Every finding on record at Lindan Park Care Center

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 (400 Hall) out of 2 hallways reviewed for quality of care.The facility failed to ensure that 1 mechanical lift was locked and secured when not in use on the 400 Hall.This failure could place residents at risk of falls and/or injuries.Findings Included:An observation of the 400 Hall on 08/12/26 at 10:55 AM, revealed 1 unlocked and unsecured mechanical lift parked on the hallway in between 2 resident rooms.An observation of the 400 Hall on 08/12/26 at 11:42 AM, revealed 1 unlocked and unsecured mechanical lift parked on the hallway in between 2 resident rooms.An observation of the 400 Hall on 08/12/26 at 2:23 PM, revealed 1 unlocked and unsecured mechanical lift parked on the hallway in between 2 resident rooms.An observation of the 400 Hall on 08/12/26 at 2:41 PM, revealed CNA B locking both wheels on the unlocked and unsecured mechanical lift parked on the hall between 2 resident rooms.An observation of the 400 Hall on 08/12/26 at 2:42 PM, revealed CNA B speaking with the ADON who provided CNA B with In-Service Training on Mechanical Lift Safety and Storage.An observation of the 400 Hall on 08/12/26 at 2:46 PM, revealed CNA B removing the mechanical lift on the 400 Hall and placing the mechanical lift in an empty room on the 300 Hall.An observation of the 300 Hall on 08/12/26 at 2:55 PM, revealed several mechanical lifts stored in an empty room on the 300 Hall. The mechanical lifts were parked, locked, and secured. Record review of the facility's staff schedule for 08/12/26 revealed CNA A and CNA B were the assigned staff for the 400 Hall.Record review of the facility's In-Service Trainings revealed the following:The DON received mechanical lift training on 02/02/26.The ADON received mechanical lift training on 03/24/26.CNA A received mechanical lift training on 06/22/26.There was no record of CNA B taking any In-Service Trainings on mechanical lifts.During an interview on 08/12/26 at 2:31 PM with CNA B, she stated that she had been employed at the facility for 18 years. CNA B stated that she was assigned to the 400 Hall on 08/12/26. CNA B stated that she was unaware that the mechanical lift parked on the 400 Hall was unlocked and unsecured on 08/12/26. CNA B stated that she had taken In-Service Trainings on mechanical lift safety and storage. CNA B stated that she did not remember when she had previously taken In-Service Trainings on mechanical lift usage, safety, and storage. CNA B stated that mechanical lifts should always be locked and secured when they were not in use; including the hallways. CNA B stated she always checked the mechanical lifts when they were on the hallways. CNA B stated she checked the mechanical lift on the 400 Hall, and the mechanical lift was locked and secured. CNA B stated in the future she would check mechanical lifts when they are parked in the hallways to ensure that they were always locked and secured. CNA B stated that if she observed a staff member store the mechanical lift, she would ask them if they ensured that the parked mechanical lifts were always locked when they were parked. CNA B stated if a mechanical lift was unlocked, there was a risk of the mechanical lift being moved by someone, which could cause the mechanical lift to roll. CNA B stated someone could be harmed by an unlocked mechanical lift, and may fall and receive injuries such as cuts, broken bones, and fractures.During an interview on 08/12/26 at 3:02 PM with the ADON, she stated that she had been employed at the facility for 9 years. LVN B stated that she was the ADON at the facility. The ADON stated that she was unaware that there was 1 mechanical lift parked on the 400 Hall that was unlocked and unsecured during 3 observations on 08/12/26. The ADON stated that she had taken In-Service Trainings on mechanical lift safety and storage. The ADON stated all staff had taken In-Service Training on mechanical lift safety and storage. The ADON stated she could not recall when all staff had previously taken In-Service Trainings on mechanical lift usage and safety. The ADON stated all mechanical lifts in the building were to always be locked and secured when they were not in use. The ADON stated if staff observed an unlocked mechanical lift on a hallway, the staff member should immediately park the mechanical lift and ensure it was in a safe area away from any hazards for residents, staff and visitors. The ADON stated that she would ensure all staff received In-Service Trainings on accidents, hazards and mechanical lift storage and safety. The ADON stated she began to provide In-Service Trainings to the staff on duty and would ensure that all staff were reeducated and retrained. The ADON stated the mechanical lifts were not to be stored on the hallways and should be stored in an empty room on the 300 Hall when not in use. The ADON stated that harm could be caused to anyone including visitors, staff and residents when a mechanical lift was unlocked, which included accidents and falls due to the unlocked and unsecured mechanical lift being moved and rolled. The ADON stated an unlocked and unsecured mechanical lift could tip over if the weight of the mechanical lift was unbalanced, which could potentially cause the mechanical lift to fall. She stated that someone could be harmed by having a serious fall with injuries, such as someone falling on their face and landing on the floor. The ADON stated harm such as fractures, broken bones, fractures and bruises can occur to someone due to a mechanical lift being on the hallway unlocked and unsecured.An attempted telephone call to CNA A on 08/12/26 at 2:34 PM was unsuccessful. A voicemail message was left for CNA A for a call back, but CNA A did not return the call.The Administrator was unable to be interviewed, as advised on 08/12/26 at 1:02 PM, regarding the unlocked and unsecure mechanical lift on the 400 Hall due to being out of the building. Record review of the facility's policy, Hazardous Areas, Devices and Equipment, reviewed December 2024 revealed, Policy Statement:All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. Policy Interpretation and Implementation:As part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident environment will be identified and addressed by the Safety Committee.The Safety Committee will consist of members from the interdisciplinary team, which will include a representative from the clinical, leadership, maintenance, and environmental services teams. Identification of Hazards:A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to:a. Equipment and devices that are left unattended.f. Objects in the hallways that obstruct a clear path. Assessment and Analysis of Hazards:1. Assessment and analysis of hazardous areas and equipment will include resident-specific information including identification of vulnerable residents.2. Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous. Interventions:1. Once identified, the Safety Committee will document recommendations for areas and equipment that can be changed or adapted to lessen the potential for accidents, such as hazardous areas that are not adequately secured or supervised, equipment that is defective, and/or devices that are used improperly due to lack of training.2. Interventions will address the specific hazards identified, and may be facility-specific or resident-specific.3. Facility-specific interventions may include staff training.12. Training on safety and interventions to reduce hazard risks will be ongoing.13. As part of an overall culture of safety, staff, residents and family will be encouraged to report anything that appears to be an environmental hazard or a safety concern. Record review of the facility's policy, Safety and Supervision of Residents, reviewed December 2024 revealed, Policy Statement:Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation and Implementation:.Resident Risks and Environmental HazardsDue to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include:.c. Falls/Accidents;.

Based on observation, interviews, and record review the facility failed to ensure all drugs and biologicals were stored in locked compartments and permit only authorized personnel to have access to the keys for one (medication cart #1) of 6 medication carts reviewed for storage of medications.The facility failed to ensure medication cart #1 was locked while unattended on 06/04/26.This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. Findings included:An observation on 06/04/26 at 8:10 PM revealed medication cart #1 was unlocked and unattended with no staff within eyesight of medication cart #1. All drawers could be opened, and medication and supplies (needles, gauze, ointments, etc.) could be easily accessed. In an observation and interview on 06/04/26 at 8:15 PM, with LVN B she stated medication cart #1 belonged to her. LVN B locked medication cart #1. LVN B said she had allowed MA A to get supplies out of medication cart #1, unaware it was not locked after the supplies were obtained. LVN B said by not locking medication cart #1 residents can get into the cart and have access to medications.In an interview on 06/04/26 at 8:20 PM, MA A returned to medication cart #1 to return the supplies she used. MA A saw medication cart #1 was locked. MA A stated LVN B was right there, as she pointed to a resident's room next to the medication cart. Observed MA A could not see LVN B with the curtain pulled closed. MA A stated she should have locked medication cart #1. MA A stated the worst that could have happened would be a resident taking medication that did not belong to them, getting sick.In an interview on 06/04/26 at 8:25 PM, the DON stated that her expectation was medication cart#1 was always locked unless it was in use. The DON stated that any staff member could lock medication cart #1 if they observed it unlocked. The DON stated the MA A is expected to lock medication cart #1 after getting supplies from it and returning supplies to the cart. DON stated it was important for medication cart #1 to be locked when not in use to not allow access when a nurse is not using medication cart #1.Review of the facility policy titled Storage of Medications dated Reviewed December 2025 reflected: 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on observation, interview, and record review, the facility failed to secure confidential and personal medical records for 22 (Resident #1, Resident #2, Resident #3, Resident #5, Resident #6, Resident #9, Resident #11, Resident #19, Resident # 24, Resident #26, Resident #27, Resident #32, Resident #35, Resident #36, Resident #37, Resident #42, Resident #45, Resident #44, and Resident #47, Resident #49, and Resident #54) of 22 residents reviewed for privacy and confidentiality of records.The facility failed to ensure that the Thickened Liquid List was not accessible to visitors in the Dining Room on 05/04/26 and 05/05/26.The facility failed to ensure that the Red Napkin List was not accessible to visitors in the Dining room [ROOM NUMBER]/04/26 and 05/05/26.The facility failed to ensure that the Shower Log Binder on the counter at the Nurses Station was not accessible to visitors on 05/05/26.The facility failed to ensure that the EBP List for 14 residents (Resident #1, Resident #2, Resident #3, Resident #5, Resident #6, Resident #26, Resident # 27, Resident #32, Resident #36, Resident #37, Resident #42, Resident #47, Resident #49, and Resident #54) on the counter at the Nurses Station was not accessible to visitors on 05/05/26.The facility failed to ensure that 1 resident (Resident #2) Shower Sheet was not accessible on the counter at the Nurses Station on 05/05/26.These failures could place all residents at risk of exposure of their personal and medical information disclosed to unauthorized individuals including visitors and other residents, causing embarrassment, frustration, loss of dignity, decreased privacy and psycho-social well-being.Findings included:During a Dining Observation in the facility's Dining Room on 05/04/26 at 11:00 AM, revealed a posting on the Information Board beside the entrance to the Kitchen. There were 2 pieces of white paper and the first sheet of white paper was labeled as Thickened Liquid List. The second sheet of white paper was labeled, Thickened Liquids, included a subheading labeled, Mildly Thick/NTL and underneath the subheading included 4 residents names [Resident #24, Resident #28, Resident #45, and Resident #44]. The second page labeled, Thickened Liquid, included a second subheading labeled, Moderately Thick/HTL and underneath the subheading include 2 residents names [Resident #35 and Resident #1]. At the bottom of the second sheet of white paper labeled, Thickened Liquids, included a revision date of 04/22/2026.During a Dining Observation in the facility's Dining Room on 05/04/26 at 11:00 AM, revealed a posting on the Information Board beside the entrance to the Kitchen. There were 2 pieces of white paper, and the first sheet of white paper was labeled as Red Napkin Program. The second sheet of white paper was labeled, Red Napkin Program: The Red Napkin Program has been designed for those residents who have been identified as having weight loss. Our goal is to feed/offer those residents who receive a Red Napkin with their meals and ensure they eat at least 75%. Offer them a supplement if <50% of meal consumed. The second sheet of white paper was labeled, Red Napkin Program, included a subheading labeled, Red Napkin List, which included 6 residents names [Resident #1, Resident #9, Resident #11, Resident #19, Resident #37, and Resident #47]. At the bottom of the second sheet of white paper labeled, Red Napkin Program, included a revision date of 04/22/2026.During an interview with the Administrator on 05/04/26 at 2:52 AM, the state surveyor asked her about the 2 postings in the Dining Room labeled, Thickened Liquid List, and Red Napkin Program. The Administrator stated that the 2 postings did not violate the residents HIPPA and Resident Rights because they were posted in the Dining Room and both postings were covered by a white sheet of paper. The Administrator stated the residents room numbers were not visible on the sheet, therefore she felt that no HIPPA violations were present.During an Observation on 05/05/26 at 10:45 AM, the postings for the Thickened Liquid List and Red Napkin Program were posted in the same area as the previous observations in the facility's Dining Room on the Information Board beside the entrance to the kitchen.During an Observation on 05/05/26 at 12:17 PM, there was a Shower Log Binder observed on the counter of the unattended Nurses Station. The Shower Log Binder included a 1 Shower Sheet for 1 resident [Resident #2] and was dated 02/06/2026. The Shower Log Binder also included an EBP List for 14 residents (Resident #1, Resident #2, Resident #3, Resident #5, Resident #6, Resident #26, Resident # 27, Resident #32, Resident #36, Resident #37, Resident #42, Resident #47, Resident #49, and Resident #54).During an Observation on 05/05/26 at 1:55 PM, the postings for the Thickened Liquid List and Red Napkin Program were posted in the same area as the previous observations in the facility's Dining Room on the Information Board beside the entrance to the kitchen.During an interview with the Dietary Manager on 05/05/26 at 2:04 PM, he stated that he had been employed at the facility for 4 months. He stated that he was advised by the Administrator to post the Thickened Liquid List and Red Napkin Program List were posted on the Information Board in the facility's Dining Room. He stated that both lists were revised by him every month. He stated that both lists were a tool for the volunteers and staff to assist the residents on each list with their food intake and ensure that the residents on the lists were receiving their maximum nutritional meals daily. He stated that he did not know that posting both lists on the Information Board with the residents names was a HIPPA violation. He stated that he had only worked at the facility for 4 months and was following the directives that were given to him by Management to revise and place both lists on the Information Board in the facility's Dining Room. The Dietary Manager stated that he could see how the posted information on both lists a violation of HIPPA and Resident Rights after the subject matter was brought to his attention by the state surveyor. The Dietary Manager removed both lists from the Information Board in the facility's Dining Room. He stated that he would speak with the Administrator and inform her that he would not be posting both lists on the Information Board in the facility's Dining Room. He stated that he and his staff have taken In-Service Trainings on HIPPA and ensuring residents medical charts are not visible to anyone who was not supposed to have access to the information. The Dietary Manager stated harm could be caused to a resident with having their medical information posted on the Information Board in common areas such as the Information Board in the facility's Dining Room. He stated that there was potential for residents to feel violated, uncomfortable, and their residents rights were not taken seriously. The Dietary Manager stated harm such as retaliation, dignity and teasing can occur to a resident if their information is viewed by any unauthorized person (s) that viewed any of their health information.During an interview with the ADON on 05/06/26 at 12:19 PM, she stated she had been employed at the facility for 17 years. The ADON stated she observed the state surveyor reviewing the information in the Shower Log on 05/05/26. The ADON stated the DON made the Shower Log for the CNA's to ensure the residents were provided with showers/baths during their scheduled shower/bath days. The ADON stated at the beginning of each shift, the staff are all on the computers and the Shower Log being on the Nurses Station made it easier for the CNA's to look at the Shower Log verses everyone trying to get on the computer at the same time to review different things for each resident. The ADON was advised that inside of the Shower Sheet Log for residents, there was a single sheet of paper for [Resident #2] for 02/06/26. The ADON was advised that there was an EBP List for 14 residents (Resident #1, Resident #2, Resident #3, Resident #5, Resident #6, Resident #26, Resident # 27, Resident #32, Resident #36, Resident #37, Resident #42, Resident #47, Resident #49, and Resident #54) inside the Shower Log on the counter at the Nurses Station was accessible to visitors. The ADON stated that the EBP List should not have been inside of the Shower Log and was incorrectly placed inside of the Shower Log. The ADON stated that the Red Napkin List and Thickened Liquid List were not used by staff. She stated that both lists in the Dining Room were more helpful as a tool for visitors who volunteer to feed the residents. She stated the Red Napkin Program was designed to ensure that meals are enhanced for the residents for their nutritional well-being including weight loss and weight gain. The ADON stated she did not feel there was any harm or risk to residents with their medical information being accessible to visitors in the Dining Room or at the Nurses Station.During an interview with the DON on 05/06/26 at 2:26 PM, she stated she had been employed at the facility for 22 years. The DON stated that she was unaware the state surveyor observed the Thickened Liquid List, and Red Napkin Program List on the Information Board beside the facility's kitchen entrance. The DON stated that the Dietary Manager updated both lists, but she was unsure how often the lists were updated. The DON stated she had observed both lists posted on the Information Board in the facility's Dining Room on several occasions. The DON stated that she did not know that there was any issue of HIPPA violations with both lists being posted in the Dining Room. The DON stated she thought both posted lists did not violate HIPPA because they were covered by a piece of paper and did not include any residents room numbers. The DON was advised that inside of the Shower Sheet Log for residents, there was a single sheet of paper for [Resident #2] for 02/06/26. The DON was advised that there was an EBP List for 14 residents (Resident #1, Resident #2, Resident #3, Resident #5, Resident #6, Resident #26, Resident # 27, Resident #32, Resident #36, Resident #37, Resident #42, Resident #47, Resident #49, and Resident #54) inside the Shower Log on the counter at the Nurses Station was accessible to visitors. The DON stated that the EBP List should not have been included in the Shower Log and an unknown staff member incorrectly placed it inside of the Shower Log. The DON stated that the Shower Log should not be placed on the counter at the Nurses Station and should not be placed anywhere for anyone other than Nursing Staff to have access to the binder. The DON stated it was the responsibility of any nursing staff member who utilized the computer or laptop to access resident information. The DON stated all employees were expected to provide full privacy and confidentiality of all patient information for all residents. The DON stated it was her expectation that residents' health information was to always remain private to prevent HIPPA violations. The DON stated she would begin In-Service Training to all staff on privacy and confidentiality of the residents' information and HIPAA protection for residents. She stated that the facility follows the HIPAA Guidelines in relation to the Health Insurance Portability and Accountability Act of 1966. The DON stated the failure to not protect the resident information may result identity theft due to the medical information being accessible. She stated that there was no potential of harm if someone who was not authorized to view the patient health records gained access to the records.During an interview with the Administrator on 05/06/26 at 2:42 PM, she stated she had been employed at the facility for 22 years. The Administrator stated that she was unaware there was any issue with the Thickened Liquid List, and Red Napkin Program List on the Information Board beside the facility's kitchen entrance relating to HIPPA. The Administrator stated that the Dietary Manager updated both lists from PCC (is a cloud-based electronic health record (EHR) platform specifically designed for the long-term and post-acute care (LTPAC), but she was unsure how often the lists were updated. The Administrator stated she had observed both lists posted on the Information Board in the facility's Dining Room on several occasions and did not think anything was wrong with it. The Administrator stated she thought both posted lists did not violate HIPPA because they were covered by a piece of paper and did not include any residents room numbers. She stated that both lists had been posted on the Information Board for a long period of time. She stated that purpose of the Red Napkin Program was a red napkin was wrapped around the silverware at mealtime, which meant the resident was experiencing weight loss and they were to be fed enhanced food or pasta during their meals. She stated if there was a new staff member employed and he/she were not familiar with the residents, they would go to the Information Board and look at the special instructions for the residents. She stated that the Red Napkin Program, and Thickened Liquid Lists were a safety precaution for the residents and there had not been any visitors observed opening the lists to see what the lists were used for. The Administrator was informed that inside of the Shower Sheet Log for residents, there was a single sheet of paper for [Resident #2] for 02/06/26. The Administrator was advised that there was an EBP List for 14 residents (Resident #1, Resident #2, Resident #3, Resident #5, Resident #6, Resident #26, Resident # 27, Resident #32, Resident #36, Resident #37, Resident #42, Resident #47, Resident #49, and Resident #54) inside the Shower Log on the counter at the Nurses Station was accessible to visitors. The Administrator stated she did not know that the EBP List was included in the Shower Log. The Administrator stated the EBP List should not be included in the Shower Log. The Administrator stated that the Shower Log should not be placed on the counter at the Nurses Station and should not be placed anywhere for anyone other than Nursing Staff to have access to the binder. The Administrator stated there were not any potential harm or risks to residents with their medical information being accessible to visitors or anyone who was not authorized to view them.Record review of the Shower Log Binder at the Nurses Station revealed, Shower Sheet Log for residents, there was a single sheet of paper for [Resident #2] for 02/06/26. The EBP List for 14 residents (Resident #1, Resident #2, Resident #3, Resident #5, Resident #6, Resident #26, Resident # 27, Resident #32, Resident #36, Resident #37, Resident #42, Resident #47, Resident #49, and Resident #54) including their names, rooms and the reason each resident was on EBP.Record review of the facility's In-Service Training records from 02/01/26 to 05/04/26 revealed there were no In-Service Trainings conducted on residents' privacy during this period.Record review of the facility's policy, Resident Rights, revised 01/2022, did not provide any information regarding HIPPA, Protected Health Information (PHI), and/or Safeguarding Electronic Records.Record review of the facility's policy, Safeguarding of Resident Identifiable Information, dated 07/2017 and reviewed and revised 12/1/2025, reflected the following: Policy:It is the facility's policy to implement reasonable and appropriate measures to protect and maintain the safety and confidentiality of the resident's identifiable information and to safeguard against destruction or unauthorized release of information and records.Policy Explanation and Compliance Guidelines:1. A facility may not release information that is resident-identifiable to the public.4. Medical records shall not be left in open areas where unauthorized persons could access identifiable resident information.8. Paper notes or reminders with resident's personal or medical information shall not be left unattended or viewable by unauthorized persons. These paper notes and reminders will be disposed of in a way that will not compromise resident's personal or medical information.Record review of the facility's policy, HIPAA Security Measures, dated 05/09/2009 and reviewed and revised 12/1/2025, reflected the following:Policy:It is the facility's policy to implement reasonable and appropriate measures to protect and maintain the confidentiality, integrity, and availability of the resident's identifiable information and /or records that are in electronic format.Policy Explanation and Compliance Guidelines:1. Facility leadership will ensure the implementation of policies and procedures to prevent, detect, contain, and correct any security violations.a. A risk analysis will be performed, consisting of an accurate and thorough assessment of the potentialrisks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information held by the facility or business associate of the facility.b. Security measures will be implemented to manage risks and vulnerabilities as identified in the risk analysis.c. Appropriate sanctions will be applied against any employee who fails to comply with the facility's security policies and procedures.2. The facility will designate a security official who is responsible for the development and implementation of the facility's security policies and procedures.3. Only appropriate employees will have access to electronic protected health information. These employees will receive appropriate training related to the security of the information for which they have access.4. The facility will implement policies and procedures to address security incidents, including identification and response to suspected or known incidents; mitigation, to the extent practicable, harmful effects of any security incidents; and documentation of security incidents and their outcomes.8. Physical safeguards will be implemented that limit physical access to its electronic information systems and the facility or facilities in which they are housed, while ensuring that properly authorized access is allowed.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety.1. The facility failed to ensure food in the facility's dry storage area and refrigerator areas were labeled and dated according to guidelines.2. The facility failed to seal open items in plastic bags, containers, and boxes in the dry storage pantry, refrigerator, and freezer areas.3. The facility failed to ensure that expired items in the dry storage area were removed.4. The facility failed to ensure that dented cans were removed in the dry pantry area and were separated from the other canned food.5. The facility failed to ensure that the A/C vents in the kitchen's food preparation area were cleaned.These deficient practices could affect residents who received meals and/or snacks from the main kitchen and place them at risk for cross contamination and other food-borne illnesses.Findings Included:An Observation of the kitchen during the brief initial tour of the kitchen on 05/04/26 at 9:04 AM, revealed the following:Kitchen:* 2 A/C Vents above the Food Preparation area were dusty.Dry Pantry area:* 3 packages of 24 oz. red raspberry gelatin mix were not labeled with an expiration date.* 2 packages of 30 oz. instant refried beans were not labeled with an expiration date.* 1 package of 5 lb. cornbread muffin mix was not labeled with an expiration date.* 1 package of 24 oz. peppered gravy mix with an expiration date of 03/16/26.* 1 box labeled Emergency Food included 6 cans of 6 lb. 12 oz. beef ravioli in tomato and meat sauce with an expiration date of 03/17/26.* 4 cans of 1 gallon mayonnaise with an expiration date of 05/01/25.* 1 box of 16 oz. cornstarch was undated and was unsealed and exposed to air.* 1 jar of 4.5 oz cherries with stems were unsealed and exposed to air. * 2 cans of 4.16 lb. tuna light chunk in water were unsealed and exposed to air.* 1 bag of 1 lb. corn chips were unsealed and exposed to air.* 1 plastic container labeled, thickener, was unsealed and exposed to air.* 1 package of hot dogs unsealed and exposed to air.* 1 package of white bread unsealed and exposed to air.* 1 dented can of 6.75 oz. classic con carne with beans.* 1 dented can of 6 lb. diced beets.* 5 cans of 6 lb. 11 oz. crushed pineapples.Refrigerator area:* 1 clear plastic container with a green lid was not labeled and was unsealed and exposed to air.* 1 clear plastic container with a red lid labeled, chocolate fudge topping, was unsealed and exposed to air.* 1 clear plastic container with a green lid labeled, cranberry sauce, was unsealed and exposed to air.* 1 gallon of fat free Italian dressing was unsealed and exposed to air.Freezer area:* 1 box of 10 lb. natural pork sausage patties were unsealed in an unsealed box and exposed to air.* 1 box of pancakes were unsealed in an unsealed box and exposed to air.* 1 box of beef patties were unsealed in an unsealed box and exposed to air.* 1 box of green beans were unsealed in an unsealed box and exposed to air.During an interview with the Dietary Manager on 05/04/26 at 6:14 AM, he stated that he had been employed at the facility for 4 months. The Dietary Manager stated he had a total of 6 staff members in the kitchen, which included 2 staff members per shift. The Dietary Manager was informed about the state surveyors findings during the initial brief tour of the kitchen on 05/04/26, which included dented cans, labeling, expired and unsealed items in the dry storage, refrigerator, and freezer areas. He stated that the items that were found by the state surveyor were overlooked by mistake by himself and all kitchen staff. He stated that he performed weekly checks in the facility's kitchen dry storage, refrigerator, and freezer areas. He stated that the items that were found by the State Surveyor were not found by his staff and himself during their weekly inspections. He stated every day he performed a brief tour of the kitchen's dry storage, refrigerator, and freezer areas. He stated that all staff in the facility's kitchen were responsible for ensuring that the items in the dry storage, refrigerator, and freezer areas in the kitchen are labeled, including the name of the item(s), the date the item(s) were stored and the items(s) use by date. He stated that all items in the facility's dry storage, refrigerator, and freezer areas were to be sealed and closed and expired items, if found were to be immediately thrown in the trash. The Dietary Manager stated all staff are scheduled to ensure items in the kitchen's dry pantry, refrigerator, and freezer areas were not expired, unsealed, including dented cans should be thrown away immediately. He stated after the state surveyor's findings in the kitchen, all staff will be directed to perform an audit of everything in the kitchen to ensure there are not any unopened and expired items in the dry pantry, refrigerator and freezer areas and the dented cans were removed from the facility's kitchen. He stated his expectation was for all kitchen staff to immediately throw away any items that are expired or opened in the kitchen's dry pantry, refrigerator and freezer areas and notify him of what was found and/or thrown away. He stated that if staff were to find dented cans, the dented cans were to be immediately removed from the shelf and placed in the designated area with a white sheet of paper labeled, Dented Cans, which was in his Office. He stated staff had received several in-services relating to food preparation, storage, and labeling and immediately remove any expired items and the removal of dented cans. The Dietary Manager stated all kitchen staff have been reeducated and retrained on Food Storage, Food Safety and Food Preparation via in-service training. He stated that the staff also have been reeducated on using the First In, First Out (an asset management and valuation method where the oldest inventory, stock, or data items are processed, sold, or used first) procedures to ensure there were not any expired food items throughout the dry pantry, refrigerator, and freezer areas facility's kitchen. The Dietary Manager stated he would immediately notify all kitchen staff on all shifts of the findings of the state surveyor's initial brief tour of the kitchen and provide In-Service Trainings on food storage, labeling and ensuring that dented cans were removed from the shelf and placed in the designated area for dented cans. He stated that the In-Service Training beginning on 05/04/26 will include reeducation on removing expired items from the shelf and utilizing the FIFO method. He stated if staff were to find any food items such as expired items, her expectation was they immediately throw away the item(s) and inform him about the item(s) that were thrown away. He stated if any item (s) were not labeled and/or dated, his expectation was for the staff members(s) who found the error to inform him of their findings and all kitchen staff would be reeducated and retrained via in-service training. The Dietary Manager stated all kitchen staff were to ensure items in the kitchen's dry pantry, refrigerator, and freezer areas were not expired, unsealed, labeled, dated, and dented cans should be removed. He stated the kitchen staff were reeducated and retrained through in-service training regularly, which was monthly and/or as needed. The Dietary Manager stated all staff inspect the ceiling and A/C vents in the facility daily. He stated if the A/C vents were dirty or had dust, he would notify the Maintenance Supervisor. He stated he signed the Cleaning Schedule for the A/C vents on 05/04/26. He stated he would immediately notify the Maintenance Supervisor via text message that the A/C vents needed to be cleaned. He stated he would add the maintenance of the A/C vents in the In-Service Training with all kitchen staff for 05/04/26. He stated that he could not recall when the kitchen staff received their previous in-service training on Food Storage was taken. He stated if anyone ate food from the kitchen that was expired, dented cans, and unsealed containers or bags, and dusty A/C vents there was risk of becoming very ill, due to cross-contamination and food-borne illness, which caused stomach aches, vomiting and diarrhea.During an interview with Dietary Aide A on 05/06/26 at 2:01 PM, he stated he had been employed at the facility for 20 years. He stated that he was unaware there were expired and unsealed items in the dry storage, and refrigerator areas on 05/04/26. Dietary Aide A stated he was unaware that dented cans were observed in the facility's dry storage area on 05/04/26. Dietary Aide A stated he was unaware that 2 A/C vents in the kitchen above the food preparation area were observed to be dusty on 05/04/26. Dietary Aide A stated that the Dietary Manager informed the kitchen staff about the state surveyors findings during the initial brief tour of the kitchen on 05/04/26. He stated all the staff were responsible for labeling and storing the items on the shelf and making sure the expiration dates was on everything in the facility's kitchen dry storage, refrigerator, and freezer areas. Dietary Aide A stated dented cans should not be on the same shelf as other cans to prevent food-borne illness. Dietary Aide A stated dented cans were to be immediately removed from the shelf with the other dented cans and placed in the designated area labeled Dented Cans, which was in the Dietary Managers Office. He stated that all kitchen staff received previous education and training from In-Services Trainings from the Dietary Manager. Dietary Aide A stated the in-service trainings on food storage included the FIFO method and making sure the A/C vents were cleaned. Dietary Aide A stated there was a daily Cleaning Schedule posted in the facility's kitchen that had a checklist of items to be audited including the cleaning of all A/C vents in the facility's kitchen. Dietary Aide A stated if he observed food that was expired and/or unsealed, and not labeled in the dry pantry, refrigerator, and/or freezer areas, he would immediately trash the item(s), then immediately notify the Dietary Manager of his findings. Dietary Aide A stated that prior to 05/04/26, the Dietary Manager provided several in-service training courses for all kitchen staff on food storage, handling, preparation, and ensuring the A/C vents were cleaned. He stated all the staff were responsible for labeling and storing the items on the shelf and checking the expiration dates on everything in the dry storage, refrigerator, and freezer areas in the facility's kitchen. He stated if he observed any food item(s) that was expired and/or unsealed, and not labeled in the facility's dry pantry, refrigerator, and/or freezer, he would immediately trash the item (s), then immediately notify the Dietary Manager of his findings. Dietary Aide A stated if someone ingested food from the facility's kitchen dry pantry, refrigerator and freezer areas that were unsealed or expired, from dented cans, and dusty A/C vents, they were at risk of food-borne illness from cross-contamination and could become sick. He stated that any ingestion of food that had been unsealed or expired, or from dented cans, and dusty A/C vents can cause a person to have stomach issues including stomach aches, diarrhea and vomiting.During an interview with the Maintenance Supervisor on 05/06/26 at 3:02 PM, he stated he had been employed at the facility for 6 months. He stated that the Dietary Manager told him on 05/04/26 that the state surveyor observed the 2 A/C vents above the food preparation area in the facility's kitchen needed to be cleaned. He stated on 05/04/26, he cleaned all the A/C vents in the kitchen. He stated that prior to 05/04/26, he last cleaned the A/C vents in the facility's kitchen weekly. He stated that he did not have a cleaning schedule for the cleaning of the A/C vents but would change the A/C filters at the beginning of each month. He stated that the cleaning of the A/C vents included taking them down and washing them off with soap and water. He stated anyone can send a text message to him to request repairs including the kitchen staff. The Maintenance Supervisor stated typically the Dietary Manager will send him a text message, give him a call, or send a text message in the facility's group text message chat and tell him if any repairs were needed. He stated that the risks of residents or anyone eating any food that was prepared underneath A/C vents that were dusty and unclean was the potential for dust particles to fall from the A/C vents counts fall into the food and be ingested. He stated that there was potential for some harm to anyone that ingested any dust that had fallen from the A/C vents, but he was unsure what kind of harm could be caused.Record review of the Kitchen's Cleaning Schedule for January 1, 2026 - May 4, 2026, reflected signatures by kitchen staff for inspecting all racks, ceiling, air vents, and fire extinguishers for dust/debris.Record review of the facility's Maintenance Log for January 1, 2026 - May 4, 2026, reflected no entries for the A/C vents in the facility's kitchen.Record review of facility's policy titled, Food Storage, dated 2023 reflected, Policy:Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination.Procedure: .7. All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods.a. Old stock is always used first (first in - first out method or FIFO). The person designated to manage stock should be trained to rotate it properly.b. Food should be dated as it is placed on the shelves if required by state regulation.c. Date marking should be visible on all high risk food to indicate the date by which a ready-to-eat TCS food should be consumed, sold or discarded.d. Food will be stored and handled to maintain the integrity of the packaging until ready for use. Food stored in bins may be removed from its original packaging.8. Plastic containers with tight fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables and broken lots of bulk foods or opened packages. All containers or storage bags must be legible and accurately labeled and dated.12. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days or discarded as per the 2022 Federal Food Code. (Also see policy on Use of Leftovers later in this chapter.) Check state regulations as some states may allow shorter time frames for the use of leftovers.13. Refrigerated food storage:. f. All foods should be covered, labeled and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their use by dates, or frozen (where applicable) or discarded.g. All foods should be stored to allow air circulation.h. Refrigerated foods should be stored upon delivery and careful rotation procedures should be followed.14. Frozen Foods:a. All freezer units should be kept clean.c. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their use by dates or discarded.d. All foods should be stored to allow adequate air circulation.Record review of the facility's policy titled, Cleaning and Disinfection of Environmental Surfaces, dated December 2025 reflected, Policy Statement:Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and OSHA Blood-borne Pathogens Standard.Policy Interpretation and Implementation:1.Food storage areas shall be clean at all times.2.The dietary manager, or his/her designee, will check refrigerators and freezers at least daily.Record review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

Based on interviews and record reviews, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level 1 residents with mental illness were provided with a PASRR Level 2 evaluation for 1 of 5 residents (Resident #3), reviewed for resident assessment. Resident #3's PASRR Level 1 screening did not reflect mental illness, and the resident did not have a PASRR Level II evaluation. This could place residents at risk of not receiving necessary specialized services to meet their individual needs.The findings were: Record Review of Resident #3s Care Plan dated 05/28/2025, reflected: 03/08/2026: The resident will show decreased episodes of s/s of depression related to diagnosis of Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). 05/28/2025: The resident will maintain the ability to make own decisions independently and establish own goals related to diagnosis of schizoaffective disorder (a rare mental illness that affects how a person thinks, feels, and behaves). Record review of Resident #3's quarterly MDS assessment, dated 04/14/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. BIMS was not indicated. His diagnoses included Schizoaffective Disorder Bipolar Type (a rare mental illness that affects how a person thinks, feels, and behaves that includes bouts of hypomania or mania and sometimes major depression), Unspecified Dementia (diagnosis given when a person has clear signs of dementia, but the exact type hasn't been identified) Hypertension (a condition in which the blood against the artery wall is too high), and Seizures (a sudden burst of electrical activity in the brain). Record review of Resident #3's PASRR Level 1 screening, dated 04/01/2023, reflected the resident did not have a mental illness was checked as no. Resident #3 did not have a PASRR Level II evaluation completed. An interview on 05/06/2026 at 2:30 PM with MDS Coordinator revealed she did not know why Resident #3 had a negative PASRR Level 1 screening. She stated she was responsible for ensuring information is correct and accurate. MDS Coordinator stated the resident was at risk of not getting the proper care needed with a negative PASARR Level 1 screening. An interview on 05/06/2026 at 2:55 PM with the Administrator revealed she did not know why Resident #3 had a negative PASRR Level 1 screening. She said the MDS Coordinator was responsible for checking for accuracy of PASARR Level 1 screenings. Administrator stated the resident was at risk for denied services that could enhance their quality of life. Review of the facility policy, PASRR Requirements Level 1 and Level II Screen Policy and Procedure, dated 03/2022, reflected: 2. Review the Level I screen at least quarterly and assure that it is filed in the medical record and accurately reflects the resident/patient's status. 3. Ensure that the appropriate State-designated agency is contacted for any resident/patient requiring a Level II screen either upon preadmission, annually, or upon learning of an SMI/ID diagnosis which was previously unknown or undetermined.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one (Resident #3) of three residents reviewed for abuse. The facility failed to protect Resident #3 from physical abuse when CNA A force fed her on 03/03/25. The resident suffered psychosocial harm. On 03/20/25 at 1:00 PM, an Immediate Jeopardy (IJ) was identified. The IJ template was provided to the facility on [DATE] at 1:15 PM. While the IJ was removed on 03/20/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of choking, aspiration, serious injury, harm, and death. Findings included: Record review of Resident #3's Annual MDS, dated [DATE], reflected she was a [AGE] year-old admitted to the facility on [DATE]. Her cognitive skills for daily decision making were severely impaired. Her diagnoses included aphasia (lack of ability to comprehend or communicate), stroke, non-Alzheimer's dementia, and dysphagia (difficulty swallowing). She was dependent on staff for eating. Record review of Resident #3's Care Plan, dated 01/07/14, reflected: 1. The resident had a nutritional problem related to hypertension. The resident was on a regular diet, pureed texture, and nectar thick/mildly thick liquids. Sometimes the resident refused to eat or drink supplements. Facility interventions included provide and serve diet as ordered. 2. The resident had a swallowing problem related to dysphagia. Facility interventions included follow prescribed diet, and to keep head of bed elevated 90 degrees during meals. 3. The resident had an ADL self-care performance deficit related to dementia, activity intolerance, and limited mobility. Facility interventions included the resident required total assistance to eat. Record review of CNA A's personnel file and background checks reflected no issues. An observation on 03/03/25 at 11:47 AM of Resident #3 revealed she was being fed by CNA A. The resident was in her room and the door was slightly open. CNA A forcefully pushed the resident's head back by placing her palm on the resident's forehead and pushing the head back. CNA A forced a large spoonful of food in the resident's mouth very quickly while the resident's head was pushed back. The CNA forcefully fed the resident three times very rapidly. The CNA then picked up a glass of fluids and gave the resident a drink. The resident tried to stop drinking. CNA A kept forcing the resident to drink. The resident began coughing and sputtering. The Surveyor intervened and told the CNA to stop and step away from the resident. Another State Surveyor observed the incident. CNA A said she did not do anything wrong. CNA said she was gently lifting the resident by the side of her side of head to get her to eat. She said she was not forcing her to eat and drink. The State Surveyor asked CNA A to go get the DON. An interview on 03/03/25 at 11:55 AM revealed the DON entered the resident's room. He told CNA A to go to his office. CNA A continued to deny the abuse occurred. The DON told CNA A to go to the Human Resources office. CNA A continued to deny the incident. Resident #3 was non-verbal and did not make any movements to indicate she was still in distress. An interview on 03/03/25 at 11:59 AM revealed the Administrator entered the conference room and said Resident #3 would lean forward and that staff had to place a hand on her and lift her head. State Surveyor informed the Administrator that CNA A was abusive, and force fed the resident. The Administrator said she would self-report the incident. An interview on 03/03/25 at 12:15 PM revealed Resident #3 was in her wheelchair, awake, alert, and non-verbal. The resident was smiling and watching TV. The resident did not respond to questions. The resident did not make any movements to indicate she was still in distress. An interview on 03/03/25 at 1:36 PM with the family member of Resident #3 revealed she was very upset. She said that CNA A was the only staff member who was able to get Resident #3 to eat and meet her needs. The family member said the required technique to feed Resident #3 was a little aggressive. The family member said Resident #3 could speak and she wanted to be present for an interview to show the State Surveyor that the resident could say she was not abused by CNA A. An interview on 03/03/25 at 2:20 PM with the DON revealed the facility was able to meet Resident #3's needs without CNA A. The DON said feeding the resident was not an aggressive technique and the only requirement was to gently hold up the resident's head if it dropped down. An observation and interview on 03/04/25 at 12:07 PM with Resident #3 revealed her family member and the Administrator was in the room. Another State Surveyor was present as a witness. The resident spoke a few words to the family member and smiled. The resident was awake and alert. The resident was asked if she remembered eating lunch on 03/03/25 and if she felt CNA A was abusive during the lunch. The resident did not answer. The family member asked the resident if CNA A was mean to her, and the resident said yes. The family member asked the resident if she was mean to the resident and the resident said yes. The resident was asked if the Administrator was mean, and the resident said no. The family member asked the resident if CNA A ever forced her to do anything. The resident became upset and said yeah. The interview was ended, and the resident was thanked for talking to the State Surveyor. An interview on 03/04/25 at 3:56 PM with the Rehabilitation Director revealed Resident #3 did not require any aggressive or special techniques for feeding. She said Resident #3 had poor trunk control and cervical neck issues. The Rehabilitation Doctor said Resident #3 was usually able to keep her head neutral and that if she leaned to the side, the staff could use their fingertips to gently position her head back up and give her a bite. The Rehabilitation Director said the family member rarely came to visit. The Rehabilitation Director said a CNA should never force feed a resident and that there should be nothing aggressive about feeding Resident #3. The Rehabilitation Director said she never saw CNA A feed Resident #3. An observation on 03/04/25 at 4:41 PM revealed Resident #3 was being fed by LVN B. The resident was sitting up in a wheelchair in the dining room. LVN B offered appropriately sized-bites and the resident swallowed well. Resident #3 drank fluids with no issues. LVN B encouraged the resident to hold her head up and she did so without difficulty. LVN B did not use any abusive or aggressive techniques to feed Resident #3. An interview on 03/05/25 at 1:44 PM with the DON revealed he said the charge nurses were responsible for ensuring residents were fed correctly. The DON said the only resident that CNA A fed on 03/03/25 was Resident #3. The DON said he saw CNA A feed residents with no issues. He said he and Administration did random observations to observe CNAs feed residents. He said Resident #3 did not require any special technique to be fed and would droop her head. The DON said it was easily fixed by placing a towel under her neck to help her sit up more. He said that if a resident was forcefully fed; they were at risk for choking and injury. He said Resident #3 was assessed after the incident and did not have any harm. The DON said CNA A was terminated from employment. An interview on 03/05/25 at 3:48 PM with the Administrator revealed CNA A was terminated from employment. Additionally, the facility conducted in-services with staff for abuse. Record review of the facility policy, Abuse, Neglect, and Exploitation, dated January 2012, reflected: Policy It is the policy of this facility to provide protections for the health, welfare and rights of each resident . This was determined to be an IJ on 03/20/25 at 1:00 PM. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 03/20/25 at 1:15 PM. The following Plan of Removal was submitted by the facility and was accepted on 03/20/25 at 3:20 PM and reflected the following: 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 3/3/25) The Administrator or designee immediately ensured the safety and well-being of the residents who alleged abuse by removing the accused staff member, CNA A, from the facility. They were suspended pending investigation. The Administrator or designee immediately initiated abuse investigation into Resident #3's abuse allegation. Physical assessment was completed on Resident #3 to identify any injuries of unknown origin and/or evidence of abuse or neglect. No concerns were identified. Medical Director and resident's Attending Physician were both notified of the issue. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 3/4/25) Disciplinary action was taken with staff member accused of abuse (CNA A was immediately terminated from her position and never returned to the facility). All Federal and State protocols were followed in investigating and reporting the abuse allegation (Facility immediately completed a Self-Report to Health and human Services. Residents with BIMS scores of 8 or higher were interviewed/assessed to identify if they felt safe and if they had ever experienced abuse while living at the facility. Concerns were not identified. All staff received education on facility abuse policies. All staff received education on abuse prevention and reporting. Facility abuse policies and procedures were reviewed with any staff prior to their shift. Staff members were not permitted to work a shift until education had been completed. The Administrator and DON received education from corporate consultant team member on timely and thorough abuse investigations. The regional/corporate/hired consultant team member will visit the facility twice per week to provide oversight, audits, and additional training as needed. The Activities Director held a Resident Council meeting in which the residents were educated on the facility's abuse policies and procedures. The Social Services Director began discussing facility abuse policies with residents and families at the initial care plan conference. The Administrator or designee will continue to interview residents with BIMS scores of 8 or higher on a monthly basis to ensure they have not experienced abuse. The findings of these interviews will be presented to the Quality Assurance/Performance Improvement (QAPI) Committee as a PIP project. Monitoring of the facility's Plan of Removal included the following: Record review of Resident #3's clinical records revealed the resident had been assessed by nursing after the incident on 03/03/25 and did not have any injuries. Record review of the facility in-services revealed all staff were trained. Interviews were conducted on 03/20/25 from 3:26 PM to 4:05 PM with staff from various shifts. The staff included LVN D, CNA E, LVN F, LVN H, CNA I, LVN J, and CNA K. All staff were able to identify: What abuse was and the different types of abuse. The staff understood that a resident could not be force fed. Observations and interviews with residents on 03/20/25 from 2:50 PM to 3:15 PM revealed they felt safe and were not force fed. An interview on 03/20/25 at 4:00 PM with the DON revealed his roles in the facility plan of removal included: Assisting the Administrator with continued training of staff. He said he would be doing monitoring to ensure residents were fed appropriately. He said that all staff were in-serviced on 03/03/25. An interview on 01/05/25 at 4:05 PM with the Administrator revealed he would be making sure in-services and monitoring were completed to prevent abuse from happening again. He said the issues would continue to be discussed in QAPI. The Administrator and DON were informed the Immediate Jeopardy was removed on 03/20/25 at 4:20 PM. On 03/20/25 at 1:00 PM, an IJ was identified. While the IJ was removed on 03/20/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety. 1. The facility failed to ensure food in the facility's dry storage, and refrigerator areas were labeled and dated according to guidelines. 2. The facility failed to seal open items in plastic bags in the dry storage pantry and the refrigerator areas. 3. The facility failed to ensure that expired items in the dry storage pantry and the refrigerator areas were removed. 4. The facility failed to ensure that 1 dented can was removed from the shelf in the dry pantry area. These deficient practices could affect residents who received meals and/or snacks from the main kitchen and place them at risk for cross contamination and other air-borne illnesses. Findings Included: Observation of the kitchen during the brief initial tour of the kitchen on [DATE] at 9:20 AM, revealed the following: Dry storage area contained: *1 dented can of 105 fl. oz. of [NAME] Monte Lite Diced Pears, *1 unsealed bag of 160 fl. oz. [NAME] Noodle, *1 unsealed bag of 21 lb. Sysco Classic Confectioners [NAME] Sugar, *1 bag of 21 lb. Sysco Classic Confectioners [NAME] Sugar with a sticker labeled [DATE] with an expiration date on the package of [DATE], *1 unsealed bag of 32 oz. Sysco Classic Light [NAME] Sugar, *1 package of 15 oz. Lawry's Sloppy [NAME] Seasoning Mix with an expiration date of [DATE], *3 unsealed bags of 11.3 oz. Imperial Turkey Gravy Mix without an expiration date, *2 unsealed bags of Ms. Baird's Wheat Bread, *1 unsealed clear plastic container with a blue lid labeled cornmeal, *1 unsealed clear plastic container with a blue lid labeled flour, Refrigerator area contained: *1 metal pan of unsealed red Jello with 4 puncture marks on the foil without an expiration date, *1 white plate with unsealed plastic wrap labeled Burger Setup, which included 4 pickles, brown lettuce, and sliced tomatoes, *1 unsealed bag of 5 lb. Arrezzio Parmesan Cheese with an expiration date of [DATE], *1 unsealed plastic container with a green lid with 3 packages of unsealed mixed vegetables with a sticker labeled, ,d+[DATE] and use by ,d+[DATE], *1 unsealed plastic container with a green lid with 1 container of pears with a sticker labeled, [DATE] without a use by date, *1 container of caramel with a sticker labeled [DATE] without a use by date, * 1 unsealed package of Driscoll's strawberries, * 4 stacked pans of bacon with unsealed parchment paper cover each pan of bacon dated [DATE] without a use by date, * 3 red juices without sealed lids, *4 orange juices without sealed lids, and *6 cups of tea without sealed lids. In an observation and interview with the Dietary Manager on [DATE] at 10:05 AM, she stated she has been employed at the facility as the Dietary Manager for 1 year. She was shown the items that were found in the dry pantry and refrigerator areas. She stated she would correct everything that was found and would do an in-service training with her staff regarding food storage and labeling and checking for expired items throughout the kitchen including the dry pantry, refrigerator, and freezer areas. She stated all staff were responsible for ensuring items in the kitchen's dry pantry, refrigerator, and freezer areas were not expired and unsealed. She stated staff were to notify her if they find anything in the dry pantry, refrigerator, or freezers areas that was expired, unsealed, and undated. She stated her expectation was for staff to throw away any items that were expired or opened in the kitchen's dry pantry, refrigerator, and freezer areas and notify herself or the Dietician of their findings. She stated that on a daily basis she would check the inventory in the dry pantry, refrigerator, and dry pantry areas to ensure that everything was sealed, labeled, dated, and not expired. She stated that the items found in the dry pantry and refrigerator areas on [DATE] was an oversight and she missed or overlooked the items in both areas of concern. She stated she would throw away all expired items in the kitchen and the unsealed items as well. She stated she and the kitchen staff would do a walkthrough of the dry pantry, refrigerator, and freezer areas to ensure that nothing was overlooked. She stated the kitchen staff have received several in-services relating to food preparation, storage, labeling, and immediately removing expired items. She stated staff have been trained and educated when they were restocking to place the items already on the shelf in the front and the new items behind the items that were already shelved. She stated she would throw away the expired items in the kitchen and retrain and reeducate the staff via in-service trainings . She stated that the risk of residents eating anything from the kitchen that is expired, unsealed items, and dented cans could result in anyone that eats the food from the facility's kitchen can make them sick and they could experience illnesses such as vomiting and diarrhea. In an interview with [NAME] C on [DATE] at 10:40 AM, she stated that she had been employed at the facility for [AGE] years. She stated she was unaware that there were expired and unsealed items in the dry storage, and refrigerator areas. She stated all the staff were responsible for storing the items on the shelf and checking the expiration dates on everything in the kitchen. She stated that the Dietary Manager was responsible for ensuring the items in the dry storage, and refrigerator areas were sealed, labeled, and dated. She stated she had taken in-service trainings on food preparation and storage, and she was unable to provide a timeframe when she had taken her last in-service training. She stated if a staff member sees an item(s) that were expired, the staff member was to throw the item away in the trash can and then inform the Dietary Manager what they threw away. She stated everything in the dry storage, freezer, and refrigerator should be labeled and dated per her in-service trainings. [NAME] A stated if any residents were given food from the kitchen's dry pantry, freezer, and refrigerated that was unsealed or expired, they would ingest food that had been cross-contaminated. She stated that if a resident eats any food that has been cross contaminated, they can become very sick and have a stomachache, vomit, and diarrhea. She stated that with food in the dry pantry, refrigerator, and freezer areas being unsealed and expired, the items could cause anyone who ingested the food to have a foodborne illness and become sick and cause them harm. In an interview with the Dietary Aide on [DATE] at 10:55 AM, he stated that she had been employed at the facility for [AGE] years. He stated that he was unaware that there were expired and unsealed items in the dry storage and refrigerator areas. He stated that all the staff were responsible for storing the items on the shelf and checking the expiration dates on everything in the kitchen. He stated that his expectations for all staff in the kitchen was to use the First In, First Out (FIFO) Method, which means that kitchen staff should label the food with the dates they store them, and when staff were restocking the shelves, they were to put the older foods in front or on top so they could be used first. He stated the Dietary Manager in-serviced staff often on food storage, labeling, and dating and removing expired items from the shelves in the dry pantry, freezer, and refrigerator areas. He stated that there were risks of foodborne illness anytime someone ingested food items from the kitchen, any items that have not been labeled and stored properly. He stated anyone who ingested food that has the potential of foodborne illness can become ill, have a stomachache, and vomit which would cause them pain and discomfort. Record review of the Dietary Supervisor's Job Description revised [DATE], reflected: Reports to: Administrator Position Purpose: Establish and maintain systems and procedures for all food services for the facility, while ensuring requirements for appropriate diets, sanitation and safety levels are met. Plans, organizes, supervises, and directs all administrative and operational activities of the Dietary Department. Essential Functions of the Position: o Oversees .food preparation, services, and storage . Record review of the facility's policy titled Policy & Procedure Manual for Food Storage, dated 2023 reflected, Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored .by methods designed to prevent contamination or cross contamination. Procedure: 7. All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods. a. Old stock is always used first (first in - first out method or FIFO). The person designated to manage stock should be trained to rotate it properly. b. Food should be dated as it is placed on the shelves if required by state regulation. c. Date marking should be visible on all high risk food to indicate the date by which a ready-to-eat TCS food should be consumed, sold or discarded. d. Food will be stored and handled to maintain the integrity of the packaging until ready for use . 8. Plastic containers with tight filling covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables, and broken lots of bulk foods or opened packages. All containers or storage bags must be legible and accurately labeled and dated. 12. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days or discarded as per the 2022 Federal Food Code . 13. Refrigerated food storage: f. All foods should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their use by dates, or frozen (where applicable), or discarded. 14. Frozen Foods: c. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their use by dates or discarded . Record review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S ,d+[DATE].18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts ,d+[DATE] - ,d+[DATE].

Based on observations, interviews, and record review, the facility failed to notify residents or their representatives on how to file a grievance in an anonymous manner for three (Residents #5, #11, #46, #37, #30, and #59) of three residents reviewed for knowledge of how to file a grievance. The facility failed to notify residents or their representatives either individually or through prominent postings throughout the facility on how to file a grievance or complaint in an anonymous manner. These failures could affect 6 of 60 resident's ability to file a grievance without the fear of discrimination, reprisal, retribution, and their right to anonymously file their grievance. Observation on 03/05/25 at 2:45 PM Surveyor attempted to open the frame with many attempts were required. When the frame was opened the 1 grievance printed in small print on blue paper fell out of the frame where the grievances were kept. Interview on 03/04/2025 at 1:30PM with five residents during the confidential Resident Counsel revealed the residents were unaware where grievance forms were located. The residents stated that they did not know how to anonymously file a grievance. Interview on 3/5/25 at 3:00PM with the Activities Director revealed she was unaware of the grievances being kept in the frame hanging on the wall in the hallway around the nursing station. Activities Director was unaware of how to access the grievance forms inside the frame and when she tried to access the frame opening, she had difficulty getting the frame open and the forms fell out when it was opened. Interview with the facility's Administrator on 03/03/25 at 3:50PM revealed there had been no concerns with residents being able to file a grievance as they usually file verbally. Review of the facility's policy titled, Grievances/Complaints, Filing dated March 2017 revealed, The resident and their representatives have the right to file grievances, either orally or in writing to the agency designated to hears grievances (e.g. the State Ombudsman) Review of the Resident's Rights subsection Grievances revealed. The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The facility must make information on how to file a grievance or complaint available to the resident.

Based on interviews and record review, the facility failed to complete a discharge summary that included but was not limited to, (i) A recapitulation of the resident's stay that includes, but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results; (ii) A final summary of the resident's status; (iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter) for two (Resident #58, Resident #59) of two residents reviewed for discharge planning. 1. The facility failed to complete a discharge summary and a reconciliation of medications for Resident #58 for his planned discharge home on [DATE]. 2. The facility failed to complete a discharge summary and a reconciliation of medications for Resident #59 for his planned discharge to the hospital on [DATE]. These failures could place residents at risk of a recapitulation of the stay being unavailable to help ensure continuity of care once they went back home and/or discharged from the facility. Findings included: Record Review of Resident #58's admission face sheet dated 03/05/25 reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Resident #58's active diagnoses included dementia (without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety), hypertension, chronic obstructive pulmonary disease, chronic Stage 4 kidney disease, history of transient ischemic attack (a temporary blockage of blood flow to the brain and cerebral infraction without residual deficits), restlessness, and agitation. Record review of Resident #58's Entry MDS assessment dated [DATE], reflected she was admitted to the facility from a Short-Term General hospital on [DATE]. Record review of Resident #58's admission MDS assessment dated [DATE] reflected a BIMS score was a 13, which indicated she was cognitively intact meaning she was able to recall information immediately, orient herself to time and place, and retain information for a short period. Record review of Resident #58's Discharge MDS assessment dated [DATE], reflected she had a planned discharge home. Record review of Resident #58's Care Plan dated 11/30/2023 reflected, Focus: CANCELLED: I plan on discharging Home. Date Initiated: 12/13/2024 Revision on: 12/18/2024 Cancelled Date: 12/18/2024 Goals: CANCELLED: I will safely discharge home (specify). Date Initiated: 12/13/2024 Revision on: 12/18/2024 Target Date: 12/13/2024 Cancelled Date: 12/18/2024 Interventions/Tasks: CANCELLED: Assure continuity of care with home health. Date Initiated: 12/13/2024 Revision on: 12/18/2024 Cancelled Date: 12/18/2024 o CANCELLED: Assure that all equipment required is available. Date Initiated: 12/13/2024 Record review of Resident #58's Nursing Progress Note dated 12/09/2023 reflected, The resident discharged home via Transport x 2 Transport Drivers at this time. The resident's medications were sent with the resident . Record Review of Resident #59's admission face sheet dated 03/05/25 reflected that he was a [AGE] year-old male initially admitted to the facility on [DATE] with a readmission date of 02/10/25. Resident #59's active diagnoses included dementia (without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety), secondary hypertension, atherosclerotic heart disease (buildup of fats, cholesterol, and other substances in and on the artery walls including the heart), sepsis (a life-threatening medical emergency resulting from the body's extreme response to an infection, potentially leading to organ damage and death if not treated promptly), and cerebral infraction (condition where brain tissue dies due to a blockage or severe restriction of blood flow, depriving brain cells of oxygen and nutrients). The resident was discharged from the facility on to an Acute Care hospital on [DATE]. Record review of Resident #59's Entry MDS assessment dated [DATE], reflected the residents BIMS score was a 1, which indicated he had severe cognitive impairment. Record review of Resident #59's Death MDS assessment dated [DATE], reflected that he passed away at the facility on 02/26/25. Record review of Resident #59's Record of Death Notice dated 02/26/25, reflected he passed away at the facility on 02/26/25 at 6:58 AM. Record review of Resident #59's Care Plan dated 11/30/2023 reflected: Focus: Discharge Planning Date Initiated: 06/11/2023 Revision on: 02/26/2025 Cancelled Date: 02/26/2025 Goal: CANCELLED: Resident Will Attain Their Highest Quality of Life at Discharge. Date Initiated: 06/11/2023 Revision on: 02/26/2025 Target Date: 02/27/2025 Cancelled Date: 02/26/2025 o CANCELLED: Resident Will Be Prepared to Return to Community Upon Discharge. Date Initiated: 06/11/2023 Revision on: 02/26/2025 CANCELLED: CM and interdisciplinary team to determine the next most appropriate setting of care and expected discharge interval. Date Initiated: 06/11/2023 Revision on: 02/26/2025 Cancelled Date: 02/26/2025 o CANCELLED: Coordinate, facilitate and communicate all plans for follow-up and future care needs. Date Initiated: 06/11/2023 Revision on: 02/26/2025 Cancelled Date: 02/26/2025 o CANCELLED: Determine Resident / Representative's goals for discharge. Date Initiated: 06/11/2023 Revision on: 02/26/2025 Interventions/Tasks: Target Date: 02/27/2025 Cancelled Date: 02/26/2025 Cancelled Date: 02/26/2025 o CANCELLED: Identify necessary home modification. Date Initiated: 06/11/2023 Revision on: 02/26/2025 Cancelled Date: 02/26/2025 o CANCELLED: Identify need for home or community resources. Date Initiated: 06/11/2023 Revision on: 02/26/2025 Cancelled Date: 02/26/2025 o CANCELLED: Include Resident / Representative / interdisciplinary team in discharge planning process. Date Initiated: 06/11/2023 Revision on: 02/26/2025 Cancelled Date: 02/26/2025 o CANCELLED: Perform medication reconciliation of all prescribed and nonprescribed Medications. Date Initiated: 06/11/2023 Revision on: 02/26/2025 Cancelled Date: 02/26/2025 o CANCELLED: Prepare and provide Resident with a discharge summary document upon discharge from facility. Date Initiated: 06/11/2023 Revision on: 02/26/2025 Cancelled Date: 02/26/2025 o CANCELLED: Upon admission, evaluate Resident / Representative's desire to return to the community. Date Initiated: 06/11/2023 Revision on: 02/26/2025 Cancelled Date: 02/26/2025 Record review of Resident #58 and Resident #59's Clinical Records reflected no discharge summary and reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter). In an interview with the MDS Nurse on 03/05/25 at 10:04 AM, she stated she could not locate a Discharge Summary for Resident #58 and Resident #59. She reported that the Social Worker was responsible for completing the Discharge Summaries for discharged residents. She stated the facility has hired a new Social Worker, but she has not started working at the facility . In an interview with the DON on 03/05/25 at 11:15 AM, he acknowledged that discharge summaries should be completed for each resident that discharges from the facility. He stated there was not a Discharge Summary for Resident #58 and Resident #59. He stated the facility's Social Worker was responsible for completing the Discharge Summaries for residents. He stated the facility has been without a Social Worker for about 2 months. He stated since the facility has been without a Social Worker, he believed the Discharge Summaries for discharged residents were being completed by the Charge Nurses, who have been doing some of the Discharge Summaries since the Social Worker position has been vacant. The DON stated there was a risk to residents being discharged from the facility without a Discharge Summary. He stated without a Discharge Summary, the discharge residents would not be able to meet with the staff to discuss their reconciliation of medications and their discharge plans such as home health and care responsibilities. He stated if a resident did not have a Discharge Summary, there was potential for there being a gap of follow-up appointments for medical needs. The DON stated if there was not a Discharge Summary for discharged residents, they would miss the opportunity for any continuous care and appointments. In an interview with the previous Social Worker on 03/05/25 at 3:04 PM, she reported she was employed at the facility as the Social Worker from October 2024 - November 2024. She stated on her first day of employment, she was told by the Administrator that she would have to complete the Discharge Summaries for residents who discharged from the facility. She stated she later learned the previous Social Worker did not complete the Discharge Summaries for discharged residents and was advised by the Administrator that she needed to complete the Discharge Summaries that were outstanding including the current Discharge Summaries for discharged residents. She stated there have been several Social Workers employed at the facility throughout the year and the facility has not been completing the Discharge Summaries for discharged residents and expected her to get the facility caught up with their incomplete Discharge Summaries which was a daunting task . In an interview with the Administrator on 03/05/2024 at 3:48 PM, she acknowledged that discharge summaries should be completed for each resident that discharged from the facility. She stated the Social Worker was responsible for completing the Discharge Summaries for residents who discharged from the facility. She stated the facility has not had a Social Worker since the beginning of November. She stated the facility hired a Social Worker, but she had not begun working at the facility. The Administrator stated she was not familiar with the Discharge Planning process and the Discharge Summary because the process was done by the Social Worker. She stated she knew before a resident was discharged from the facility, there was a note done in the PCC . If the resident was discharging home, the staff would speak with the family and a doctor to ensure the resident was being sent home with some instructions regarding the care that would be needed at home. She stated different Nursing Staff Managers have been assigned to the task of ensuring the Discharge Summaries for discharging or discharged residents had been completed. She stated there was not anyone overseeing that Nursing Staff Managers to ensure the Discharge Summaries were being completed. She stated she felt the staff at the facility did their due diligence when a resident was being discharged home, and the staff would write a detailed progress note in their file on PCC. She stated that families, including the residents (if they are alert and oriented) were talked to before they were discharged home to ensure that follow-up appointments would be done. She stated she felt the facility had done good with safe discharges for residents. The Administrator stated she did not know if there was any risk or harm that can be caused to a resident if they were discharged home without a Discharge Summary. Record review of the Social Worker Job Description dated 11/11/24 revealed, Reports to: Social Services Director, Administrator Classification: Position Purpose: Provide support to residents and their families in coping with placement in a long-term care facility. Be the understanding, helpful and caring person they turn to at this difficult time. Perform assessment at admission; update as needed. Essential Functions of Position: *Work with the resident, family, and other team members to plan discharge. Record review of the facility's policy titled, Discharge Summary and Plan, reviewed December 2024, reflected, Policy Statement: When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. Policy Interpretation and Implementation 1. When the facility anticipates a resident's discharge to a private residence, another nursing care facility (i.e., skilled, intermediate care, ICF/IID, etc.), a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment. 2. The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's: a. Current diagnosis; b. Medical history (including any history of mental disorders and intellectual disabilities); c. Course of illness, treatment and/or therapy since entering the facility; d. Current laboratory, radiology, consultation, and diagnostic test results; Physical and mental functional status; f. Ability to perform activities of daily living including: (1) bathing, dressing and grooming, transferring and ambulating, toilet use, eating, and using speech, language, and other communication systems; (2) the need for staff assistance and assistive devices or equipment to maintain or improve functional abilities; and (3) the ability to form relationships, make decisions including healthcare decisions, and participate (to the extent physically able) in the day-to-day activities of the facility. g. Sensory and physical impairments (neurological, or muscular deficits; for example, a decrease in vision and hearing, paralysis, and bladder incontinence); - h. Nutritional status and requirements: (1) weight and height; (2) nutritional intake; and (3) eating habits, preferences, and dietary restrictions. i. Special treatments or procedures (treatments and procedures that are not part of basic services provided); j. Mental and psychosocial status (ability to deal with life, interpersonal relationships and goals, make health care decisions, and indicators of resident behavior and mood); k. Discharge potential (the expectation of discharging the resident from the facility within the next three months); I. Dental condition (the condition of the teeth, gums, and other structures of the oral cavity that may affect a resident's nutritional status, communications abilities, quality of life, and the need for and use of dentures or other dental appliances); m. Activities potential (the ability and desire to take part in activity pursuits which maintain or improve physical, mental, and psychosocial well-being); n. Rehabilitation potential (the ability to improve independence in functional status through restorative care programs); o. Cognitive status (the ability to problem solve, decide, remember, and be aware of and respond to safety hazards); and p. Medication therapy (all prescription and over-the-counter medications taken by the resident including dosage, frequency of administration, and recognition of significant side effects that would be most likely to occur in the resident). 3. As part of the discharge summary, the nurse will reconcile all pre-discharge medication with the resident's post-discharge medications. The medication reconciliation will be documented. 4. Every resident will be evaluated for his or her discharge needs and will have an individualized post discharge plan. 5. The post-discharge plan will be developed by the Care Planning Interdisciplinary Team with the assistance of the resident and his or her family and will include: a. Where the individual plans to reside; b. Arrangements that have been made for follow-up care and services; c. A description of the resident's stated discharge goals; d. The degree of caregiver/support person availability, capacity and capability to perform required care; e. How the IDT will support the resident or representative in the transition to post-discharge care; f. What factors may make the resident vulnerable to preventable readmission; and g. How those factors will be addressed. 6. The discharge plan will be re-evaluated based on changes in the resident's condition or needs prior to discharge. 7. The resident/representative will be involved in the post-discharge planning process and informed of the final post-discharge plan. 8. Residents will be asked about their interest in returning to the community. If the resident indicates an interest in returning to the community, he or she will be referred to local agencies and support services that can assist in accommodating the resident's post-discharge preferences. 9. If it is determined that returning to the community is not feasible, it will be documented why this is the case and who made the determination. 10. Residents transferring to another skilled nursing facility or who are discharged to a home health agency, long-term care hospital or inpatient rehabilitation facility will be assisted in selecting a post-acute care provider that is relevant and applicable to the resident's goals of care and treatment preferences. Data used in helping the resident select an appropriate facility includes the receiving facility's: a. standardized patient assessment data; b, quality measure data; and c. data on resource use. 11. The resident or representative (sponsor) should provide the facility with a minimum of a seventy -two (72) hour notice of a discharge to assure that an adequate discharge evaluation and post-discharge plan can be developed. 12. A member of the IDT will review the final post-discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place. 13. A copy of the following will be provided to the resident and receiving facility and a copy will be filed in the resident's medical records: a. An evaluation of the resident's discharge needs; .

Based on interviews and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review for one (Resident #29) of five residents reviewed for PASARR services. The facility failed to ensure Resident #29 was properly screened for PASARR services This failure could place residents at risk of not receiving specialized PASARR services which would enhance their highest level of functioning and could contribute to residents decline in physical, mental, and psychosocial well-being. Findings included: Record review of Resident #29's quarterly MDS Assessment, dated 02/17/25, revealed she was an [AGE] year-old-female admitted to the facility on [DATE] with diagnoses including depression, schizophrenia, and post-traumatic disorder. Resident #29's BIMs score of 3 indicated the resident's cognition was severely impaired. Record review of Resident #29's PASARR Level I screening, dated 04/01/23, reflected the resident did not have a history of mental illness. Record review of Resident #29's Care Plans, dated 03/26/23, reflected: The resident had an ADL self-care performance deficit related to dementia, PTSD, and Schizophrenia. Facility interventions included assist resident with ADLs. An observation on 03/03/25 at 10:43 AM with Resident #29 revealed she was awake, alert, and confused. An interview on 03/05/25 at 10:02 AM with the MDS Nurse revealed she was responsible for entering PASARR information. She said she did not double-check the PL-1 for Resident #29 for accuracy. She said she received the PL-1 for Resident #29 from another facility and documented the information as it was. The MDS Nurse said the resident did not receive an evaluation or PL-2 screening. The MDS Nurse said that no one oversaw her work. She said the resident was at risk of not receiving PASARR services if her PL-1 was incorrect. An interview on 03/05/25 at 1:42 PM with the DON revealed Resident #29 admitted with a negative PL-1. He said the MDS Nurse was responsible for PASARR screenings. He said he did not know if there was a process in place to double check PL-1's. He said the resident was at risk to miss out on PASARR services if her PL-1 was incorrect. Record review of the facility policy and procedure, PASRR Requirements Level I & Level II, not dated, reflected: Preadmission screening will be conducted prior to admission as the PASRR process is a federally mandated pre-admission screening program (see 42 CFR S 483.100) required to be performed on all individuals prior to admission to a Nursing Home. The screening is reviewed by Admissions for suspicion of serious mental illness & intellectual disability to ensure appropriate placement in the least restrictive environment and to identify the need to provide applicants with needed specialized services. PASRR screening applies to all new admissions into a Medicaid certified nursing facility & includes private pay, Medicare, & Medicaid admissions regardless of payer source.

Based on observations, record reviews, and interviews the facility failed to post required postings with the required contact information for the public, residents and family. The facility failed to post required notification to residents or their representatives through prominent postings throughout the facility on how to contact someone to file a complaint. This failure could place 60 of 60 residents at risk for physical and verbal abuse, which could result in decreased self-esteem, reduced quality of life, injury, or decline in condition. Findings included: Observation on 03/05/2025 throughout 10:00AM-3:00PM, revealed the required Adult protective services posting was missing. Interview with the Administrator on 03/05/25 at 3:50PM revealed she confirmed the posting was not posted. The Administrator revealed she is responsible for ensuring the required postings are posted. Facility Surveyor/Liaison emailed the Administrator with a link to order the required posting. The Administrator said she made a sign and posted on the wall

Based on observations, interviews, and record review, the facility failed to notify the resident's physician consistent with his or her authority, when there was a change in condition for 1 of 1 resident (Resident #1) reviewed for notification of changes. The facility failed to promptly notify Resident #1's physician when a change in condition was discovered by RN A (Registered Nurse) on Resident #1 on 1/26/2025 at 5:16 AM. The physician was not notified of the change in condition by RN A (Registered Nurse). This deficient practice could place residents at risk of not having their physician informed when there was a change in condition resulting in a delay in medical intervention and decline in health. Findings included: Record review of Resident #1's Care Plan, dated 01/30/25, revealed that the resident was a [AGE] year-old male. He was admitted to the facility on [DATE]. Diagnoses of lack of coordination, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, heart failure, secondary hypertension, type 2 diabetes mellitus with other diabetic arthropathy, hyperlipidemia, chronic kidney disease, pneumonia, chronic pulmonary disease. Record review of Resident #1's Annual MDS (Minimum data set) Assessment, dated 01/09/2025, reflected Resident #1 had a BIMS (Brief Interview for Mental Status Test) score of 10 (Moderate Cognitive Impairment). Resident #1 was assessed to require assistance with ADLs (Activities of Daily Living) including the following: transfers, personal hygiene, showers, and dressing. Resident was oxygen dependent due to suffering from Chronic Obstructive Pulmonary Disease (COPD). Record review of Resident #1's electronic medical records reflected Resident #1 had a progress note on 1/26/2025 that was entered by RN (Registered Nurse) A at 5:16 AM. The progress note stated that resident #1's o2 (Oxygen) was low 77%. The resident was repositioned and provided Albuterol Sulfate Inhalation Nebulization Solution (breathing treatment). After the breathing treatment the residents o2 (Oxygen) was checked again at 5:23 AM. The o2 (Oxygen) had increased to 83-85%. The resident did not complain of pain. The resident was to be monitored. RN B (Registered Nurse) was made aware. Record review of Resident #1's electronic medical records reflected Resident #1 had o2 (Oxygen) checked on 1/26/2025 that was entered by RN B (Registered Nurse) at 8:19 AM. The progress note stated that resident #1's o2 (Oxygen) was 90%. Record review of Resident #1's electronic medical records reflected Resident #1 had 02 (Oxygen) checked on 1/27/2025 that was entered by RN C (Registered Nurse) at 3:08 AM. The progress note stated that resident #1's o2 (Oxygen) was 88%. The resident was being sent to the hospital related to respiratory distress. The resident's pulse was checked to be beating at 55 bpm (Beats Per Minute). The physician, responsible party, and VA (Veterans Affair) Nurse was promptly notified by RN C (Registered Nurse) when the resident was transferred to the hospital. Interview on 1/30/2025 at 10:30 AM with RN A (Registered Nurse) revealed that RN A (Registered Nurse) did not follow the facility policy by notifying the physician of a change in condition. He stated that he came into the resident's room at the start of his shift around 10 PM on 1/25/25. The resident was doing fine and his o2 (Oxygen) levels were at 91%. Later, he checked the resident before shift change and discovered that the o2 (Oxygen) levels had dropped to 77%. He stated that the resident was laying on his side with his bed a little elevated. RN A (Registered Nurse) reposition the resident and performed a breathing treatment which raised his o2 (Oxygen) levels back to 85%. He stated that this resident usually has an o2 (Oxygen) level of around 85% when he is sleeping. He stated that he later checked his o2 (Oxygen) again with RN B (Registered Nurse) and the o2 (Oxygen) level was 90%. The patient was talking and acting normal. There was no concern. He stated that he didn't see any respiratory issue because his breathing was normal. It wasn't fast or labored. Interview on 1/30/2025 at 11:30 AM with Physician D revealed that RN A (Registered Nurse) did not follow the facility policy by notifying the physician of a change in condition. He stated that the facility did not notify him of the residents o2 (Oxygen) dropping to 77%. He stated that the resident was not in the best of health. The resident suffered from Chronic Obstructive Pulmonary Disease (COPD) and heart issues. He stated that if he had known that the resident's oxygen had dropped to 77%, he would have recommended the facility to perform a breathing treatment. If the resident responded well to the breathing treatment, then he would have kept him in the facility to be monitored. He stated that if a patient was having o2 (Oxygen) levels at 77 then he should have been notified either way. Record Review of the Facility Change in a Resident's Condition or Status dated December 2024 states that when a change in a resident's condition or status occurs the facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). 1) The nurse will notify the residents Attending Physician or physician on call when there has been a(an): A. Accident or incident involving the resident; B. Discovery of injuries of an unknown source; C. Adverse reaction to medication; D. Significant change in the resident's physical/emotional/mental condition; E. Need to alter the resident's medical treatment significantly; F. Refusal of treatment or medications two (2) or more consecutive times); G. Need to transfer the resident to a hospital/treatment center; H. Discharge without proper medical authority; and/or I. Specific instruction to notify the Physician of changes in the resident's condition. 2) A significant change of condition is a major decline or improvement in the resident's status that: A. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting)

Based on observations, interviews, and record review, the facility failed to notify the resident's physician and responsible party consistent with his or her authority, when there was an injury of unknown origin for 1 of 1 resident (Resident #1) reviewed for notification of changes. The facility failed to promptly notify Resident #1's physician, and Resident #1's responsible party when an injury of unknown origin was discovered on Resident #1. The physician and responsible party were not made aware of the injury of unknown origin until Resident #1 was admitted to the hospital for unrelated treatment. This deficient practice could place residents at risk of not having their physician or responsible party informed when there was a change in condition resulting in a delay in medical intervention and decline in health. Findings included: Record review of Resident #1's Care Plan, dated 01/03/25, revealed that the resident was a [AGE] year-old female. She was admitted to the facility on [DATE]. Diagnoses of dementia, diabetes, schizophrenia, depression, secondary hypertension, poor impulse control, impaired visual function, impaired communication problem, impaired decision-making, short-term memory loss, asthma, and poor nutrition. Resident #1 had behaviors that included rubbing inner thigh, hitting, and kicking. Record review of Resident #1's Annual MDS Assessment, dated 04/3/2024, reflected Resident #1 had a BIMS (Brief Interview for Mental Status Test) score of 3 (Severe Cognitive Impairment). Resident #1 was assessed to require assistance with ADLs including the following: transfers, personal hygiene, showers, and dressing. Record review of Resident #1's electronic medical records reflected Resident #1 had a progress note on 12/31/2024 that was entered by LVN A. The progress note stated that there was a large area of purplish-blue discolorations on bilateral inner thigh seen during ADL care. The resident could not explain how she received the discoloration. There was no open area. The ADON was made aware. Interview on 1/03/2025 at 9:40 AM with Director of Nursing B revealed that LVN A did not follow the facility policy by notifying the responsible party, physician, administrator, director of nursing of the injury of unknown origin. He stated that if he had been notified when the injury of unknown origin was discovered on 12/31/2024, he would have made sure that all notifications were made. LVN A was no longer an employee at the facility. The facility performed an in-service training on who to report and notify to if an injury of unknown origin was discovered and an abuse/neglect training. In an interview on 1/03/2025 at 11:00 AM, Administrator D stated that she was not notified of Resident #1 being found with an injury of unknown origin in a timely manner. She stated that she did not find out about the injury of unknown origin that occurred on 12/31/2024 until 1/02/2025, when she returned from the holiday. Her expectation was for a nurse to assess a resident anytime a resident was found to have an injury of unknown origin and notify the administrator, director of nursing, physician, and responsible party of the resident with an injury of unknown origin. The injury of unknown origin should have been reported to the physician by LVN A after she assessed Resident #1 and discovered the inner thigh bruising. She stated that the facility has a policy in place for these situations and that LVN A failed to follow the policy. LVN A has been terminated and the facility has performed in-services on abuse, neglect, and reporting. Interview on 1/03/2025 at 12:30 PM with Assistant Director of Nursing C revealed that ADON C was made aware of the injury of unknown origin on 12/31/2024. Assistant Director of Nursing was working at the facility with LVN A when the injury of unknown origin was discovered on 12/31/2024. ADON C assessed Resident #1 with LVN A at the end of her shift before leaving the facility on 12/31/2024. She stated that there was a skin assessment that was performed earlier in the day and there was nothing notable on the skin assessment. When she saw the resident herself, she did not see anything that was a woah moment, but she did see a small discoloration. It was her understanding that LVN A was going to log the incident and notify the administrator, director of nursing, physician, and responsible party of the injury of unknown origin. ADON C stated that she had a conversation with LVN A before she left and stated that LVN A understood that it was her responsibility to document the injury of unknown origin. She stated that she did not notify the physician, responsible party, or report the injury of unknown origin herself because she thought that LVN A was going to do it. Interview on 1/03/2025 at 1:50 PM with Physician G revealed that the facility did not notify the physician of the injury of unknown origin on Resident #1's inner thigh that was discovered on 12/31/2024. The physician stated that he was already in the process of treating her for the redness that had occurred on her right eye on 12/18/2024. He stated that he believed the redness was a result of a hemorrhage to one of the eye vessels. The blood eventually pooled over time and presented itself as a bruise. He stated that resident #1 is likely to bruise easily as a result of being on blood thinners. He also stated that since this resident was someone who could easily bruise an injury of unknown origin could occur to her inner thigh during repositioning, changing, transferring, or the resident pushing down on her thigh with her hands. The resident has a behavior of pushing down on her thigh with her hands. He stated that he never saw the bruising on Resident #1's inner thigh. The facility did notify Physician G about the resident being sent to the hospital on 1/01/2025. He stated that he was at the facility when Resident #1 was discharged to the hospital. Interview on 1/03/2025 at 2:00 PM with Responsible Party #1 revealed that the facility did not notify Responsible Party #1 of the injury of unknown origin. Responsible Party #1 was made aware of the injury of unknown origin by the Responsible Party #2. The facility did notify Responsible Party #1 about the resident being sent to the hospital on 1/01/2025 for labored breathing. Interview on 1/03/2025 at 2:30 PM with Responsible Party #2 revealed that the facility did not notify Responsible Party #2 of the injury of unknown origin. Responsible Party #2 was made aware of the injury of unknown origin by the hospital staff during her visit to see Resident #1 at the hospital. The facility did notify Responsible Party #2 about the resident being sent to the hospital on 1/01/2025 for labored breathing. Record Review of the Facility Abuse & Neglect Reporting Policy dated December 2024 states that when an injury of unknown origin occurs the facility staff will identify the staff member responsible for the initial reporting, investigation of alleged violations & reporting abuse, & to determine the direction of the investigation. Facility will be in compliance with Federal regulations and State specific reporting requirements. An immediate report will be filed with the Department of Health and Human Services for alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

Based on interviews and record review the facility failed to report abuse, neglect, exploitation, or critical incidents for 1 of 1 resident (Resident #1) reviewed for reporting. The facility failed to report an injury of unknown origin in a timely manner, that was discovered on 12/31/2024, to HHSC. The facility reported the injury of unknown origin on 1/02/2025. This failure could place clients at risk for abuse, neglect, and incidents. Findings included: Record review of Resident #1's Care Plan, dated 01/03/25, revealed that the resident was a [AGE] year-old female. She was admitted to the facility on [DATE]. Diagnoses of dementia, diabetes, schizophrenia, depression, secondary hypertension, poor impulse control, impaired visual function, impaired communication problem, impaired decision-making, short-term memory loss, asthma, and poor nutrition. Resident #1 had behaviors that included rubbing inner thigh, hitting, and kicking. Record review of Resident #1's Annual MDS Assessment, dated 04/3/2024, reflected Resident #1 had a BIMS (Brief Interview for Mental Status Test) score of 3 (Severe Cognitive Impairment). Resident #1 was assessed to require assistance with ADLs including the following: transfers, personal hygiene, showers, and dressing. Record review on 01/03/25 of TULIP revealed that the facility did not report the injury of unknown origin in a timely manner. The facility was required to report the incident within 24 hours of discovering the incident. The facility failed to do so by reporting the incident on 1/02/2025. Record review of Resident #1's electronic medical records reflected Resident #1 had a progress note on 12/31/2024 that was entered by LVN A. The progress note stated that there was a large area of purplish-blue discolorations on bilateral inner thigh seen during ADL care. The resident could not explain how she received the discoloration. There was no open area. The ADON was made aware. Interview on 1/03/2025 at 9:40 AM with Director of Nursing B revealed that the report was submitted to the Texas Health and Human Services on 1/02/2025. DON B stated that the report was submitted late because the nurse that was working during the holiday schedule did not follow the facility policy by reporting the injury of unknown origin to the responsible party, physician, administrator, director of nursing, and the Texas Health and Human Services. He stated that if he had been notified when the injury of unknown origin was discovered on 12/31/2024, he would have made sure that all notifications were made. LVN A was no longer an employee at the facility. The facility performed an in-service training on who to report and notify to if an injury of unknown origin was discovered and an abuse/neglect training. In an interview on 1/03/2025 at 11:00 AM, Administrator D stated that she was not notified of Resident #1 being found with an injury of unknown origin in a timely manner. She stated that she did not find out about the injury of unknown origin that occurred on 12/31/2024 until 1/02/2025, when she returned from the holiday. Her expectation was for a nurse to assess a resident anytime a resident was found to have an injury of unknown origin and notify the administrator, director of nursing, physician, and responsible party of the resident with an injury of unknown origin. The injury of unknown origin should have been reported to the state by LVN A after she assessed Resident #1 and discovered the inner thigh bruising. She stated that the facility has a policy in place for these situations and that LVN A failed to follow the policy. LVN A has been terminated and the facility has performed in-services on abuse, neglect, and reporting. Interview on 1/03/2025 at 12:30 PM with Assistant Director of Nursing C revealed that ADON C was made aware of the injury of unknown origin on 12/31/2024. Assistant Director of Nursing was working at the facility with LVN A when the injury of unknown origin was discovered on 12/31/2024. ADON C assessed Resident #1 with LVN A at the end of her shift before leaving the facility on 12/31/2024. She stated that there was a skin assessment that was performed earlier in the day and there was nothing notable on the skin assessment. When she saw the resident herself, she did not see anything that was a woah moment, but she did see a small discoloration. It was her understanding that LVN A was going to log the incident and notify the administrator, director of nursing, physician, and responsible party of the injury of unknown origin. ADON C stated that she had a conversation with LVN A before she left and stated that LVN A understood that it was her responsibility to document the injury of unknown origin. She stated that she did not notify or report the injury of unknown origin herself because she thought that LVN A was going to do it. Record Review of the Facility Abuse & Neglect Reporting Policy dated December 2024 states that when an injury of unknown origin occurs the facility staff will identify the staff member responsible for the initial reporting, investigation of alleged violations & reporting abuse, & to determine the direction of the investigation. Facility will be in compliance with Federal regulations and State specific reporting requirements. An immediate report will be filed with the Department of Health and Human Services for alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #1) of 6 residents reviewed for accuracy of medical records. The facility failed to ensure Resident #1's Care Plan did not include an inaccurate diagnosis of Parkinsonism. This failure could place residents at risk for medication and /or treatment errors and omissions in care. Findings included: Record review of Resident #1's face sheet, dated 12/19/24, reflected a [AGE] year-old male, with an admitted [DATE]. Resident #1 had a diagnosis of Multiple Sclerosis (Chronic disease that affects the central nervous system), Major Depressive Disorder (mental illness that can affect the way a person thinks, feels, and functions), Elevated [NAME] Blood Cell Count, Bipolar Disorder (Mental illness that causes extreme shifts in mood, energy, activity, and concentration), Other Frontotemporal Neurocognitive Disorder (Progressive brain disease), Other Lack of Coordination, and Personal History of Traumatic Brain Injury. There was no diagnosis of Parkinsonism on the face sheet. Record review of Resident #1's MDS asssessments dated 07/05/24, 07/20/24, and 09/15/24 did not reflect any diagnosis of Parkinson's Disease or Parkinsonism. Record review of Resident #1's care plan, with an initial date of 06/28/24, reflected an updated, dated 07/24/24, reflected the following: I have limited physical mobility r/t Parkinsonism Disease Process Date Initiated: 07/24/2024 Revision on: 07/24/2024 In an interview on 12/19/24 at 12:32 PM, the DON stated Resident #1 did not have Parkinson's Disease. He stated he was not sure why his care plan noted Parkinsonism. The DON stated he would correct the care plan. He stated the Director of Therapy must have added that to the care plan. The DON stated the MDS nurse was responsible for reviewing the care plan for accuracy before it was put into effect. The DON stated the risk of inaccurate information on the care plan was the resident could get incorrect care based on the plan. In an interview on 12/19/24 at 1:20 PM, the Director of Therapy stated the DON showed her Parkinsonism was noted on Resident #1' care plan, but it was in an area that she would not complete. The Director of Therapy stated the MDS nurse was the one that would usually fill in that area of the care plan. In an interview on 12/19/24 at 1:26 PM, the MDS Nurse stated she did not know how Parkinsonism got on Resident #1's care plan. The MDS Nurse stated she did not see where Resident #1 had a current diagnosis of Parkinsonism, but stated she would go review his file to see if it was ever listed anywhere in the past. In an interview on 12/19/24 at 1:35 PM, Resident #1's Nurse Practitioner stated Resident #1 did not have a diagnosis of Parkinsonism listed on his chart. She stated she did not recall Resident #1 ever having a diagnosis of Parkinsonism. In a follow-up interview on 12/19/24 at 1:57 PM, the MDS Nurse stated she reviewed Resident #1's hospital paperwork and other documents he admitted to the facility with, and she did not see any diagnosis of Parkinsonism. The MDS Nurse stated so far, she was not able to determine who added Parkinsonism to Resident #1's care plan. The MDS Nurse stated the risk of incorrect information on the care plan was inaccurate treatment for the resident. In an interview on 12/19/24 at 2:37 PM, the Administrator stated staff had been messing up on care plans for a long time now. She stated she would try to figure out who made the mistake and correct it. The Administrator stated the risk of inaccurate information on a resident's care plan was a financial issue from the administrator standpoint, and for clinical, the resident could possibly receive the wrong medication. Record review of the facility's policy titled, Charting and Documentation, dated 12/2023, reflected the following: Policy Statement All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure nonfood-contact surfaces were kept free of dust and other debris. These failures could place residents, who received food from the kitchen, at risk for food contamination and food-borne illness. Findings included: An observation and interview with the Dietary Manager on 02/06/2024 at 9:30 AM revealed a vent over the plate warmer and food prep area. The vent grate displayed a build up of dust and fluttering fuzz. The Dietary Manager stated Maintenance cleaned the vents. She said dust could dislodge and contaminate the food in prep area. A utensil rack over the food prep area was observed with dust and fuzz. The vent over the rear exit to the kitchen was observed with dust and fuzz. Dust and grease were observed on electric plugs near the stove. Five fire sprinklers in the kitchen were observed with dust, grease and fuzz build up. The light cover in the dry food storage pantry was observed with dead bugs inside the cover. The Dietary Manager stated each area of concern could cause possible food contamination. Interviewed the with Maintenance Director on 02/07/2024 at 8:36 AM. He stated he had logbooks at the nurses station where staff enters requests. The log was reviewed from 1/31/24-present and there was no note on kitchen cleaning. He stated he checked the log daily and addresses concerns, and if someone asks him to do something he asks them to log it. He stated the vents in the kitchen were to be cleaned by the kitchen staff. He did not know who was responsible for cleaning the sprinkler heads and he thought the kitchen should be responsible for cleaning the sprinkler heads. Observed and interviewed with the Dietary Manager on 02/07/2024 at 2:50 PM revealed that areas of concern were cleaned. She stated the Maintenance Director cleaned the vents and even though she was not responsible, she wiped the fire sprinklers. She provided the kitchen cleaning schedule and this surveyor observed that the plugs were not included on the schedule. She stated she doesn't have a schedule for the vents, but maintenance should have a schedule. She stated maintenance cleans the vents once a week. Interviewed with the Maintenance Director on 02/07/2024 at 2:55 PM, he stated he cleaned the filters and vents in the kitchen every week. He doesn't keep a written schedule or log for cleaning the vents. He cleaned the vents in the kitchen after the concern was expressed to the Dietary Manager. Interviewed with the Dietitian on 02/07/2024 at 3:02 PM reveled she didn't know if there is a log for cleaning the vents. She doesn't know if the vents are cleaned at the beginning of the week or the end of the week. Her expectation is that the vents are cleaned because they could cause contamination. Interviewed with the Administrator on 02/07/2024 at 3:15 PM revealed the vents should be cleaned weekly or when needed. No one has ever brought to her attention that the vents were dirty. She doesn't know if there is a cleaning schedule for cleaning the vents. There is a log that any department head can put concerns in that they want maintenance to take care of and the logs are looked at daily. Record review of Food and Drug Administration Food Code dated 2017 section 4-601.11 revealed, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils revealed (C) Non FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

Based on observation, interview, and record review the facility failed to provide a private meeting space for residents' monthly council meetings for 6 of 6 residents reviewed for resident council. The facility did not provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy. Findings included: Observation on 02/07/2024 at 10:30 AM, at a confidential group meeting held with 6 Resident Council participants revealed the meeting was planned and held in the facility's dining room. There were two doors leading to the dining room from the facility halls and a door in the dining room leading to the kitchen. Both doors to the dining room were closed and displayed signs, which reflected Resident Counsel Meeting. During the meeting, MA B and MA C entered the dining room and went to the kitchen, interrupting the meeting, on two separate occasions. A group interview on 02/07/2024 at 10:40 AM, with group meeting participants revealed their Resident Council Meetings were always held in the Dining Room. The stated staff were always coming through the Dining Room to the kitchen, during their meetings. They said that did not allow them to have private meetings. They said they had not complainted to anyone about it previously. In an interview on 02/07/2024 at 10:50 AM, MA B said she came into the dining room to bring and ice chest back to the kitchen. MA B said there was a sign on the dining room door noting a Resident [NAME] Meeting was going on, but she did not think it was an issue to enter the Dining Room because she has always done that. She said the Resident Council always met in the Dining Room and knows they should have a private space to do that. She said she did not believe she had any training to inform her of this. In an interview on 02/07/2024 at 10:58 AM, MA C said she did see the sign on the dining room door but had never been told not to enter when a Resident Counsel meeting was being held. She stated residents should have a private place to meet to ensure confidentiality of their meetings. In an interview on 02/07/2024 at 11:50 AM, the Activities Director stated Resident Council Meetings were always held in the Dining Room and signs were placed on the dining room entrances noting the meetings. She said staff knew they should not enter the dining room while Resident Council Meetings were being held to ensure resident privacy. She said staff were not in serviced on this but had been told verbally. She said residents had the right to meet in private without staff present. In an interview on 02/07/2024 at 12:00 PM, the [NAME] President of Clinical Services stated residents should have a private place to meet and the dining room were not private. She said the facility was limited on space, but they needed to find a solution to ensure meetings were private. She said the signage placed on the doors in the dining room are not sufficient to ensure privacy for the meetings because staff still entered the dining room during meetings. In an interview on 02/07/2024 at 2:24 PM, the Administrator stated the Resident Council Meetings should be held in a private space for the residents, but the facility was limited on space. She said the Activities Director used signage on the dining room doors to control privacy but that did not always work. She said residents had the right to meet in private. Record review of the facility's policy titled, Resident Council Meetings, revised, 12/2023, reflected, Policy: This facility supports the rights of residents to organize and participate in resident groups in the facility. This policy provides guidance to promoting structure, order, and productivity in the group meetings. Definitions: Resident or family group is defined as a group of residents or residents' family members that meets regularly to discuss and offer suggestions about facility policies and procedures affecting residents' care, treatment, and quality of life; support each other; plan resident and family activities; participate in educational activities; or for any other purpose.

Based on observation, interview and record review, the facility failed to ensure each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one (Resident #21) of three residents reviewed for dignity. The facility failed promote Resident #21's dignity by not covering his catheter's urinary collection bag with a privacy bag. This failure could place residents with catheters at risk for a loss of dignity, decreased self-worth and decreased self-esteem. Findings included: Record review of Resident #21's Face Sheet dated 02/08/2024, reflected, an [AGE] year old-male admitted to the facility on [DATE] with diagnosis which included, Heart failure, Type-2 Diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel); Peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel); Diabetic retinopathy without macular edema (two common vision conditions related to diabetes) Record review of Resident #21's last quarterly MDS dated , 02/06/2024 reflected the resident had an indwelling catheter and a BIMs score of 15 indicating no cognitive impairment. Record review of Resident #21's Care Plan dated 10/22/2022, reflected, Focus: [Resident #21's] rights will be respected and maintained through the review date. Focus: [Resident #21] has an Indwelling Catheter, Intervention: Change Catheter and drainage bag based on clinical indications such as infection, obstruction, when the integrity of the closed system is compromised. An observation on 02/06/2024 at 11:29 AM revealed Resident #21's catheter bag hanging under his wheelchair uncovered. The bag, half full of yellow urine, was visible while the bag cover was also hanging under the wheelchair empty. Resident #21 was observed in the 300 Hall self-ambulating into the dining room and out of the dining room door on the 400 Hall and to his room. The dining room was full of residents awaiting lunch service. In an interview on 02/06/2024 at 11:31 AM, Resident #21 said the staff hung his catheter bag under his wheelchair. He said he did not recall who hung it there today. He said staff did not always put the bag in the cover but he preferred it to be covered. In an interview on 02/07/2024 at 12:00 PM, the [NAME] President of Clinical Services said catheter bags should be covered by a privacy bag to ensure the resident's privacy and dignity. She said staff were in serviced on residents' rights practices but could not recall when the last in-service was. She said it was all staffs responsibility to watch for those issues to ensure the resident's privacy. In an interview on 02/07/2024 at 2:45 PM, the Administrator stated the catheter bags should be covered. She said the resident's privacy was important and nursing staff were responsible to ensure catheter bags were covered. She said not covering the bag could be a dignity concern for the resident. In an interview on 02/08/2024 at 11:16 AM, CNA E stated she worked on Resident #21's hall. She stated she tried to ensure catheter bags were covered. She said it was important to ensure resident dignity. She said all staff were responsible to make sure the catheter bags were covered. She said she had received dignity training but could not recall when the last time was. In an interview on 02/08/2024 at 11:16 AM, RN F said he worked on the hall where Resident #21 resided. He stated catheter bags should be in a privacy bag to ensure the resident's dignity. He stated he rounded often and expected CNAs to watch for that throughout their shift. A review of the facility's policy titled, Quality of Life - Dignity, reviewed December 2023, reflected, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality . Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: a. Helping the resident to keep urinary catheter bags covered.

Based on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Residents #53 and #58) of seventeen residents reviewed for call lights. The facility failed to ensure Residents #53's and #58's call light were placed within their reach. This failure could place dependent residents at risk of injuries and unmet needs. The findings included: Record review of Resident #53's face sheet, dated 02/08/2024, reflected he was an [AGE] year-old male who originally admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease (type of dementia that affects memory, thinking and behavior. Symptoms eventually grow severe enough to interfere with daily tasks); mild dementia, with psychotic disturbance (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life); Anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells, Dizziness and giddiness; Abnormalities of gait and mobility; and repeat falls. Record review of Resident #53's quarterly MDS Assessment, dated 11/21/2023 reflected a BIMs score of 6 which indicated mild cognitive impairment. Record review of Resident #53's care plan, dated 04/21/2023, reflected the following: Focus: [Resident #53]is at risk for falls r/t HX Repeated falls Confusion, Unaware of safety needs . Goal: Will attempt to be free of falls through the next review date . Interventions: Call light is within reach and encourage me to use it for assistance as needed. I need prompt response to all requests for assistance. Anticipate and meet my needs. Record review of Resident #58's face sheet, dated 02/08/2024, reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included Spondylosis with myleopathy (neurologic condition that develops insidiously over time as degenerative changes of the spine result in compression of the cord and nearby structures); Hypertension (when the pressure in your blood vessels is too high); Benign neoplasm of prostate (noncancerous enlargement of the prostate gland); Hypokalemia (potassium in the blood is too low); Age-related osteoporosis (bone density loss). Record review of resident #56's quarterly MDS Assessment, dated 01/07/2024 reflected a BIMs score of 6 which indicated mild cognitive impairment. Record review of Resident #58's care plan, dated 02/08/2022, reflected the following: Focus: [Resident #58] is at risk for falls r/t right-sided weakness. I have an actual fall with no injuries .Goal: Will not sustain serious injury through the review date .Interventions: Anticipate and meet my needs. Re-educate resident to turn call light on for help. Be sure my call light is within reach and encourage me to use it for assistance as needed. I need prompt response to all requests for assistance. Observation on 02/06/2024 at 10:56 AM revealed Resident #53 was lying in bed. The call button was hanging on the wall behind the privacy curtain and out of reach of Resident #53. Observation on 02/08/2024 at 08:20 AM revealed Resident #53 lying in bed. The call button was on the floor behind the bedside dresser and out of reach of Resident #53. An observation and interview on 02/06/2024 at 10:51 AM, revealed Resident #58 was in bed. The call button was between the wall and the mattress at the foot end of the bed and out of reach of Resident #58. Resident #58 stated he used his call light when he needed assistance and was not sure why the button was at the foot of his bed. He said he was not able to reach the button but would yell for assistance if he needed it. In interview on 02/07/2024 at 08:55 AM, the LVN A stated call lights should be placed for all residents so they could call for assistance. She said she often reminded CNAs to place call lights in reach, but all staff were responsible to ensure they were accessible to residents. She said when the call light was not placed in reach residents were at risk of not having their needs met. In interview on 02/07/2024 at 12:00 PM, the [NAME] President of Clinical Services said she expected call lights to be placed in reach for all residents at all times. She said they needed to be within reach of the residents, no matter what their functional capabilities were, and it was the resident's right to be able to call for assistance. In interview on 02/07/2024 at 02:45 PM, the Administrator said all staff were responsible to ensure call lights were placed in reach of residents. She said she expected the staff to follow the facility's policy which was to ensure residents had access to their call light. In interview on 02/08/2024 at 08:21 AM, CNA G said she Resident #53 was eating in his chair and she did have his call button placed near him. She said when he moved to the bed she should have placed the call button there. She stated call lights needed to be accessible to all resident to ensure they could call for assistance as needed. She stated placing call lights within reach was expected at all times. In interview on 02/08/2024 at 08:30 AM, the ADON stated call lights needed to be accessible to residents to ensure they could call for assistance when they needed it. She said the button needed to be near the resident even if they did not use it because it was their right to have a way to call for assistance. She stated staff were trained to place call lights and knew to do so. She said she rounded constantly and reminded staff of this regularly. Record review of the facility's policy titled, Resident Rights, reviewed December 2023, reflected, Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility . These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation; d. be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident's symptoms; e. self-determination; f. communication with and access to people and services, both inside and outside the facility

Based on observation, interview and record review, the facility failed to ensure the comprehensive care plan described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #52) of 7 residents reviewed for comprehensive care plans. The facility failed to accurately define the quantity and type of alcohol the doctor's order authorized Resident #52 to safely consume daily on his care plan. The failure could place residents at risk of receiving inadequate interventions not individualized to their care needs. Findings included: Record review of Resident #52's face sheet, dated 01/08/2024, revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #52's diagnoses included: schizoaffective disorder, which is a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania, benign neoplasm of the prostate, which is a noncancerous enlargement of the prostate gland, hyperlipidemia, which is an elevated level of lipids such as cholesterol and triglycerides in the blood, alcohol abuse with withdrawals, nicotine dependence (cigarettes), nerve root and plexus disorder, which is caused by pressure, pinching or stretching the nerve roots that exit or enter the spinal cord, chronic pain syndrome, secondary hypertension (high blood pressure that is caused by another medical condition), Atherosclerotic hearth disease of native coronary artery without angina pectoris, Arteriosclerosis occurs when the blood vessels that carry oxygen and nutrients from the heart to the rest of the body (arteries) become thick and stiff and sometimes restricting blood flow to the organs and tissues, chronic ischemic heart disease which is heart weakening caused by reduced blood flow to the heart, Arthropathy (a joint disease, of which can be associated with a hematologic (blood) disorder or an infection), spondylolysis in the lumbar region, which is a stress fracture through the pars interarticularis of the lumbar vertebrae. The pars interarticularis is a thin bone segment joining two vertebrae, viral hepatitis C (a viral infection that causes liver swelling, called inflammation and can lead to liver disease), malignant neoplasm of bladder (bladder cancer) which occurs when cells in the bladder start to grow without control, cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), suspected exposure to COVID-19 (Coronavirus disease is an infectious disease caused by the SARS-CoV-2 virus, which is a strain of the species severe-acute-respiratory-syndrome-related coronavirus. Record review of Resident #52's MDS assessment, dated 11/16/2023, revealed his BIMS score was 12, which indicated moderate cognitive impairment. Resident #52 did not have any behaviors listed on his MDS assessment. Record review of Resident #52's Orders Summary Report, dated 02/07/2023 revealed an active telephone order for Resident #52 authorized by the Medical Director on 10/06/2023 with a start date of 10/07/2023. The telephone order by the Medical Director authorized that on 10/07/2023, Resident #52 may have 4-6 ounces of beer or wine every day shift. Record review of Resident #52's care plan dated 12/07/2023 revealed it did not reflect the Medical Director's telephone order that that Resident #52 may have 4-6 ounces of beer or wine every day shift. On 02/07/2024 at 12:30 p.m., Resident #52 was observed in the facility with 1 open 16 ounce can of Bud-Light beer. In an interview on 02/07/2024 at 12:35 p.m., The ADON stated that Resident #52 had a doctor's order for him to have 1 beer a day. The ADON stated Resident #52 was also care planned to have 1 beer a day during the day shift. In an interview on 02/07/2024 at 1:30 p.m., the ADON confirmed that the care plan for Resident #52 did not address that he may have 4-6 ounces of beer or wine every day shift per the Medical Director's active order for Resident #52. The ADON stated that she would contact the Medical Director for Resident #52 to request that Resident #52's order be changed. The ADON confirmed that Resident #52's care plan should reflect the active doctor's order for Resident #52 to consume 1 can of beer or wine per day according to the order. On 02/07/2024 at 1:45 p.m., a request was made for the ADON to unlock the Medication Storage Room. The ADON granted the request and unlocked the Medication Storage Room and opened the refrigerator. Inside the refrigerator there was a box of 12 16 ounce cans of Bud-Light beer inside the refrigerator on the door labeled with Resident #52's name on the box. In an interview with the Medical Director on 02/07/2024 at 2:14 p.m., she confirmed that she approved for Resident #52 to have 1 beer a day during the day shift. She stated that she approved an active order for Resident #52 to have 1 beer a day, but did not know that the active order reflected, may have 4-6 ounces of beer or wine per day during the day shift. She was informed that according to the Bud-Light website, the company does not produce 4-6 ounces of beer. The Medical Director stated that her staff must have called in the incorrect order, and she would change the telephone order and notify the facility with the updated order. The Medical Director stated that she would change the current active order for Resident #52 to reflect that he may have 1 can of beer a day up to 16 ounces and limit wine to 6 ounces a day. The Medical Director stated that although the current active telephone order was incorrect, she did not feel as though there was any harm done to Resident #52 after consuming the 1 can of 16 ounce beer. She stated that Resident #52 has not exhibited any behavioral or health issues or concerns since his active current order to consume beer daily. Observation and interview on 02/07/2024 at 3:45 p.m., Resident #52 was observed in the facility sitting in his wheelchair in the hallway. Resident #52 did not appear to be in any distress, and he stated that he was feeling good and did not have any complaints. Record review of Resident #52's Orders Summary Report dated 02/08/2024 revealed an updated active telephone order for Resident #52 signed and dated by the Medical Director on 02/07/2024 at 6:47 p.m. The active telephone order reflected Resident #52, may have 1 can of beer a day up to 16 ounces, limit wine to 6 ounces a day for every day shift. In an interview on 02/08/2024 at 9:16 a.m., with the [NAME] President of Clinical Services, she stated that she was unaware that Resident #52's care plan did not have information regarding his approved doctor's order to consume alcohol daily. She stated that it is the duty of the Director of Nursing to ensure that the most recent and updated information for each resident is in their care plan. She stated that the facility no longer has a Director of Nursing due to the previous person that held the position resigning from the agency. She reported that she has been fulfilling the role of the Director of Nursing at the facility until a replacement Director of Nursing is hired at the facility. She was advised that Resident #52 was observed with a 16 ounce can of beer on 02/07/2024 although his doctors order reflected that he may have 4-6 ounces of beer or wine every day shift. She stated that there have not been any notifications from staff of Resident #52 having behavior issues due to his consumption of alcohol. She stated that she feels that Resident #52 has not received any harm from drinking alcohol daily . In an interview on 02/08/2024 at 9:30 a.m. with the Social Worker, she confirmed that Resident #52 had a doctor's order for him to have 1 can of beer per day on the day shift. The Social Worker stated that the staff on the floor have provided Resident #52 with his beer every day shift per his doctor's order. She stated that there have not been any concerns brought to her attention regarding Resident #52 having any behavioral issues after his daily consumption of alcohol. The Social Worker stated that it appears that Resident #52 has not had any adverse reactions to his daily consumption of alcohol. In an interview on 02/08/2024 at 10 a.m. with the Administrator, she confirmed that Resident #52 had a doctor's order for him to have 4-6 ounces of beer or wine per day during the day shift. She stated that Resident #52's family will purchase the beer for him. The Administrator stated that she does not know when Resident #52's family purchased and brought the current pack of beer to the facility. The Administrator stated that she felt that there was no harm done to Resident #52's well-being after drinking the 16 ounce beer he was observed drinking on 02/07/2024. The Administrator stated that Resident #52 is given an assessment by staff after his daily consumption of beer and there have not been any problems. She stated that Resident #52 is safe in a wheelchair and has not had any history of becoming drunk and belligerent after consuming the alcohol and he has not had any history of falls. The Administrator stated that Resident #52's care plan should reflect that the doctor approved for him to have 1 beer a day . She stated that she was unaware that Resident #52's care plan did not include that he may consume 1 beer per day. In an interview with Resident #52 on 02/08/2024 at 1:03 p.m., he stated that he had a doctor's order for him to have 1 can of beer a day. Resident #52 stated that he prefers to drink beer and does not drink wine. He stated that his family member purchases his beer for him and brings it to the facility. He stated that he is limited to 1 beer per day but would prefer 2 peers per day, but the facility will only has allowed him 1 beer per day. Resident #52 stated that he does not know how many ounces of beer his doctor approved for him to have per day. He stated he has been educated by staff about alcohol consumption and the effects of drinking alcohol with his health conditions. Resident #52 stated that when he drinks 1 beer per day and his consumption of alcohol has not had any affects to his body, or his behavior and it just makes him feel good. Record review of the facility's policy titled Care Plan - Interdisciplinary Plan of Care from Interim to Meeting last revised in March 2023, revealed The facility shall support that each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility shall assess and address care issues that are relevant to individual residents, to include, but may not be limited to monitoring resident condition and responding with appropriate interventions. The comprehensive care plan is an interdisciplinary communication tool. It includes measurable objectives and time frames and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan is reviewed and revised periodically, and the services provided or arranged are consistent with each resident's written plan of care.

Based on interview and record review, the facility failed to notify the physician and resident representative regarding changes in condition for one (Resident #1) of seven residents reviewed for notification of changes. The facility failed to notify Resident #1's physician and resident representative 08/09/23 when he initially developed a wound which deteriorated to a Stage 4 and on 08/20/23 it deteriorated where it was unstageable with wound odor and bloody drainage. Resident #1 was transferred to the ER because of possible infection and need for surgical debridement. Resident #1 was still in the hospital at the time of the investigation and with a diagnosis of sepsis (the body's extreme response to an infection and a life-threatening medical emergency) according to the hospital representative. An IJ was identified on 08/24/23. The IJ template was provided to the facility on [DATE] at 4:36 PM. While the IJ was removed on 08/25/23, the facility remained out of compliance at a scope of actual harm that was not immediate and a severity level of isolated because all staff had not been trained on the facility change in condition policy. This failure could place residents at risk of not having their physician and resident representative notified of changes, a delay in medical intervention, and decline in health, hospitalization , or death. Findings included: Review of Resident #1's face sheet dated 08/23/23 reflected he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of cerebral infarction (stroke as result of disrupted blood flow to the brain), Parkinson's disease, dementia, hypertensive heart disease (changes of the heart and arteries as a result of chronic blood pressure elevation), and cognitive communication deficit. Review of Resident #1's Quarterly Minimum Data Set assessment dated [DATE], reflected he had a BIMS score of 9 indicating he was moderately cognitively impaired. Resident #1's MDS reflected he required extensive assistance with turning and positioning in bed from side to side with staff providing weight bearing support. Resident #1's MDS reflected he was always incontinent of urine, bowel, and at risk for development of a pressure ulcer injury. Review of Resident #1's care plan dated 08/23/23 reflected he had actual impairment to skin integrity related to small open area on his sacrum found on 08/11/23. Interventions included in the care plan reflected Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD. Resident #1's care plan also reflected a focus on disease management with the intervention to alert provider of any condition alerts identified during resident evaluations. Review of Resident #1's Braden Scale for Predicting Pressure Ulcer Risk assessment dated [DATE] indicated he was at high risk for development of a pressure ulcer due to his limited sensory perception (ability to feel pain or discomfort over 1/2 of his body), his skin almost always moist, being chairfast (ability to walk severely limited or non-existent), being completely immobile, and friction and shear to his skin being a problem (due to the requirement for frequent repositioning with maximum assistance). Review of Resident #1's Skin Evaluation completed by LVN B dated 08/07/23 reflected he had no skin issues. Review of Resident #1's Nurse's Note created by LVN A dated 08/09/23 reflected Resident resting in the bed at this time, no s/s of pain/distress noted. Assisted with all ADLS by the staff, wound in between the buttocks fold, skin barriers applied, Low bed, call light and personal items within reach. Review of the facility skin assessments and risk management incident reports did not reflect either skin assessment or incident report was created on 08/09/23 to reflect wound between the buttocks fold of Resident #1. Review of Resident #1's Nurse's Note dated 08/11/23 created by LVN C reflected, Resident resting in the bed at this time, no s/s of pain/distress noted, resp (respiration) even and unlabored, assisted with all ADLS by the staff, wound in between the buttocks fold, skin barriers applied, Low bed, call light and personal items within reach. Review of the facility risk management incident report dated 08/11/23 created by the DON reflected Incident Description: Charge nurse reported a small skin area on the buttocks that required [NAME] (s/p barrier) cream and turning of the resident every 2 hours. Immediate Action Taken: The skin area is likely cause by the resident sliding from the wheelchair. Resident is constantly be pulling up by staff on the wheelchair. Resident has appointment at [hospital name] for a new wheelchair. DR., resident's [family member] notified about the skin area. Left message for Veteran's Administration representative . Review of Resident #1's physician orders created 08/11/23 by LVN C reflected Clean between buttocks with NS, pat dry, apply barrier cream, apply dry dressing until seen by wound doctor. Review of Resident #1's Nurse's Note dated 08/14/23 reflected, Resident in bed to be turn and repositioned every 2 hours until open area healed. Treatment for wound Dr. to see the resident requested from [hospital name] nurse today, pending approval. Left buttocks measure 3x4 and right buttock measure 3.5 x 4cm. Treatment order received from (attending) Dr. to treat until wound Dr. sees the resident. Review of Resident #1's Skin Evaluation completed by LVN C dated 08/14/23 reflected; .Skin issue #1 .r) Pressure Ulcer/Injury .Location between buttock .Pressure ulcer/Injury stage .b) Stage II: Partial thickness skin loss .wound bed .d) granulation .wound exudate .b) purulent: thin, thick, opaque, tan/yellow drainage .periwound condition .a) normal .dressing saturation .c) minimal:<25% .wound odor .b. none .tunneling .b. no .tissue .a. painful .no other skin issues identified .General Note: Head to toe assessment skin warm and dry, pressure injury located between buttock cleaned with NS, pat dry and applied barrier, educate staff to continue to turn q2h and apply barrier until wound doctor come to follow up with order. Review of Resident #1's Physician Order dated 08/15/23 reflected Cleanse all open areas to coccyx and buttocks with Dakin's solution, pat dry and apply Collagen to all areas, cover with a dry dressing; every day and night shift for Skin/Wound Support. Review of Resident #1's Treatment Administration Record for the month of August 2023 reflected; Cleanse all open areas to coccyx and buttocks with Dakin's solution, pat dry and apply Collagen to all areas, cover with a dry dressing. Every day and night shift for skin/wound support start date 08/15/23. Review of Resident #1's Skin Evaluation completed by LVN D at 06:47 PM on 08/20/23 reflected; .Skin issue #1 .e)Deep tissue pressure injury .location: right buttock .pressure ulcer/injury stage .e) unstageable .length 8cm X 5.3 cm X 1cm .wound bed .c) slough (soft area) .wound exudate(drainage) .e)sanguineous (bloody drainage) .periwound condition (tissue surrounding the wound) .d)fragile .dressing saturation .a)heavy:>75% .wound odor .a. yes .tunneling .a. yes .tissue .a) painful .c) mushy .Skin issue #2 .e) deep tissue pressure injury .location .left buttocks .pressure ulcer/injury stage .unstageable .length 3 cm .width .2.5 cm .wound bed .slough .wound exudate .e) sanguineous (bloody drainage) .peri wound condition .d) fragile .dressing saturation .a)heavy>75% .wound odor .a. yes .tunneling .a. yes .tissue .a. painful .c. mushy. Review of the facility risk assessment/incident reports did not reflect LVN D completed an incident report or notified Resident #1's physician and or resident representative of the change in condition to Resident #1's skin indicated on skin evaluation 08/20/23. Review of Resident #1's Wound Physician's note at 10:05 AM dated 08/21/23 reflected; Stage 4 Pressure Wound Sacrum Full thickness . wound size (LxWxD) .10x 9.5x 4.5cm .exudate: .Heavy Purulent .Slough: .10% .Coordination of Care .The patient's plan of care was discussed with Patient, Family Member and with another health care provided: Primary Care Physician (discussed wound and transfer to the ER) . Review of Resident #1's physician order dated 08/21/23 reflected Send (Resident #1) out to the hospital for wound evaluation dx: possible infection. In an interview with the DON on 08/23/23 at 09:39 AM, she revealed Resident #1 was at risk for skin breakdown due to his age, fragile skin, incontinence for urine and bowel, his limited mobility and fluctuating appetite. The DON stated when there was injury or wound noted to a resident's skin by staff those staff should notify herself, the ADON, physician, and resident representative immediately as they discover an injury or wound. The DON stated Resident #1 had his family member and a Veteran's Administration nurse who served as resident representatives. The DON stated she was not notified by LVN A on 08/09/23 of a wound LVN A found on Resident #1. The DON stated she was first alerted by LVN C of Resident #1's skin breakdown. LVN C described as a little crack on his sacrum that required application of barrier cream, along with turning and repositioning of Resident #1. The DON stated when notified on 08/11/23 of the change to Resident #1's skin she was not in the facility and upon her return 08/14/23 she assessed Resident #1's skin, documented the assessment, consulted the facility wound care physician, and notified the hospital nurse and resident's family member. The DON stated the ADON notified the wound care physician on 08/14/23 and conducted a telehealth visit for Resident #1. The DON stated on 08/14/23 Resident #1's wound appeared to be a Stage II and the wound care physician provided updated treatment orders for Resident #1's wound. The DON stated in addition to wound care Resident #1 was being turned and repositioned every 2 hours, barrier cream was applied to intact skin not associated with Resident #1's wound during incontinent episodes, he was provided toileting assistance a minimum of every 2 hours, and foam repositioning devices were used to position him off of his sacrum where the wound was located. The DON stated on 08/21/23 the wound care physician was able to visualize Resident #1's wound at bedside. The DON stated she was shocked at the appearance of Resident #1's wound on 08/21/23 and could not believe it had deteriorated that much since last seining it on 08/14/23. The DON stated LVN D caring for Resident # 1 did not report to her Resident #1's wound change in getting worse and the last time she visualized the wound which was 08/18/23 it had not appeared as it did on 08/21/23. The DON stated on 08/18/23 Resident #1's wound had no depth and on 08/21/23 the wound was noticeably deep. In an interview with the ADON on 08/23/23 at 12:08 PM she revealed first being notified of Resident #1's wound to his right and left buttocks on 08/14/23 and on 08/09/23 she was not alerted by any staff Resident #1 had a wound. The ADON stated Resident #1's skin was intact, with noted pink color to his skin, and no depth to the wound. The ADON stated on 08/14/23 she conducted a telehealth visit with the wound care physician for Resident #1 and at that time received a physician order to treat the area with Dakin's solution and collagen dressing. The ADON stated from 08/14/23 facility nursing staff had provided wound care as directed by the physician order and notified herself, DON, wound care physician, and resident representative of any improvement and or deterioration of the wound. The ADON stated staff needed to report any changes in Resident #1's wound so wound care treatment changes could be evaluated and changed if necessary. The ADON stated the risk of staff not reporting changes in Resident #1's wound status would be the wound could worsen and or become infected. The ADON stated was not notified by LVN D on 08/20/23 when there was a documented change in Resident #1's wound condition. The ADON stated on 08/21/23 with the wound care physician at Resident #1's bedside there was some noted depth to Resident #1's wound that was not present on her last assessment of the resident's wound on 08/14/23. The ADON stated the change noted by LVN D on 08/20/23 was a change in condition she expected LVN D to be notify herself, the DON, wound care physician, family, and Veteran's Administration of because treatment may have needed to be changed. The ADON stated on 08/21/23 when the wound care physician visited with Resident #1, the physician ordered Resident #1 to be sent to the hospital. In an interview with LVN A on 08/23/23 at 01:36 PM, she revealed she did not remember working 08/09/23 but had cared for Resident #1 while working at the facility. LVN A stated should Resident #1 have wounds she would have documented their presence in a Nurse's note along with the treatment she provided. LVN A stated she had provided care to Resident #1's wound. LVN A stated she was first alerted by LVN C to the presence Resident #1's wound between the cheeks of his buttocks. LVN A stated the last time she had cared for Resident #1's wound was 08/12/23 and it appeared to be open. She stated she provided treatment for Resident #1's wound by following the treatment order by applying barrier cream and did not notice any changes in Resident #1's wound during her shift on 08/12/23. LVN A stated she was not aware if LVN C reported the presence of Resident #1's wound to anyone else. LVN A stated when a wound was noted on a resident's skin the DON, ADON, Veteran's Administration representative, family and physician needed to be notified in order to receive orders for treatment. LVN A stated should a wound get worse the DON, ADON, Veteran's Administration representative, family and physician also needed to notified to receive alternative treatment in order to improve the condition of the wound. LVN A stated she was not the initial nurse who first found Resident #1's wound on 08/09/23 and could not state definitively she placed the Nurse's Note signed by her on 08/09/23 without seeing the note. LVN A stated the nurse who first saw the wound to Resident #1 should have notified the DON, ADON, [hospital name], family, and physician. In an interview with LVN B on 08/23/23 at 02:07 PM, she revealed for any wound found on a resident the DON, ADON, family members, and physician needed to be notified as well as the presence of the wound and who was notified documented in a facility skin assessment and incident report. LVN B stated a change in condition to a resident's skin identified by nursing aides during a resident's shower were communicated to her directly and documented on shower sheets. LVN B stated weekly as she and staff nurses also perform head to toe skin assessments for each resident. LVN B stated she also would communicate to other nursing staff a change in resident's skin by documenting it on a skin assessment and risk assessment incident report. LVN B stated for a change in a resident's skin she would also communicate it directly to the ADON, DON, family and physician. LVN B stated she worked with Resident #1 on 08/07/23 and at that time he had no skin injuries/wounds. LVN B stated she worked again with Resident #1 on 08/12/23 and 08/17/23. LVN B stated when she saw Resident #1's wound on 08/12/23 there was a crack on the resident's coccyx area that appeared to be a shearing injury. LVN B stated Resident #1's wound was not open, there was no noted drainage or odors. LVN B stated there was a treatment order in place, but she was unaware if the physician had been notified of the injury to Resident #1's skin. LVN B stated LVN C and LVN A both reported to her Resident #1 had been scheduled to see the wound care physician. In an interview with LVN B on 08/23/23 at 02:59 PM, revealed she worked with Resident #1 on 08/20/23 and assisted LVN D with the cleaning of his wound and repositioning Resident #1. LVN B stated she last observed Resident #1's wound on 08/19/23 and on 08/20/23 she noted it had changed significantly. She stated it went from a small area to two bigger areas. LVN B stated the wound to Resident #1's left buttocks started to open along with the wound to Resident #1's right buttocks. LVN B stated she texted the DON to notify her of the change to Resident #1's wound but the DON had not responded to her text message. LVN B stated she had also talked to the DON the morning of 08/20/23 about Resident #1's wound and was told by the DON the wound care physician was scheduled to see Resident #1 the morning of 08/21/23. LVN B stated other than notifying the DON she should have notified the family and physician of the change to Resident #1's wound. LVN B stated the reason she did not notify anyone other than the DON was because LVN D was assigned to care for the resident and should have notified the DON, ADON, physician, and resident representative. LVN B stated the risk of not notifying the physician, family, resident representative, ADON, DON of a change in resident condition it could be potentially dangerous for the resident and cause a wound to get worse. In an interview with LVN D on 08/23/23 at 02:32 PM, she revealed a change to a resident's skin should be reported by the staff to the family and physician. LVN D stated she is alerted to changes in a resident's skin by performing weekly skin assessments which she documented in a resident's electronic medical record. LVN D stated she assessed a resident's skin for any open areas, maceration, and or rashes. LVN D stated she communicated any changes in a resident's skin to other staff by documenting the skin assessment in the resident's electronic medical record and communicating it directly to the DON, ADON, family and physician. LVN D stated should a resident's wound also worsen by getting bigger in size the family and physician should be notified. LVN D stated she worked with Resident #1 on 08/20/23 and documented a wound to his right and left inner buttocks. LVN D stated it was the first time she cared for Resident #1. LVN D stated LVN B assisted her with assessing Resident #1's wound and LVN B remarked to her at that time the Resident #1's wound worsened. LVN D stated LVN B notified the DON of the change in condition to Resident #1's wound. LVN D stated she had not documented or made any attempts to notify the DON, physician and or Resident #1's family of the change to his wound. LVN D stated she was advised by LVN B the wound care physician was scheduled to visit with Resident #1 and that was why she did not call the physician. LVN D stated the risk of not notifying the physician of the change to a resident's condition was it could pose harm to the resident and looking back on Resident #1's situation, she should have notified the physician on 08/20/23 of the change she observed to his skin. In an interview with Resident #1's secondary attending physician on 08/23/23 at 03:16 PM, he revealed a deterioration of a resident's wound should be reported to him or the wound care physician. The secondary attending physician stated on 08/09/23 when Resident # 1's wound was identified by LVN A neither he nor the resident's primary attending physician was notified. The secondary attending physician stated he started covering for the primary attending physician on 08/19/23 due to her traveling out of the country ( the primary attending physician was not available for interview). The secondary attending physician stated he should have been notified because if treatment was not instituted, Resident #1's wound could have worsened. The wound care physician stated on 08/20/23 he was not notified by LVN D or LVN B about Resident #1's change to his wound condition. The secondary physician stated he should have been notified on 08/20/23 of the deterioration of Resident #1's wound because the wound was worsening, and he would have notified the wound care physician about the worsening of the wound. The secondary attending physician stated if notified of Resident #1's condition on 08/20/23 he would have ordered labs and cultures of the wound. In an interview with the VA resident representative for Resident #1 on 08/23/23 at 3:45 PM she revealed being a registered nurse for the Dallas Veterans Administration whose role was to provide oversight for the clinical care of veterans within the facility. She stated being first notified of Resident #1's wound on 08/11/23 by the facility DON. She stated the facility staff was contracted to provide notice to the Veteran's Administration within 24 hours of any physical or behavioral change in condition to veterans cared for by the facility. The VA resident representative stated she reviewed Resident #1's facility electronic chart and saw his wound was first documented by a nurse on 08/09/23. She stated neither she or her office had been alerted about the presence of Resident #1's wound on 08/09/23. The VA resident representative also stated she could not see where on 08/09/23 facility staff documented notification of Resident #1's physician the change to his skin. The VA resident representative stated the facility should have contacted her on 08/09/23 when the nurse first discovered the wound and at that time she would have obtained authorization for the wound care physician to provide Resident #1 care. She stated the wound care physician visited with Resident #1 at the facility 08/21/23 and decided Resident #1 needed to go to the emergency room because the wound had deteriorated. She stated as of 08/24/23 Resident #1 was at the Dallas Veteran's Hospital and had been diagnosed with a sacral pressure ulcer and sepsis. In an interview with LVN C on 08/24/23 at 8:25 AM revealed LVN A worked the 08/09/23 10:00PM to 6:00AM shift on 08/10/23 and LVN A notified her on 08/10/23 when she assumed care of Resident #1 at 6:00 AM of a small wound to Resident # 1's bottom. LVN C stated being told by LVN A the presence Resident #1's wound was documented in his electronic medical record. LVN C stated Resident #1's wound was an open wound between his buttocks. LVN C stated she worked again with Resident #1 on 08/11/23 and in morning meeting alerted the DON of the resident's wound. LVN C stated she noticed LVN A did not open a risk assessment incident report which was a requirement of staff should a change in resident's skin be identified. LVN C stated she notified the DON the risk assessment incident report was not completed by LVN A and the DON told her she would have LVN A complete the report. LVN C stated a risk assessment incident report would document the family, physician, and Veteran's Administration resident representative who would need to be notified of Resident #1's change in condition. LVN C stated the DON told her she would notify the Veteran's Administration resident representative to receive authorization for the wound care physician to see Resident #1. LVN A stated on 08/11/23 Resident #1's wound appeared to be pink, no slough to the wound, it was located in the middle of his bottom, no signs of infection, with no discoloration to his surrounding skin. LVN C stated she cleaned Resident # 1's wound with normal saline, applied barrier cream, and covered it with a dry dressing. LVN C stated she applied barrier cream to Resident #1 because at the start of any redness or skin breakdown it was nursing judgment to apply barrier cream to the area to keep the area from breaking down. LNV C stated she notified Resident #1s wife, ADON, and DON on 08/11/23 of his skin breakdown. LVN C stated she did not notify Resident #1's physician because LVN A should have notified the physician. LVN C stated she should have notified Resident #1's physician because when there was a change in condition the physician would need to monitor the resident's condition and provide orders as needed for treatment. LVN C stated she also educated nursing aide staff to turn and reposition Resident #1 every 2 hours to relieve pressure to his wound. LVN C stated she worked with Resident #1 again on 08/14/23. LVN C stated she along with the ADON visualized Resident #1's wound. LVN C stated Resident #1's wound had gotten worse since 08/11/23. LVN C stated Resident #1's wound appeared to be spreading from between his buttocks to the outer edges of his buttocks, she stated there was no depth nor slough tissue present. LVN C stated the ADON obtained measurements of the wound provided wound care. LVN C stated the would care physician was scheduled to see Resident #1 on 08/14/23 and she followed up with the ADON and DON who both were going to notify Resident # 1's primary attending physician. LVN C stated 08/14/23 was her last day working at the facility. In an interview with the DON on 08/24/23 at 9:03 AM, she revealed Resident #1's Nurse's Note dated 08/09/23 completed by LVN A indicated there was a wound between his buttocks and skin barrier cream was applied to the wound. The DON stated LVN A's Nurse Note on 08/09/23 for Resident #1 did not indicate who she reported the presence of the wound to; she stated LVN A did not notify Resident #1's family, Veteran's Administration representative, physician, the ADON, or herself of the wound she documented in Resident #1's 08/09/23 Nurse's Note. The DON stated LVN A upon finding a skin change to Resident #1 on 08/09/23 completed a risk assessment incident report and skin assessment. The DON stated a part of the risk assessment incident report would have documented the physician, family, and any other staff she reported the wound to and the time she reported the wound. The DON stated when an initial risk assessment incident report was generated by any staff member it notified all other staff who accessed Resident #1's medical record to follow up on the reported incident over the course of next 72 hours. The DON reviewed the LVN A's Nurse's Note documented on Resident #1 at 07:34pm and stated the risk to resident's should staff not follow the policy and complete a risk assessment incident report when discovering a wound other staff would not know to follow up on the progress of the resident's care and the wound could get worse. The DON stated she was not aware of the wound to Resident #1 until 08/11/23. The DON stated on 08/10/23 LVN C worked with Resident #1 and documented also in a Nurse's Note the presence of a wound to Resident #1 and also did not complete a risk assessment incident report or document who she notified. The DON stated she was notified by LVN C on 08/11/23 about Resident #1's wound. The DON stated LVN C stated she did not complete a risk assessment incident report on 08/10/23 for Resident #1 because she was waiting on LVN A to complete the incident report since she was the initial nurse who found the wound. The DON stated it was important for both nurses to have completed a risk assessment incident report and notify the family, physician, ADON, Veteran's Administration representative, and herself to ensure the change in Resident #1's condition could be monitored and treated to prevent it from getting worse. The DON stated on 08/11/23 she completed an incident report for Resident #1 and notified the resident's [hospital name] nurse of the wound to obtain a consult to have the wound care physician visit with the resident. The DON stated LVN C indicated she notified the resident's family member and physician of the wound on 08/11/23. The DON reviewed the physician order on 08/11/23 created by LVN C reflected Clean between buttocks with NS, pat dry, apply barrier cream, apply dry dressing until seen by wound doctor .electronically signed by Resident #1's primary attending physician. The DON stated she visualized Resident #1's wound along with the ADON on 08/14/23 and described the wound as an open area with redness the area to the left buttocks measured 3cm x 4cm and the wound to the right buttocks measured 3.5cm x 4 cm. The DON stated Resident #1's wound had no depth to either of the two wounds. The DON stated on 08/14/23 the wound care physician was consulted and visualized Resident #1's wound and provided updated wound care orders. The DON stated Resident #1 received new wound care orders on 08/15/2 to cleanse all open areas to coccyx and buttocks with Dakin's solution, pat dry and apply Collagen to all areas, cover with a dry dressing; every day and night shift for skin/wound support electronically signed by primary attending physician. The DON stated on 08/20/23 the Skin Evaluation completed by LVN D was a change in condition for Resident #1. The DON stated LVN B also worked with LVN D on 08/20/23 and LVN B reported to her there was a change in Resident #1's wound condition but did not describe the extent of the change. The DON stated the told LVN B the wound care physician would visit with Resident #1 the flowing day 08/21/23 and at that time provide updated treatment orders and or evaluate if Resident #1 needed to be sent out to the hospital for wound evaluation. The DON stated she told LVN D and LVN B to notify Resident #1's family, physician, or [hospital name] nurse of the change in condition to his wound but neither staff member did. The DON stated on 08/21/23 she with the wound care physician and ADON saw Resident #1's wound and at that time the wound care physician provided the order to transfer Resident #1 to the hospital for wound evaluation. In an interview with the wound care physician on 08/24/23 at 10:57 AM, he revealed he had been consulted via telehealth (via telephone) visit for Resident #1's wound. The wound care physician stated when he visualized Resident #1's wound on 08/14/23 it was superficial, appeared to be a skin tear or superficial stage 2 pressure related wound, there was one wound near the center left of his bottom, the surrounding skin was intact, there was no drainage, no edema or mention of odor provided to him. The wound care physician stated the treatment Resident #1 received of clean with normal saline, pat dry, apply barrier cream and dry dressing could have been appropriate when first identified on 08/09/23 up to the given the state of Resident #1's wound when he saw it on 08/14/23. The wound care physician stated he provided updated wound treatment orders to mitigate the risk of infection to Resident #1. The wound care physician stated when he saw Resident #1 on 08/21/23 and saw a significantly different wound than he observed on 08/14/23. The wound care physician described Resident #1's wound on 08/21/23 as deep, much bigger, and had purulent (containing pus) discharge. The wound care physician stated he sent Resident #1 to the ER for surgical debridement of the wound because the resident needed intervention beyond what he could provide in the facility. The wound care physician stated between 08/14/23 and 08/21/23 he had not been informed by anyone on facility staff of the change to Resident #1's condition. The wound care physician stated the change in condition documented on 08/20/23 by LVN D was significant and if noticed within a hour or two of him arriving to the facility to see the resident that may explain why staff had not contacted him. The wound care physician stated due to Resident #1's comorbidities and nutritional status his wound was capable of deteriorating rapidly. Review of the facility's policy titled, Change in a Resident's Condition or Status revised December 2022 reflected; Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation.1. The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): .b. discovery of injuries of an unknown source; .d. significant change in the resident's physical/emotional/mental condition; .e. need to alter the resident's medical treatment significantly; .g. need to [NAME] [TRUNCATED]

Based on interview, and record review the facility failed to ensure residents received care consistent with professional standards of practice, to prevent pressure ulcers, to promote healing, prevent infection, and prevent new ulcers from developing for one (Resident #1) of seven residents reviewed for skin breakdown. The facility failed to ensure LVN A, who identified Resident #1's wound on 08/09/23, followed-up to notify his physician, and the facility did not get orders for treatment until 08/11/23. LVN D on 08/20/23 documented Resident #1's wound had an odor, bloody drainage and was unstageable. LVN D on 08/20/23 did not notify Resident #1's physician, DON, or resident representative when she noticed his wound had deteriorated. The facility on 08/20/23 took no additional interventions to care for Resident #1's wound. Resident #1 initially developed a wound which deteriorated to a Stage 4 and on 08/20/23 it deteriorated where it was unstageable with wound odor and bloody drainage. Resident #1 was transferred to the ER because of possible infection and need for surgical debridement. Resident #1 was still in the hospital at the time of the investigation and with a diagnosis of sepsis (the body's extreme response to an infection and a life-threatening medical emergency) according to the hospital representative. The facility failed to ensure Resident #1's wound treatment was completed per physician orders on 08/17/23. An IJ was identified on 08/24/23. The IJ template was provided to the facility on [DATE] at 4:36 PM. While the IJ was removed on 08/25/23, the facility remained out of compliance at a scope of actual harm that was not immediate and a severity level of isolated because all staff had not been trained on the facility change in condition policy. This failure could place residents at risk of new or worsening pressure wounds, serious infections, hospitalization , or death. Findings included: Review of Resident #1's face sheet dated 08/23/23 reflected he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses cerebral infarction (stroke as result of disrupted blood flow to the brain), Parkinson's disease, dementia, hypertensive heart disease (changes of the heart and arteries as a result of chronic blood pressure elevation), and cognitive communication deficit. Review of Resident #1's Quarterly Minimum Data Set assessment dated [DATE], reflected he had a BIMS score of 9 indicating he was moderately cognitively impaired. Resident #1's MDS reflected he required extensive assistance with turning and positioning in bed from side to side with staff providing weight bearing support. Resident #1's MDS reflected he was always incontinent of urine, bowel, and at risk for development of a pressure ulcer injury. Review of Resident #1's care plan dated 08/23/23 reflected he had actual impairment to skin integrity related to small open area on his sacrum found on 08/11/23. Interventions included in the care plan reflected Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD. Resident #1's care plan also reflected a focus on disease management with the intervention to alert provider of any condition alerts identified during resident evaluations. Review of Resident #1's Braden Scale for Predicting Pressure Ulcer Risk assessment dated [DATE] indicated he was at high risk for development of a pressure ulcer due to his limited sensory perception (ability to feel pain or discomfort over 1/2 of his body), his skin almost always moist, being chairfast (ability to walk severely limited or non-existent), being completely immobile, and friction and shear to his skin being a problem (due to the requirement for frequent repositioning with maximum assistance). Review of Resident #1's Skin Evaluation completed by LVN B dated 08/07/23 reflected he had no skin issues. Review of Resident #1's Nurse's Note created by LVN A dated 08/09/23 reflected VA Resident resting in the bed at this time, no s/s of pain/distress noted. Assisted with all ADLS by the staff, wound in between the buttocks fold, skin barriers applied, Low bed, call light and personal items within reach. Review of facility skin assessments and risk management incident reports did not reflect either skin assessment or incident report was created on 08/09/23 to reflect wound between the buttocks fold of Resident #1. Review of Resident #1's Nurse's Note dated 08/11/23 created by LVN C reflected, VA Resident resting in the bed at this time, no s/s of pain/distress noted, resp (respiration) even and unlabored, assisted with all ADLS by the staff, wound in between the buttocks fold, skin barriers applied, Low bed, call light and personal items within reach. Review of facility risk management incident report dated 08/11/23 created by the DON reflected Incident Description: Charge nurse reported a small skin area on the buttocks that required [NAME] (s/p barrier) cream and turning of the resident every 2 hours. Immediate Action Taken: The skin area is likely cause by the resident sliding from the wheelchair. Resident is constantly be pulling up by staff on the wheelchair. Resident has appointment at VA for a new wheelchair. DR., resident's family member notified about the skin area. Left message for Veteran's Administration representative . Review of Resident #1's physician orders created 08/11/23 by LVN C reflected Clean between buttocks with NS, pat dry, apply barrier cream, apply dry dressing until seen by wound doctor. Review of Resident #1's Nurse's Note dated 08/14/23 reflected, Resident in bed to be turn and repositioned every 2 hours until open area healed. Treatment for wound Dr. to see the resident requested from VA nurse today, pending approval. Left buttocks measure 3x4 and right buttock measure 3.5 x 4cm. Treatment order received from (attending) Dr. to treat until wound Dr. sees the resident. Review of Resident #1's Skin Evaluation completed by LVN C dated 08/14/23 reflected; .Skin issue #1 .r) Pressure Ulcer/Injury .Location between buttock .Pressure ulcer/Injury stage .b) Stage II: Partial thickness skin loss .wound bed .d) granulation .wound exudate .b) purulent: thin, thick, opaque, tan/yellow drainage .periwound condition .a) normal .dressing saturation .c) minimal:<25% .wound odor .b. none .tunneling .b. no .tissue .a. painful .no other skin issues identified .General Note: Head to toe assessment skin warm and dry, pressure injury located between buttock cleaned with NS, pat dry and applied barrier, educate staff to continue to turn q2h and apply barrier until wound doctor come to follow up with order. Review of Resident #1's Physician Order dated 08/15/23 reflected Cleanse all open areas to coccyx and buttocks with Dakin's solution, pat dry and apply Collagen to all areas, cover with a dry dressing; every day and night shift for Skin/Wound Support. Review of Resident #1's Treatment Administration Record for the month of August 2023 reflected; Cleanse all open areas to coccyx and buttocks with Dakin's solution, pat dry and apply Collagen to all areas, cover with a dry dressing. Every day and night shift for skin/wound support start date 08/15/23 .The night shift of 08/17/23 there were no initials of the staff to indicate the treatment was provided. Review of Nurse's notes on 08/17/23 also did not provide any evidence that the treatment was provided during the evening or night shift staff. Review of the facility's staffing schedule dated 08/17/23 revealed LVN B was assigned to work with Resident #1 on the evening 2:00 PM to 10:00 PM shift and LVN E with Resident #1 on the night 10:00 PM to 6:00 AM shift. Review of Resident #1's Skin Evaluation completed by LVN D at 06:47 PM on 08/20/23 reflected; .Skin issue #1 .e)Deep tissue pressure injury .location: right buttock .pressure ulcer/injury stage .e) unstageable .length 8cm X 5.3 cm X 1cm .wound bed .c) slough (soft area) .wound exudate(drainage) .e)sanguineous (bloody drainage) .periwound condition (tissue surrounding the wound) .d)fragile .dressing saturation .a)heavy:>75% .wound odor .a. yes .tunneling .a. yes .tissue .a) painful .c) mushy .Skin issue #2 .e) deep tissue pressure injury .location .left buttocks .pressure ulcer/injury stage .unstageable .length 3 cm .width .2.5 cm .wound bed .slough .wound exudate .e) sanguineous (bloody drainage) .peri wound condition .d) fragile .dressing saturation .a)heavy>75% .wound odor .a. yes .tunneling .a. yes .tissue .a. painful .c. mushy Review of facility risk assessment/incident reports did not reflect LVN D completed an incident report or notified Resident #1's physician and or resident representative of the change in condition to Resident #1's skin indicated on skin evaluation 08/20/23. Review of Resident #1's Wound Physician's note at 10:05 AM dated 08/21/23 reflected; Stage 4 Pressure Wound Sacrum Full thickness . wound size (LxWxD) .10x 9.5x 4.5cm .exudate: .Heavy Purulent .Slough: .10% .Coordination of Care .The patient's plan of care was discussed with Patient, Family Member and with another health care provided: Primary Care Physician (discussed wound and transfer to the ER) . Review of Resident #1's physician order dated 08/21/23 reflected Send (Resident #1) out to the hospital for wound evaluation dx: possible infection. In an interview with the DON on 08/23/23 at 09:39 AM she revealed Resident #1 was a risk for skin breakdown due to his age, fragile skin, incontinence for urine and bowel, his limited mobility and fluctuating appetite. The DON stated when there was injury or wound noted to a resident's skin by staff those who staff should notify were herself, the ADON, physician, and resident representative. The DON stated Resident #1 had family member and a Veteran's Administration nurse who served as his resident representatives. The DON stated she was not notified by LVN A on 08/09/23 of a wound LVN A found on Resident #1. The DON stated she was first alerted by LVN C of Resident #1's skin breakdown LVN C described as a little crack on his sacrum that required application of barrier cream, along with turning and repositioning of Resident #1. The DON stated when notified on 08/11/23 of the change to Resident #1's skin she was not in the facility and upon her return 08/14/23 she assessed Resident #1's skin, documented the assessment, consulted the facility wound care physician, and notified the Veteran's Administration nurse and resident's wife. The DON stated the ADON notified the wound care physician on 08/14/23 and conducted a telehealth visit for Resident #1. The DON stated on 08/14/23 Resident #1's wound appeared to be a Stage II and the wound care physician provided updated treatment orders for Resident #1's wound. The DON stated in addition to wound care Resident #1 was being turned and repositioned every 2 hours, barrier cream was applied to intact skin not associated with Resident #1's wound during incontinent episodes, he was provided toileting assistance a minimum of every 2 hours, and foam repositioning devices were used to position him off of his sacrum where the wound was located. The DON stated on 08/21/23 the wound care physician was able to visualize Resident #1's wound at bedside. The DON stated she was shocked at the appearance of Resident #1's wound on 08/21/23 and could not believe it had deteriorated that much since last seining it on 08/14/23. The DON stated LVN D caring for Resident # 1 did not report to her Resident #1's wound change in getting worse and the last time she visualized the wound which was 08/18/23 it had not appeared as it did on 08/21/23. The DON stated on 08/18/23 Resident #1's wound had no depth and on 08/21/23 the wound was noticeably deep. In an interview with the ADON on 08/23/23 at 12:08 PM she revealed first being notified of Resident #1's wound to his right and left buttocks on 08/14/23 and on 08/09/23 she was not alerted by any staff Resident #1 had a wound. The ADON stated Resident #1's skin was intact, with noted pink color to his skin, and no depth to the wound. The ADON stated on 08/14/23 she conducted a telehealth visit with the wound care physician for Resident #1 and at that time received an physician order to treat the area with Dakin's solution and collagen dressing. The ADON stated from 08/14/23 facility nursing staff have provided wound care as directed by the physician order and notified herself, DON, wound care physician, and resident representative of any improvement and or deterioration of the wound. The ADON stated staff needed to report any changes in Resident #1's wound so wound care treatment changes could be evaluated and changed if necessary. The ADON stated the risk of staff not reporting changes in Resident #1's wound status would be the wound could worsen and or become infected. The ADON stated was not notified by LVN D on 08/20/23 when there was a documented change in Resident #1's wound condition. The ADON stated when a nurse performed wound care they should document care was on the resident's treatment administration record. The ADON stated blank spaces on a resident's treatment administration record could indicate treatment was not provided. The ADON stated treatment was not indicated on a resident's treatment administration record it might also be documented in a Nurse's Note. The ADON reviewed Resident #1's treatment administration record and stated 08/17/23 there was no documentation provided by any staff member that treatment was provided nor was there a Nurse's note which indicated Resident #1's treatment was provided. The ADON stated on 08/21/23 with the wound care physician at Resident #1's bedside there was some noted depth to Resident #1's wound that was not present on her last assessment of the resident's wound on 08/14/23. The ADON stated the change noted by LVN D on 08/20/23 was a change in condition she expected LVN D to be notify herself, the DON, wound care physician, family and Veteran's Administration because treatment may have needed to be changed. The ADON stated on 08/21/23 when the wound care physician visited with Resident #1, the physician ordered Resident #1 to be sent to the hospital. In an interview with LVN A on 08/23/23 at 01:36 PM she revealed she did not remember working 08/09/23 but had cared for Resident #1 while working at the facility. LVN A stated should Resident #1 have wounds she would have documented their presence in a Nurse's note along with the treatment she provided. LVN A stated she had provided care to Resident #1's wound. LVN A stated she was first alerted by LVN C to the presence Resident #1's wound between the cheeks of his buttocks. LVN A stated the last time she had cared for Resident #1's wound was 08/12/23 and it appeared to be open, stated she provided treatment for Resident #1's wound by following the treatment order by applying barrier cream, and did not notice any changes in Resident #1's wound during her shift on 08/12/23. LVN A stated she was not aware if LVN C reported the presence of Resident #1's wound to anyone else. LVN A stated when a wound is noted on a resident's skin the DON, ADON, VA, family and physician needed to be notified in order to receive orders for treatment. LVN A stated should a wound get worse the DON, ADON, VA, family and physician also needed to notified to receive alternative treatment in order to improve the condition of the wound. LVN A stated she was not the initial nurse who first found Resident #1's wound on 08/09/23 and could not state definitively she placed the Nurse's Note signed by her on 08/09/23 without seeing the note. LVN A stated the nurse who first saw the wound to Resident #1 should have notified the DON, ADON, Veteran's Administration representative, family and physician. In an interview with LVN B on 08/23/23 at 02:07 PM she revealed for any wound found on a resident the DON, ADON, family members, and physician needed to be notified as well as the presence of the wound and who was notified documented in a facility skin assessment and incident report. LVN B stated a change in condition to a resident's skin identified by nursing aides during a resident's shower were communicated to her directly and documented on shower sheets. LVN B stated weekly as she and staff nurses also perform head to toe skin assessments for each resident. LVN B stated she also would communicate to other nursing staff a change in resident's skin by documenting it on a skin assessment and risk assessment incident report. LVN B stated for a change in a resident's skin she would also communicate it directly to the ADON, DON, family and physician. LVN B stated she worked with Resident #1 on 08/07/23 and at that time he had no skin injuries/wounds. LVN B stated she worked again with Resident #1 on 08/12/23 and 08/17/23. LVN B stated when she saw Resident #1's wound on 08/12/23 there was a crack on the resident's coccyx area that appeared to be a shearing injury. LVN B stated Resident #1's wound was not open, there was no noted drainage or odors. LVN B stated there was a treatment order in place but she was unaware if the physician had been notified of the injury to Resident #1's skin. LVN B stated LVN C and LVN A both reported to her Resident #1 had been scheduled to see the wound care physician. LVN B stated she worked with Resident #1 on 08/17/23 during the 2:00 PM to 10:00 PM shift. LVN B stated she was aware of what treatment a resident requires because it is noted on the resident's treatment administration record. LVN B stated she did not provide wound care because the resident's dressing had been changed during the morning shift and was scheduled to be changed again on the night 10:00 PM to 6:00 AM shift. LVN B stated she turned and repositioned Resident #1 off of his wound throughout her shift and each time applied barrier cream to his thighs and intact skin of his sacrum. In an interview with LVN B on 08/23/23 at 02:59 PM revealed she worked with Resident #1 on 08/20/23 and assisted LVN D with the cleaning of his wound and repositioning Resident #1. LVN B stated she last observe Resident #1's wound on 08/19/23 and on 08/20/23 she noted it had changed significantly, she stated it went from a small area to two bigger areas. LVN B stated the wound to Resident #1's left buttocks started to open along with the wound to Resident #1's right buttocks. LVN B stated she texted the DON to notify her of the change to Resident #1's wound but the DON had not responded to her text message. LVN B stated she had also talked to the DON the morning of 08/20/23 about Resident #1's wound and was told by the DON the wound care physician was scheduled to see Resident #1 the morning of 08/21/23. LVN B stated other than notifying the DON she should have notified the family and physician of the change to Resident #1's wound. LVN B stated the reason she did not notify anyone other than the DON was LVN D was actually assigned to care for the resident and should have notified the DON, ADON, physician, and resident representative. LVN B stated the risk of not notifying the physician, family, resident representative, ADON, DON of a change in resident condition it could be potentially dangerous for the resident and cause a wound to get worse. In an interview with LVN D on 08/23/23 at 02:32 PM she revealed a change to a resident's skin should be reported by the staff to the family and physician. LVN D stated she is alerted to changes in a resident's skin by performing weekly skin assessments which she documented in a resident's electronic medical record. LVN D stated she assessed a resident's skin for any open areas, maceration, and or rashes. LVN D stated she communicated any changes in a resident's skin to other staff by documenting the skin assessment in the resident's electronic medical record and communicating it directly to the DON, ADON, family and physician. LVN D stated should a resident's wound also worsen by getting bigger in size the family and physician should be notified. LVN D stated she worked with Resident #1 on 08/20/23 and documented a wound ot his right and left inner buttocks. LVN D stated it was the first time she cared for Resident #1. LVN D stated LVN B assisted her with assessing Resident #1's wound and LVN B remarked to her at that time the Resident #1's wound worsened. LVN D stated LVN B notified the DON of the change in condition to Resident #1's wound. LVN D stated she had not documented or made any attempts to notify the DON, physician and or Resident #1's family of the change to his wound. LVN D stated she was advised by LVN B the wound care physician was scheduled to visit with Resident #1 and that is why she did not call the physician. LVN D stated the risk of not notifying the physician of the change to a resident's condition was it could pose harm to the resident and looking back on Resident #1's situation she should have notified the physician on 08/20/23 of the change she observed to his skin. In an interview with Resident #1's secondary attending physician on 08/23/23 at 03:16 PM he revealed a deterioration of a resident's wound should be reported to him or the wound care physician. The secondary attending physician stated on 08/09/23 when Resident # 1's wound was identified by LVN A neither he or the resident's primary attending physician was notified. The secondary attending physician stated he started covering for the primary attending physician on 08/19/23 due to her traveling out of the country. The primary attending physician was not available for interview. The secondary attending physician stated he should have been notified because if treatment was not instituted Resident #1's wound could have worsened. The wound care physician stated on 08/20/23 he was not notified by LVN D or LVN B about Resident #1's change to his wound condition. The secondary physician stated he should have been notified on 08/20/23 of the deterioration of Resident #1's wound because the wound was worsening and he would have notified the wound care physician about the worsening of the wound. The secondary attending physician stated if notified of Resident #1's condition on 08/20/23 he would have ordered labs and cultures of the wound. In an interview with the VA resident representative for Resident #1 on 08/23/23 at 3:45 PM she revealed being a registered nurse for the Dallas Veterans Administration whose role was to provide oversight for the clinical care of veterans within the facility. She stated being first notified of Resident #1's wound on 08/11/23 by the facility DON. She stated the facility staff was contracted to provide notice to the Veteran's Administration within 24 hours of any physical or behavioral change in condition to veterans cared for by the facility. The VA resident representative stated she reviewed Resident #1's facility electronic chart and saw his wound was first documented by a nurse on 08/09/23. She stated neither she or her office had been alerted about the presence of Resident #1's wound on 08/09/23. The VA resident representative also stated she could not see where on 08/09/23 facility staff documented notification of Resident #1's physician the change to his skin. The VA resident representative stated the facility should have contacted her on 08/09/23 when the nurse first discovered the wound and at that time she would have obtained authorization for the wound care physician to provide Resident #1 care. She stated the wound care physician visited with Resident #1 at the facility 08/21/23 and decided Resident #1 needed to go to the emergency room because the wound had deteriorated. She stated as of 08/24/23 Resident #1 was at the Dallas Veteran's Hospital and had been diagnosed with a sacral pressure ulcer and sepsis. An attempt to interview LVN E was made on 08/24/23 at 8:10am and again at 11:17 AM. voice messages indicated she was not accepting calls. In an interview with LVN C on 08/24/23 at 8:25 AM revealed LVN A worked the 08/09/23 10:00PM to 6:00AM shift on 08/10/23 and LVN A notified her on 08/10/23 when she assumed care of Resident #1 at 6:00 AM of a small wound to Resident # 1's bottom. LVN C stated being told by LVN A the presence Resident #1's wound was documented in his electronic medical record. LVN C stated Resident #1's wound was an open wound between his buttocks. LVN C stated she worked again with Resident #1 on 08/11/23 and in morning meeting alerted the DON of the resident's wound. LVN C stated she noticed LVN A did not open a risk assessment incident report which was a requirement of staff should a change in resident's skin be identified. LVN C stated she notified the DON the risk assessment incident report was not completed by LVN A and the DON told her she would have LVN A complete the report. LVN C stated a risk assessment incident report would document the family, physician, and Veteran's Administration resident representative who would need to be notified of Resident #1's change in condition. LVN C stated the DON told her she would notify the Veteran's Administration resident representative to receive authorization for the wound care physician to see Resident #1. LVN A stated on 08/11/23 Resident #1's wound appeared to be pink, no slough to the wound, it was located in the middle of his bottom, no signs of infection, with no discoloration to his surrounding skin. LVN C stated she cleaned Resident # 1's wound with normal saline, applied barrier cream, and covered it with a dry dressing. LVN C stated she applied barrier cream to Resident #1 because at the start of any redness or skin breakdown it was nursing judgment to apply barrier cream to the area to keep the area from breaking down. LNV C stated she notified Resident #1s wife, ADON, and DON on 08/11/23 of his skin breakdown. LVN C stated she did not notify Resident #1's physician because LVN A should have notified the physician. LVN C stated she should have notified Resident #1's physician because when there was a change in condition the physician would need to monitor the resident's condition and provide orders as needed for treatment. LVN C stated she also educated nursing aide staff to turn and reposition Resident #1 every 2 hours to relieve pressure to his wound. LVN C stated she worked with Resident #1 again on 08/14/23. LVN C stated she along with the ADON visualized Resident #1's wound. LVN C stated Resident #1's wound had gotten worse since 08/11/23. LVN C stated Resident #1's wound appeared to be spreading from between his buttocks to the outer edges of his buttocks, she stated there was no depth nor slough tissue present. LVN C stated the ADON obtained measurements of the wound provided wound care. LVN C stated the would care physician was scheduled to see Resident #1 on 08/14/23 and she followed up with the ADON and DON who both were going to notify Resident # 1's primary attending physician. LVN C stated 08/14/23 was her last day working at the facility. In an interview with the DON on 08/24/23 at 9:03 AM she revealed Resident #1's Nurse's Note dated 08/09/23 completed by LVN A indicated there was a wound between his buttocks and skin barrier cream was applied to the wound. The DON stated LVN A's Nurse Note on 08/09/23 for Resident #1 did not indicate who she reported the presence of the wound to; she stated LVN A did not notify Resident #1's family, Veteran's Administration representative, physician, the ADON, or herself of the wound she documented in Resident #1's 08/09/23 Nurse's Note. The DON stated LVN A upon finding a skin change to Resident #1 on 08/09/23 completed a risk assessment incident report and skin assessment. The DON stated a part of the risk assessment incident report would have documented the physician, family, and any other staff she reported the wound to and the time she reported the wound. The DON stated when an initial risk assessment incident report was generated by any staff member it notified all other staff who accessed Resident #1's medical record to follow up on the reported incident over the course of next 72 hours. The DON reviewed the LVN A's Nurse's Note documented on Resident #1 at 07:34pm and stated the risk to resident's should staff not follow the policy and complete a risk assessment incident report when discovering a wound other staff would not know to follow up on the progress of the resident's care and the wound could get worse. The DON stated she was not aware of the wound to Resident #1 until 08/11/23. The DON stated on 08/10/23 LVN C worked with Resident #1 and documented also in a Nurse's Note the presence of a wound to Resident #1 and also did not complete a risk assessment incident report or document who she notified. The DON stated she was notified by LVN C on 08/11/23 about Resident #1's wound. The DON stated LVN C stated she did not complete a risk assessment incident report on 08/10/23 for Resident #1 because she was waiting on LVN A to complete the incident report because she was the initial nurse who found the wound. The DON stated it was important for both nurses to have completed a risk assessment incident report and notify the family, physician, ADON, VA nurse, and herself to ensure the change in Resident #1's condition could be monitored and treated to prevent it from getting worse. The DON stated on 08/11/23 she completed an incident report for Resident #1 and notified the resident's Veteran's Administration representative of the wound to obtain a consult to have the wound care physician visit with the resident. The DON stated LVN C indicated she notified the resident's wife and physician of the wound on 08/11/23. The DON reviewed the physician order on 08/11/23 created by LVN C reflected Clean between buttocks with NS, pat dry, apply barrier cream, apply dry dressing until seen by wound doctor .electronically signed by Resident #1's primary attending physician. The DON stated she visualized Resident #1's wound along with the ADON on 08/14/23 and described the wound as an open area with redness the area to the left buttocks measured 3cm x 4cm and the wound to the right buttocks measured 3.5cm x 4 cm. The DON stated Resident #1's wound had no depth to either of the two wounds. The DON stated on 08/14/23 the wound care physician was consulted and visualized Resident #1's wound and provided updated wound care orders. The DON stated Resident #1 received new wound care orders on 08/15/2 to cleanse all open areas to coccyx and buttocks with Dakin's solution, pat dry and apply Collagen to all areas, cover with a dry dressing; every day and night shift for skin/wound support electronically signed by primary attending physician. The DON reviewed Resident #1's treatment administration record and stated on 08/17/23 there was no documentation to reflect LVN E assigned during the night 10:00PM to 6:00 AM shift completed Resident #1's wound care. The DON also reviewed nursing notes for 08/17/23 and stated there was no documentation by LVN E in the Nurse's notes either to indicate treatment was provided to Resident #1. The DON stated LVN E should have documented the completion of Resident #1's wound treatment on his treatment administration record. The DON stated the risk to Resident #1 should he not receive his wound treatment as ordered was that his wound would not improve. The DON stated she attempted to call LVN E and find out why she did not document the treatment but was unable to reach her by phone. The DON stated on 08/20/23 the Skin Evaluation completed by LVN D was a change in condition for Resident #1. The DON stated LVN B also worked with LVN D on 08/20/23 and LVN B reported to her there was a change in Resident #1's wound condition but did not describe the extent of the change. The DON stated the told LVN B the wound care physician would visit with Resident #1 the flowing day 08/21/23 and at that time provide updated treatment orders and or evaluate if Resident #1 needed to be sent out to the hospital for wound evaluation. The DON stated she told LVN D and LVN B to notify Resident #1's family, physician or Veteran's Administration representative of the change in c [TRUNCATED]