to verify the WanderGuard was operating correctly, and the WanderGuard began to beep very loudly, and the front door did not open. Record review of the in-services dated 09/15/24 through 09/20/24 reflected staff had been in-serviced on elopements, and instructed the front doors would remain locked unless there was a receptionist at the front entrance. Record review of the facility elopement drills revealed they were conducted on 09/16/24, 09/22/24, and 09/30/24 with all facility staff of various shifts to include dietary, nursing, housekeeping, and therapy. Record review of the elopement assessment dated [DATE] reflected Resident #2 remained at a low risk of elopement. Record review of Resident #2's one-to-one monitoring revealed he was being checked on every 15 minutes and initialed by staff from 09/15/24 through 09/18/24. Record review of Resident #2's care plan revealed it had been updated after the incident on 09/15/24 to reflect the following: Elopement risk/wanderer related to history of attempts to leave the facility unattended. Impaired safety awareness. The resident enjoys sitting in the front portico area on warm days. Interventions included to document wandering behavior, monitor the wanderguard to the left ankle and staff will check on the resident if he wished to sit outside. Interviews on 10/08/24 from 10:27 AM to 3:48 PM with the DON, Housekeeping Supervisor, LVN F, RN G, CNA H, LVN I, and LVN J, who worked various shifts, revealed they were all aware Resident #2 was only allowed in the enclosed courtyard and could not be alone in the front patio unattended. Record review of the facility's Elopement/Unsafe Wandering policy, revised December 2003, reflected the following: Policy It is the policy to provide a safe environment, as free of accidents as possible, for all residents through appropriate assessment, interventions, and adequate supervision to prevent accidents related to unsafe wandering or elopement while maintaining the least restrictive manner for those at risk for elopement.

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents (Resident #1) observed for quality of care. The facility failed to apply Resident #1's compression socks as ordered. This failure could place the resident at risk of developing blood clots in his legs Findings included: Record review of Resident #1's undated Admission Record reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included fusion of the vertebrae of the lower back, diabetes, and high blood pressure. Record review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 15 indicating he was cognitively intact. His Functional Status assessment indicted he required limited assistance with his ADLs. Record review of Resident #1's care plan, dated 09/27/24, reflected the risk for decreased activity related to his spinal surgery was not listed as a focus, and his compression socks were not listed as an intervention. Record review of Resident #1's physician's orders reflected an order, dated 09/26/24, which reflected: apply TED hose in the am, off in the pm, indicating the resident's compression socks were to be applied in the morning and removed overnight. Record review of Resident #1's TAR reflected no order to place the resident's compression socks. Interview on 10/02/24 at 12:00 PM with Resident #1 and his family member revealed his compression socks had not been applied since he was admitted . The family member stated they were present for his admission, and his socks were removed and placed on his dresser. The family member stated the socks had not been moved since they were placed there, and they were present at the facility most of the day every day since admission. The family member stated the socks were to prevent blood clots in the resident's legs due to decreased activity. Observation on 10/02/24 at 12:00 PM revealed Resident #1 was not wearing his compression socks. The socks were located on the resident's dresser. Observation on 10/02/24 at 3:30 PM revealed Resident #1 was not wearing his compression socks, and they remained unmoved on his dresser. Observation on 10/03/24 at 8:30 AM revealed Resident #1 was not wearing his compression socks. Interview on 10/03/24 at 8:30 AM with Resident #1 revealed the CNA had placed his socks on around 4:00 PM on 10/02/24, and they had been removed before bedtime. Observation on 10/03/24 at 10:45 AM revealed Resident #1 was wearing his compression socks. Record review of the facility's investigation report indicated the physician had not completed the order process which resulted in the order not transferring to Resident #1's TAR. The investigation report also had a written statement from CNA A reflecting she had applied Resident #1's compression socks on 09/26/24, 09/27/24, 09/29/24, 10/02/24, and 10/03/24. Interview on 10/03/24 at 11:25 AM with Resident #1 revealed he did not recall anyone applying his compression socks until the previous afternoon. Interview on 10/03/24 at 11:35 AM with CNA A revealed she had placed Resident #1's compression socks on him every day with the exception of one day when he refused them. CNA A stated she knew to apply the socks, even if they were not on the TAR, because the resident's family had told her they needed to be applied. Interview attempts via telephone on 10/02/24 at 3:29 PM and 10/03/24 at 11:49 AM with LVN B, who admitted Resident #1, were unsuccessful. Interview on 10/03/24 at 12:45 PM with the DON revealed the admitting nurse was responsible for ensuring all physician's orders had been placed and initiated. The nurse should check the MAR and TAR to ensure all orders were initiated.

Based on observation, interview and record review, the facility failed to ensure the resident's right to receive services in the facility with reasonable accommodation of resident needs and preferences for 5 of 10 residents (Residents #2, #3, #4, #5, and #6) observed for accommodation of needs. The facility failed to ensure Residents #2, #3, #4, #5, and #6 had call lights within reach. This failure could place the residents at risk of not being able to request assistance when needed. Findings included: 1. Review of Resident #2's Admission Record dated 06/06/24 revealed the resident was a [AGE] year-old male who had been admitted to the facility on [DATE]. Review of Resident #2's annual MDS, dated [DATE], revealed a BIMS score of 00, indicating score not calculated with diagnoses that included seizure disorder, anxiety disorder, cognitive communication deficit, lack of coordination, general weakness. Functional abilities indicated Resident was dependent on staff for all activities of daily living. Review of Resident #2's care plan revealed he had self-care performance deficit. Goal revealed she will safely perform bed mobility, transfers, eating, dressing and personal hygiene along with other daily living skills. Intervention included encouragement to use bell to call for assistance. Resident was at risk for falls. Goal revealed resident will not sustain serious injury. Intervention included to be sure call light was within reach and encourage use. Ensure safe environment: working and reachable call light, low bed, clear floor path. 2. Review of Resident #3's Admission Record dated 06/06/24 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. Review of Resident #3's quarterly MDS, dated [DATE], revealed a BIMS score of 00, indicating score not calculated with diagnoses that included seizure disorder, depression, chronic pain due to trauma, stroke. Review of Resident #3's care plan revealed alteration in musculoskeletal status related to pain. Goals included resident will remain free from pain or at a level of comfort acceptable. Intervention included to anticipate and meet needs. Be sure call light within reach and respond promptly to all request for assistance. 3. Review of Resident #4's Admission Record dated 06/06/24 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #4's yearly MDS, dated [DATE], revealed a BIMS score of 15 indicating her cognition intact with diagnoses that included anxiety disorder, bipolar disorder, respiratory failure, developmental disorder of speech and language, tracheostomy status, stroke. Her Functional Status indicated she required set up or clean up assistance with her ADLs. Review of Resident #4's care plan revealed she had tracheostomy related to impaired breathing mechanics. Goal included to have clear and equal breath sounds bilaterally. Interventions included to keep call light or alternate call system within reach. Resident is a fall risk, Goal to be free from falls. Intervention included a safe environment with low bed, reachable call light. 4. Review of Resident #5's Admission Record dated 06/06/24 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Review of Resident #5's quarterly MDS, dated [DATE], revealed a BIMS score not calculated with diagnoses of depression, contracture of right knee, generalized weakness, cognitive communication deficit. Functional Status was not indicated. Review of Resident #5's care plan revealed she was at risk for falls related to left knee pain, bedbound status and weakness. Goals included not to sustain injuries. Interventions included to be sure call light was withing reach at all times and encourage use of call light for assistance as needed. Safe environment low bed, call light in reach, personal items within reach, floor free from clutter. 5. Review of Resident #6's Admission Record dated 06/06/24 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] and readmitted [DATE]. Review of Resident #6's MDS revealed a BIMS score of 10 indicating cognition moderately impaired with diagnoses that included high blood pressure, anxiety disorder, depression, repeated falls, abnormal gait and mobility, muscle weakness. Her Functional Status indicated he required set up and clean up assistance with eating, toileting and personal hygiene, supervision with oral hygiene, showering, and dressing. Review of Resident #6's care plan revealed she had self-care performance deficit. Goal revealed she will safely perform bed mobility, transfers, eating, dressing and personal hygiene along with other daily living skills. Intervention included encouragement to use bell to call for assistance. Resident was at risk for falls. Goal revealed resident will not sustain serious injury. Intervention included to be sure call light was within reach and encourage use. Ensure safe environment: working and reachable call light, low bed, clear floor path. 6. Review of Resident #7's Admission Record dated 06/06/24 revealed the resident was an [AGE] year-old male who had been admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #7's annual MDS, dated [DATE], revealed a BIMS score of 2, indicating severe cognitive impairment with diagnoses that included cognitive communication deficient, lack of coordination, repeat falls, stroke. Review of Resident #7's care plan revealed he was at risk for decreased communication skills related to deficit related to Dementia. Goals included Resident #2 making basic needs known on a daily basis. Interventions included to ensure/provide a safe environment: Call light in reach, adequate low glare light, bed in lowest position and wheels locked, Avoid isolation. Observation on 06/06/24 at 11:12 AM revealed Resident #2's call light was on the floor under his bed not within reach. Observation on 06/06/24 at 11:15 AM revealed Resident #3's call light was laying on the floor underneath Resident #3's bed. Observation on 06/06/24 at 11:19 AM revealed Resident #4's call light was on the far side of Resident #4's bed between her bed and the wall, not within Resident #4's reach. Observation on 06/06/24 at 11:20 AM revealed Resident #5's call light was hanging of the bed, on the floor near Resident #5's bed not within Resident #5's reach. Observation on 06/06/24 at 11:31 AM revealed Resident #6's call light was behind the bed, on the floor near Resident #6's headboard not within Resident #6's reach. Observation on 06/06/24 at 2:45 PM revealed Resident #7's call light was on the floor behine Resident #7's night stand not within Resident #7's reach. Observation and interview on 06/06/24 at 2:45 PM with CNA A stated the reason call lights were not within was because the residents were not using them. CNA A stated nursing staff were responsible for ensuring call lights were within reach at all times. CNA A stated she was aware of the facility policy to have the call lights within reach. CNA A stated not having call lights within the reach of residents placed residents at risk of not having their needs met. Interview on 06/06/24 at 4:17 PM with the ADON revealed she was not aware call lights on 200 hall not being within residents' reach. The ADON stated nursing staff should be ensuring resident call lights were near and within residents reach at all times and during their rounds. The ADON stated call lights on the floor was an issue because it placed residents at risk of not having their needs met. The ADON stated this was an intervention to help resident communicate their needs and facility policy that should be followed at all times. Interview on 06/06/24 at 5:20 PM with the DON revealed call lights were required to be placed within reach of the resident, even if the resident was believed incapable of using the call light. The DON stated the nursing team was responsible for ensuring call lights were within reach of each resident. The DON stated family and other staff needed to be able to easily call for help if they were in the room. Review of the facility's Call Light Bell policy, revised October 2022, reflected: .It is the policy of the facility to provide the resident a means of communication with nursing staff. .4.Leave resident comfortable. Place the call light within resident reach before leaving room. If call light/bell deficit immediately report to unit supervisor .

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for supervision. The facility failed to ensure a resident with known wandering behaviors was provided with adequate supervision to prevent her from eloping and subsequently falling and sustaining a left hip fracture. The noncompliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began on 05/12/23 and ended on 05/13/23. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of harm and/or serious injury. Findings included: Record review of Resident #1's face sheet, dated 05/25/23, revealed the resident was an [AGE] year-old female, who was initially admitted to the facility 11/09/20 and readmitted on [DATE]. Resident #1 had diagnoses which included displaced fracture of base of left femur, dementia without behavioral disturbance (impaired ability to remember, think, or make decisions), and Type 2 diabetes (elevated levels of blood sugar). Record review of Resident #1's MDS quarterly assessment, revealed her BIMS score was 6, indicative of severe cognitive impairment. Resident #1 was ambulatory. Record review of Resident #1's care plan, revised 05/17/23, reflected, Focus: Due to changes in my cognition r/t dementia. I have the potential for a negative behavior i.e agitates and will make suggestions of going home. For the most part, I'm redirectable. Goal: Will have fewer episodes of agitation by review date. Interventions: Approach in a calm manner. Assist to develop more appropriate methods of coping and interacting encourage to express feeling appropriately .Focus: Elopement risk/wandering r/t history of attempts to leave facility unattended, impaired safety awareness. Goal: Will not leave facility unattended through the review date. Safety will be maintained through the review date. Will demonstrate happiness with daily routine through the review date. Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation. Document wandering behavior and attempted diversional interventions. Elopement Episode 5/12/23 .Focus: Has had an actual fall with left hip fracture r/t poor balance, psychoactive drug use, unsteady gait. Goal: Will resume usual activities without further incident through the review date. Left hip fracture will resolve without complication by review date. Interventions: Provide activities that promote exercise and strength building were possible Room assignment close to the nurse's station. Therapy consults for strength and mobility. Record review of the facility Incident by Incident report, from 05/25/22 - 05/25/23, revealed Resident #1 eloped on 05/12/23. Record review of the facility's Incident Report, dated 05/13/23, reflected the facility received a call from staff at a restaurant located 0.4 miles away from facility on the same side of the road that they may have one of our residents in their establishment. Facility staff went to the restaurant and identified [Resident #1]. [Resident #1] had sustained a ground level fall and was complaining of left hip and leg pain. EMS was present and transported [Resident #1] to the hospital for evaluation and treatment. Facility staff had last visualized Resident #1 in the facility at approximately 2230 hours [10:30 PM] ambulating in the hallway near her room after she had received her last scheduled medication for the day. It is believed that Resident #1 had exited the facility through the front door. The facility doors are unlocked while the receptionist is present and locked via keypad code at the end of the receptionist's shift. Record review of Resident #1's hospital record, dated 05/16/23, revealed Resident #1 admitted on [DATE], with the reason for admission identifed as a fall. The hospital record reflected Resident #1 was diagnosed with a closed fracture of the neck of her left femur. Resident #1 was discharged on [DATE]. Record review of Resident #1's Elopement Risk Assessment/Wander Data Collection completed on 02/12/23 indicated Resident #1 had a diagnosis of dementia, and she could ambulate independently or with supervision. Resident #1's mental status was alert and oriented. Resident #1 had no history of elopement in the last 6 months, and she made statements about desire to leave the facility. Resident #1 had not exhibited wandering behavior but had a history of wandering. Resident #1 was at low risk for elopement and wandering. Record review of Resident #1's Elopement Risk Assessment/Wander Data Collection completed on 05/13/23 indicated Resident #1 had a diagnosis of dementia and Alzheimer's disease (brain disorder that slowly destroys memory and thinking skill), and she could ambulate independently or with supervision. Resident #1's mental status was intermittent confusion. Resident #1 had one episode of elopement history in the last 6 months, and the resident made statements about the desire to leave the facility. Resident #1 wandered, was aimless with potential to go outside, and had active exit-seeking behavior. Resident #1 was at high risk for elopement and wandering. Record review of progress note, documented by LVN A on 05/13/2023 at 1:37 AM, reflected: Late Entry: Call was received to facility by the nurse on 400/500 hall the person on the end of the line was asking if this is the home of [Resident #1] inform the nurse that resident was at the restaurant, she arrived and fell . This nurse drove to the restaurant and found resident sitting on the chair surrounded by restaurant staff, customer and EMT. Upon arrival the EMT confirmed resident name and date of birth with this nurse, nurse confirmed information. This nurse assessed resident, she was alert and oriented able state name, date of birth, notice that resident was having hard time putting left leg down, resident confirm that she was in pain. Resident couldn't get up, EMT load resident in the ambulance and took resident to the hospital. Observation and interview on 05/25/23 at 9:30 AM revealed Resident #1 lying in bed and watching television. Resident #1 stated she was doing well. Resident #1 was not a good historian and could not recall leaving the facility or having a fall. Resident #1 denied having any pain. Interview on 05/25/23 at 11:37 AM with CNA B revealed she was the assigned CNA on 200 Hall on 05/12/23. CNA B stated her shift ended at 10:00 PM. CNA B stated Resident #1 could ambulate on her own before the elopement incident, and the resident would walk around the facility all the time. She stated Resident #1's usual routine would be walking around the facility until she would get tired and would go back to her room. CNA B stated she could not recall when the last time she had last seen Resident #1 on 05/12/23; however, Resident #1 was walking the halls. CNA B stated Resident #1 did not have an elopement history. She stated Resident #1 would mention wanting to go home; however, the resident had not attempted to leave. Interview on 05/25/23 at 1:21 PM, with LVN A, by phone, revealed she was the nurse on duty for the night of 05/12/23. LVN A stated she was assigned to 100 and 200 Hall. She stated Resident #1's day-to-day behavior was to wander the halls. She stated Resident #1 was known to walk the halls even during the night, and once she was tired the resident would go to bed. She stated Resident #1 had wandering behaviors; however, the resident had not attempted to leave before. She stated Resident #1 eloped during her shift. She stated the last time she observed Resident #1 was around 10:30 PM, she stated the resident was coming from 400 Hall and going towards 600 Hall. LVN A stated the facility had a receptionist until 8:00 PM. LVN A stated the receptionist was responsible for locking and unlocking the entrance doors, she stated they had the code. She stated between 11:45 PM and midnight (12:00 AM) she received a call from a nearby restaurant asking her if Resident #1 was a resident at the facility. She stated she looked around the facility and could not locate Resident #1. She stated she rushed to the restaurant that was about 2-3 minutes away by car. She stated when she arrived at the restaurant Resident #1 was sitting on a chair and was drinking water. She stated Resident #1 verbalized being okay. LVN A stated she assessed the resident, and the resident stated she was in pain. LVN A stated EMTs were on scene already, and they transported Resident #1 to the hospital because she was not able to walk and complained of pain to her left hip. LVN A stated the restaurant staff informed her Resident #1 had a fall. LVN A stated Resident #1 exited the facility through the front entrance door because when she was leaving the facility to go to the restaurant, the front entrance door was unlocked. LVN A stated she was unaware the front door was unlocked until after the incident. She stated she did not hear any alarms going off. Interview on 05/25/23 at 1:36 PM with Receptionist F revealed she worked the day of 05/12/23. She stated her shift was from 2:00 PM-8:00 PM. She stated it was the receptionist's responsibility to lock and unlocked the front entrance door. Receptionist F stated the receptionist had the codes to the door. She stated the front door had two different codes: one code to unlock and lock the door, and the second code was used to exit the front door once it was locked. She stated the night of 05/12/23 when her shift ended, there were still visitors at the facility, so she provided the code to the night nurse whom she believed was RN C or LVN D, so they could let the visitors out. She stated she provided the code that allowed people to exit the facility once the door was locked. Receptionist F stated she locked the door before she left the facility. Receptionist F stated this was the first time Resident #1 had ever eloped. She stated they had not had any previous elopement incidents. Interview on 05/25/23 at 1:43 PM with RN C revealed she worked the night of 05/12/23. She stated her shift started at 10:00 PM; however, she arrived around 9:50 PM. RN C stated she never observed Receptionist F because she was already gone. RN C stated when she arrived at the facility the front door was locked. She stated she was unable to open the front door and called someone to open it for her. RN C stated she observed Resident #1 walking the hallways as her usual routine. RN C stated she could not remember what time she last saw Resident #1. RN C stated between the times of 11:30 PM- before midnight LVN A notified her a restaurant had contacted the facility to notify them Resident #1 was there. RN C stated she and LVN A drove to the restaurant where they observed Resident #1 seated on a chair in the company of the restaurant staff and the EMT team. She stated Resident #1 complained of pain to her left lower limb, and they made the decision to have her checked at the hospital. RN C stated when they left the facility to go to the restaurant the front entrance door was open, and no alarms were heard the entire time. She stated Resident #1 eloped through the front door. RN C stated she was never informed of any family in the facility, and she did not talk to Receptionist F. An attempt was made to contact LVN D by phone on 05/25/23 at 1:49 PM; however, the phone call was unsuccessful. Interview on 05/25/23 at 2:02 PM, the ADON stated she was off duty on 05/12/23. The ADON stated she was made aware of the elopement incident on Monday, 05/15/23. The ADON stated during the facility investigation it was determined Resident #1 eloped from the facility at approximately 11:00 PM via a secured door leading to the main road. The front door of the facility was unlocked because no alarms were heard. The ADON stated there was a miscommunication between Receptionist F, who worked from 2:00 PM-8:00 PM, and the nurse on duty, LVN D. She stated there were still visitors at the facility, and Receptionist F provided the code to LVN D. The ADON stated Resident #1 had a fall and sustained a left hip fracture. She stated Resident #1 was known to wander around but had never attempted to exit the facility before. The ADON stated Resident #1 was easy to redirect. The ADON stated following this incident they trained all staff on missing persons/elopement. She stated they all trained the nurses on conducting a midnight census head count before and after their shift and checking all the doors to ensure they were locked. The ADON stated they changed the front door code so only one code had to be used, and they provided walkie talkies on each nurse's station for communication. Additionally, they implemented random elopement drills and would continue for the drills for the next 4 weeks. Interview on 05/25/23 at 2:12 PM, the DON stated she received a call on 05/13/23 at 12:15 AM from LVN A who informed her Resident #1 had eloped from the facility and was reported to be at a restaurant. The DON stated LVN A went to the restaurant and Resident #1 had complained of pain and EMTs were already on the scene so they took Resident #1 to the hospital. The DON stated during the facility investigation it was determined Resident #1 eloped from the facility at approximately 11:00 PM via the main entrance front door. She stated the front door of the facility was unlocked because no alarms were heard. The DON stated there was a miscommunication between the Receptionist, who worked from 2:00 PM-8:00 PM, and the nurse on duty. She stated there were still visitors at the facility around 8:00 PM, and the Receptionist provided the code to LVN D. The DON stated the front door had two different codes: one code unlocked and locked the door, and the second code was used to exit the front door after it was locked. The DON stated following the incident they trained all staff on missing persons/elopement. The nurses were trained to conduct a midnight census head count before and after their shift and to check that all the doors were locked. They also changed the front door code so only one code had to be used. The DON stated they provided walkie talkies on each nurse's station for communication, and they implemented random elopement drill and would continue the drills for the next 4 weeks. The DON stated they completed an elopement assessment on all current residents. The DON stated Resident #1 had been a resident since 2020 and had not had any elopement incidents. The DON stated Resident #1 had wandering behaviors but had not attempted to leave before. She stated Resident #1 currently could not walk due to her fracture; however, once the resident became more mobile and upon assessment if the resident showed any exit-seeking behaviors, they would find an alternative placement and would transfer Resident #1 to a secure unit. Interview on 05/25/23 at 2:39 PM with CNA E by phone revealed she was the assigned CNA for 200 Hall on 05/12/23. CNA E stated her shift started at 10:00 PM. CNA E stated Resident #1 was known to wander around the facility but did not attempt to leave. CNA E stated the night of 05/12/23 Resident #1 was walking around the halls, she stated she was assisting other residents and the last time she had seen Resident #1 was between 10:30 PM and 11 PM walking on the hall. CNA E stated the entrance door was always locked and they needed a code to unlock it. CNA E stated she did not know the code to unlock the door, she stated the receptionists were responsible for locking and unlocking the doors. CNA E stated Resident #1 did not have an elopement history but she was known to wander the facility. CNA E stated Resident #1 was easy to redirect. CNA E stated facility was notified that Resident #1 was at a nearby restaurant. Interview on 05/25/23 at 4:47 PM with the Maintenance Director revealed the morning of 05/13/23 he received a call from the DON notifying him Resident #1 had eloped. The Maintenance Director stated he came to the facility that night and the door was functioning correctly. The Maintenance Director stated there was a miscommunication between the receptionist and LVN D regarding the door code and the door was left unlocked. The Maintenance Director stated he had been conducting random elopement drills with the staff which consisted of picking a volunteer resident and hiding that volunteer resident in the facility . He stated the nurse on that hall must conduct a head count on the residents on the hall and if someone was missing, they must call Code Pink which was the code for a missing person. The Maintenance Director stated all the staff must meet at the nurse's station where the Code Pink was called and they all got the walkie talkies and they started the search. He stated once the volunteer resident was found the staff who called the Code Pink was the only person who could call it off. He stated he would provide feedback on the staff on how to do things better. He stated the elopement drills will continue for the next 4 weeks. Observation on 05/25/23 at 5:15PM of the Maintenance Director unlocking and locking the main entrance door. Observed Maintenance Director hold the door for 15 seconds and alarms went off. This was determined to be a Past Non-Compliance Immediate Jeopardy on 05/25/23 at 3:00 PM. The DON and the ADON were notified. The DON was provided with the IJ template on 05/25/23 at 5:30PM. The facility took the following actions to correct the non-compliance prior to the survey: Record review of the following in-services dated 05/13/2023, Elopement policy and procedure, Visual/Documented census protocol, and Missing Resident/Elopement. In-service reveal all staff completed the training. Record review of the facility Midnight Census reports, starting date 05/13/2023 through 05/25/23, revealed residents head count on both shifts from 6AM-6PM & 6PM-6AM. Nurses signatures on each form were observed. Record review of the facility Emergency Preparedness Drills - Missing Person/ Elopement revealed drills were conducted by the Maintenance Director on 5/13/23 at 1:35 PM and 5/24/23 at 10 AM. Interviews on 05/25/23 from 11:30 AM through 5:20 PM with Receptionist G, Receptionist F, CNA B, CNA E, CNA H, CNA K, CNA L, CNA M, LVN A, LVN I, LVN J and RN C who work the shifts of 6:00 AM-6:00 PM and 6:00 PM-6:00 AM were able to verify education was provided to them, nursing staff were able to accurately summarize missing person/elopement policy, missing/elopement code, emergency preparedness missing person/elopement drills, and midnight census count. Record review of the facility's Elopement/Unsafe Wandering policy and procedure, revised 1.2022, reflected the following: It is the policy of this facility to provide a safe environment for all resident through appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement. 1. Resident with capabilities of ambulation and/or mobility in wheelchair will have an elopement/wandering evaluation completed to determine risks for elopement and unsafe wandering on admission and with observed behaviors of wandering or attempting to elope. 3. Staff shall promptly report any resident who is trying to leave the premises or suspected or being missing to the charge nurse or supervisor to evaluate the need for further interventions. The noncompliance was identified as past non-compliance. The IJ began on 05/12/23 and ended on 05/13/23. The facility had corrected the noncompliance before the survey began.

Based on observations, interviews, and record reviews, the facility failed to provide care and treatments, consistent with professional standards, to promote healing of pressure ulcers and to prevent development of new pressure ulcers for three (Resident #1, Resident #2 and Resident #4) of 19 residents reviewed for wound care. 1. The facility failed to implement new wound treatment orders and provide wound care to Resident #1's stage 4 pressure ulcer, to her sacrum/coccyx which had deteriorated. The resident was sent out to the ER two days after the wound treatment orders were changed due to a change in condition, including altered mental status and a low blood pressure of 50/30. The hospital determined she had been in pain, [MEDICAL CONDITION] and her wound was found to have necrotic tissue in her pressure ulcer, she had e-coli and negative gram bacteria. Her white blood count was 66 (normal is 5-11). 2. The facility failed to ensure wounds on Resident #2's left 2nd toe and on his abdomen, under his gastrostomy tube, were identified, assessed, and treatment was provided to promote healing. 3. The facility failed to ensure Resident #4's wound vac treatment on her stage 4 buttock wound was applied and functioning per physician's orders [REDACTED]. 4.The facility failed to ensure wounds on Resident #4's right and left lower extremities and sacrum (right buttock) were thoroughly assessed, treatment orders obtained for each wound site and/or treatment orders completed as ordered by the physician. The resident did not have physician ordered heel protective boots on or heels off loaded as ordered. The resident was also found to have a black, necrotic-like left heel that the facility had not identified, assessed, or obtained treatment orders to promote healing. An Immediate Jeopardy (IJ) was identified on 11/12/20 at 4:49 PM. The facility was provided with the IJ template on 11/12/20. While the IJ was lowered on 11/15/20, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of their Plan of Removal. These failures placed residents at risk of a potentially life-threatening infection, [MEDICAL CONDITION] which could manifest into other health complications, pain, worsening pressure ulcers and a decreased quality of life. Findings Included: 1. Review of Resident #1's quarterly MDS Resident Assessment, dated 09/23/20, revealed she was an [AGE] year old female who admitted to the facility on [DATE] and readmitted after a hospital stay on 09/20/20. Her active [DIAGNOSES REDACTED]. Resident #1 has clear speech, was always understood and had no vision or hearing issues. The assessment indicated she was unable to complete a Brief Interview of Mental Status, therefore the staff assessed her and determined she had no short or long-term memory issues. She required extensive assistance of two or more staff for bed mobility (how she moves to and from lying position in bed, side to side and body positions while in bed) and for toileting needs. She needed physical help of at least one staff for bathing. She was no steady with surface to surface transfers and needed staff assistance. She had range of motion impairment on one side of her lower extremity and used a wheelchair for mobility with assistance. She had an indwelling catheter and was always incontinent of bowel. She was at risk of developing pressure ulcers and had one or more unhealed pressure ulcers at the time of the assessment, which included one Stage 4 that was present upon entry. She had no other skin issues, ulcers or wounds. Resident #1's pressure ulcer treatment included application of non-surgical dressings, ointments and medications. Review of Resident #1's care plan, dated 07/02/20 and revised on 10/29/20, revealed she was on antibiotic therapy and had a stage 4 pressure ulcer to her sacrum. Interventions included: 1) Administer dietary supplements as ordered, 2) Administer medications as ordered, 3) Monitor/document for side effects and effectiveness, 4) Administer treatments as ordered and monitor for effectiveness, 5) Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD, 6) Float Heels, 7) Low air loss mattress, 8) Offer assist with repositioning q2hrs and 9) Wheelchair cushion. Review of Resident #1's most recent Braden Scale (pressure ulcer risk scale) dated 09/,20/20, revealed a score of 7 which indicated she was at high risk of developing pressure ulcers. Resident #1's Braden Scale assessment reflected she was completely limited in her sensory perception, meaning she was unresponsive to painful stimuli, her skin was exposed to constant moisture, she was bedfast and completely immobile, she had inadequate nutritional intake and was at risk for friction and shear. Resident #1's weekly Pressure Ulcer Review Assessment, completed on 11/02/20, revealed the assessment was completed by the ADON. Resident #1's assessment reflected for site #1, she had an unknown onset date of a stage 4 pressure ulcer to her sacrum that measured 10 cm x 8 cm (length and width) and 3.5 cm deep, exudate (drainage) was serous, exudate amount was moderate, no odor, negative pressure wound vac used and resident needed to be repositioned every two hours. For site #2, Resident #1 had an unstageable pressure ulcer on her right lower, rear leg, onset unknown, measuring 2.5 cm x 2 cm. Exudate was noted to be serous, exudate amount was moderate, no odor and offload heels and reposition every two hours needed. For site #3, Resident #1 had a right lower ankle, unstageable pressure ulcer from an unknown onset date that was 1.0 cm x 0.5 cm. The ADON documented during the assessment that Resident #1 was experiencing episodic pain as evidenced by moaning and grunting. Resident #1 indicated the pain she experienced was all over her body and was mild to moderate in severity. Review of Resident #1 wound care progress notes from the WC-PHY revealed the following: 11/02/2020-STAGE 4 PRESSURE WOUND SACRUM- 10.0 x 8.0 X 3.5 CM Surface Area - 80.00 cm2 Exudate - Moderate Serous Thick adherent devitalized necrotic tissue - 20% Granulation Tissue - 80% This wound is in an [MEDICAL CONDITION] stage and is unable to progress to a healing phase because of the presence of biofilm. 11/05/2020 -STAGE 4 PRESSURE WOUND SACRUM- 21.0 x 15.0 X 3.5 CM Surface Area - 315.00 cm2 Cluster Wound Exudate - Moderate Serous Thick adherent devitalized necrotic tissue - 20% Granulation Tissue - 50% Skin 30% This wound is in an [MEDICAL CONDITION] stage and is unable to progress to a healing phase because of the presence of biofilm. An interview with RN G on 11/06/20 at 12:59 PM revealed when she worked with Resident #1 she babied her wound religiously. She said Resident #1's wound, looked great, it was starting to close, the wound care doctor looked at it every Monday, red wound bed was a good pink red and she took a protein supplement. She said she talked to the charge nurse on the floor, who was from a temp agency and mentioned Resident #1 had a wound vac and did he need assistance; he said yes. RN G said she changed Resident #1's wound vac on Monday 10/26/20 and that was the last she had seen of her wound. RN G said when she saw Resident #1 the morning of 11/06/20 to say hello, she did not look good and her face looked peaked. A confidential interview with facility staff revealed Resident #1's wound had declined since she had moved to the long-term care hall. They said Resident #1's wound vac could no longer be used because she had necrotic tissue. The individual said current treatment was Santyl and the individual assumed the nurses were packing it and covering it. The individual said Resident #1 admitted with a sacral wound at a stage 4. They said the facility's wound care nurse had recently been fired and the facility had recently received a deficiency in wound care for failing to turn and reposition a male resident who developed deep tissue injury on his heels as a result. An interview with RN C on 11/06/20 at 3:40 PM revealed it was her first day by herself on the floor for one and a half halls. RN C said she had not completed any wound care for Resident #1 on her shift, other than putting some ointment on a wound to her ankle. She said she did not conduct wound care to the pressure ulcer on her sacrum. Review of Resident #1's TAR reflected, Wound VAC to coccyx to be changed by wound care nurse. 125mm/Hg continuous negative pressure. Do not turn off or disconnect patient from unit. Record VAC drainage on I&O each shift. If VAC loses seal and unable to rectify problem remove dressing and begin BID dressing changes using Kerlix moistened with [MEDICATION NAME] gel to pack wound, cover with ABD and secure until seen by WOC one time a day every Mon, Wed, Fri related to PRESSURE ULCER OF SACRAL REGION, STAGE 4. Monitor when repositioning. -Order Date- 09/26/2020. The TAR reflected the treatment was completed on 11/02/20 and 11/04/20 by LVN D and on 11/06/20 by RN C. An observation of Resident #1 on 11/06/20 at 4:43 PM revealed Resident #1 was in bed, her heels were floated in pressure relieving boots, but her body was not offloaded for her sacral pressure ulcer. She did not indicate she was in any pain other than the itching she had from her crusted scabies all over the top half of her body. Review of Resident #1's nursing progress notes revealed the nurse went into administer medications and obtain vitals and observed Resident #1 resting with her eyes closed. The nurse tried to arouse Resident #1 but she was slow to respond. Resident #1 would not open her eyes and she was moaning but not speaking. Vitals obtained were : 85/49, 79, 20, 97%, 97.4. The nurse obtained vitals three different times but not stable BP was still low. The nurse offered fluids to Resident #1 to try to bring her BP up but it was not effective. The nurse notified the physician and NP of Resident #1's change in condition. An order was given to send the resident out for evaluation and treatment. EMT arrived to facility at 11:00 PM to transport Resident #1 to the hospital. An interview with RN C on 11/08/20 at 2:30 PM revealed she was Resident #1's nurse on 11/06/20 and did not conduct any wound care to the pressure ulcer on her sacrum. She said she worked 6:00 AM to 6:00 PM on 11/06/20. She said she worked on 11/07/20 but Resident #1 was sent out to the hospital after her shift was over. She said during her shift, the resident had complained of pain in her leg so she administered her pain medication. An interview with the hospital nurse case manager on 11/09/20 at 12:21 PM revealed Resident #1 was in the ICU. She reviewed Resident #1's ER, ICU and lab clinical notes and said she had [MEDICAL CONDITION] and a sacral decubitus ulcer and it looked like it had been present when she was at the hospital a couple months ago, but this time, it had became worse. She said Resident #1 had been diagnosed with [REDACTED]. She said her most recent white blood cell count that morning was 41.2. She said her initial labs in the ER reflected her white blood count at 66. An interview with RN C on 11/11/20 at 1:48 PM revealed when she was in training, the early part of last week, she observed wound care for Resident #1. She said Resident #1 had a large pressure ulcer about the size of her palm and it went to her muscle/bone. She re-iterated she did not provide wound care to Resident #1's sacral pressure ulcer and she did not know who conducted the wound care for Resident #1's wound on 11/06/20. She said she had never performed wound care on that pressure ulcer and would need help from someone because it would be her first time doing it. She said, I don't know how to do that type of wound. RN C said she did not see Resident #1's pressure ulcer on her sacrum on Friday (11/06/20) or Saturday (11/07/20), even though she was her nurse. She said, I did not know she needed the one on her bottom taken care of. I did not alert anyone because I did not know. RN C was asked why she initiated Resident #1's TAR on 11/06/20 which reflected she had completed wound care for Resident #1's stage 4 pressure ulcer to the sacrum. RN C looked at the TAR and said she did not know why she initialed it because she did not complete the wound care. She reiterated it was her first day on the floor by herself as the nurse for one and a half halls on 11/06/20. She said prior to that day, she had been training and shadowing other nurses for about a week and was on the floor by herself on Friday. An interview with RN C and the ADON on 11/11/20 at 2:32 PM revealed the ADON, who had just started conducting wound care over the past weekend, said she did not complete wound care for Resident #1 on 11/06/20 because she was off of work and came in around 2:00 PM. The ADON said she was the person that rounded with the wound care doctor since the last wound care nurse left. She said her role was to take measurements and document them in the clinical notes. She said the previous DON had said it was the ADON's responsibility to put the treatment orders in for wound care and let the charge nurses know they would be doing the treatments until a wound care nurse was hired. The ADON said the previous DON had also completed an in-service for the nurses indicating they would be responsible for wound care and if there were any changes, the ADON would let them know and put the treatment order changes in the e-chart. Regarding Resident #1, the ADON said she had a televisit with the wound care doctor on 11/02/20. Then she looked at it four days later on 11/05/20 because LVN D had asked her to come and look at it because it looked different to her. When she observed Resident #1's pressure ulcer on her sacrum, she said the dressing was off and there was some redness on the top part of her skin going around it. She said it looked different from the observation she made of it three days earlier. She said the pressure ulcer did not look infected. The ADON said the wound vac was already off. She said she left assuming LVN D completed a full dressing change and applied medication per treatment orders. The ADON said wound care was usually conducted in the mornings from 9:00 AM to 11:00 AM and if the nurse could not get to it, they usually passed it over to the next nurse. An interview with LVN D on 11/11/20 at 3:05 PM revealed she was concerned about Resident #1's wound on her sacrum on 11/04/20 because the tape had become soiled from feces and she irrigated it with a water treatment. She said the wound looked way different with damaged tissue and was not pink anymore. She asked the ADON to look at it. She said the ADON said to put on a dry dressing until they could have televisit with the wound care doctor. The ADON came back about an hour later and measured it and the wound care doctor observed the wound via the phone video. LVN D said he noted there was tissue damage and he wanted to discontinue the wound vac and gave the ADON other treatment orders such as calcium alginate. LVN D said the ADO, another nurse, and she removed Resident #1's wound vac and finished the water irrigation. She said she did not put the wound vac back on. She said the wound was then covered with a dry dressing. She said the new treatment orders were not administered that day because she was going to do it the next day instead. She said she put on a gauze on the wound. LVN D was asked why the wound vac orders were not discontinued as it continued to stay on the TAR for the next two days. She said the wound care doctor gave the ADON the orders so she would have been responsible to enter them and change the TAR. LVN D said she had only conducted wound care on a stage four pressure ulcer with a wound vac just one time prior, when another nurse showed her how to do it with Resident #1. LVN D said she felt Resident #1 should have been turned more because it seemed like she was not being turned enough as evidence by her wound deterioration. An interview with the I-DON on 11/11/20 at 2:43 PM revealed she said, We've been challenged from a staffing aspect, we are working with three staffing agencies. The treatment nurse left about three weeks ago. I am in the process of educating nursing staff on the facility procedures and protocols. In all areas I find issues, but state has been out here almost every week since I have been here and since the ADM has been here and we are trying to get things done but it's hard when state is out here all the time. An interview with Resident #1's family member on 11/12/20 at 10:34 AM revealed when she saw her face to face at the hospital, she was concerned about her condition and felt she had just been left at the facility to deteriorate. She said Resident #1 had moved from the skilled side of the building where she had received therapy to the long-term care side of the facility and ever since then, she barely heard from anyone about Resident #1. She said, Someone dropped the ball. She felt the facility was not repositioning her to relieve pressure from the wound. The family member said that the nurse in ICU had told her Resident #1's pressure ulcer on her sacrum was so deep, she could see her spinal cord. The family member said the hospital doctor told her Resident #1 had become septic and had extremely low blood pressure upon arrival due to her pressure sore. She said every day she had been in the hospital, she had gotten better and better and her blood pressure had finally leveled out to a suitable level. Resident #1's family member said she got her to eat , the hospital had gotten her blood pressure stabilized. The family member said she would not return Resident #1 to the facility and had located an alternate location. An interview with the wound care doctor (WC-Phy) on 11/12/20 at 10:08 AM revealed he had been conducting televisits in the facility due to COVID-19 precautions. He said the ADON contacted him on 11/04/20 because she was worried about Resident #1's wound on her sacrum and said it had became worse and had an odor. He said he assessed the wound and it had increased in size and had a lot of necrotic tissue and that was when he changed the treatment orders to Santyl and Calcium Alginate. He said there was redness around the edges of her wound because of the amount of necrotic tissue and a clear deterioration. He said he did not keep a wound vac as treatment when a wound needed to be debrided. He said since he was not in the facility to perform the debridement, he wanted to use Santyl as the [MEDICATION NAME] agent. He said it was an enzyme and only removed dead tissue. The WC-Phy said the Santyl was to be applied once a day because it took eight hours for the enzyme to penetrate and then 14 hours to have an effect. He said the plan was to make the change on Thursday (11/05/20) and re-evaluate it the following Monday. He said if the new wound care treatment orders were not carried out on 11/05/20 and 11/06/20, then he could only assume no one looked at it and that was a problem. He said it was not optimal care. The WC-Phy said if the wound care to the pressure ulcer on Resident #1's sacrum was not done on, that might not have prevented her from developing an infection, but it did not help. He said Resident #1 was sent to the hospital in the interim and he was not notified of that until two days later on 11/09/20. The WC-Phy said the key tenet to wound care and healing was to relieve the pressure. He said, If it is worsening, then I wonder if the pressure was really being alleviated. He said with the COVID pandemic, many facilities were understaffed and it was a constant struggle to get CNAs and nurses to offload patients everywhere he went. The WC-Phy said the facility had a revolving door for the DONs since he had seen patients in that building. He said he did not know who the acting DON was presently. He said, When you see the Administrator and DON with a revolving door, it worries me, that's a red flag for me. He said he had a brief conversation with the previous acting DON during the last state visit two or three weeks ago about a resident with a wound the facility had not notified him about. He said he tried to institute a corrective plan of action at that time where the ADON, who is basically the only stable person there and rounds with me would be provided free of charge her wound nurse certification paid for by his company. He said the facility never followed up with him about it. The WC-Phy said the ADON was only responsible presently to get the wound dressing supplies set up for the nurses on the floor. Review of Resident #1's November 2020 TAR, November 2020 physician's orders [REDACTED].#1's stage 4 pressure ulcer were entered into the e-chart and implemented as ordered on [DATE], 11/06/20 and 11/07/20. 2. A review of Resident #2's Admission Record dated 11/12/20 revealed he was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's quarterly MDS (Minimum Data Set) assessment, completed on 10/29/20, revealed the resident had moderately impaired mental status with a BIMs (Brief Interview for Mental Status) score of 9. The resident required extensive assistance from two staff members for bed mobility, transfers, and toileting. The resident was incontinent of bowel/bladder and had a tube feeding. The resident had no impaired skin conditions or wounds and did not receive skin or ulcer preventative treatments per the MDS assessment. Review of Resident #2's care plan, undated, revealed he was at risk of impaired skin integrity. To ensure no complications related to any type of skin injury, the only intervention identified was to encourage good nutrition and hydration. No other interventions were identified to prevent skin breakdown or to promote healing of identified skin breakdown Review of Resident #2's Braden Scale (pressure ulcer risk scale) reveal dated 10/07/20 revealed a score of 14 which indicated he was a moderate risk of developing pressure ulcers. Review of Resident #2's Order Summary Report, dated 11/12/20, revealed the following orders: -On 10/07/20, the physician ordered, CLEANSE [DEVICE] STOMA WITH NSS (normal saline solution), PAT DRY AND APPLY DRY DRESSING as needed -On 10/07/20, the physician ordered, CLEANSE [DEVICE] STOMA WITH NSS, PAT DRY AND APPLY DRY DRESSING every night shift -On 10/07/20, the physician ordered, INSPECT AND MONITOR GASTROSTOMY STOMA FOR SIGNS & SYMPTOMS OF LOCAL INFECTION SUCH AS REDNESS; PAIN; TENDERNESS, UNUSUAL ODOR, DRAINAGE OR DISCHARGE; HYPERGRANULATION OF TISSUE SURROUNDING STOMA. NOTIFY MD IF S/S NOTED. A review of a weekly skin assessment, completed by LVN A, dated 11/12/20 at 9:31 a.m. revealed Resident #2 had the following skin impairments: right antecubital arm had skin irritation and a skin tear to his right elbow. No other impaired skin integrity was noted. On 11/12/20 at 11:45 a.m. a second skin assessment was completed on Resident #2 by the I-DON (Interim Director of Nursing) with the surveyor present. The resident was found to have a wound on his left 2nd toe near the nail bed. The wound was crusted and covered in dried blood. The skin assessment was immediately stopped and delayed when I-DON discovered a possible scabies rash on the resident. Staff immediately moved the resident into isolation. On 11/12/20 at 1:20 p.m., after Resident #2 had been placed in isolation for possible scabies the resident's skin check was finished by I-DON. Resident #2 had a gastrostomy (feeding) tube in his abdomen. The tube did not have a split gauze dressing underneath the gastrostomy tube around the stoma. A brown substance was observed under the tube around the stoma. I-DON began to clean under and around the tubing at the stoma. I-DON was able to remove two chunks of brown, crusty, scab-looking substance that had accumulated around the resident's feeding tube . After I-DON removed the substance it was noted Resident #2 had a small pea sized, red, raw area under the tube near the tube entrance in the abdomen. I-DON stated she would ensure the physician was called and orders obtained to treat the open area. 3. Resident #3's Admission Record, dated 11/12/20, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's admission MDS assessment, dated 10/20/20, revealed the resident had intact mental status with a BIMs (Brief Interview for Mental Status) score of 15. The resident required extensive to total assistance from two staff members for bed mobility, transfers, and toileting. The resident was incontinent of bowel/bladder. The resident had a stage 4 pressure ulcer and was to receive pressure ulcer/injury care Review of Resident #3's undated care plan revealed she was at risk for pressure ulcers related to limited mobility. The care plan identified that she had a stage 4 pressure ulcer wound on her left buttock. To ensure intact skin, free of redness, blisters, or discoloration, staff were to implement the following interventions which included but were not limited to: -Administer treatments as ordered and monitor for effectiveness -Follow facility policies/protocols for the prevention/treatment -Daily dressing Review of Resident #3's Braden Scale assessment (pressure sore risk), dated 10/01/20, revealed a score of 16 which indicated she was a low risk of developing pressure ulcers. Review of Resident #3's Order Summary Report, dated 11/12/20, revealed on 11/02/20 the physician ordered the resident to have a negative pressure (wound vac) applied to the resident's left buttock and for the dressing/wound vac to be changed every Monday, Wednesday, and Friday. The wound vac was supposed to run continuous at 100 mmhg pressure. Review of Resident #3's wound care telemedicine evaluation, dated 11/09/20, revealed the resident continued to have a stage 4 pressure ulcer of the left buttock which she had for at least 35 days duration. The wound size was 7.0 cm L x 7.0 W x 7.0 cm D. The treatment plan included negative pressure applied three times per week for 23 days via a wound vac in continuous mode with dressing changes 3x (three times) a week and as needed. Review of Resident #3's November 2020 TAR (Treatment Administration Record) revealed an order, dated 11/02/20, for the resident to have a wound vac applied to her pressure ulcer continuously and dressing changes completed on Monday, Wednesday, and Friday. The TAR reflected the order was transcribed as every other day and to be completed at 9:00 a.m. Further review of the TAR revealed blanks on Wednesday 11/04/20 and Friday 11/06/20, Review of Resident #3's nurses progress note, dated 11/11/20 at 3:42 p.m., revealed a nurse had changed the resident's wound vac dressing. The nurse documented, Suction device tube did not fit to canister that is used. The nurse informed the ADON (Assistant Director of Nursing which was also the wound nurse at the time). The nurse documented the ADON told her she would take care of it. Observation and interview on 11/12/20 at 3:40 p.m. of Resident #3's wound vac with I-DON revealed the resident thought the wound vac was attached and working. She stated the machine was sitting on the left side of the bed. However, when I-DON looked for the wound vac machine she found it sitting on the floor, behind the bed detached from the tubing, not functioning. The I-DON looked at Resident #3's left buttock and the wound dressing was not secured to the resident. The dressing looked old and was half pulled off of the resident's skin. The wound vac tubing was still in the dressing but it was hanging out lying on the bed, not attached to the wound vac machine. There was no drainage in the tubing or in the machine. The resident did not know the wound vac was not working and was unsure how long it had been detached. On 11/12/20 at 3:15 p.m., a telephone interview was conducted with the ADON (acting wound nurse) in the presence of I-DON. The ADON stated the prior day, 11/11/20 at approximately 3:42 p.m., an agency nurse told her she had changed Resident #3's wound vac dressing but the wound vac was not working because the nurse could not connect the wound vac tubing. The ADON said the facility did not have the correct tubing to fit the wound vac canister. The ADON said she did not call the physician on 11/11/20 when she found out the wound vac was not functioning because the facility did not have the correct tubing for the wound vac canister. When asked why she did not call the physician immediately on 11/11/20, the ADON was unable to provide an answer. She admitted she waited until 11/12/20, over 23 hours, to call the physician. A review of Resident #3's progress notes, dated 11/12/20 at 2:57 p.m., revealed the ADON documented she called the physician to notify him the wound vac was not working and an alternative treatment order was obtained. 4. Review of Resident #4's undated care plan revealed she had the potential of developing pressure ulcers and had, WOUND ON THE LEFT, DISTAL, LATERAL CALF. In addition, had, UNSTAGEABLE (DUE TO NECROSIS) SACRUM. The care plan also reflected she was resistive to care and refused to wear her heel boots for her wound and refused to have her legs elevated or her heels put on pillows. Interventions to meet the resident's needs included, administer treatments as ordered and monitor effectiveness, daily body checks, float heels, follow facility policies/protocols for prevention/treatment, educate the resident on treatment, and give clear explanation of all care activities prior to contact. Review of Resident #4's Skin Evaluation, dated 11/07/20, and completed by the wound nurse revealed the resident the resident had the following wounds: -Right leg, dried necrosis -Left leg has area being treated by wound doctor -Sacrum area being treated by wound doctor -Left foot, second toe redness -Both hands, discolored areas Review of Resident #4's Wound Care Evaluation, dated 11/09/20, and completed by the wound doctor, revealed the resident had multiple wounds. The following two wounds were assessed: -Left, distal, lateral calf with moderate serious exudate with at least 7 days duration. The wound was measured to be 4.0 cm L x 3.5 cm W. Thick adherent devitalized necrotic tissue was at 100%. The physician recommended Santyl, calcium alginate dressing once a day for 23 days. Review of Resident #4's Order Summary Report on 11/12/20 revealed no treatment order for her left calf. -Sacrum was unstageable due to necrosis. The wound was measured to be 10.0 cm L x 1.5 cm W. The physician recommended a daily calcium alginate dressing to be applied for 23 days and to offloading the wound. Review of Resident #4's Order Summary Report on 11/12/20 revealed the following current physician wound orders (review of the TAR revealed nursing was initialing that all these orders were being carried out as ordered) : -On 02/14/20, an order was obtained for the resident to wear heel protective boots at all times for wound care. -On 04/23/20, an order was obtained for the resident's bilateral (both sides) lower extremities to be elevated with pillows wile in bed for wound care. -On 07/03/20, an order was obtained for the resident to wear a pressure relieving boot to her left foot every shift and to off load her heels when in bed. -On 09/09/20, an order was obtained to clean (TRUNCATED)

Based on observation, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate administering of all drugs and biological's, to meet the needs for six (Resident #1, Resident #7, Resident #5, Resident #6, and Resident #9) of nine residents reviewed for pharmacy services. 1. The facility did not provide Resident #1's full course of antibiotic therapy of [MEDICATION NAME] 250 mg twice a day for seven days for a urinary tract infection. 2. The facility did not provide Resident #7''s full course of antibiotic therapy of [MEDICATION NAME] 300 mg twice a day for seven days for a urinary tract infection as ordered. 3. The facility did not provide Resident #5's Parkinson medication [MEDICATION NAME] 1 mg once a day as ordered. 4. The facility did not provide Resident #6 with her routine narcotic pain medication [MEDICATION NAME]-[MEDICATION NAME] 10-325mg every four hours as ordered. 5. The facility did not provide Resident #9 with an IV antibiotic Meropenem Solution every 12 hours for a bacterial infection as ordered. These failures placed residents at risk of not receiving necessary medications, not receiving the intended therapeutic benefits of their medications and a decline in health. Findings included: 1. Review of Resident #1's quarterly MDS Resident Assessment, dated 09/23/20, revealed she was an [AGE] year old female who admitted to the facility on [DATE] and readmitted after a hospital stay on 09/20/20. Her active [DIAGNOSES REDACTED]. The assessment indicated she was unable to complete a Brief Interview of Mental Status, therefore the staff assessed her and determined she had no short or long-term memory issues. She required extensive assistance of two or more staff for her toileting needs. She had an indwelling catheter and was always incontinent of bowel. She had frequent pain but the effect on her ability to function and the pain intensity was not assessed. Review of Resident #1's care plan, revised on 10/29/20, revealed she was on antibiotic therapy and the interventions included administer medication as ordered. Review of Resident #1's physician order [REDACTED]. Review of Resident #1's November 2020 MAR revealed from 11/01/20 through 11/05/20 she missed eight out of ten doses. An interview with NP H on 11/08/20 at 7:50 PM revealed she was at the facility on 11/06/20 and the physician was there on 11/04/20. NP H said she did not know Resident #1 had not been given her full course of antibiotic therapy for a urinary tract infection. She said she remembered prescribing the antibiotic for Resident #1 initially for three days until the culture came back. She said RN G sent her the results of the culture and she saw the medication was sensitive to [MEDICATION NAME] and extended the order for seven days total. She said no one let her know the medication was not continued. She said she was contacted the night prior (11/07/20) by a nurse who stated Resident #1 had low blood pressure and was not very responsive and was sent to the ER. She said if Resident #1 did not receive the full dose of her antibiotic per order, it could cause a problem. NP H felt that not getting her [MEDICATION NAME] would have contributed to her decline and said, But more than likely she had a lot of comorbidities and until we know if it is urosepsis, it could be from the pressure wound. An interview on 11/09/20 at 12:21 PM with the hospital ICU nurse case manager revealed Resident #1 admitted to the hospital on [DATE] with [MEDICAL CONDITION] and acute organ disfunction due to gram negative bacteria. She said her most recent white blood cell count this morning was 41.2, but labs upon admission showed it was at a 66. 2. Review of Resident #7's admission MDS Assessment, dated 11/05/20, revealed he was a [AGE] year old male admitted to the facility on [DATE]. He had no cognitive impairment and no behavioral issues. His score was elevated and indicated issues with [MEDICAL CONDITION], depression, fatigue, concentration and movements. He was occasionally incontinent of urine and frequently incontinent of bowel. He needed limited assistance of at least one staff to assist him with toileting needs. His MDS did not indicate he had any active diagnoses. Review of Resident #7's care plan dated 11/01/20 revealed his antibiotic medication was not care planned. Review of Resident #7's November 2020 physician order [REDACTED]. Review of Resident #7's November MAR revealed he was not administered [MEDICATION NAME] on 11/02/20, 11/03/20, 11/04/20 and 11/05/20, which totaled eight missed doses. Review of Resident #7's nursing progress notes for 11/02/20 through 11/05/20 revealed, [MEDICATION NAME] Capsule 300 MG Give 1 capsule by mouth two times a day for ABT for 7 Days until finished on order with pharmacy. Interview with MA Z on 11/06/20 at 4:35 PM revealed she passed medications for Resident #7 during the times his [MEDICATION NAME] was not administered. She said it was not available and she told the nurses who were working on those shifts because she (MA Z) did not order medications from the pharmacy. She said she did not remember who she told but she wrote down any medication that needed to be reordered and gave it to the charge nurse for that shift. She said Resident #7 had not received the [MEDICATION NAME] until the morning of 11/06/20. Interview with the DON on 11/06/20 at 5:22 PM revealed MA Z was capable of ordering medication for residents, it was not the sole responsibility of the nurses. She said the pharmacy delivered to the facility twice a day, and if the order came in prior to 8:00 PM, it would be on the midnight run. She said the pharmacy could also contact the local pharmacies in order to get a medication delivered to the facility stat. 3. Review of Resident #5's quarterly MDS assessment, dated 09/19/20, revealed she was a [AGE] year old female admitted to the facility on [DATE] and readmitted from an acute care hospital on [DATE]. Her active [DIAGNOSES REDACTED]. Her cognitive patterns and mood were not assessed on the MDS. Resident #5 required physical limited assistance of at least one staff for locomotion and bed mobility, extensive assistance for toilet use and personal hygiene and physical help with bathing. She used a wheelchair for mobility. A pain assessment interview was not completed for the resident or by staff for the MDS. Resident #1 received antianxiety, antidepressant and opioid medications. Review of Resident #5's care plan, revised 11/08/19, revealed she had tremors and uncontrolled body movements related to her [DIAGNOSES REDACTED]. (Note: [MEDICATION NAME], a drug approved for [MEDICAL CONDITION] treatment, slows the breakdown of [MEDICATION NAME] and other brain chemicals.) An observation and interview with Resident #5 on 11/07/20 at 3:12 PM revealed she was in her room sitting in a wheelchair next to her bed. She was observed to have visible tremors in extremities and neck, moving forward and backwards. Resident #5 said she had not received her [MEDICAL CONDITION] medication like she was supposed to and they told her they were ordering it. She said when she does not get her medications for [MEDICAL CONDITION], it made her tremors worse, as she was presently experiencing. Review of Resident #5's November 2020 physician order [REDACTED]. She was prescribed [MEDICATION NAME] 1 mg once a day (start date 04/16/20-open ended) Review of Resident #5's November 2020 MAR revealed she did not receive [MEDICATION NAME] on 11/02/20, 11/04/20, 11/06/20, 11/07/20, 11/08/20 and 11/09/20, which totaled six missed doses. Review of Resident #5's nursing progress notes revealed : 11/02/20: No documentation of the medication not being given. 11/04/20: medication was pending delivery. 11/06/20: medication was on order. 11/07/20: No documentation of the medication being given. 11/08/20: medication request was faxed to the pharmacy; RP/MD/DON notified and Waiting MD to return call. Medication will be sent via stat order. 11/09/20: medication was pending delivery from pharmacy. An interview with RN C on 11/08/20 at 2:30 PM revealed if medication for a resident was not available, she would talk to the supervisor and check the e-kit. She said if it was not available in the e-kit, then she would order the medication from the pharmacy. RN C said she did not know how often the pharmacy delivered medications to the facility and was not sure how to order them. She said she was still learning how to order medications and would need help. RN C said she had not yet ordered medications from the pharmacy since she started her position as a nurse the past week. RN C said Resident #5 was waiting on her [MEDICATION NAME] to be delivered. She said she ordered it the day prior with help from another nurse an got a confirmation but was still waiting on it. An interview with NP H on 11/08/20 at 7:50 PM revealed she had just been made aware that Resident #5 was out of her [MEDICATION NAME] for five days. She said if the resident missed the medication doses it could cause her to have increased rigidity, increased tremors, everything motor related could decline and she could have more difficulty speaking. She said, I don't know that there will be long term consequences, but definitely during that time of missing the medication, you would have noticed a change in her symptoms. She said she would have expected the nurses to let her know sooner and that many medications do not need a prior authorization or triplicate; the nurse could order directly from the pharmacy. A follow up interview with Resident #5 on 11/09/20 at 12:15 PM revealed she had just received her [MEDICATION NAME] that morning. She said not having it for several days had an effect on her. She said she could not get around and with people with [MEDICAL CONDITION] would freeze and could not do anything, even if they wanted to, their body would not move. She said she normally used the bathroom on her own, but with the medication having been not available, she could not do it and had to have the staff assist her. She said it was scary to see her tremors worsen over the past week. She said she also could not use utensils like she could before, and when her tremors got really bad, she just did not eat because it was too hard to pick up the food. She said she was thankful the medication was finally delivered and she had not known if she was going to be alright over those previous days she went without it. 4. Resident #6's annual MDS Resident Assessment, dated 09/04/20, revealed she was a [AGE] year old female who admitted to the facility on [DATE]. Her active [DIAGNOSES REDACTED]. Her assessment for her cognitive status was not completed and her mood was not assessed. She received a schedule pain medication regimen, but a pain interview and assessment was not completed. Review of Resident #6's care plan for pain management, initiated on 05/14/20, revealed, Is on pain medication therapy r/t (related to)acute and chronic pain. Interventions included: 1) Administer medication as ordered, 2) Monitor respiratory rate, depth, and effort after administration of pain medication and 4) Monitor for increased risk of falls. An additional pain management goal initiated on 08/01/18 and revised on 03/31/19 reflected, (Resident #6) is at risk for pain relating to: GERD, Gout, [MEDICAL CONDITION], Muscle Aches, Joint Pin, [MEDICAL CONDITION] and (Restless Leg Syndrome). Interventions included: 1) Anticipate need for pain relief and respond immediately to any complaint of pain and 2) Give [MEDICATION NAME] as ordered. An observation and interview with Resident #6 on11/07/20 at 3:05 PM revealed she was in her room sitting in her wheelchair; she was verbal and appeared A/O x4. She had a large ping pong size growth on the wrist of her right hand. She said she had not been given her pain medication routinely over the past week. She said the facility nurses told her they had run out. She said she asked the nurses about it often but they said they were waiting on the pharmacy to deliver it. She said she had used a [MEDICATION NAME] prior in the past and [MEDICATION NAME] PRN, but the physician and she agreed she would discontinue the [MEDICATION NAME] and take [MEDICATION NAME] routinely. She said not having the [MEDICATION NAME] available had been difficult because she had constant back pain and a large abscess on her right wrist which she was waiting to get removed in the future, but was causing her pain presently with any movement. She said the facility had an issue with medications not always being available or if they were, like pain pills, they gave them outside of the time they were supposed to be given, hours after. Review of Resident #6's November 2020 physician's orders [REDACTED]. Resident #6 had no other pain medication orders. Review of Resident #6's November 2020 MAR revealed she did not receive [MEDICATION NAME]-[MEDICATION NAME] on the following dates: November 1st-4th, 2020. She was to receive the medication every four hours. Resident #1 missed 16 doses of the medication. Review of Resident #1's nursing notes from 11/01/20-11/04/20 revealed: -11/01/20- Pending delivery, triplicate needed to be faxed by MD. -11/03/20- Pending delivery from pharmacy. -11/04/20- Pending delivery from pharmacy. An interview with Resident #6's NP on 11/08/20 at 7:50 PM revealed if the facility failed to administer a medication, she would expect to be notified. She said she was not aware that Resident #6 had run out of [MEDICATION NAME]-[MEDICATION NAME]. She said when a narcotic needed to be reordered, typically the facility would text the resident's name, date of birth and what they needed. She said she would then forward it to the physician. She said she was in the facility consistently and this was the first time she was aware Resident #6 had run out of her pain medication. She said she was familiar with Resident #6 and said she had chronic back pain and [MEDICAL CONDITION] in her legs. She said she was on more powerful pain medications but had tapered down to only [MEDICATION NAME] but it was something she took routinely because of her chronic pain issues. The NP said there was no negative long-term effect of not receiving the medication for four days, but there was a short-term effect of her pain not being managed. She said the [MEDICATION NAME] was not a medication the facility typically had in their e-kit. An interview with LVN E on 11/09/20 at 2:13 PM revealed Resident #6 did go without her [MEDICATION NAME] for three to four days. He said she was not in serious pain but she was used to getting it routinely and in a timely fashion. He said there was no e-kit available so he was not able to obtain it from there when she ran out. An interview with LVN D on 11/09/20 at 2:44 PM revealed with the new pharmacy changeover, the e-kit was available but she did not have access authorization yet so could not use it. She said with Resident #6's [MEDICATION NAME], the problem was that the new pharmacy needed a triplicate. She said the physician and the NP were notified. She said notified the I-DON in the morning meeting about the missed doses of [MEDICATION NAME] because (Resident #6) counts down the hours she hasn't gotten it, every 4 hours, she will let us know. LVN D said during the four days Resident #6 did not receive her [MEDICATION NAME] every four hours, she was in pain with bad arthritis and the cist on her arm. She said Resident #6 never cried about it, but she was angry. Review of the E-Kit Inventory provided by the I-DON on 11/09/20 revealed the inventory log was current from 11/01/20 and included 24 tablets of [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg tablets in the lock box on row 3, slot 7. 5. Review of Resident #9's annual MDS assessment, dated 08/12/20, revealed she was a [AGE] year old female admitted to the facility on [DATE]. Her active [DIAGNOSES REDACTED]. Review of Resident #9's care plan, revised on 10/14/19, revealed it did not address her need for antibiotic therapy. Review of Resident #9's November 2020 physician order [REDACTED]. Review of Resident #9's November 2020 MAR revealed she was not administered the medication on 11/06/20 for the evening dose and on 11/07/20 for the evening dose. There were no nursing notes on 11/06/20 to indicate why the medication was not administered. There was an e-MAR administration note for the missed dose on 11/07/20 which reflected, Meropenem Solution Reconstituted 1 GM Use 1 gram intravenously every 12 hours for bacterial infection for 8 Days Medicine not found. An interview with LVN AA on 11/08/20 at 3:12 PM revealed she worked with Resident #9 and the overnight nurse did not tell her when they were rounding that morning that he could not locate the resident's antibiotic medication. She said she had worked the day prior and rounded with him when he came on shift. She said she brought out the medication, which was kept in the med room, not on the cart and showed him how to use it since it was a liquid medication with a special mechanism to mix it and administer it properly. LVN AA said she did not tell the overnight nurse that the medication was in the med room, not on the med cart. She said she thought he understood. She said the medication was for bacterial pneumonia. She said she surmised the night nurse was new to the facility. LVN AA said if a nurse could not find a medication they were supposed ask another nurse and if it still could not be located, they were to call/notify the ADON. An interview with LVN O on 11/08/20 at 6:50 PM revealed he was a new nurse. He said he did not see Resident #9's antibiotic medication on the med cart. He said he used his nursing judgement to look around for where it might have been but he could not find it. He said he looked in the medication room as well. He said the skilled halls had four carts and he looked in all of them and could not locate it. He said he went to the nurse on the other side of the building but she was in the process of sending a resident out to the hospital and would help him look for it when she was done. He said he thought maybe he could wait until morning and ask the oncoming nurse where the medication was since they had worked there longer. He said the other nurse from the other side of the building never came back to help him. LVN I said he did have the phone number to the ADON and DON but decided to wait for the morning nurse to arrive. He said when she got there, he informed her that he could not locate Resident #9's antibiotic medication. He said she did not show him where it was located but next time he worked on the hall, he said he was going to make sure he made a list of any missing medications and would find out where they were. 6. An interview with NP I on 11/07/20 at 1:57 PM revealed if the facility could not obtain a resident's medication from the pharmacy and there would be a delay, then typically she would send the resident to the hospital to get the necessary treatment, especially if they did not have their antibiotic or pain medication available. She said there had been a lot of management changes at the facility and she and PHY M had noticed and have had to call the facility about some of the residents because they could not confirm if they were receiving their medication. An interview with RN C on 11/08/20 at 2:30 PM revealed when she rounded with other nurses at the beginning and end of her shift, the rounds entailed talking about any resident problems, resident conditions, medication that had run out and were on order and if a resident was on an antibiotic, then they were to track it and document. An interview with NP H on 11/08/20 at 7:50 PM revealed her expectation was when an order was written, that it was carried out. She said if staff failed to administer a medication, she expected to be notified. An interview with LVN E on 11/09/20 at 2:13 PM revealed if medication was not available at the facility, the nurses were supposed to call the pharmacy and re-order it. He said there was a recent change in the pharmacy company used, so there have been some missing medications as a result. He said when the medication ran out, he would call the pharmacy and tell them the patient's name and what medication was needed. He said once an order for [REDACTED]. LVN E said after 5:00 PM, it would be delivered the next day. He said if it was after 5:00 PM and an emergency, the nurse could stat order a medication like an antibiotic or pain medication and that it usually arrived within four hours. He said if it was a routine medication, it should not run out because the nurses were supposed to reorder it within four to five days of it running out. He said there was a new e-kit in the pharmacy but he did not think it had been stocked with medications yet. He said he did not have a login to use the machine. LVN E said if a pain medication continued to be waiting for delivery from the pharmacy and it had been several days, then the nurse who initially ordered/reordered that medication was supposed to follow up. He said then whoever came in for the next shift was to follow up and after a few says, then the supervisor should be notified it was not delivered. He said if there was a blank on the MAR and no initial, that meant the medication had not been charted as administered and the nurse would need to write a nursing note to explain. He said the nurses were not supposed to leave blanks on the MARs. He said there were a lot of nursing progress notes entries that said medications were pending delivery because of the new pharmacy changeover; That's why you are seeing so many medications missing. An interview with the I-DON on 11/11/20 at 2:32 PM revealed she had only been at the facility for a few weeks and they had been challenged from a staffing aspect and were working with three staffing agencies. She said she was in the process of educating nursing staff on the facility procedures and protocols in all areas she found issues with. 7. Review of the facility's Pharmaceutical Services policy revised May 2007, revealed, It is the policy of the facility to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological) to meet the needs of each resident. Review of the facility's Obtaining and Refilling Medications policy, revised July 2017, revealed It is the policy of this facility to obtain medications from new physician orders [REDACTED]. Procedure: It is the responsibility of each staff member who passes medications, to ensure each resident has an adequate amount of ever prescribed medication at all times 5. For those medications not filled or refilled in a timely manner (resulting in a missed dose), the physician will be notified.

Based on observation, interview and record review, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #6) of four residents reviewed for pain. The facility failed to administer Resident #6's routine narcotic [MEDICATION NAME]-[MEDICATION NAME] Tablet 10-325 mg every four hours for chronic pain to prevent discomfort that resulted in the resident experiencing pain throughout the day in her back and hand. Resident #6 missed 16 doses of her medication. This failure placed residents at risk for unnecessary pain, stress, fear of treatment, and decreased quality of care. Findings included: Resident #6's annual MDS Resident Assessment, dated 09/04/20, revealed she was a [AGE] year old female who admitted to the facility on [DATE]. Her active [DIAGNOSES REDACTED]. Her assessment for cognitive status was not completed and her mood was not assessed. The MDS further reflected she received a schedule pain medication regimen, but a pain interview and assessment was not completed. Review of Resident #6's care plan for pain management, initiated on 05/14/20, revealed, Is on pain medication therapy r/t (related to) acute and chronic pain. Interventions included,1) Administer medication as ordered, 2) Monitor respiratory rate, depth, and effort after administration of pain medication and 4) Monitor for increased risk of falls. An additional pain management goal initiated on 08/01/18 and revised on 03/31/19 reflected, (Resident #6) is at risk for pain relating to: GERD, Gout, [MEDICAL CONDITION], Muscle Aches, Joint Pin, [MEDICAL CONDITION] and (Restless Leg Syndrome). Interventions included, 1) Anticipate need for pain relief and respond immediately to any complaint of pain and 2) Give [MEDICATION NAME] as ordered. An observation and interview with Resident #6 on11/07/20 at 3:05 PM revealed she was in her room sitting in her wheelchair; she was verbal and appeared A/O x4. She had a large ping pong size growth on the wrist of her right hand. She said she had not been given her pain medication routinely over the past week. She said the facility nurses told her they had run out. She said she asked the nurses about it often but they said they were waiting on the pharmacy to deliver it. She said she had used a [MEDICATION NAME] prior in the past and [MEDICATION NAME] PRN, but the physician and she agreed she would discontinue the [MEDICATION NAME] and take [MEDICATION NAME] routinely. She said not having the [MEDICATION NAME] available had been difficult because she had constant back pain and a large abscess on her right wrist which she was waiting to get removed in the future, but was causing her pain presently with any movement. She said the facility had an issue with medications not always being available or if they were, like pain pills, they gave them outside of the time they were supposed to be given, hours after. Review of Resident #6's November 2020 physician's orders [REDACTED]. Resident #6 had no other pain medication orders. Review of Resident #6's November 2020 MAR indicated [REDACTED]. She was to receive the medication every four hours. Resident #1 missed 16 doses of the medication. Review of Resident #1's nursing notes from 11/01/20-11/04/20 revealed: -11/01/20- Pending delivery, triplicate needed to be faxed by MD. -11/03/20- Pending delivery from pharmacy. -11/04/20- Pending delivery from pharmacy. An interview with Resident #6's NP on 11/08/20 at 7:50 PM revealed if the facility failed to administer a medication she would expect to be notified. She said she was not aware Resident #6 had run out of [MEDICATION NAME]-[MEDICATION NAME]. She said when a narcotic needed to be reordered, typically the facility would text the resident's name, date of birth and what they needed. The NP said she would forward it to the physician. She said she was in the facility consistently and this was the first time she was aware Resident #6 had run out of her pain medication the week prior. She said she was familiar with Resident #6 and said she had chronic back pain and [MEDICAL CONDITION] in her legs. She said she was on more powerful pain medications but had tapered down to only [MEDICATION NAME]. She said it was something she took routinely because of her chronic pain issues. The NP said there was no negative long-term effect of not receiving the medication for those four days, but there was a short-term effect of her pain not being managed. An interview with RN C on 11/08/20 at 2:30 PM revealed she was a new nurse and it was her first few days by herself on the floor as the charge nurse of one and a half halls which included Resident #6. RN C said when a resident did not have medication available on the medication cart, she was supposed to talk to the supervisor and go to the e-kit and look for the medication. If the medication was not in the e-kit then she would order it through the pharmacy. She said she was not sure how often the pharmacy delivered medications and she was still learning how to order medications. She said Resident #6's [MEDICATION NAME] had arrived from the pharmacy on 11/06/20. An interview with LVN E on 11/09/20 at 2:13 PM revealed if medication was not available at the facility, the nurses were supposed to call the pharmacy and re-order it. He said there was a recent change in the pharmacy company used, so there had been some missing medications as a result. He said when the medication ran out he would call the pharmacy and tell them the patient's name and what medication was needed. He said once an order for [REDACTED]. LVN E said ifit was after 5:00 PM and an emergency, the nurse could stat order a medication like an antibiotic or pain medication and that usually arrived within four hours. He said there was a new e-kit in the pharmacy but he did not think it had been stocked with medications yet. He said he did not have a login to use the machine. LVN E said if a pain medication continued to be waiting for delivery from the pharmacy and it had been several days, then the nurse who initially ordered/reordered that medication was supposed to follow up and whoever came in for the next shift was to follow up. He said after a few days, the supervisor should be notified if the medication was not delivered. LVN E said nurses should not until the last pill was given to reorder a medication. He said within 4-5 days was when a medication would need to be reordered. LVN E said Resident #6 did go without her [MEDICATION NAME] for three to four days. He said she was not in serious pain but she was used to getting it routinely and in a timely fashion. He said there was no e-kit available so he was not able to obtain it from there when she ran out. An interview with LVN D on 11/09/20 at 2:44 PM revealed with the new pharmacy changeover, the e-kit was available but she did not have access authorization yet so she could not use it. She said with Resident #6's [MEDICATION NAME], the problem was that the new pharmacy needed a triplicate. She said the physician was notified and the NP. She said notified the I-DON in the morning meeting about the missed doses of [MEDICATION NAME] because (Resident #6) counts down the hours she hasn't gotten it, every 4 hours, she will let us know. LVN D said during the four days Resident #6 did not receive her [MEDICATION NAME] every four hours and she was in pain with bad arthritis and with the cyst on her arm. She said Resident #6 never cried about it, but she was angry. Review of the E-Kit Inventory provided by the I-DON on 11/09/20 revealed the inventory log was current from 11/01/20 and included 24 tablets of [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg tablets available in the lock box on row 3, slot 7. Review of the facility's Policy for Obtaining and Refilling Medications, dated July 2017, revealed, It is the policy of this facility to obtain medications from the new physician and refill medications needed in a timely manner; Procedure: It is the responsibility of each staff member who passes medications, to ensure each resident has an adequate amount of every prescription medication at all times; 1. For those resident medications on a monthly cycle-fill, staff will ensure cycle-fill meds are received and placed in the medication carts before the current month supply is depleted .5) For those medications not filled or refilled in a timely manner (resulting in a missed dose), the physician will be notified.

Based on observation, interview and record, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan for two (Resident #1 and Resident #2) of six residents reviewed for quality of care. 1. The facility failed to ensure Resident #1 was accurately assessed, monitored, and treated for [REDACTED]. Resident #1 was observed to have areas of her body covered in a thick, scaly, crust, including her hands, wrists, arms, torso, abdomen, and neck. She also had raised, reddened bumps on these areas as well as her face. There was no documentation Resident #1 had received a head to toe skin assessment within the last seven days to assess the condition of her skin or the progress of the infection. She experienced a decline on 11/07/20 and was sent to the hospital where it was determined she was septic. 2. The facility did not accurately identify Resident #2's skin had deteriorated when a skin assessment was completed. This failure placed residents at risk for exposure to scabies and could result in pain, decreased quality of life, serious illness (including [MEDICAL CONDITION] that lead to the development of secondary infections, such as Staphylococcus bacteria) and hospitalization . Findings included: 1. Review of Resident #1's quarterly MDS Resident Assessment, dated 09/23/20, revealed she was an [AGE] year old female who admitted to the facility on [DATE] and readmitted after a hospital stay on 09/20/20. Her active [DIAGNOSES REDACTED]. The assessment revealed she was unable to complete a Brief Interview of Mental Status, therefore the staff assessed her and determined she had no short or long-term memory issues. She required extensive assistance of two or more staff for bed mobility (how she moved to and from lying position in bed, side to side and body positions while in bed) and for toileting needs. She required limited assistance of two staff to get dressed, and supervision for hygiene such as brushing her teeth and combing her hair. She needed physical help of at least one staff for bathing. Review of Resident #1's care plan, dated 07/02/20 and revised on 10/29/20, revealed on 11/05/20 Resident #1's care plan was updated to include, Has rash arms, chest, abdomen related to scabies, she is on contact isolation. Interventions were to, Avoid scratching and keep hands and body parts from excessive moisture, contact isolation, seek medical attention if skin becomes bloody or infected and treat as directed by MD. Review of Resident #1's last skin assessment dated [DATE] revealed no documentation of a skin rash or bumps. The skin assessment reflected she had two pressure ulcers, one on her right outer ankle and one on her sacrum. There was no other head to toe skin assessment completed after 10/17/20, only the weekly pressure ulcer review assessment. Review of Resident #1's nursing progress note dated 11/4/20 revealed, This nurse call MD call service about resident's rash not getting any better. Asked for MD or NP to come examine skin and/or test for scabies. Instructed to order [MEDICATION NAME] (anti-parasitic lotion) (follow direction on the box) for possible scabies. An observation of Resident #1 on 11/06/20 at 4:43 PM with the I-DON revealed she was in bed. The I-DON assessed Resident #1's skin and confirmed red dots on her arms and also confirmed she had crusted areas on her hands, webbing between fingers, side of arm and under her breasts. Resident #1 was also observed to have red/pink bumps trailing up her chest, on her laugh lines (face) and temples on her head as well. The I-DON said, I knew she had spots on her, but not to this extent. I can't chase everything down. There are a lot of issues I walked into as the interim DON here. The I-DON said she had not seen Resident #1's skin before and claimed no one told her it was getting worse. When the I-DON assessed Resident #1's skin, Resident #1 was visibly wincing indicate discomfort when her arms were moved up and down and when her blouse was moved. Review of Resident #1's nursing progress note dated 11/05/20 revealed, Medication Administration Note Text: [MEDICATION NAME] Lotion 1 % Apply to body topically one time a day for scabies follow directions on box; Pending delivery from pharmacy. Review of Resident #1's November 2020 MAR indicated [REDACTED]. There were no other administration dates and no nursing notes for 11/07/20 to indicate why the medication was not applied to her skin for scabies treatment. Interview with Resident #1 on 11/06/20 at 4:47 PM revealed she said she was itching very badly. On 11/07/20 at 1:23 PM, a second observation was made of Resident #1. Resident #1 was in a partially elevated bed (approximately 35 degrees) and rolled slightly to right side with pillows for support. With Resident #1's permission, observation of skin revealed a heavy rash across her abdomen, legs and feet. Her left outer breast had heavy crusting extending to left axilla. Burrowing was observed to bilateral arms and upper, inner arms with light rash and some gray crusting noted. Bilateral hands had areas of thick, gray crusts and there was a small open fissure with scant red seepage noted in webbing at base of left thumb. An interview with Resident #1 on 11/07/20 at 1:27 PM revealed she was alert and oriented time two. She stated she was itching and had been for a while. Resident #1 denied pain but reiterated she was itching all over body. Resident #1 stated she did not know how long itching had been present. An interview with RN G on 11/06/20 at 12:59 PM revealed she said she had been caring for Resident #1 since the beginning of her employment at the facility, about four weeks ago. She said ever since she had been Resident #1's nurse, Resident #1's skin was so itchy and crusty and red. She said the physician prescribed [MEDICATION NAME], which was a cream that helped prevent itching and calmed the skin and said, So obviously it was not scabies cream. RN G said the cream did help with the itching but about a week or two ago, Resident #1 was moved from her hall to the long-term care hall on the other side of the building. RN G said she did not know if Resident #1 had scabies while she took care of her, but she suspected she did. RN G said when she went to see Resident #1 after she was moved off the skilled unit she noticed her skin was more crusty and it had not been like that when she was her nurse. She said, Maybe it was dormant. RN G said when she saw Resident #1 on the long-term care unit she had crusty skin on her breasts. An interview on 11/06/20 at 12:23 PM with the ADM and I-DON revealed the facility was currently dealing with scabies and were treating individuals. When asked if any of the residents identified had Norwegian crusting scabies, the I-DON said, No. She said the nurses conducted a head to toe skin assessment on every resident weekly. She said Ivermectin and [MEDICATION NAME] was supposed to be the best thing to treat scabies and if the rash was still present after 14 days, then the facility would conduct a scraping and determine what to do. The I-DON said the residents identified with suspected scabies were Resident #1, her roommate (Resident#14 who did not have any symptoms) and Resident #7 (who did not have a roommate). The ADM said the nursing management was currently doing resident skin assessments. A confidential interview with facility staff revealed they expressed concern related to scabies that baths and showers were not being completed for the residents according to the facility's schedule. The individual also stated that the facility had not directed the nursing staff to increase their frequency of skin monitoring for residents either. The individual said with 20+ residents each, it was hard for the nurses to complete all skin assessments as it was. An interview with RN C on 11/06/20 at 3:40 PM revealed it was her first day by herself on the floor for one and a half halls. She said she was off the day prior so did not know Resident #1 had scabies and had been on isolation. She said she saw it on the 24-hour report. RN C said she had observed that Resident #1 had some bumps on her chest and was itching a little. She said there was a cream to apply to her skin, but she had not applied it to her yet. She said the isolation for Resident #1 had been discontinued because it was for 24 hours only. RN C was asked to locate Resident #1's [MEDICATION NAME] cream or [MEDICATION NAME] lotion on the medication cart. She was unable to locate it. An interview with the I-DON on 11/06/20 at 4:30 PM revealed LVN D was the nurse who put Resident #1's verbal physician's orders [REDACTED]. She said the nurse did not know how to correct the MAR indicated [REDACTED]. The I-DON said she had just called the night nurse (LVN F) and he said he gave the scabies medication but he did not know how to change the MAR indicated [REDACTED]. The I-DON said, These are some of the issues I am telling you about, the nurses here, many are new and needing a lot of education. She said LVN F was going to come to the facility and write a late-entry nursing note to indicate he gave the medication. An interview with CNA K, LVN A and RN C on 11/06/20 at 5:03 PM occurred as they were the staff who had worked with Resident #1 that day. The three staff went into Resident #1's room look at her skin. They did not don any contact isolation PPE outside of her room, including an isolation gown. When they came out of her room, LVN A said she saw what looked like yeast on Resident #1's skin, yellow and brown around her breast. LVN A said she had been told Resident #1 had scabies, but after looking at her, stated she did not think Resident #1 had scabies. RN C said Resident #1's skin looked brown on her nipple and her breast skin was dry. CNA K said Resident #1's skin, Looked like when your skin is dying and I could tell it is itching. CNA K, LVN A and RNC all stated they had not received any education or in-service about scabies or scabies protocol. Review of the facility's shower book and all loose shower sheets stored in a shelf at the nurses' station on 11/06/20 at 5:05 PM revealed no shower sheets for Resident #1 for the past three weeks 10/15/20 through 11/06/20. An interview with the I-DON on 11/07/20 at 1:19 PM revealed the facility did not have any documented evidence to indicate a physician or nurse practitioner had examined Resident #1's skin. An interview with the ADM on 11/07/20 at 1:23 PM revealed he was asked if the facility had determined who was the initial case of scabies. He said he was not the administrator when the initial case could have happened. He said he had not had a chance to dive that deep into it. He said the odds were, the person treated the longest for a rash was Resident #1, which had been thought was caused by a fungus so she was given a medication for itching. The ADM said, Even staff who have it on their arm, it looks like contact [MEDICAL CONDITION]. He said there was a way to confirm if it was scabies through a scraping, but they had not pursued that yet. An interview with NP I on 11/07/20 at 1:57 PM revealed the facility had informed her about the scabies and she was in the building when it had been discovered. She said the first person that came to her was a nurse who showed her a rash of unknown origin on 11/04/20. NP I said when she started to realize several nurses had the same rashes, that was when the interim DON called all the nurses on the floor to the office and NP I looked at anyone with a rash staff wise, which was about six or seven. She said she then gave orders to isolate residents that anyone saw with a rash because she was trying to see if they needed to treat the whole building. She said any of the residents on her caseload that showed symptoms of scabies would need to isolate for at least 24 hours and orders were given to initiate [MEDICATION NAME] cream for 7-14 hours and after 24 hours of treatment which typically killed it, they could come off isolation. She said she also ordered three days of the steroid [MEDICATION NAME], and ivermectin oral over the course of 14 days. NP I said Resident #1 was not on her caseload and she asked the facility to contact Resident #1's physician or NP to get further orders and to isolate her. NP I said she did see Resident #1's exposed skin, and saw various stages of bumps, excoriation and [DIAGNOSES REDACTED] (redness in areas) on her arms, her upper torso and her leg/thigh. NP I said she did not see Resident #1's breasts or abdomen and did not complete a full head to toe skin assessment as she was not her patient. She said she could see by the tracking of excoriation on Resident #1's exposed skin that she could observe that she presented like the other residents and nurses in how it was spreading. NP I said she did not order a scraping because, It was a differential dx on what else could it be. She said a dermatologist would have to complete the scraping. Review of Resident #1's nursing progress note, dated 11/07/20 at 10:50 PM, revealed Resident #1 was slow to respond when the nurse went in to take vitals. She would not open her eyes and was moaning but not speaking. Her blood pressure reading was 85/49. It was taken three different times; all readings were low. PHY K and NP H were notified of change on condition as well as the I-DON. Resident #1 was sent to the ER for evaluation and treatment. An interview with NP H in 11/08/20 at 7:50 PM revealed LVN D called her on 11/03/20 and told her the facility thought Resident #1 had scabies. NP H said she assessed over phone and ordered treatment and did not see Resident #1's skin directly or through any photos or video. She said no one had notified her prior about Resident #1's change of skin. She said Resident #1 did have a previous order for a [MEDICAL CONDITION] rash, but it had been treated. NP H said she ordered Elemite cream ([MEDICATION NAME]). She said additional orders were placed on 11/06/20 including Ivermectin, a steroid and [MEDICATION NAME] for itching. She said at that time she was told by the facility on 11/06/20 or 11/07/20 that there were other residents showing signs and symptoms of scabies as well. NP H said on 11/06/20, she also told the facility Resident #1 would need a dermatology referral to get a scraping. NP H said she was at the facility on 11/06/20 but she did not see Resident #1 as no one asked her to assess her. NP H said she saw the long-term care residents once a month or when there was a decline, change in condition or as needed. She said when she was at the facility on 11/06/20 no one mentioned any concerns related to Resident #1's skin. An interview with the hospital nurse case manager on 11/09/20 at 12:21 PM revealed Resident #1 was in the ICU. She reviewed Resident #1's ER, ICU and lab clinical notes and said she had [MEDICAL CONDITION] and a sacral decubitus ulcer and it looked like it was already present when she was at the hospital a couple months ago, but this time, it had became worse. She said Resident #1 had been diagnosed with [REDACTED]. She said her most recent white blood cell count that morning was 41.2. Initial labs in the ER had her white blood count at 66. An interview with LVN D on 11/09/20 at 2:44 PM revealed NP I looked at Resident #1's stomach only, no other areas. LVN D said Resident #1 had, a little rash on her chest, arms and back. LVN D said she asked NP I to look at her arm which had a rash. She said NP I said nine times out of ten, what she was seeing was scabies. LVN D said Resident #1 moved from the skilled unit to the long-term care hall about two weeks ago and already had the same rash on her skin. She said she never saw Resident #1 scratching, but she would complain of itchiness, so LVN D would apply an itch cream which would help somewhat. She said the cream was not for scabies. LVN D said she did see Resident #1's breast area and the skin looked extra dry. She said she wanted the CNAs to give her a shower because it would be more moisturizing and she had only been receiving bed baths. LVN D said, I think I told the CNA but either it wasn't her day or we were very short. An interview with CNA N on 11/10/20 at 1:35 PM revealed she had worked with Resident #1 on 11/02/20, 11/03/20 and 11/04/20. She stated she also cared for her when the resident was on the other side of the building, once. CNA N said at that time, she saw Resident #1 had a rash, like some red bumps. She told the nurse and was told they were putting cream on it. She said then when Resident #1 moved to the long-term care hall a couple of weeks ago, CNA N said she saw her skin again because she was her CNA. She said she noticed she had what looked like dry skin and crust on her skin, especially on her left breast area. She said she informed a nurse but did not remember who. CNA N said she did work with Resident #1 for three days the week prior and she could not remember if she gave her a bed bath on Monday or Wednesday. She said she did not fill out a shower sheet. She said, I know that the crust looked awful though when I was doing other ADLS with her. I was supposed to fill out a shower sheet but honestly, I forgot to. I get distracted after if something else needs to be done. So, I cannot say for certainty if I bathed her Monday or Wednesday. An interview with Resident #1's family member on 11/12/20 at 10:34 AM revealed she knew about the scabies, but the facility had only stated it was a little rash and they were going to give her medicine. She said she had not seen Resident #1's skin for two weeks since she last visited her. She said when she last saw her skin, it looked fine. The family member said since Resident #1 had been sent out to the hospital, she was able to see her skin firsthand. She said, They downplayed it to the tenth power. They said one little rash, they did not tell me it was all over her freaking body and these mass patches on her boob, they look like patches as big as the palm of my hand. It looks like they just left her there. Review of the facility's policy on Care of Residents with Scabies, revised September 2007, revealed, .1. General Information: Scabies begins with intense itching, popular eruptions, usually in the inter-digital spaces, but other areas can be involved. These areas may include skin over the wrists, elbows, anterior axillary folds, belt line, thighs, nipples, abdomen, lower portion of the buttocks in women and external genitalia in men. The scabies mite burrows under the skin and these burrows look like short, zig-zag, grayish white lines; .E. Apply scabicide as ordered. Cover the entire body from the neck down; pay special attention to the folds and creases, fingernails and interdigital spaces. Leave on the skin for 10-12 hours. Review of the CDC's (Centers for Disease Control) guidance on scabies revealed, Control measures for an outbreak involving one or more cases of crusted scabies should involve rapid and aggressive detection, diagnosis, infection control, and treatment measures because this form of scabies is so highly transmissible. Unrecognized crusted scabies often is the source of institutional outbreaks of scabies. Infection control personnel and dermatologists should be involved as soon as scabies is suspected in an institution. An institution-wide information program should be implemented to instruct all management, medical, nursing, and support staff about scabies, the scabies mite, and how scabies is and is not spread. Until successfully treated, patients with crusted scabies should be isolated from other patients who do not have crusted scabies. Assigning a cohort of caretakers to care only for patients with crusted scabies can reduce the potential for further transmission. Direct skin-to-skin contact between a patient with crusted scabies and his/her caretakers and visitors should be eliminated by following strict contact precautions, including the use of protective garments such as gowns, gloves, and shoe covers. The patient's room should be cleaned thoroughly. Bedding and clothing used by a person with scabies should be machine-laundered using the hot water and hot dryer cycles. Persons with crusted scabies generally require treatment at least twice, a week apart. Topical treatment with [MEDICATION NAME] or oral treatment with ivermectin has been used successfully, although ivermectin currently is not FDA-approved for treatment of [REDACTED].cdc.gov/parasites/scabies)