Every finding on record at Live Oak Nursing and Rehabilitation Center

Based on observation, 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 storage, preparation, and sanitation.1.The facility failed to ensure the walk-in freezer did not have ice accumulation inside of it.2.The facility failed to ensure all items in the refrigerator were labeled and dated.3.The facility failed to ensure the resident's refrigerator in the 400 hall did not have staff items in it.4.The facility failed to ensure items in the resident's refrigerator in the 400 hall were labeled and dated.5. The facility failed to ensure dented food-holding pans were removed from service. These failures could place residents who received meals and/or snacks from the kitchen or resident refrigerator at risk for food contamination and food-borne illness.Findings included:During the initial tour of the kitchen on 07/06/26, beginning at 11:20 am, 8 trays of varied beverages were revealed in covered plastic glasses that were not dated or labeled. Each tray held 8-24 glasses. The walk-in freezer door was difficult to open and close. There was approximately a half-inch layer of ice around the seal of the door and the jam. There was heavy ice build-up behind the fan/condenser along with its tubing in the walk-in freezer. There were multiple dented food-holding pans on the clean rack. The corners of 4 food holding pans had crevices from dents in the corners of the pans. Observation of the resident-designated refrigerator in the 400 hall on 07/06/26 at 12:02 pm revealed a personal bag with a container of mustard, a bottle of water, and zip-type baggies containing sandwich meat, bread, and fruit. The bag and its contents were neither labeled nor dated. There was a plastic container of fruit that appeared to be soggy. The container was not labeled or dated. There was an open 12-pack of soda with a resident's name on it next to the personal bag. Observation and revisit of the walk-in freezer on 07/08/26 at 2:00 pm revealed that the ice from the fan/condenser and its tubing had been chipped off, leaving chunks of ice on the floor and on top of boxes of product on the shelf under the fan/condenser. The pieces of ice had black objects stuck in them, similar to the insulation that was around the fan/condenser tubing. The chunks of ice on the floor were a hazard to walk on due to potential tripping and/or slipping. In an interview with the DM on 07/06/26 at 11:30 am, she said the dietary aids and/or the cook were responsible for labeling and dating everything in all refrigerators and the freezer. She said the facility used an electronic work order system and she had put in a work order about the walk-in freezer door about a month ago. She said she was unaware the dents and crevices in the food holding pans could harbor bacteria.In an interview with the [NAME] on 07/06/26 at 11:32 am, she said everyone was responsible for making sure items in the refrigerators, freezer, and storage room were labeled and dated. She said they were using the drinks today, but they should have been labeled and dated. In an interview with the charge nurse, LVN F on 07/07/26 at 12:02 pm, she said the refrigerator in the 400 hall was for residents only. She said staff had a breakroom, and there was no excuse for keeping personal items in the resident's refrigerator. She said the refrigerator was kept locked for resident safety, so they did not eat or drink something that belonged to someone else because they could have an allergy to it or choke on something if they were on a pureed diet, for example. She said personal belongings with resident belongings were a hazard to residents in general because of cross-contamination, and the residents could become ill. In an interview with the ADM on 07/08/26 at 2:10 pm, he said workers came yesterday and determined a new hinge was needed for the walk-in freezer door, and he was in the process of ordering a new hinge, but he did not have an invoice at this time.Record review of the electronic work order #21454 dated 06/29/26 by the ADM noted, Get the freezer door unfrozen around edges. Record review of the facility kitchen policy revised 06/01/19, titled Food Storage revealed under Policy: To ensure that all food served by the facility is of good quality and safe forconsumption, all food will be stored according to the state, federal, and US Food Codes and HACCP (Hazard Analysis Critical Control Point) guidelines. Under Procedure: 2. Refrigerators d. Date, label, and tightly seal all refrigerated foods using clean, non-absorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old.Record review of the facility kitchen policy dated 10/01/18, titled Cleaning and Sanitation of Refrigerators and freezers on Units revealed under Procedure: 1. d. Only resident food will be stored in the pantry refrigerators. All food will be labeled, dated and covered. Refrigerators will be checked each day for any food or supplement over 72 hours old and any outdated food will be discarded by the nutrition and foodservice staff.References: FDA (Food and Drug Administration) Food Code 2022 Ch. 4-202 Cleanability 4-202.11 Food-Contact Surfaces. (A)Multiuse FOOD-CONTACT SURFACES shall be: (1) Smooth; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections.

Based on interview and record review the facility failed to develop a QAPI plan that described the process for conducting quality assessment and assurance activities, including the process on how the committee would identify and correct quality deficiencies for one of one laundry rooms, five of eighteen residents (Resident #1, Resident #49, Resident #8, Resident #10, and Resident #3), and one of one kitchens. The facility failed to implement an effective QAPI program that identified, monitored, and corrected systemic quality deficiencies, including infection prevention and control. The facility failed to ensure the WCN performed hand hygiene for at least 20 seconds prior to and after performing Resident #1's wound care and performed hand hygiene after glove removal. CNA A performed hand hygiene for at least 20 seconds prior and after assisting the WCN with Resident #1's wound care.The facility failed to ensure the ES maintained the integrity of clean laundry by hanging laundered slings and heel protectors on the dirty side of the laundry area instead of the clean side. Laundry staff dried wet linen and resident clothing after washing them. The facility failed to ensure LVN B put on a gown prior to administering medication through a gastrostomy tube (also called a G-tube, enteral tube, or feeding tube) for Resident #49.The facility failed to ensure CNA C and CNA D wore proper PPE during incontinent care for Resident #10 who required enhanced barrier precautions. CNA C cleaned front to back during incontinent care for Resident #10. CNA C and CNA D properly changed gloves and performed hand hygiene during incontinent care for Resident #10.The facility failed to ensure CNA E properly changed gloves and performed hand hygiene during incontinent care for Resident #8.The facility failed to ensure Resident #3 had EBP signage and PPE readily available for dressing changes.This failure could place residents at risk of not receiving quality care and services. The findings include: Observation and interview with Resident #3 on 07/06/26 at 3:19 pm, she said she had a pressure ulcer on her bottom, which she got at the facility. She said it hurts. She said she had never seen any of the staff wear a gown when they changed her dressings. She said she had other dressings they changed-on her right BKA, left toes, and right wrist. There was no signage outside the door, on the door, or inside the room. There was no PPE readily available, neither outside nor inside the room.Observation of Resident #3's room on 07/07/26 at 9:24 am revealed no signage outside the door, on the door, or inside the room. There was no PPE readily available, neither outside nor inside the room.In an interview with the RNC, WCN, DON, and ICP on 07/07/26 at 2:33 pm, the WCN said Resident #3 was getting dressing changes daily. She said Resident #3 had an acquired sacrum pressure ulcer, L 1st big toe, and a right BKA. She said Resident #3 should be on EBP. She said there were orders for EBP on 06/22/26 and 07/07/2026. She said she did not use gowns during dressing changes for Resident #3 and could not say why. The DON said there probably was not a sign up in her room and did not know why. ICP said she was responsible for EBP and ran antibiotic orders once a week and at the end of each month. She said if residents were not on antibiotics, she printed the order listing to see if EBP was ordered. She said she was not familiar with the facility's policy on EBP. She said she thought only open wounds needed EBP. The RNC said if there were wounds requiring dressing changes, that included surgical sites, the right outer wrist, right BKA, and acquired pressure ulcers. The WCN said there was a DTI on the sacrum/intact blister, and it got staged as a stage II. She said Resident #3 was admitted on [DATE] with a surgical incision/site, and dressing changes were ordered. She said Resident #3 was supposed to be on EBP, but never was. The ICP said all nursing should know about qualifying wounds and dressing changes should be on EBP. The ICP said she usually did in-services, and it was in the orders to initiate EBP on Resident #3. The DON said residents who were supposed to be on EBP but were not could put others at risk for infections, meaning families, children, staff, and other residents. The ICP said the last hand-washing in-service was about 2 months ago and they had hand-washing demonstration skills for 20 seconds of vigorous lathering, and at least one minute in total. The ICP was not sure when the last in-service for EBP was done. She said she was responsible for surveillance and monitoring for infection control. She said nothing when asked why Resident was not on EBP. The RNC said she would conduct facility-wide in-services for all staff and administration pertaining to hand washing, wound care, EBP, and glove changes. During an observation on 7/07/2026 at 11:00 a.m., LVN B administered medications to Resident #49 through his G-tube. LVN B wore gloves during the administration and did not wear a PPE gown. The EBP sign was posted at the entrance to Resident #49's room.During an interview on 7/07/2026 at 11:10 a.m., LVN B said she should have worn a gown during medication administration for Resident #49. She said it was important to follow EBP for infection control. She said there was no negative outcome for Resident #49 from not wearing appropriate PPE. LVN B said the last in-service on EBP and TBP was in June 2026. During an observation on 07/07/26 at 1:55 pm, the WCN was observed washing her hands for approximately 6 seconds prior to providing wound care for Resident #1. CNA A was observed washing her hands for approximately 4 seconds prior to assisting the WCN with Resident #1's wound care. During Resident #1's wound care, the WCN removed her gloves and did not perform hand hygiene before continuing the wound care procedure. Following the completion of Resident #1's wound care, the WCN was observed washing her hands for approximately 5 seconds. In an interview on 07/07/26 at 2:18 pm, the WCN stated hands should be washed for approximately 10 to 15 seconds to help prevent the spread of infection. The WCN stated hand hygiene should be performed after glove removal. The WCN stated she believed she had sanitized her hands after removing her gloves. The WCN further stated that if Resident #1's wound came into contact with bacteria, the wound could worsen or fail to heal.In an interview on 07/07/26 at 2:24 pm, CNA A stated hands should be washed for approximately 20 to 30 seconds to remove any germs from the hands. CNA A stated that if Resident #1's wound came into contact with any germs, the wound could become infected. In an interview on 07/07/26 at 2:39 pm, the ICP stated handwashing should be performed for at least 20 seconds with lathering to help prevent the spread of infection. The ICP stated that if hand hygiene was not performed correctly, germs could be transferred to the residents. The ICP further stated that hand hygiene should be performed after every glove removal by washing hands or using hand sanitizer. In an interview on 07/08/26 at 8:36 am, the DON stated handwashing should be performed for approximately 20 seconds to clean off all the germs with friction and soap combined. The DON stated that if Resident #1's wound came into contact with germs, it could worsen or delay the healing process due to possible infection. During an observation beginning on 07/08/26 at 8:51 am, a sling used for a mechanical lift transfer and a heel protector were observed drying on the dirty side of the laundry area. In an interview on 07/08/26 at 9:00 am, the ES stated that after slings and heel protectors were washed, the slings were hung to dry, and the heel protectors were placed on top of a rack located at the entrance of the dirty side of the laundry area. The ES stated there was no other location available for the items to dry, and that was the process she had been taught. The ES stated she did not believe the practice was incorrect because the items had been washed. During an observation of one of the lint traps located underneath the dryer on 07/08/26 at 9:05 am, the ES stated that was the first load of laundry drying that morning and that she planned to clean the lint trap after the load had finished. The ES stated the previous night shift had washed the laundry and left it in the washer overnight, and she transferred the laundry to the dryer upon arriving for work that morning. The ES further stated that because the laundry was washed with chemicals in an industrial washer, she believed it was acceptable to leave the wet laundry in the washer overnight. The ES stated that was how she was trained when she first started, and that was the way it was done. In an interview on 07/08/26 at 10:26 am, the ICP stated she had served as the Infection Control Preventionist for approximately 2 years. The ICP stated she oversaw all of the facility's infection prevention and control program in conjunction with the DON. The ICP stated she was unaware that infection control oversight included monitoring the dietary and laundry departments and that she had not conducted routine infection control surveillance or monitoring in those areas. The ICP stated that slings and heel protectors should not be hung to dry on the dirty side of the laundry area because they could become contaminated by airborne microorganisms. The ICP further stated that washed, wet linen should not be left in the washer overnight because microorganisms could grow on the linen. During an observation on 7/08/26 at 9:27 am, CNA C and CNA D entered Resident #10's room for incontinent care. CNA C and CNA D performed hand washing, donned gloves, and did not don PPE gown. EBP sign was posted at the entrance to Resident #10's room.During an interview on 7/08/26 at 9:40 am, CNA D said she was not aware Resident #10 required EBP. She said she was supposed to wear PPE when performing incontinent care for Resident #10. She said the nurses informed her whenever a resident was under EBP. She said it was important to wear PPE because of germs and transferring germs from one to another. CNA D said she had reviewed videos on infection control in June 2026.During an interview on 7/08/26 at 9:42 am, CNA C said he looked for the EBP signs at the resident's doors to determine if he had to wear PPE. He said he was unaware of EBP for Resident #10 and did not pay attention to the sign posted outside Resident #10's door. He said he had a web-based in-service on infection control this year, 2026. CNA C said it was important to follow infection control procedures so as not to spread disease.During an observation on 7/8/26 at 10:00 a.m., CNA C and CNA D provided incontinent care to Resident #10. Both CNAs washed their hands and applied gloves. CNA C used wipes to clean the front peri-area. CNA D rolled Resident #10 reposition to right side and changed. CNA D removed her soiled gloves and applied clean gloves without performing hand hygiene. CNA C used wipes to clean the back peri-area, wiping back to front, then front to back. CNA C removed the soiled brief and applied a clean brief and fastened it into place, wearing the same soiled gloves. Both CNAs removed their gloves and performed handwashing before leaving the room.During an observation on 7/8/26 at 10:15 a.m., CNA E and CNA G provided incontinent care for Resident #8. Both CNAs applied PPE for EBP, washed their hands, and applied gloves. CNA E opened her brief and used wipes to clean the front peri area. CNA G rolled Resident #8 to her right side. CNA E removed the soiled brief and applied a clean brief, and fastened it into place, wearing the same soiled gloves. Both CNAs removed their PPE and performed handwashing before leaving the room.During an interview on 7/8/26 at 10:27 a.m., CNA E said clean gloves were changed when placing a clean brief on a resident. She said she did not change her gloves when she had placed the clean brief for resident #8. She said hand hygiene was performed after removing gloves. CNA E said she had an in-service on peri-care and handwashing in July 2026. She said it was important to follow infection control to avoid contamination, spreading germs, and infection control was followed as a precaution.During an interview on 7/8/26 at 10:50 a.m., CNA D said she was supposed to wash her hands after changing her gloves. She said it was important to wash hands and perform hand hygiene because of germs and transferring germs to one another. CNA D said she had reviewed instructional videos on infection control and handwashing in June 2026.During an interview on 7/8/26 at 11:00 a.m., CNA C said perineal care was performed by wiping from front to back. He said he began the process of peri-care for Resident #10 wiping from back to front and then resumed front to back. He said gloves were changed when they were visibly soiled and when placing a new brief. He said he had not changed gloves when he applied the clean brief. CNA C said hand hygiene was done before putting on clean gloves. He said he had a web-based in-service on infection control this year, 2026. CNA C said it was important to follow infection control measures to avoid the spread of disease.During an interview on 7/08/26 at 2:27 p.m., the ICP said she provided training for the CNAs for peri-care. She said new CNAs worked three days and checked their skills check-off for peri-care and infection control. The ICP said the CNAs skills checkoffs were completed upon hire and annually. She said training continued for a CNA that needed improvement. The ICP said CNA C, CNA D, and CNA E were up to date with their skills check-offs for infection control and peri-care. She said she expected the staff to completely understand the process and why infection control was important. During an interview on 7/08/26 at 2:52 p.m., the DON said she expected staff to follow infection control policies and procedures. She said the annual competency checklists were completed with the CNAs. The DON said she had not noticed an increase in UTIs and monitored increased trends in infections. She said she provided in-services on infection control quarterly and as needed, through the facility's web-based education portal. Record review beginning on 07/06/26 of the facility's infection prevention audits, infection control surveillance, and QAPI documentation revealed no evidence the facility identified, monitored, trended, or implemented corrective actions related to hand hygiene, PPE use, Enhanced Barrier Precautions, wound care practices, G-Tube medication administration, or laundry processes. Multiple infection prevention deficiencies were identified during the survey affecting five of the eighteen sampled residents (Residents #1, Resident #49, Resident #8, Resident #10, and Resident #3), these issues were not identified through the facilities infection prevention monitoring or QAPI activities. In an interview on 07/08/26 at 1:54pm, the ADM stated that the QAA committee met once a month and as needed. The ADM stated the facility had not identified any systemic infection control concerns through its QAPI program, and there was no current PIP related to infection control. The ADM stated that the ICP was responsible for overseeing the Infection Prevention and Control Program. During a concurrent interview, the ICP stated she was unaware that infection control oversight included monitoring the dietary and laundry departments and that she had not conducted routine infection control surveillance or monitoring in those areas. Despite the facility's failure to identify infection control concerns, the survey team identified infection control deficient practices in the dietary, laundry, and nursing departments during the survey. Record review of the facility's Quality Assessment Assurance Committee policy dated 10/24/22 reflected: Policy This facility will maintain a Quality Assessment and Assurance (QAA) Committee to identify quality issues and develop appropriate plans of action to correct quality deficiencies through an interdisciplinary approach. 2. The infection preventionist must be a member of the QAA committee and report to the committee on the infection prevention and control program (IPCP) and incidents (eg., healthcare-associated infections (HAIs) identified under the program on a regular basis.) i. Facility process and outcome surveillance

Based on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for five of eighteen residents (Resident #1, Resident #49, Resident #8, Resident #10, and Resident #3), and one of one laundry rooms reviewed for infection control and transmission-based precautions policies and practices.1. The facility failed to ensure the WCN performed hand hygiene for at least 20 seconds prior to and after performing Resident #1's wound care and performed hand hygiene after glove removal. CNA A performed hand hygiene for at least 20 seconds prior and after assisting the WCN with Resident #1's wound care.2. The facility failed to ensure the ES maintained the integrity of clean laundry by hanging laundered slings and heel protectors on the dirty side of the laundry area instead of the clean side. Laundry staff dried wet linen and resident clothing after washing them. 3. The facility failed to ensure LVN B put on a gown prior to administering medication through a gastrostomy tube (also called a G-tube, enteral tube, or feeding tube) for Resident #49.4. The facility failed to ensure CNA C and CNA D wore proper PPE during incontinent care for Resident #10 who required enhanced barrier precautions. CNA C cleaned front to back during incontinent care for Resident #10. CNA C and CNA D properly changed gloves and performed hand hygiene during incontinent care for Resident #10.5. The facility failed to ensure CNA E properly changed gloves and performed hand hygiene during incontinent care for Resident #8.6. The facility failed to ensure Resident #3 had EBP signage and PPE readily available for dressing changes.These failures could place residents who require wound care, incontinent care, and isolation at risk for healthcare-associated cross-contamination and infections.The findings included:1.Record review of Resident #1's face sheet dated 07/07/26 reflected an [AGE] year-old-male with an original admission date of 01/18/26. Diagnosis included stage 3 (full-thickness skin loss, with exposure of the fatty tissue beneath) pressure ulcer (injuries to the skin and underlying tissues caused by prolonged pressure on the skin) to the right heel, dementia ((loss of memory, language, problem solving and other thinking abilities which significantly impairs a person's ability to perform daily activities), Alzheimer's disease (progressive brain disorder that slowly destroys memory and thinking skills)and type 2 diabetes (insufficient insulin production in the body).Record review of Resident #1's significant change MDS dated [DATE] reflected that he had an unhealed stage 3 pressure ulcer and was at risk of developing more.Record review of Resident #1's physician orders dated 07/03/23 reflected:Cleanse stage 3 pressure ulcer with normal saline wound cleanser, pat dry, and apply Santyl (medication designed to debride chronic skin ulcers, severe burns, and other wounds), then apply calcium alginate (gel-like, cream-colored material used to promote wound healing) and cover with a dry dressing. Wrap with kerlix (woven gauze dressing used primarily for wound care). Change dressing daily and as needed if saturated, loose, or soiled. Assess wound for size, drainage, odor, redness, warmth, and signs of infection. Notify the provider of increased drainage, odor, surrounding redness, swelling, pain, or wound deterioration. Record review of Resident #1's care plan reflected:Resident #1 has a stage 3 pressure ulcer to the right heel initiated on 03/29/26. Interventions included:Administer treatments as ordered and monitor for effectiveness. Resident #1 has the need for enhanced barrier protection due to open wound initiated on 04/01/26.Interventions included:Use non-shared resident medical equipment if possible. Disinfect shared equipment with the appropriate disinfectant.Assess for signs and symptoms of infection, such as: Increased white blood cell count, fever, redness, swelling, purulent drainage of areas of non-intact skin, changes in urine or sputum, and report to the nurse practitioner and medical doctor as indicated.Assess the resident for risk factors or current injuries or treatments that could put the patient at risk for infection (wounds, central lines, drains, catheters, Tracheostomy).During an observation on 07/07/26 at 1:55 pm, the WCN was observed washing her hands for approximately 6 seconds prior to providing wound care for Resident #1. CNA A was observed washing her hands for approximately 4 seconds prior to assisting the WCN with Resident #1's wound care. During Resident #1's wound care, the WCN removed her gloves and did not perform hand hygiene before continuing the wound care procedure. Following the completion of Resident #1's wound care, the WCN was observed washing her hands for approximately 5 seconds. In an interview on 07/07/26 at 2:18 pm, the WCN stated hands should be washed for approximately 10 to 15 seconds to help prevent the spread of infection. The WCN stated hand hygiene should be performed after glove removal. The WCN stated she believed she had sanitized her hands after removing her gloves. The WCN further stated that if Resident #1's wound came into contact with bacteria, the wound could worsen or fail to heal. In an interview on 07/07/26 at 2:24 pm, CNA A stated hands should be washed for approximately 20 to 30 seconds to remove any germs from the hands. CNA A stated that if Resident #1's wound came into contact with any germs, the wound could become infected. In an interview on 07/07/26 at 2:39 pm, the ICP stated handwashing should be performed for at least 20 seconds with lathering to help prevent the spread of infection. The ICP stated that if hand hygiene was not performed correctly, germs could be transferred to the residents. The ICP further stated that hand hygiene should be performed after every glove removal by washing hands or using hand sanitizer. In an interview on 07/08/26 at 8:36 am, the DON stated handwashing should be performed for approximately 20 seconds to clean off all the germs with friction and soap combined. The DON stated that if Resident #1's wound came into contact with germs, it could worsen or delay the healing process due to possible infection. 2. During an observation beginning on 07/08/26 at 8:51 am, a sling used for a mechanical lift transfer and a heel protector were observed drying on the dirty side of the laundry area. In an interview on 07/08/26 at 9:00 am, the ES stated that after slings and heel protectors were washed, the slings were hung to dry, and the heel protectors were placed on top of a rack located at the entrance of the dirty side of the laundry area. The ES stated there was no other location available for the items to dry, and that was the process she had been taught. The ES stated she did not believe the practice was incorrect because the items had been washed. During an observation of one of the lint traps located underneath the dryer on 07/08/26 at 9:05 am, the ES stated that was the first load of laundry drying that morning and that she planned to clean the lint trap after the load had finished. The ES stated the previous night shift had washed the laundry and left it in the washer overnight, and she transferred the laundry to the dryer upon arriving for work that morning. The ES further stated that because the laundry was washed with chemicals in an industrial washer, she believed it was acceptable to leave the wet laundry in the washer overnight. The ES stated that was how she was trained when she first started, and that was the way it was done. In an interview on 07/08/26 at 10:26 am, the ICP stated she had served as the Infection Control Preventionist for approximately 2 years. The ICP stated she oversaw all of the facility's infection prevention and control program in conjunction with the DON. The ICP stated she was unaware that infection control oversight included monitoring the dietary and laundry departments and that she had not conducted routine infection control surveillance or monitoring in those areas. The ICP stated that slings and heel protectors should not be hung to dry on the dirty side of the laundry area because they could become contaminated by airborne microorganisms. The ICP further stated that washed, wet linen should not be left in the washer overnight because microorganisms could grow on the linen. 3. Record review of Resident #49's face sheet, dated 7/7/26, reflected a [AGE] year-old male with an admission date of 3/8/25. His relevant diagnoses included dysphagia (difficulty or discomfort in swallowing), gastrostomy status (surgically created opening directly into the stomach, typically used for a feeding tube), and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills).Record review of Resident #49's quarterly MDS assessment, dated 6/8/26, reflected a BIMS score of 7, which indicated severe cognitive impairment. Section K, titled swallowing/nutritional status, indicated he had a feeding tube while was a resident.Record review of Resident #49's care plan, dated 3/24/25, reflected Resident #49 has the need for Enhanced Barrier Precautions due to gastronomy. Interventions: Place on Enhanced Barrier Precautions, ensure a sign is placed on the door to notify staff and visitors of the precautionary measures: Gown and gloves only for high-contact resident care activities (dressing, bathing/showering, personal hygiene, changing linens, assisting with toileting, perineal/incontinent care, medical device care or use, wound care), no room restriction and may participate in communal activities. Use a mask, goggles/eye shields as indicated.Record review of Resident #49's physician order, dated 7/8/26, indicated EBP: Use gown and gloves for high contact resident care activities for those who are known to be colonized or infected with a CDC-targeted MDRO, as well as those with increased risk of MDR. (residents with wounds or indwelling medical devices) every shift. Start date 5/8/25.During an observation on 7/07/2026 at 11:00 a.m., LVN B administered medications to Resident #49 through his G-tube. LVN B wore gloves during the administration and did not wear a PPE gown. The EBP sign was posted at the entrance to Resident #49's room.During an interview on 7/07/2026 at 11:10 a.m., LVN B said she should have worn a gown during medication administration for Resident #49. She said it was important to follow EBP for infection control. She said there was no negative outcome for Resident #49 from not wearing appropriate PPE. LVN B said the last in-service on EBP and TBP was in June 2026.Record review of Resident #10's face sheet, dated 7/8/26, reflected a [AGE] year-old male with an admission date of 7/3/25. His relevant diagnoses included osteomyelitis of vertebra (a serious but treatable infection of the bones in the spine) and malignant neoplasm of unspecified bronchus or lungs (a cancerous tumor in the lungs or breathing tubes).Record review of Resident #10's comprehensive MDS assessment, dated 5/11/26, reflected a BIMS score of 10, which indicated moderate cognitive impairment.Record review of Resident #10's care plan, dated 2/17/26, reflected Resident #10 has the need for Enhanced Barrier Precautions due to: Hx of MSSA. Interventions: Place on Enhanced Barrier Precautions, ensure a sign is placed on the door to notify staff and visitors of the precautionary measures: Gown and gloves only for high-contact resident care activities (dressing, bathing/showering, personal hygiene, changing linens, assisting with toileting, perineal/incontinent care, medical device care or use, wound care), no room restriction and may participate in communal activities. Use a mask, goggles/eye shields as indicated.Record review of Resident #10's physician orders, dated 7/08/26, indicated Enhanced Barrier Precautions: Use gown and gloves for high contact resident care activities for those known to be colonized or infected with a CDC targeted MDRO as well as those with increased risk of MDR. (residents with wounds or indwelling medical devices). Order date: 3/4/26.During an observation on 7/08/26 at 9:27 am, CNA C and CNA D entered Resident #10's room for incontinent care. CNA C and CNA D performed hand washing, donned gloves, and did not don PPE gown. EBP sign was posted at the entrance to Resident #10's room.During an interview on 7/08/26 at 9:40 am, CNA D said she was not aware Resident #10 required EBP. She said she was supposed to wear PPE when performing incontinent care for Resident #10. She said the nurses informed her whenever a resident was under EBP. She said it was important to wear PPE because of germs and transferring germs from one to another. CNA D said she had reviewed videos on infection control in June 2026.During an interview on 7/08/26 at 9:42 am, CNA C said he looked for the EBP signs at the resident's doors to determine if he had to wear PPE. He said he was unaware of EBP for Resident #10 and did not pay attention to the sign posted outside Resident #10's door. He said he had a web-based in-service on infection control this year, 2026. CNA C said it was important to follow infection control procedures so as not to spread disease.During an interview on 7/08/2026 at 2:52 p.m., the DON said she expected the staff to follow infection control policies and procedures. She said the infection preventionist monitored EBP processes. The DON said she reviewed paperwork for newly admitted residents and checked for EBP. She said Resident #10 had MRSA upon admission and did not have active MRSA any longer. The DON said she provided in-services on infection control quarterly through the facility's web-based education portal.4. Record review of Resident #10's face sheet, dated 7/8/26, reflected a [AGE] year-old male with an admission date of 7/3/25. His relevant diagnoses included osteomyelitis of vertebra (a serious but treatable infection of the bones in the spine) and malignant neoplasm of unspecified bronchus or lungs (a cancerous tumor in the lungs or breathing tubes).Record review of Resident #10's comprehensive MDS assessment, dated 5/11/26, reflected a BIMS score of 10, which indicated moderate cognitive impairment. Section GG indicated he needed partial/moderate assistance with toileting hygiene.Record review of Resident #10's care plan, dated 2/17/2026, reflected resident #10 has an ADL self-care performance deficit r/t weakness- osteomyelitis - thoracic spine. Interventions: Personal hygiene: requires max assist by staff with personal hygiene and oral care.During an observation on 7/8/26 at 10:00 a.m., CNA C and CNA D provided incontinent care to Resident #10. Both CNAs washed their hands and applied gloves. CNA C used wipes to clean the front peri-area. CNA D rolled Resident #10 reposition to right side and changed. CNA D removed her soiled gloves and applied clean gloves without performing hand hygiene. CNA C used wipes to clean the back peri-area, wiping back to front, then front to back. CNA C removed the soiled brief and applied a clean brief and fastened it into place, wearing the same soiled gloves. Both CNAs removed their gloves and performed handwashing before leaving the room.During an interview on 7/8/26 at 10:50 a.m., CNA D said she was supposed to wash her hands after changing her gloves. She said it was important to wash hands and perform hand hygiene because of germs and transferring germs to one another. CNA D said she had reviewed instructional videos on infection control and handwashing in June 2026.During an interview on 7/8/26 at 11:00 a.m., CNA C said perineal care was performed by wiping from front to back. He said he began the process of peri-care for Resident #10 wiping from back to front, and then resumed front to back. He said gloves were changed when they were visibly soiled and when placing a new brief. He said he had not changed gloves when he applied the clean brief. CNA C said hand hygiene was done before putting on clean gloves. He said he had a web-based in-service on infection control this year, 2026. CNA C said it was important to follow infection control measures to avoid the spread of disease.5. Record review of Resident #8's admission record, dated 7/8/26, reflected an [AGE] year-old female with an admission date of 1/18/25. Her relevant diagnoses included vascular dementia, muscle wasting and atrophy, and shortness of breath.Record review of Resident # 8's quarterly MDS assessment, dated 6/9/26, reflected her BIMS score was 11, which indicated moderate cognitive impairment. Section GG indicated she was dependent on staff for toileting and hygiene.Record review of Resident #8's care plan, dated 7/23/23, reflected Resident #8 has bowel incontinence r/t immobility, dementia. Interventions: Provide peri care after each incontinent episode.During an observation on 7/8/26 at 10:15 a.m., CNA E and CNA G provided incontinent care for Resident #8. Both CNAs applied PPE for EBP, washed their hands, and applied gloves. CNA E opened her brief and used wipes to clean the front peri area. CNA G rolled Resident #8 to her right side. CNA E removed the soiled brief and applied a clean brief, and fastened it into place, wearing the same soiled gloves. Both CNAs removed their PPE and performed handwashing before leaving the room.During an interview on 7/8/26 at 10:27 a.m., CNA E said clean gloves were changed when placing a clean brief on a resident. She said she did not change her gloves when she had placed the clean brief for resident #8. She said hand hygiene was performed after removing gloves. CNA E said she had an in-service on peri-care and handwashing in July 2026. She said it was important to follow infection control to avoid contamination, spreading germs, and infection control was followed as a precaution.During an interview on 7/08/26 at 2:27 p.m., the ICP said she provided training for the CNAs for peri-care. She said new CNAs worked three days and checked their skills check-off for peri-care and infection control. The ICP said the CNAs skills checkoffs were completed upon hire and annually. She said training continued for a CNA that needed improvement. The ICP said CNA C, CNA D, and CNA E were up to date with their skills check-offs for infection control and peri-care. She said she expected the staff to completely understand the process and why infection control was important. During an interview on 7/08/26 at 2:52 p.m., the DON said she expected staff to follow infection control policies and procedures. She said the annual competency checklists were completed with the CNAs. The DON said she had not noticed an increase in UTIs and monitored increased trends in infections. She said she provided in-services on infection control quarterly and as needed, through the facility's web-based education portal.6. Record review of Resident #3's face sheet dated 06/19/26 revealed a [AGE] year-old female with an admission date of 06/19/26. Relevant diagnoses included UTI, diabetes with neuropathy (nerve damage), and foot ulcer (sore, open wound, or skin crater), high blood pressure, muscle wasting, peripheral vascular disease (a slow, progressive disorder where blood vessels outside the heart and brain-typically in the legs and feet- narrow, spasm, or become blocked), osteomyelitis (bone infection), ESBL (extended spectrum beta-lactamase is an enzyme found in some strains of bacteria. ESBL producing bacteria cannot be killed by many common antibiotics. This makes it harder to treat) resistance, right lower extremity surgical amputation, and abnormalities of gait and mobility.Record review of Resident #3's admission MDS dated [DATE] revealed a BIMS score of 10, indicating moderate cognitive impairment with inattention and disorganized thinking. She could ambulate with assistance and a walker. She could self-propel her wheelchair. She required substantial assistance with lower body dressing, moderate assistance with toileting, transfers, and bathing, supervision with upper body dressing and positioning, and was independent with rolling, eating, and oral hygiene. She was frequently incontinent of bladder and continent of bowel. Her active diagnoses were medically complex and included MDRO/ESBL (a superbug that produces a special shield that destroys many common antibiotics and is very hard to treat) and UTI. She had one Stage I pressure injury and three unstageable pressure ulcers upon admission; an infection of the foot, diabetic foot ulcers, and a surgical wound. She required pressure ulcer care, surgical wound care, application of dressings, ointments/medications, and applications of dressings to her foot.Record review of Resident #3's care plan dated 06/20/26 revealed: Problem: The resident has impaired immunity r/t hx of ESBL (present on admission). Date Initiated: 07/07/2026. Interventions included: Use universal precautions as appropriate. Date Initiated: 07/07/2026. Problem: Resident has the need for Enhanced Barrier Precautions due to: hx of ESBL, wound. Is at risk for infection, depression, feelings of isolation, and decline in physical activity. Date Initiated: 07/07/2026. Interventions included: Place on Enhanced Barrier Precautions, ensure a sign is placed on the door to notify staff and visitors of the precautionary measures: Gown and gloves only for high- contact resident care activities (dressing, bathing/showering, personal hygiene, changing linens, assisting with toileting, perineal/incontinent care, medical device care or use, wound care), no room restriction and may participate in communal activities. Use a mask, goggles/eye shield as indicated. Date Initiated: 07/07/2026. Problem: The resident has potential/actual impairment to skin integrity of the lower extremity r/t PVD (peripheral vascular disease, which is poor circulation in the body. Most often, it means clogged, narrowed, or blocked vessels in the legs and feet). The resident has potential/actual impairment to skin integrity of the right lower extremity r/t BKA surgical site. The resident has potential/actual impairment to skin integrity of the right wrist area of concern r/t unknown. Present upon admission. The resident has a potential/actual impairment to skin integrity, abrasion of the right 2nd toe. Date Initiated: 06/20/2026. Resolved 6/29/26. Interventions did not include EBP. Problem: The resident has occasional bladder incontinence r/t immobility. HX of UTI with admission from the hospital. Date Initiated: 06/27/2026. Interventions did not include EBP.Record review of Resident #3's Change of condition documentation dated 06/20/26 revealed drainage noted to left great toe to unstageable wound. Primary diagnoses- BKA to right extremity. Charge nurse performed wound care to left great toe, after cleansing wound with normal saline and pat dry, an unstageable wound to left great toe had drainage.Record review of Resident #3's Skin check dated 06/22/26 revealed a medial right shin issue, a surgical wound present on admission, a right gluteus (buttocks) unstageable pressure ulcer/injury present on admission, a left dorsum (top) foot, an in-house acquired medial left heel stage I pressure injury, an unstageable left gluteus pressure ulcer/injury present on admission, an unstageable left dorsum great toe pressure ulcer/injury present on admission, a left second toe abrasion present on admission, a right outer wrist wound present on admission, and a right lower quadrant (abdomen) bruise present on admission.Record review of Resident #3's active physician orders revealed Enhanced Barrier Precautions: Use gown and gloves for high contact resident care activities for those with known to be colonized or infected with a CDC-targeted MDRO, as well as those with increased risk of MDRO (residents with wounds or indwelling medical devices) every shift for Hx. ESBL- Blood. Prescriber Written Active 06/22/2026.Record review of Resident #3's Change of condition documentation dated 07/03/26 revealed stage 2 pressure ulcer/intact blister to right upper medial buttocks due to friction. Intact t blister stage 2 ulcer to right upper medial buttocks-not a reopening of previous ulcer.Record review of Resident #3's Change of condition documentation dated 07/06/26 revealed a decline in stage 2 ulcer to buttocks.Record review of Resident #3's progress notes dated 06/19/26 revealed 3 new skin issues (as described above). Skin Issues Note: resident admitted with wounds, staged by in-house nursing and referred to local wound management. Skin issue education included dressing change(s), care of skin issue(s), signs and symptoms of infection, treatment of skin issue, moisture barrier, change clothing/briefs, change/shift positions frequently, and turn every 2 hours. Skin issue notification: Family and Wound nurse. Observation and interview with Resident #3 on 07/06/26 at 3:19 pm, she said she had a pressure ulcer on her bottom, which she got at the facility. She said it hurts. She said she had never seen any of the staff wear a gown when they changed her dressings. She said she had other dressings they changed-on her right BKA, left toes, and right wrist. There was no signage outside the door, on the door, or inside the room. There was no PPE readily available, neither outside nor inside the room.Observation of Resident #3's room on 07/07/26 at 9:24 am revealed no signage outside the door, on the door, or inside the room. There was no PPE readily available, neither outside nor inside the room. In an interview with the RNC, WCN, DON, and ICP on 07/07/26 at 2:33 pm, the WCN said Resident #3 was getting dressing changes daily. She said Resident #3 had an acquired sacrum pressure ulcer, L 1st big toe, and a right BKA. She said Resident #3 should be on EBP. She said there were orders for EBP on 06/22/26 and 07/07/2026. She said she did not use gowns during dressing changes for Resident #3 and could not say why. The DON said there probably was not a sign up in her room and did not know why. ICP said she was responsible for EBP and ran antibiotic orders once a week and at the end of each month. She said if residents were not on antibiotics, she printed the order listing to see if EBP was ordered. She said she was not familiar with the facility's policy on EBP. She said she thought only open wounds needed EBP. The RNC said if there were wounds requiring dressing changes, that included surgical sites, the right outer wrist, right BKA, and acquired pressure ulcers. The WCN said there was a DTI on the sacrum/intact blister, and it got staged as a stage II. She said Resident #3 was admitted on [DATE] with a surgical incision/site, and dressing changes were ordered. She said Resident #3 was supposed to be on EBP, but never was. The ICP said all nursing should know about qualifying wounds and dressing changes should be on EBP. The ICP said she usually did in-services, and it was in the orders to initiate EBP on Resident #3. The DON said residents who were supposed to be on EBP but were not could put others at risk for infections, meaning families, children, staff, and other residents. The ICP said the last hand-washing in-service was about 2 months ago and they had hand-washing demonstration skills for 20 seconds of vigorous lathering, and at least one minute in total. The ICP was not sure when the last in-service for EBP was done. She said she was responsible for surveillance and monitoring for infection control. She said nothing when asked why Resident was not on EBP. The RNC said she would conduct facility-wide in-services for all staff and administration pertaining to hand washing, wound care, EBP, and glove changes. In an interview with CNA E on 07/08/2026 at 8:57 am, she said the CNAs did rounds every 2 hours or more as needed and spot rounds, especially with incontinent patients. She said signs on the doors indicated EBP or Isolation. She said several residents got new signs yesterday because they were supposed to be on EBP but were not. She said Resident #3 was one of them. She said the signs and PPE were important for staff and visitors for protection from open sores or wounds, and so we did not take anything (germs) home. She said the purpose of EBP was to prevent cross-contamination among other residents and themselves (staff). She said she felt wrong about not having used EBP, but she did not know. She said the nurses were not on it to gown up, meaning they did not enforce it-she said, it was lazy and neglectful. She would not name the staff. She said the ICP was supposed to be responsible for making sure the signs and PPE were in place. She said the signs and PPE should be posted immediately to prevent any cross-contamination.Record review of the facility's Hand Hygiene policy dated 10/24/22 reflected: Policy:All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.3. Hand hygiene technique when using soap and water:c. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. 5. Additional considerations:a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. Record review of the facility's Infection Prevention and Control Program policy dated 05/13/23 reflected: PolicyThis facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. 12. Linens:a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent the spread of infection.Record review of the facility's laundry procedures reflected: 4) Drying Linens should be moved from washer to dryer as quickly as possibleRecord review of the facility's policy titled Enhanced Barrier Precautions, dated 11/24/25, stated, Policy Explanation and Compliance Guidelines: 1. c. The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of PPE prior to providing high-contact care activities. 3. a. Make gowns and gloves available near or outside of the resident's room. b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. 4. High-contact resident care activities include: . f. changing briefs or assisting with toileting. g. Device care or use: .feeding tubes .Record review of the facility's policy titled Perineal Care, dated 10/24/22, stated, It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. Policy Explanation and Compliance Guidelines: . 9. a. Cleanse buttocks and anus front to back: vagina to anus in females, scrotum to anus in males, using a separate washcloth or wipes. 16. Remove gloves and discard. Perform hand hygiene.

Based on observation, record review, and interview, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment, for one of eighteen residents (Resident #39) that were observed for a safe, comfortable, homelike environment. The facility failed to ensure temperatures in Resident #39's restroom did not rise above 81 F for approximately one month. This failure could place residents at risk of decreased quality of life and comfort.The findings include: Record review of Resident #39's face sheet dated 07/07/26 reflected an [AGE] year-old-female with an original admission date of 08/10/24. Diagnoses included Alzheimer's disease (progressive brain disorder that slowly destroys memory and thinking skills), dementia (loss of memory, language, problem solving and other thinking abilities which significantly impairs a person's ability to perform daily activities), type 2 diabetes (insufficient insulin production in the body), anemia, and hypertension (high blood pressure).Record review of Resident #39's quarterly MDS dated [DATE] reflected a BIMS score of 6 (severe cognitive impairment). Resident #39 used a walker and was independent for eating, toileting, oral hygiene, shower/bathe, dressing, and personal hygiene. During an interview on 07/06/26 at 2:34pm, Resident #39 stated her room and restroom were hot and she was very uncomfortable. She reported her family had brought in two fans, but they had not helped much. Resident #39 stated she had previously reported the issue to staff, but nothing appeared to have been done. She stated she liked to spend most of her day participating in activities and is not in her room often. Resident #39 stated staff would bring her cold water whenever she wanted, but she was usually not in her room during the day and stayed cooled for the most part. During an observation on 07/06/26 at 2:52pm, a temperature of 80.3 F in Resident #39's room and a temperature of 83.4 F in the restroom. During an observation and interview on 07/06/26 at 3:10pm, the ADM entered Resident #39's room and used the facility's temperature gun to obtain a reading of 79.3 F in Resident #39's room and a temperature of 87.7 F in the restroom. The ADM stated he believed the room felt warmer because Resident #39 kept her blinds open, allowing direct sunlight into the room. He further stated Resident #39 kept her restroom door closed, and that a high window in the restroom allowed additional sunlight into the area. The ADM stated that leaving the restroom door open could help cool the room. The ADM further stated Resident #39 had previously informed him that her room was hot (date unknown). The ADM stated that the MD adjusted the air vent and sealed the windows from the outside and inside to reduce heat infiltration and prevent conditioned air from escaping. The ADM stated staff ensured Resident #39 was hydrated and offered cold water often. The ADM stated Resident #39's family later brought in two fans, which he believed helped, and that the resident did not raise the concern again. In an interview on 07/06/26 at 3:18pm, Resident #5, the roommate of Resident #39, stated she was always cold and had no issue with the room or the restroom being hot. In an interview on 07/06/26 at 3:28pm, the MD stated the facility planned to replace the exhaust manifold located above Resident #39's room. The MD stated the air conditioning vent was blowing cold air but because the exhaust manifold was not functioning properly, the cooled air was being exhausted from the room. The MD stated the exhaust manifold had not been functioning properly for approximately one month but was unsure of the exact time frame. The MD stated the facility had ordered the replacement part through one vendor, but they were unable to obtain it. The facility then ordered the part through a different vendor, and the MD stated it was expected to arrive and be replaced within the next one to two days if not today. The MD stated he was obtaining temperature readings in Resident #39's room and restroom, and the temperature would stay around 77 F in the room and up to about 84 F in the restroom. On 07/07/26 at 9:10am, Resident #39 and Resident #5 were relocated to another room until the repairs could be completed. The ADM stated that the repairs would be completed by the end of the day. Record review of the facility's Statement of Rights not dated reflected: You have the right to: (1) all care necessary for you to have the highest possible level of health; (2) safe, decent and clean conations

Based on observation and interviews the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the residents needs, in one of one medication room reviewed for safe medication storage.The facility failed to dispose of expired influenza vaccines stored in the refrigerator in the medication room.This failure could place residents at risk of receiving medications which were expired.The findings include:During an observation of the medication storage room on 7/7/26 at 7:21 a.m., ten unopened boxes of influenza vaccines with an expiration date of 6/30/2026 were in the refrigerator in the medication storage room.During an interview on 7/7/26 at 7:35 a.m., the ADON said the influenza vaccines were given between October 2025 through March 2026. She said the vaccines were not given during this time. The ADON said the facility received the vaccines during the flu season which began in October 2025. She said the left-over flu vaccines were disposed of by the pharmacist once the flu season was over. The ADON said she was responsible for checking expired medication and disposing of medication as needed. She said the pharmacy consultant performed in-services on disposing medication and checked for expired medication. The ADON said the last in-service on disposing of medication was in May 2026. She said there were no negative outcomes to the residents as residents did not receive flu vaccines in June 2026.During an interview on 7/08/26 at 2:52 p.m., the DON said in March 2026 was the last time influenza vaccines were administered to the residents. She said the ADON monitored expiration dates and removed medications from the medication storage room. The DON said her expectation from the staff was that they removed expired medication from the medication storage room and medication carts. She said the pharmacy consultant came to the facility every month and checked for expired medication in the medication storage room and medication carts.Record review of the facility's policy titled Expiration Dating and Expired Medication, dated 10/01/19, stated Policy- Drugs which have been dispensed for individual residents, are not to be used beyond the expiration date indicated by the manufacturer, by the pharmacy, or based on the following criteria. The facility is to strictly adhere to the expiration dating. Procedure- .8. It is the responsibility of all nurses who administer medications to monitor the expiration dates of the medications. Expired medications will not be administered in the facility. All expired medications will be disposed of per facility policy.

Based on interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 5 residents (Resident #1) reviewed for accuracy and completeness of clinical records.The facility failed to ensure LVN A documented Resident #1's blood pressure on the eMAR when Resident #1's amlodipine (blood pressure medication) was held on March 3rd, 8th, 12th, and 16th of 2026. This failure could place residents at risk of not receiving proper care or having needs met due to inappropriate documentation.The findings included:Record review of Resident #1's face sheet dated 03/17/26 revealed a [AGE] year-old female with an original admission date of 04/27/21 and a current admission date of 05/05/25. Diagnosis included Essential Primary Hypertension (chronic high blood pressure with no single, identifiable cause, developing slowly over time). Record review of Resident #1's Comprehensive MDS assessment dated [DATE] revealed a BIMS score of 7 which indicated severe cognitive impairment. Record review of Resident #1's comprehensive care plan dated 03/17/26 revealed the problem The resident has hypertension initiated 05/06/25. An intervention listed for the problem included Give anti hypertensive medications as ordered. initiated on 05/06/25. Record review of Resident #1's order summary dated 03/17/26 revealed an active order for amlodipine oral tablet 10 mg Give 1 tablet by mouth one time a day for hypertension related to ESSENTIAL (PRIMARY) HYPERTENSION. Hold for blood pressure less than 100/60 initiated on 05/06/25. Record review of Resident #1's eMAR for March 2026 revealed no blood pressure was recorded on 03/03/26, 03/08/26, 03/12/26, and 03/16/26. All dates were signed by LVN A indicating amlodipine was held because Resident #1's blood pressure was less than 100/60. In an interview with LVN A at 8:37 AM on 03/18/26, LVN A stated she always checked Resident #1's blood pressure before administering any blood pressure medication. LVN A stated when she held amlodipine she was able to sign the eMAR without entering the blood pressure she had measured. LVN A stated she was confident Resident #1's blood pressure was outside of the physician's parameters on the 4 days she held the medication in March. LVN A stated it was important to have accurate and complete documentation in a resident's medical record in case their medications needed to be adjusted or any trends in the blood pressure readings needed to be monitored. In an interview with the DON at 9:09 AM on 03/18/26, the DON stated a resident's blood pressure should always be measured before any blood pressure medication was administered. The DON stated the blood pressure should be documented in the eMAR regardless of whether the medication was administered. The DON stated it was important to always document blood pressure readings so an accurate history could be obtained when reviewing a resident's medical record to adjust medication dosages appropriately. Record review of the facility policy Medication Administration dated 10/24/22 revealed the following policy: .17. Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR.

Based on observation, interview, and record review the facility failed to ensure each resident had the right to be free from abuse for one of ten residents (Resident #1) reviewed for abuse/neglect. The facility failed to protect Resident #1's right to be free from abuse which resulted in Resident #1 being pushed from behind by Resident #2 and caused her to fall as she was walking out of resident #2 room and sustained a knee scrape on both knees. These failures have the potential to result in serious injury or death as a result of abuse. The findings included:Record review of Resident #1's face sheet revealed an [AGE] year-old female initially admitted on [DATE], with diagnoses of Alzheimer's Disease with late on set (a progressive disease that destroys memory and other important mental functions), Insomnia( a common sleep disorder characterized by difficulty falling asleep, staying asleep, or both, leading to insufficient or poor-quality sleep),Unspecified mood disorder, Dementia (A group of thinking an social symptoms that interferes with daily functioning), Anxiety(a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), depression(a group of conditions associated with the elevation or lowering of a person's mood). Record review of Resident #1's MDS Quarterly dated 06/03/2025 revealed Resident #1 had a BIMS Score of 06-severe cognitive impairment and needed extensive assistance with all ADLs.Record review of Resident #1's Care Plan date initiated on 06/30/25 revealed Resident #1 had an ADL self-care performance deficit related to Alzheimer's Dementia and is resistant to care from staff. Resident #1 is dependent on staff for meeting emotional, intellectual, physical, and social needs related to Alzheimer's disease, Dementia, Depression, Anxiety, and Mood Disorder. Intervention included administered psychoactive medications as ordered monitored and documented for side effects and effectiveness. Monitor and record mood to determine if problems seem to be related to external causes for example medications, treatments, concern over diagnosis. Observe for signs and symptoms of mania or hypomania racing thoughts or euphoria; increased irritability; frequent mood changes; pressured speech; flight of ideas; marked change in need for sleep; agitation or hyperactivity. [NAME] is an elopement risk/wanderer related to Dementia and her interventions included distracting resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book.Record review of Resident #1's progress notes dated 06/13/2025 to 07/14/2025 revealed on 06/26/25 at 5:15 PM Resident #1 was noted by CNA wandering into Resident's #2 room. Resident #1 walked out of Resident's #2 room when the CNA saw Resident #1 be pushed from behind by Resident #2 and landed on her knees. Resident #1 noted with redness and small superficial abrasions to both knees and no swelling was noted. Resident #2 refused to have vital signs taken, refused as needed pain medication, and refused complete head-to-toe assessment. Resident#2 yelled out, Get away from me. You're hurting me. The physician was notified along with facility administrator and director of nursing. Patient family member was also notified. Patient showing no signs of distress noted at this time.Record review of Resident #1's incident report conducted by Administrator/Abuse Coordinator dated 06/26/25 at 7:05 AM, Incident revealed Resident #1 wondered to Resident #2 doorway. When Resident #1 was leaving Resident #2 pushed Resident #1 from behind and caused her to fall to her knees in the hall and causing small abrasions to both knees. Resident #2 is a [AGE] year-old female initially admitted on [DATE] with diagnosis of Alzheimer's Disease with early onset, frontotemporal neurocognitive disorder, dementia with behavior disturbance, restlessness and agitation, insomnia, major depressive disorder, personal history of urinary tract infections.Record review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 05-severe cognitive impairment and needed extensive assistance with all ADLs no behaviors were noted in the assessment. Record review of Resident #2's Care Plan date initiated 06/26/25 revealed, the resident has an ADL self-care performancedeficit related to a diagnosis of Dementia. Resident #2 is dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits Resident #2 is at risk for distressed and fluctuating mood symptoms related to anxiety and depression. Resident #2 displays agitation and restlessness and prefers to eat meals away from other residents due to anxiety and noise. Monitor, document, and report as needed any adverse reactions to anti-anxiety therapy like drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and impulsive behavior, hallucinations. judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects include Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Resident #2 is at risk for distressed and fluctuating mood symptoms related to Anxiety and depression. Magnetic Stop sign placed across resident door to alert residents not to enter residentdemonstrated ability to remove stop sign from door to exit and enter room. Record review of Resident #2's progress notes by night nurse LVN dated 06/26/2025 at 4:48 AM revealed Resident #2 to be noted with increased agitation and aggression this morning. Resident pushed another resident in hallway due to other resident wandered into her room. Progress notes dated 06/26/25 At 5:45 AM revealed Resident #2 was noted in hallway by CNA B yelling out get out of my room. Resident seen pushing another resident from the back.Resident stated well she was in my room. Resident redirected back to her room by CNA B. Head-to-toe assessment done with no injuries noted. No c/o pain or discomfort. Director DON and physician were notified patient family responsible party was called and notified. Resident redirected by staff and currently in her room and was put on a one-to-one beginning 06/26/25 that ended on 07/30/25.Record review of Resident #2's Incident report dated 06/26/25 at 7:05 PM, revealed Resident #1 wondered into Resident #2 doorway. When Resident #1 was leaving Resident #2 pushed Resident #1 from behind and caused her to fall to her knees in the hall and causing small abrasions to both knees. Resident # 2 denied pushing Resident #1. Observation on 08/13/2025 at 10:45 AM Resident #2 was observed sleeping in her room with a banner was placed across her doorway with the a stop sign in red letters held with magnets on the door frame. Observation on 08/13/25 at 11:06 AM Resident #1 was observed in the dining room falling asleep in her chair watching TV. In an observation and interview on 08/13/25 at 11:56 AM with Resident #2 revealed she was observed sitting at the dining room table waiting for lunch. Resident #2 looked alert and was able to answer questions. Resident #2 admitted to pushing Resident #1 and stated she was sorry, but she was agitated as Resident#1 had been in her room other times. Resident #2 stated she does not like anyone in her room and was agitated by Resident #1 going in her room, so she told her to leave and pushed her. In an observation and interview on 08/13/25 at 12:05 PM with Resident #1revealed she was sitting at the dining room table waiting for lunch and stared at the wall. The state surveyor attempted to ask her simple questions, and she could not answer any questions. Resident #1 would just look and the state surveyor and smile. The state surveyor asked other simpler questions, and she still did not respond so the interview was discontinued.In an interview on 08/13/2025 at 11:43 AM with LVN A he stated on his night shift in the 300 women's locked unit on 06/26/25 at 5:15 AM he was called by CNA B to help as a resident had been pushed by another resident to the floor. LVN A stated he was not present when the incident occurred, he was doing other tasks when it occurred. When he arrived, he began to assess the Resident #1 and could not remember if she was on the floor or standing when he arrived but knows he began to assess her. The LVN did not see any major injuries other than some scraps with some redness to both of her knees. The LVN stated Resident #1 did not complain of pain, and administered a range of motion exam which did not show signs of lack of range of motion in her legs. Resident #2 was put on a one-to-one level of supervision for a few days and could not recall how long because he was off from work for some days. Resident #1 was moved to another room down the hall from Resident #2's room to prevent her from wanting to enter Resident #2's room. LVN A stated neither resident had any history of aggression to staff or other residents. The last training on abuse and neglect was given less than a month ago for abuse, neglect, and misappropriation. In a incident of a resident who has fallen the most important concern is the safety of the resident , then assessing the resident for any complaints of pain. If the resident has pain or a body part looks odd should not be move and call ambulance for assistance. In an Interview on 08/13/25 at 1:00 PM with CNA B she stated on 06/26/25 at 5:15 AM she was working in the 300 women's locked unit when an incident between two residents occurred. Resident #1 was wandering around the unit and into Residents #2's room. CNA B stated she kept redirecting Resident #1 each time she tried entering someone's room. The CNA stated as she was done assisting a resident in another room and walking out into the hall, she heard Resident #2 yell out get out of my room and saw Resident #2 push Resident #1 from behind. CNA B stated as she made her way to Resident #1 Resident #2 tried to help her get Resident #1 up and asked Resident #2 to step away. Resident #1 had screamed when she was pushed and fell on her knees. CNA B stated Resident #2 then switch positions and sat on her bottom and waited for nurse to arrive to assess her. CNA B stated LVN A arrived and assessed her, and they both helped her up and she never complained of pain and knees were slightly red. CNA B stated Resident #2 was put on a one-to-one for 4 days. CNA B stated she last received training regarding abuse and neglect the next day after the incident and had another training about 3 weeks ago. CNA B stated if abuse had taken place in any matter the resident was to be removed from the perpetrator and reported to the nurse and try to monitor resident till nurse arrives and if there was someone else involve who caused the injury to keep them away from victim. The CNA stated she knew of no other incidents for either resident in the past with staff or other residents. In an interview on 08/13/2025 at 3:00pm with the DON she said Resident #2 the incident happened during the night shift on 06/26/25 at 5:15 AM in the 300 women's locked unit hall. Immediately after the incident was reported the resident was put on one-to-one to prevent any other altercations. Resident #1 was switched to a room further down the hall so she was not close to Resident #2's room in attempt to prevent Resident #1 from entering Resident #2's room. Resident #1 was asked if she could recall how she sustained her knee scrapes and Resident #1 could not recall the incident or how she fell and scraped her knees. A magnetic banner was put to prevent other residents from entering Resident #2 room and is working very well keeping other residents out of her room. In the past Resident #2 had always just yelled to get out of her room. The DON said Resident #2 stated she never had an altercation with other residents or staff. The DON Stated training was given to all staff regarding abuse neglect and misappropriation the next day. The DON stated Resident #1 is always confused doesn't recognized anyone not even family. The DON stated she get lost and confused in the unit at times and staff redirect her to the dining room or her room. The DON stated she screams and yells at times when she is touched because she doesn't like to be touched and this was why a head-to-toe assessment was not able to be completed on the resident. The [NAME] said the staff Resident #1 had combative behavior with ADL's when staff attempted to help because she doesn't like to be touch. The DON stated Resident #1 had no history of altercations with other residents and or staff. The DON said preventive measures were care planed and implemented such as the stop sign banner in Resident #2's doorway. Resident #1 stays in the living room, her room, or close to where staff can keep an eye on her. Record review of the facility's Abuse, Neglect and Exploitation policy dated 7/15/25 indicated, Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through eh use of technology

Based on interview, observation, and record review the facility failed to ensure that residents were free of significant medication errors for 2 of 8 residents (Resident #100 and Resident #235) reviewed for pharmacy services. 1. The facility failed to ensure Resident #100 received the correct dose of phenytoin sodium (anticonvulsant medication) extended oral capsule during his stay from [DATE] - [DATE] at the facility. Resident #100 received 900 mg at bedtime instead of the ordered 300 mg at bedtime for all seven nights he was in the facility, leading to a phenytoin level of 37.1 ug/mL, indicating phenytoin toxicity (normal ,d+[DATE] ug/ml). 2. The facility failed to ensure Resident #235's order for Carbamazepine (anticonvulsant medication) 2 tablets by mouth in the morning for seizures to equal 400 mg in the morning and 1 tablet by mouth at bedtime for seizures to equal 100 mg in the evening was ordered and dispensed correctly on [DATE]. Resident #235 received 200 mg at bedtime on [DATE]. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 4:25 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because new polices implemented to prevent future errors were still in process. These failures could place residents at risk of medical complications and not receiving the therapeutic effects of their medications. The findings included: Record review of Resident #100's face sheet dated [DATE] revealed a [AGE] year-old male with an admitted [DATE] and a discharge date of [DATE]. Pertinent diagnosis included epilepsy (a neurological disorder characterized by recurrent seizures, which are episodes of abnormal brain activity). Record review of Resident #1's PPS MDS assessment dated [DATE] revealed a BIMS score of 3 (severe impairment) Record review of Resident #1's care plan dated [DATE] revealed the problem Medication error- resident received wrong dosage of dilantin (brand name of phenytoin)- order transcribed in error. dilantin toxicity of 37.1 altered mental status initiated on [DATE] and cancelled on [DATE]. Interventions listed for the problem included: - Correct dose of medication clarified initiated on [DATE] and cancelled on [DATE]. - Sent to ER for [evaluation] and treatment initiated on [DATE] and cancelled on [DATE]. - Staff education on [medication reconciliation] initiated on [DATE] and cancelled on [DATE]. Record review of Resident #100's order summary dated [DATE] revealed a discontinued order for Phenytoin Sodium Extended Oral Capsule 300 MG (Phenytoin Sodium Extended). Give 3 capsule by mouth at bedtime for seizures created on [DATE] by LVN A and discontinued on [DATE]. Record review of the admitting orders for Resident #100 dated [DATE] listed the medication order Phenytoin Sodium Extended 100 MG Oral Capsule Dose/Route/Freq: Take 3 capsules (300 mg) by mouth daily at bedtime for seizure disorder. Record review of the laboratory results from a local hospital dated [DATE] revealed the laboratory results for Resident #100 Phenytoin Level to be 37.1, with the stated normal range between 10.0 - 20.0 ug/mL were resulted at 3:58 pm. Record review of the Emergency Department Note from a local hospital dated [DATE] revealed a diagnosis for Resident #100 of Phenytoin poisoning of undetermined intent at 4:54 PM. Record review of the MAR for Resident #100 dated [DATE] revealed the order Phenytoin Sodium Extended Oral Capsule 300 MG (Phenytoin Sodium Extended) Give 3 capsule by mouth at bedtime for seizures with a start date of [DATE] and a discontinued date of [DATE]. The medication was signed off as administered on the nights of [DATE] - [DATE] by nursing staff. Record review of the nurse progress note by LVN A dated [DATE] at 5:39 PM revealed [Resident #100] arrived to facility via family vehicle from home . [MD] notified of resident arrival, all medication list received upon admission has been approved by [MD]. Facetime visit with [MD] has been performed, no new orders received. Record review of the change in condition note by LVN A dated [DATE] at 2:37 PM revealed [Resident #100] appearing to be weak to upper and lower extremities and noted to have a slower response to commands., started [DATE], since started it has gotten: Better. Record review of the nurse progress note by LVN B dated [DATE] at 10:39 AM revealed [Resident #100] noted with confusion this morning, yelling and moaning that he wants to go to his room even though resident already in his room/bed . weakness, unable to feed self, unable to transfer to wheelchair. Resident RP updated on residents' condition and in agreeance to sending resident to hospital. Record review of the nurse progress note by the DON dated [DATE] at 5:33 PM revealed Medication error noted on Dilantin dosage. MD and RP notified. Resident remains in ER for evaluation. Resident was experiencing [altered mental status] and ataxia (poor muscle control that affects balance, coordination, speech and eye movements) and slowed speech. In an interview with LVN A on [DATE] at 12:41 PM, LVN A stated she entered the phenytoin order for Resident #100 into PCC on [DATE] when he was admitted to the facility. LVN A stated when she read the medication list, she interpreted it as 3 capsules of 300 mg at bedtime for a total of 900 mg. LVN A stated anytime she had a question about a medication order she asked an ADON or the DON for clarification, but she was confident she was correct at the time she input this order. LVN A stated it was important for a resident to receive the correct dose of their medication because otherwise a resident could be hospitalized or possibly die. In an interview with LVN B on [DATE] at 2:21 PM, LVN B stated Resident #100's baseline level of function on [DATE] was much worse than when she last saw him on [DATE]. LVN B stated the sharp decrease in level of functioning over such a short time for Resident #100 led to her recommending he be sent to the hospital for evaluation. LVN B stated if a resident received the incorrect dose of their medication for an extended period of time it could lead to death. In an interview with ADON K on [DATE] at 2:38 PM, ADON K stated the two ADONs and DON reviewed medication orders of the previous day during their daily morning meetings. ADON K stated the DON was not at the morning meeting on [DATE], so it fell to the two ADONs to review medication orders. ADON K stated Resident #100's medication order for phenytoin was not reviewed during the morning meeting on [DATE] and she did not know exactly why they did not review it. ADON K stated after the incident they implemented a new white board system to better keep track of their tasks in morning meetings. ADON K stated if a resident received the wrong dose of a medication for an extended period, they might be hospitalized and die. In an interview with ADON L on [DATE] at 3:12 PM, ADON L stated it was both ADONs' responsibility to check the new admission orders of Resident #100 during the morning meeting of [DATE]. ADON K stated she did not know why they did not review Resident #100's phenytoin order. ADON K stated after the incident with Resident #100, they instituted a new policy where all new admission orders needed to be verified by two nurses at the time of entry into PCC. ADON K stated if a resident received the incorrect dose of one of their medications for an extended period, they could be hospitalized or even die. In an interview with the DON on [DATE] at 3:48 PM, the DON stated she was not at the facility on [DATE] for the morning meeting. The DON stated during morning meetings, the ADON's and the DON reviewed everything related to new admissions. The DON stated the ADONs should have verified the phenytoin order for Resident #100 was correct during the morning meeting on [DATE]. The DON stated since the incident, they added an initial nurse to review new admission orders that were put into PCC. The DON stated they now reviewed everything about a new admission as a group in the morning meetings. The DON stated they added a white board to organize their morning meetings, so nothing gets forgotten. The DON stated they had not had any problems since they implemented the new system. The DON stated if a resident took an incorrect dose of medication could led to a decrease in ADL's, decline in mental function, and then eventually death. In an interview with the CP on [DATE] at 5:40 PM, the CP stated she did an admission review of Resident #100's orders on [DATE]. The CP stated she caught the discrepancy on [DATE] and immediately notified the facility to investigate it. The CP stated the phenytoin order in PCC caught her attention because it was different from the admitting paperwork and the dose of 900 mg at bedtime seemed high. The CP stated she typically reviewed all new admission orders within a week of admission into the facility. The CP stated adverse effects of phenytoin toxicity included coma, confusion, tremors, nausea, and vomiting. The CP stated Resident #100 could have eventually died if they continued to receive the increased phenytoin dose but was unable to predict how long the increased dose would take to kill him. In an interview with the MD on [DATE] at 6:11 PM, the MD stated he did not remember the conversation he had with LVN A confirming Resident #100's admission orders on [DATE]. The MD stated a dose of 900 mg of phenytoin at bedtime might not catch his attention as being too high. The MD stated typically the extended-release version of phenytoin would be anywhere between 300 mg to 750 mg, but that he had seen 450 mg BID before. The MD stated phenytoin toxicity could cause cardiac arrythmias (irregular heartbeats that can be too fast, too slow, or irregular) and eventually death. The MD stated there were too many variables to determine how long death would have taken for Resident #100 at the increased dose of phenytoin. The MD stated he saw the resident on [DATE]. The MD stated they had an ad hoc meeting over Resident #100 on [DATE]. 2. Record review of Resident #235's face sheet dated [DATE] revealed an [AGE] year-old female with an admitted [DATE]. Pertinent diagnosis included Other Seizures (sudden, uncontrolled electrical disturbances in the brain that can cause temporary changes in behavior, movement, or awareness). Record review of Resident #235's Comprehensive MDS dated [DATE] revealed a BIMS score of 11 (moderate impairment). Record review of Resident #235's comprehensive care plan dated [DATE] did not reveal anything related to carbamazepine use to prevent seizures. Record review of Resident #235's order summary dated [DATE] revealed an active order for carbamazepine Oral Tablet Chewable 200 MG (Carbamazepine) Give 1 tablet by mouth at bedtime for seizures TO EQUAL 100 MG IN THE EVENING initiated on [DATE]. The MAR also revealed an active order for carbamazepine Oral Tablet Chewable 200 MG (Carbamazepine) Give 2 tablet by mouth in the morning for seizures to equal 400 mg IN THE MORNING initiated on [DATE]. Record review of the MAR for Resident #235 dated [DATE] revealed the order carbamazepine Oral Tablet Chewable 200 MG (Carbamazepine) Give 1 tablet by mouth at bedtime for seizure TO EQUAL 100 MG IN THE EVENING with a start date of [DATE]. The medication was signed off as administered on the nights of [DATE] - [DATE] by nursing staff. In an interview with LVN C on [DATE] at 10:55 AM, LVN C stated she administered medications to Resident #235 on the evening of [DATE]. LVN C stated Resident #235 requested that her medications were crushed before she ingested them. LVN C stated she did not remember specifically about the carbamazepine if she gave the full 200 mg tablet or not. LVN C stated she did not break any tablets in half before crushing them to administer them to Resident #235. LVN C stated it was important to give the correct dose of medication to a resident so it could have its intended therapeutic effect. In a follow-up interview with the CP on [DATE] at 12:13 PM, the CP stated if Resident #235 received an extra 100 mg in the evening one time, she may experience slight sedation related side effects. The CP stated the overall harm caused to the resident could have been minimal after just one dose with the minor daily dose increase from 500 mg to 600 mg. During an observation of the 500-hall medication cart on [DATE] at 12:42 PM, there were no tablets of carbamazepine that were 100 mg for Resident #235, only 200 mg tablets. In a follow-up interview with the DON on [DATE] at 12:45 PM, the DON stated the interventions they implemented after the first incident involving Resident #100 focused on ensuring new admittance orders were accurate. The DON stated the carbamazepine order could have been more precise, but it was a different issue since it was not a new admittance order. The DON stated if a nurse found a discrepancy between the MAR and the label on the medication, they should verify what the correct order was by calling the doctor. In an interview with LVN D on [DATE] at 1:50 PM, LVN D stated she administered medications to Resident #235 on the evenings of [DATE] and [DATE]. LVN C stated she cut the 200 mg carbamazepine tablet in half before she administered it to Resident #235. LVN D stated giving the wrong dose of a medication to a resident could harm them. Record review of the facility policy titled Medication Administration implemented on [DATE] revealed the following: .20. Correct any discrepancies and report to nurse manager. Record review of the facility policy titled Medication Reconciliation implemented on [DATE] revealed the following: .4. Admission Processes: a. Verify resident identifiers on the information received. b. Compare orders to hospital records, etc. Obtain clarification orders as needed. c. Transcribe orders in accordance with procedures for admission orders. d. Order medications from pharmacy in accordance with facility procedures for ordering medications. e. Verify medications received match the medication orders. 5. Daily processes: .b. Verify medication labels match physician orders and consider rights of medication administration each time a medication is given. c. Obtain and transcribe any new orders in accordance with facility procedures. Obtain clarification as needed. d. Order medications from pharmacy in accordance with facility procedures for ordering medications. e. Verify medications received match the medication orders. This was determined to be an Immediate Jeopardy (IJ) on [DATE]. The ADM and DON were notified. The ADM was provided with the IJ template on [DATE] at 4:25 PM. The following Plan of Removal submitted by the facility was accepted on [DATE] at 9:02 AM: [DATE] LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY Attention Sir or Madam: On [DATE], the Facility was notified by the surveyor that immediate jeopardy had been called and the Facility needed to submit a letter of removal. The Facility respectfully submits this Letter for a Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy is as follows: Issue: F 760 - Medication Error The facility failed to: - The facility failed to ensure Resident #100 received the correct dose of phenytoin sodium extended oral capsule during his stay from ,d+[DATE] /25 - [DATE] at the facility - The facility failed to ensure Resident #235's order for Carbamazepine 2 tablets by mouth in the morning for seizures to equal 400 mg in the morning and give 1 tablet by mouth at bedtime for seizures to equal 100 mg in the evening was ordered and dispensed correctly on [DATE]. Actions for Resident Involved - Resident # 100 was discharged on [DATE]. - On [DATE], the licensed nurse completed a head-to-toe assessment, vital signs and neurological check on Resident #235 and findings revealed no abnormalities noted. Attending physician was notified and no new orders were given. Identify residents who could be affected: - On [DATE], the Director of Nursing and/or Designee completed medication reconciliations to ensure that medications are given as ordered and documented on the MAR. - On [DATE], the Director of Nursing and/or designee conducted a review of all residents' changes in conditions, changes in level of care and signs and symptoms that possibly could have been medication toxicity for the last 30 days. None was identified. - On [DATE], the Director of Nursing and/or designee conducted a review of all admissions/readmissions and ER visits for the last 30 days to ensure medication orders are reconciled. - On [DATE], the Director of Nursing and/or designee conducted a toxicity Monitoring orders for all drugs with narrow therapeutic range and were added to EMAR. - On [DATE], DON and/or Designee completed 100% medication reconciliation and MAR to Cart audit to ensure that medication on hand matches order and are administered as ordered. Action Taken/ System Change: - On [DATE], All licensed nurses were re-educated by the Director of Nursing or designee on the following: - Abuse/Neglect and Exploitation - Medication Administration Policy and Seven Rights of medication administration - Medication Reconciliation - Change of Condition-signs/symptoms of medication toxicity and Md/RP notifications - Clinical Admission Process in EMR completed on [DATE] - 2 nurse verification on all new admission/readmission orders - On [DATE], 100% licensed nurses were re-educated on the following: - Medication Administration Policy and Seven Rights of medication administration - Medication Reconciliation on new and medication order changes - Verification of medication label prior to medication administration - Beginning [DATE], licensed nurses who are out on PTO/ FMLA/ Leave of Absence will have the re-education completed prior to the start of their next scheduled shift. - Beginning [DATE] and ongoing, newly hired licensed nurses will receive this training during orientation prior to providing care to residents. The training will include the above-stated educational components. - Admission/readmission/new and medication order changes will be reviewed during the morning clinical meeting to ensure orders have been reconciled with hospital records and verified with physician. New and medication order changes will be reviewed to ensure medication is administered as ordered to include verification of medication label to match physician's orders. Review will also ensure that monitoring of adverse effects is ordered, completed, and documented and physician is notified for abnormal findings. - Weekend RN and/or ADON will complete and review Medication reconciliation for admission/readmissions/new orders/medication order changes over the weekend. Completion date: [DATE] Monitoring: - Beginning [DATE] and going forward, the Director of Nursing will monitor compliance with medication administration policy and the seven rights of medication administration. - Beginning [DATE] and going forward, Director/Designee will monitor compliance each weekday morning of new admission/readmission reconciliation completion and review medication order listing report to ensure new and changed medications are administered as ordered. - Beginning [DATE], the Administrator will attend the morning clinical meeting to ensure the Director of Nursing and/or designee reviews the order listing and medication reconciliation process is followed during clinical meetings. - On [DATE], An Ad Hoc QAPI meeting was held with the Medical Director, Facility Administrator, Director of Nursing, and Regional Clinical Specialist to review the plan of removal. We respectfully submit this action plan for the removal of Immediate Jeopardy. Administrator Verification of Plan of Removal: In interviews beginning on 12:41 PM on [DATE] and ending on [DATE] at 1:47 PM with staff from multiple shifts, the DON, ADM, LVN A, LVN B, LVN C, LVN D, RN E, LVN F, LVN G, LVN H, RN I, LVN J, ADON K, ADON L, LVN M, CNA N, CNA O, CNA P, RN Q, CNA R, CNA S and LVN T were able to identify the proper procedures to follow when creating new admittance orders, recognizing possible side effects of various drug toxicities, identifying high risk drugs that needed to be monitored more closely, and what to do when they encountered a discrepancy with an order. Record review and verification of the corrective action implemented by the facility beginning on [DATE]: - On [DATE], completed medication reconciliations to ensure that medications were given as ordered and documented on the MAR - verified by interview with the DON on [DATE]. - On [DATE], conducted a review of all residents' changes in conditions, changed in level of care and signs and symptoms that possibly could have been medication toxicity for the last 30 days - verified by interview with the DON on [DATE] and record review of change of condition list. - On [DATE], conducted a review of all admission/readmissions and ER visits for the last 30 days to ensure medication orders are reconciled - verified by interview with the DON of [DATE]. - On [DATE], conducted a toxicity monitoring orders for all drugs with narrow therapeutic range and added to MAR - verified by interview with the DON on [DATE] and the CP on [DATE]. - On [DATE], completed 100% medication reconciliation and MAR to cart audit to ensure that medication on hand matches orders were administered as ordered - verified by interview with the DON on [DATE] and observation of med pass by this state surveyor on [DATE]. - On [DATE], all licensed nurses were re-educated by the DON on abuse/neglect, medication administration, medication reconciliation, change of condition signs and symptoms, clinical admission process, two nurse verification on all new admission/readmission orders - verified by interview with the DON on [DATE] and various staff from [DATE] - [DATE]. Staff were able to explain the various processes that were put in place. - On [DATE], 100% of licensed nurses were re-educated on medication administration policy, medication reconciliation, and verification of medication label prior to medication administration - verified by interview with the DON on [DATE] and various staff from [DATE] - [DATE]. Staff were able to explain the various processes that were put in place. - Admission/readmission/new and medication order changes will be reviewed during the morning clinical meeting to ensure orders have been reconciled with hospital records and verified with physician. New and medication order changes will be reviewed to ensure medication is administered as ordered to include verification of medication label to match physician's orders. Review will also ensure that monitoring of adverse effects is ordered, completed and documented and physician is notified for abnormal findings - verified through interview with the DON on [DATE]. - Weekend RN and/or ADON will complete and review medication reconciliation for admission/readmissions/new orders/medication order changes over the weekend - verified by interview with the DON on [DATE]. - Beginning [DATE], the DON will monitor compliance with medication administration policy and the seven rights of medication administration by keeping up with staff training. - verified by interview with the DON on [DATE]. - Beginning on [DATE], the DON will monitor compliance each weekday morning of new admission/readmission reconciliation completion and review medication order listing report to ensure new and changed medications are administered as ordered - verified by interview with the DON on [DATE]. - Beginning on [DATE], the ADM will attend the morning clinical meeting to ensure the DON or designee reviews the order listing and medication reconciliation process is followed during clinical meetings - verified by interview with the ADM on [DATE]. - On [DATE], an Ad Hoc QAPI meeting was held with the MD, ADM, DON, and Regional Clinical Specialist to review the POR - Verified by interview with the ADM and DON on [DATE] and record review. The ADM was informed the Immediate Jeopardy was removed on [DATE] at 4:10 PM. 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's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided with care consistent with professional standards of practice, physicians orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 3 of 5 (Resident #32, #47, #2) residents reviewed for respiratory care. The facility failed to ensure Resident #32's oxygen was administered at the physician's orders of 2.5 liters per minute on 05/19/25. The facility failed to ensure Resident #47's oxygen was administered at the correct setting of 3 liters per minute on 05/20/2025 at 8:56 AM. The facility failed to ensure Resident #2's oxygen was administered at the correct setting of 3 liters per minute on 05/19/2025 at 10:31 AM. These failures could place residents at risk for symptoms and manifestations of hypoxia, the decreased perfusion of oxygen to the tissues and a decreased quality of care. The findings include: facility on 04/12/24. Resident #32 had a diagnosis which included Review the physician's orders or facility protocol for oxygen administration. Resident #47's oxygen was administered at the incorrect setting of 2.5 liters per minute on 05/20/25 at 8:56 AM. Respiratory Failure with Hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), Shortness of breath, Hypoxemia (A low level of oxygen in the blood), and Chronic Obstructive Pulmonary Disease (A group of lung diseases that block airflow and make it difficult to breathe). Record review of Resident #32's physician order summary dated 04/25/25 revealed O2 at 3 Liters Per Minute via nasal cannula continuously maintain O2 saturation greater than 92 percent as needed for hypoxia. Record review of Resident #32 Care plan revealed Resident #32 has oxygen therapy related to COPD respiratory failure, shortness of breath, and hypoxia. Interventions dated 07/11/2024 O2 via nasal prongs at 2-3 Liters continuous. Record review of Resident #32's Significant Change Minimum Data Set, dated [DATE] revealed an active diagnosis of CODP (Chronic Obstructive Pulmonary Disease), Respiratory failure, Dyspnea (shortness of breath) with exertion and lying flat. Observation and interview of Resident #32 on 05/20/25 at 08:56 AM revealed oxygen tubing was connected, oxygen setting was at 4.50 liters per minute, Resident #32 stated she was doing fine. No respiratory distress noted. Record review of Resident #47's face sheet, dated 05/21/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #47 had a diagnosis which included Acute Respiratory Failure with Hypoxia, Pneumonia due to Coronavirus, Pleural Effusion (a buildup of fluid between the tissues that line the lungs and the chest), and Chronic Obstructive Pulmonary Disease and shortness of breath. The physician's orders or facility protocol for oxygen administration. Resident #2's oxygen was administered at the incorrect setting of 2.5 liters per minute on 05/19/25 at 10:31 AM. Record review of Resident #47's physician order summary dated 05/15/25 revealed, O2 at 3 Liters Per Minutes via nasal cannula continuously maintain O2 sats greater than 92% as needed for hypoxia. Record review of Resident #47's care plan revealed the resident had oxygen therapy related to hypoxia initiated on 01/21/25. The care plan interventions indicated oxygen settings of O2 via nasal cannula as ordered. Record review of Resident #47's Minimum Data Set, dated [DATE] revealed an active diagnosis of Active Pneumonia, Asthma COPD (Chronic Obstructive Pulmonary Disease), Respiratory failure, Chronic Lung Disease. Observation and interview of Resident #47 on 05/19/2025 at 09:44 AM revealed that the oxygen tubing was connected and the oxygen setting was set at 2 liters per minute. Resident #47 stated she was breathing fine. Record review of Resident #2's face sheet, dated 05/19/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had a diagnosis which included COPD (Chronic Obstructive Pulmonary Disease), and Acute Respiratory Failure with Hypoxia. Record review of Resident #2 care plan dated 02/08/24 revealed she had oxygen therapy related to COPD. The interventions indicated the oxygen setting at 3 liters per minute via nasal cannula. Record review of Resident #2's physician order summary dated 05/15/25 revealed O2at 3 liters per minute via nasal cannula continuously maintain O2 sats > 92% as needed for hypoxia. Record review of Resident #2's Significant Change Minimum Data Set, dated [DATE] revealed an active diagnosis of Asthma, CODP (Chronic Obstructive Pulmonary Disease), Chronic Lung Disease, and Respiratory Failure. Observation on 05/19/25 at 10:21 AM of Resident #2 revealed resident was lying down in bed and the oxygen tubing was connected to concentrator set at 2.5 liters per minute. In an interview on 05/21/25 at :04 PM with CNA N she observed and stated Resident #32 ' s oxygen concentrator was set at 4.5 liters per minute. CNA N stated she did not know what the settings should be set at and the CNA's were not responsible for the concentrator settings. The nursing staff were responsible for checking the oxygen concentrators. In an interview on 05/21/2025 at 1:30 PM, CNA R R observed and stated #47 ' s oxygen concentrator was set at 2.5 liters per minute. CNA R stated she did not know what the settings should be set. The CNA's were not responsible for the settings; only the nursing staff were responsible for checking the oxygen concentrators. In an Interview with on 05/21/2025 at 1:44 PM CNA Robserved and stated Resident #2 ' s oxygen concentrator was set at 2.5 liters per minute. The CNA R stated she did not know what the settings should be. The CNA's are not responsible for the concentrator settings the nursing staff were responsible for checking the oxygen concentrators. In an interview on 05/21/25 at 1:51 PM with LVN C she stated that at the start of every shift the LVNs were responsible for ensuring the settings on the oxygen concentrators matched the physician orders. LVN C stated she had not checked the settings on the oxygen concentrator for Resident #32 the last 4 days and admitted she forgot to check them. She stated not having the correct setting can cause the CO2 levels to be high or high levels or O2 each leading to problems such as oxygen poisoning or toxicity and can lead to lung damage and potentially life-threatening complications. In an interview on 05/21/25 at 2:01 PM with LVN C she stated that at the start of every shift the LVNs are responsible for ensuring the settings on the oxygen concentrators matched the physician orders. LVN C stated she had not checked the settings on the oxygen concentrator for Resident#47 the last 4 days she had forgotten.The levels were set at 2.5 liters per minute and correct settings were to be at 3 liters per minute when verified them in the room on her laptop. She stated not having the correct setting can cause Hypoxemia to a condition of levels of oxygen in the blood are low. This can lead to insufficient oxygen delivery, potentially resulting in low blood oxygen saturation. Symptoms of low oxygen in blood are shortness of breath, chest pain, or bluish coloring of skin. In an interview on 05/21/25 at 2:14 PM with LVN C she stated that at the start of every shift the LVNs are responsible for ensuring the settings on the oxygen concentrators match the physician orders. LVN C stated she had not checked the settings on the oxygen concentrator for Resident#2. The last 4 days the levels were set at 2.5 liters per minute and correct settings were to be at 3 liters per minute and admitted she forgot to checked the settings. LVN C Verified the setting on her lab top as the interview was conducted. She stated not having the correct setting can cause Hypoxemia a condition of levels of oxygen in the blood are low. This can lead to insufficient oxygen delivery, potentially resulting in low blood oxygen saturation. Symptoms of low oxygen in blood are shortness of breath, chest pain, or bluish coloring of skin. In an interview with ADON K 05/21/25 at 2:27 PM she stated each nurse in every shift, every day, and in all wings should be checking resident oxygen concentrators as part of their rounds. ADON K stated CNA's were not responsible for the oxygen concentrators setting. Nurses should be ensuring the oxygen delivery to the resident but need to be reporting any discrepancies as soon as they find one. The ADON stated Accuracy in administrating all doctor's orders for oxygen should be followed as written by the doctor if a discrepancy is noted, it is to be suspended until it is verified by the ordering doctor. In an interview with the DON on 05/21/25 at 02:47 PM she stated any doctor's orders for oxygen are to be followed as directed. The nurse on duty for each shift was responsible for verifying the oxygen concentrator was at the correct setting each shift. Following the doctor's orders ensured that the resident was getting enough oxygen to prevent hypoxemia, hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions or oxygen toxicity. Record review of the facility's Oxygen Administration Program policy dated 10/02/2010 reflected All residents will be assessed for the Oxygen Administration at the time of admissions, on a quarterly basis, and upon significant change in condition thereafter. Based on the results of this assessment, specific interventions will be to ensure correct settings and avoid any complications. The following is a list of commonly used interventions that may be considered to minimize improper settings symptoms of hypoxia (i.e., rapid breathing, rapid pulse rate, restlessness, confusion; signs or symptoms of oxygen toxicity (i.e., tracheal irritation, difficulty breathing, or slow, shallow rate of breathing); signs or symptoms of cyanosis(bluish or grayish color of the skin, nails, lips and around the eyes

Based on observation, interview, and record review, the facility failed to ensure the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 (Resident #4) of 5 residents reviewed for resident rights. The facility failed to treat Resident #4 with dignity and respect during perineal care (cleansing of the genital and anal areas) in Resident #4's room on 11/08/24 when CNA F wiped the buttocks of Resident #4 and showed the resident the dirty wipe with feces on it twice. This failure could place residents who require assistance with ADL's at risk of feeling disrespected. Findings included: Record review of Resident #4's face sheet dated 04/15/25 revealed an [AGE] year-old female with an initial admitted [DATE] and a current admitted [DATE]. Pertinent diagnoses included Alzheimer's Disease (progressive brain disorder that primarily affects memory, thinking, and behavior) and an unspecified mood disorder (experiencing mood disturbances but symptoms did not fully meet criteria for a specific mood disorder diagnosis). Record review of Resident #4's Quarterly MDS assessment dated [DATE] section C, cognitive patterns, revealed a BIMS score of 3 (severe impairment). Record review of Resident #4's comprehensive care plan dated 04/15/25 revealed the problem [Resident #4] has an ADL self-care performance deficit r/t Alzheimer's Disease and dementia. [Resident #4] required assistance with x 2 staff for all care need and ADL's r/t behaviors r/t Alzheimer's Dementia. [Resident #4] may be resistive to care or combative during care. Care should be provided by 2 staff members. Redirection and reapproaches should be attempted initiated on 11/19/19 and revised on 11/14/24. Interventions listed for the problem include: - Encourage [Resident #4] to make decisions regarding ADL care. Encourage as much participation as tolerated initiated on 12/24/19. - Usual functioning for toilet hygiene is dependent Initiated on 03/12/24. Record review of the facility's provider investigation report dated 11/20/24 revealed the incident occurred on 11/08/24. Resident's [Family Member] claimed that she had watched her [Resident #4] receive peri-care from nurse aide [CNA F] who had placed blankets accidentally over her face while giving incontinent care and was holding wipes up by her face to show the resident she was soiled in an effort to let the aide perform care. The director of nursing was notified that [Family Member] had observed CNA flinging blankets and wipes during pericare and that the blanket had accidentally landed over her face, and instructed that [CNA F] be sent home pending education. Record review of CNA F's undated witness statement I began changing her and she had a lot of poop but she started to attempt to scratch me again so I tried to show her the wipe with poop on it. I told her look you have doo doo let me change you because you have doo doo. She still continued being combative. I finished cleaning her as best I could and I went to put the blankets back over her and it did land on her face. I quickly tried to remove it and the resident pulled it down before I could pull it down. I didn't purposely put it on her face I was just trying to clean her by myself while she was trying to fight me and it landed there. I finished my care and left resident covered in bed and lowered the bed to the floor and left the room. During an observation of a surveillance video at 4:13 PM on 04/15/25 from Resident #4's room with an unknown timestamp, CNA F was observed showing Resident #4 the dirty cleansing wipe by intentionally holding it up in the air in Resident #4's plain view on two separate occasions. CNA F was observed to reposition Resident #4's blanket for accessibility to Resident #4's perineal area. Resident #4 was observed to immediately remove the blanket away from her face. In an interview with FM 2 at 2:56 PM on 04/15/25, FM 2 stated Resident #4 could become unruly when CNAs attempted to provide perineal care. FM 2 stated she observed the surveillance video of the incident with CNA F and felt it was abuse. FM 2 stated she was disgusted with the way CNA F treated Resident #4 in the surveillance video. An interview was attempted with Resident #4 on 04/15/25 at 4:35 PM but Resident #4 but she did not respond to any questions. In an interview with CNA G at 5:02 PM on 04/15/25, CNA G stated she always treated residents with respect and dignity. CNA G stated she always had a 2nd staff member to help her whenever she assisted Resident #4. CNA G stated she would never wipe a resident and show it to them because that would be demeaning to the resident. During an interview with LVN H at 9:08 AM on 04/16/25, LVN H stated it was not appropriate to show a resident their dirty wipe because it may upset them and cause more agitation in the resident. LVN H stated the resident's face should not be covered when performing care. LVN H stated showing a resident the dirty wipe was not treating a resident with respect and dignity. LVN H stated if she was having trouble with a resident she would leave, wait 10-15 minutes, and then come back with an extra staff member to help provide care. During an interview with the DON at 10:29 AM on 04/16/25, the DON stated she had seen the surveillance video of the incident between CNA F and Resident #4. The DON stated she did not feel like CNA F handled the situation in the most appropriate manner. The DON stated nurses and CNAs were trained to leave the room for a short time and then return with another staff member whenever they were having difficulty providing care to a resident. The DON stated she did not feel like Resident #4 was treated with dignity and respect during this incident. The DON stated it was important to treat a resident with dignity and respect because this was their home and it was their right. The DON stated if residents were not treated with dignity and respect than they could become depressed or anxious about receiving care. Record review of the facility policy titled Promoting/Maintaining Resident Dignity implemented 01/13/23 revealed the following: All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. When interacting with a resident, pay attention to the resident as an individual. Groom and dress residents according to resident preference.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse for 2 of 5 residents (Resident #2 and #3) reviewed for abuse, neglect, and exploitation. 1. The facility failed to protect Resident #3 from sexual abuse when Resident #2 slapped Resident #3 on the buttocks on 07/28/24. 2. The facility failed to protect Resident #2 from physical abuse when Resident #3 hit Resident #2 in the face for slapping him on the buttocks on 07/28/24. Findings included: This failure could place residents at risk for physical or psychological harm or injury. Record review of Resident #2's face sheet, dated 04/15/25, revealed an [AGE] year-old male with an original admitted [DATE]. Resident #2's diagnoses included Dementia (a group of symptoms affecting memory, thinking and social abilities), Cognitive Communication Deficit (communication difficulties that arise from cognitive impairments), and High Risk of Heterosexual Behavior (all unprotected heterosexual activities occurring outside of a consistent sexual relationship). Record review of Resident #2's annual MDS assessment, dated 04/08/25, revealed a BIMS score of 05, which indicated severely impaired cognition. The MDS did not indicate any behaviors for Resident #2. Record review of Resident #2's care plan, initiated 08/10/23, revealed the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs; Resident #2's care plan, initiated 04/04/23 and revised 01/07/25, revealed the resident had a behavior problem with inappropriate sexual behavior; Resident #2's care plan, initiated 03/20/24, revealed the resident had the potential to wander and become agitated and restless at times; and Resident #2's care plan, initiated 07/04/24, revealed the resident needed a structured environment. Record review of Resident #2's progress note, dated 07/28/24, revealed Resident #2 slapped Resident #3 on the left buttocks. Resident #3 turned around and punched Resident #2 in the face, knocking his glasses off, and creating a superficial scratch on the bridge of Resident #2's nose and redness to Resident #2's left cheek. Another progress note, dated 07/28/24, revealed Resident #2 had triple antibiotic ointment applied to his nose. Record review of Resident #2's physician orders, dated 07/28/24, revealed an order to apply triple antibiotic ointment to the superficial abrasion to the bridge of Resident #2's nose. Record review of Resident #3's face sheet, dated 04/16/25, revealed a [AGE] year-old male with an original admitted [DATE] and a current admitted [DATE]. Resident #3's diagnoses included Bipolar Disorder (characterized by extreme mood swings), Schizoaffective Disorder (combined schizophrenia and mood disorder), and Schizophrenia (serious mental health condition that affects how people think, feel, and behave). Record review of Resident #3's significant change MDS assessment, dated 03/26/25, revealed a BIMS score of 09, which indicated moderately impaired cognition. MDS did not indicate any behaviors for Resident #3. Record review of Resident #3's care plan, initiated 10/14/24, revealed resident was dependent on staff for meeting emotional, intellectual, physical, and social needs; Resident #3's care plan, initiated 06/20/24 and revised 09/20/24, revealed resident had a behavior problem including indecent exposure, touching genitals in public, and hitting other residents. Resident #3's care plan, initiated 07/04/24 and revised 09/20/24, revealed resident needed a structured environment. Resident #3's care plan, initiated 07/28/24 and revised 12/12/24, revealed resident had the potential to be physically aggressive and had poor impulse control, and Resident #3 could be triggered for physical aggression when touched by others in a way that he felt inappropriate. Record review of Resident #3's progress note, dated 07/28/24, revealed new order for anxiety medication given due to behavior of punching another resident, and review of other progress notes, dated 08/02/24 and 08/03/24, revealed the resident was sent to a behavior hospital due to aggressive behaviors toward staff and other residents. Record review of Resident #3's psychology note, dated 07/31/24, revealed the resident had history of behaviors and delusions (strongly held false beliefs that conflict with reality) with disorganized speech. In an interview with Resident #2 on 04/14/25 at 1:51 PM, Resident #2 was observed sitting in his wheelchair in his room. He stated he thought he remembered getting hit on the neck one time, but could not remember when or where it happened, or who hit him. In an interview with Resident #3 on 04/14/25 at 1:56 PM, Resident #3 was observed lying in his bed watching television. He stated he did not remember the incident, but thought he remembered hitting a man one time because he tried to steal his goat, but he did not remember when it happened or who the man was. In an interview with CNA-B on 04/14/25 at 2:04 PM, she stated she vaguely remembered the incident, but she knew Resident #2 had a habit of slapping or grabbing people who got close to him. She stated Resident #2 did not mean it aggressively, he forgot that he should not touch other people. She stated Resident #3 was not typically aggressive either, but he thought someone was touching or grabbing his buttocks, so he turned around and slapped him. She stated she understood that these behaviors could impact the residents both physically and/or psychologically. In an interview with LVN-A on 04/14/25 at 2:20 PM, she stated she was not here when this incident with Resident #2 slapping or grabbing Resident #3 occurred. Resident #2 was very grabby, but not in an aggressive way. He liked to touch or grab people as they walked by or got close to him. She stated Resident #3 probably thought he was being grabbed in an inappropriate way, so he responded by turning around and hitting him in the face. She stated she understood that these actions could have caused the residents physical or psychological harm. In an interview with the DON on 04/14/25 at 2:35 PM, she stated Resident #3 had some PTSD from childhood sexual abuse and trauma, so he did not like to be touched by others. She stated Resident #2 was a grabber and a toucher, and he would grab or touch anyone that walked by. When he grabbed or slapped Resident #3 on the buttocks, Resident #3 just reacted instantly by hitting him in the face. She stated Resident #3 had not hit anyone at this facility previously, and he had not hit anyone at this facility since. She stated she understood how this behavior could have caused physical or psychological trauma. She initially stated there had not been anymore issues since this incident, but then proceeded to state next time Resident #2 grabbed Resident #3, Resident #3 did not lose his temper or hit back. Resident #3 just walked away. In an interview with the Administrator on 04/14/25 at 2:55 PM, he stated Resident #2 smacked Resident #3 on the buttocks, but it was not meant as anything sexual or aggressive. He stated Resident #2 had a habit of reaching out and grabbing or tapping people as they walked by, but there had not been any more issues between Resident #2 and Resident #3 since this grabbing or slapping incident on 07/28/24 happened. The administrator stated he saw how this could cause physical or psychological harm to someone, but he also stated that was not the case here because Resident #2 didn't not mean this sexually or in an aggressive manner. In an interview with LVN C on 04/15/25 at 1:40 PM, she stated Resident #2 slapped Resident #3 on the buttocks, and even though Resident #2 did not mean anything by it, Resident #3 did not like to be touched, so Resident #3 hit him back in the face. She stated Resident #2 ended up with a scratch to the top of his nose and some redness to one of his cheeks. She stated Resident #3 did not mean to hit Resident #2, or cause any harm, it was just a reaction to being touched. She stated she understood how Resident #3 might have interpreted this as unwanted sexual behavior even though Resident #2 had a habit of grabbing everyone as they walked by. She also stated she understood how unwanted sexual behavior could cause someone to react aggressively. In an interview with the Regional Nurse on 04/15/25 at 4:50 PM, she stated that sexual abuse was inappropriate or unwanted touching. She also stated this was not considered abuse because it was not willful and there was no intent. She stated nothing was meant sexually or aggressively. Upon reading the facility's Abuse and Neglect Policy, she stated sexual abuse was any non-consensual sexual contact of any type with a resident. She also stated she was not sure how a person would determine when slapping or groping done by Resident #2 was being done in a sexual manner versus a nonsexual manner. The regional nurse stated she understood how Resident #3 could have interpreted this as unwanted sexual behavior, and that was why he reacted the way he did. She understood how these types of behaviors could cause a resident to experience physical or psychological harm. Record review of the facility's Abuse, Neglect and Exploitation Policy, implemented 08/15/22, revealed It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Sexual abuse is defined as non-consensual sexual contact of any type with a resident.

Based on interviews and record reviews, the facility failed to complete a comprehensive assessment within 14 days after a significant change in the physical condition for 1 of 5 residents (Resident #1) whose records were reviewed for assessments. The facility failed to complete a Significant Change MDS assessment for Resident #1 within 14 days after the resident had a fall with major injury (broken right arm) on 04/27/24. This failure placed residents at risk for not having interventions developed to meet their needs for care, assistance, and treatments. The findings included: Record review of Resident #1's admission record reflected a [AGE] year-old-female who was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Her diagnoses included dementia (loss of memory, language, problem solving and other thinking abilities that significantly impairs a person's ability to perform daily activities), history of falling, exudative age-related macular degeneration (an eye condition that causes permanent and rapid central vision loss), lack of coordination, need for assistance with personal care, and muscle wasting and atrophy (loss of muscle mass and strength). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 7, which indicated Resident #1 had severe cognitive impairment. Record review of Resident #1's nurse progress notes dated 04/10/24 to 05/11/24 reflected an entry by LVN D dated 04/27/24 at 12:30am that stated, Resident in room and overheard yelling by CNA. Upon entering room resident noted on floor in supine (on her back) position. Resident c/o right arm/elbow pain. Resident noted moving right arm around constantly. No shortening of limbs noted. Noted with nickel size purple discoloration below right elbow. Resident medicated with APAP 325mg 2 tabs p.o. for pain. Resident denies hitting her head. No further injuries noted. Resident assisted back into bed. Neuros initiated. X-rays to be done. Record review of Resident #1's radiology report dated 04/27/24 at 1:55pm reflected an acute right humeral neck fracture (a sudden onset of a break of the top of the bone of the right arm just below the shoulder). Record review of Resident #1's orthopedic physician notes dated 06/24/24 reflected Resident #1 did not have surgery on her broken right arm. Record review of the completed MDS reports for Resident #1 between 04/16/24 and 07/16/24 reflected a significant change MDS was not completed after Resident #1 fell and broke her proximal right humerus (the top part of the long bone at the top of the arm just below the shoulder) on 04/27/24. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected in section J1800 Resident #1 had fallen since the prior assessment. Section J1900, however, reflected only that Resident #1 had 1 fall with no injury and 1 fall with injury (except major). Resident #1's fall with a major injury that occurred on 04/27/24 was not documented. In an interview on 04/16/25 at 10:44am the DON stated the MDS nurse was responsible for submitting all of the MDS reports as well as any significant change MDS reports. The DON stated the MDS nurse was made aware of significant changes in morning meetings. In an interview on 04/16/25 at 11:55am the MDS nurse stated she had been employed at the facility for 1 year and a fall with a fracture was considered a significant change. The MDS nurse stated she relied on reports from the nurses, the DON, or the ADON to know a significant change needed to be addressed. The MDS nurse stated the time frame for a significant change to be put into the MDS assessment record was 5 to 7 days, but her personal preference was to submit a significant change MDS assessment within 5 days. The MDS nurse stated the quarterly MDS section J1900 dated 07/16/24 should have been coded as a fall with a major injury also because Resident #1 had fallen since the previous quarterly assessment was done on 04/16/24. The MDS nurse stated Resident #1 should have had a significant change MDS assessment done after her fall in April 2024 that resulted in the broken arm. The MDS nurse stated even if the significant change MDS assessment had been done within 14 days of Resident #1's fall, the next quarterly MDS assessment still should have documented the fall with major injury in section J1900. The MDS nurse stated she was not the MDS nurse at the time of Resident #1's fall, but it was the responsibility of the MDS nurse to make sure the significant change MDS assessment was completed. Record review of the facility's Assessment Frequency/Timeliness Policy dated 10/24/22 reflected in part: Policy: The purpose of this policy is to provide a system to complete standardized assessments in a timely manner, according to the current RAI Manual. Policy Explanation and Compliance Guidelines: 3. Within 14 days after the facility determines or should have determined there has been a significant change in the resident's physical or mental condition, a significant change in status assessment will be completed. 7. An entry tracking record will be completed within 7 days of the reentry event.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment, and describes services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's comprehensive care plan was revised following a significant change assessment which identified a fall occurrence on 04/27/24 in which she sustained a major injury (right arm fracture). This failure could place residents at risk of not receiving the services needed to attain or maintain their highest practicable physical well-being. The findings included: Record review of Resident #1's admission record reflected a [AGE] year-old-female who was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Her diagnoses included dementia (loss of memory, language, problem solving and other thinking abilities that significantly impairs a person's ability to perform daily activities), history of falling, exudative age-related macular degeneration (an eye condition that causes permanent and rapid central vision loss), lack of coordination, need for assistance with personal care, and muscle wasting and atrophy (loss of muscle mass and strength). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 7, which indicated Resident #1 had severe cognitive impairment. Record review of Resident #1's nurse progress notes dated 04/10/24 to 05/11/24 reflected an entry by LVN D dated 04/27/24 at 12:30am that stated, Resident in room and overheard yelling by CNA. Upon entering room resident noted on floor in supine (on her back) position. Resident c/o right arm/elbow pain. Resident noted moving right arm around constantly. No shortening of limbs noted. Noted with nickel size purple discoloration below right elbow. Resident medicated with APAP 325mg 2 tabs p.o. for pain. Resident denies hitting her head. No further injuries noted. Resident assisted back into bed. Neuros initiated. X-rays to be done. Record review of Resident #1's radiology report dated 04/27/24 at 1:55pm reflected an acute right humeral neck fracture (a sudden onset of a break of the top of the bone of the right arm just below the shoulder). Record review of Resident #1's orthopedic physician notes dated 06/24/24 reflected Resident #1 did not have surgery on her broken right arm. Record review of Resident #1's nurse progress notes dated 07/12/24 to 08/12/24 reflected an entry by LVN E dated 07/18/24 at 11:14am that stated in part, LE- this nurse called to memory care unit on 07/17/24 approximately 4:40pm- upon arrival charge nurse assessing resident that had fallen from w/c- resident sitting on floor near table in common area- legs extended out in front of not wearing shoes nor non-slip socks. Full ROM noted to lower extremities- wheelchair behind resident- unlocked. Resident with active bleeding from nares- bridge of nose from laceration and mouth- slight bruising- forming- around eyes and nasal area. Resident is stating, I fell - crying and appearance of nervousness from the bleeding- is holding towel to mouth for the bleeding full ROM to upper extremities noted. Coughing out small blood clots at times. 911 called as well as MD [provider's name] and RP [RP's name]- notified of fall and bleeding- made aware of being sent to [name of hospital] ER for evaluation and treatment. Another entry by LVN F dated 07/17/24 at 9:57pm stated in part, Resident arrived per EMS no acute distress noted . resident with [brand name of wound closure strips] (thin sticky bandages applied to the skin to help small cuts or wounds stay closed) to bridge of nose, small hematoma to top of left eyebrow . according to written report, no acute intracranial (within the skull) abnormalities, does have mildly displaced nasal bone fracture. Record review of Resident #1's care plan with revisions/cancellations dated 04/22/21 reflected Resident #1 was at risk for falls due to her impulsive behavior, dementia, impaired mobility, and a history of falls at home and in the facility with minor injury that was initiated on 04/22/21 and revised on 04/29/24. The only intervention that was added was dated 04/28/24 and stated staff would toilet Resident #1 every 2 hours and PRN. This care plan also reflected Resident #1 had an actual fall with injury due to losing her balance while leaning forward that was initiated on 07/17/24. An intervention that was initiated on 07/09/24 and revised and cancelled on 07/12/24 stated, arm positioning sling on at all times. Another intervention was also initiated on 07/09/24 and revised and cancelled on 07/12/24 stated, referral to orthopedic MD for consult post fracture. The only information in Resident #1's care plan that reflected the fall which resulted in a broken right arm on 04/27/24 were the 2 interventions that were initiated on 07/09/24, 73 days after the fall. In an interview on 04/16/25 at 10:44am the DON stated she thought she may have deleted the fall that occurred on 04/27/24 on the care plan and replaced it with the fall that occurred on 07/17/24 and that was why it did not show on the care plan. The DON stated she did not remember if it was done, on time or late or what. The DON stated she apparently did it wrong when she deleted items instead of marking them resolved or cancelled. The DON stated it was ultimately her responsibility to make sure significant changes got care planned and if things were not care planned, it could result in the resident not receiving the necessary treatment, care and services. The DON stated significant changes were communicated to the interdisciplinary team during morning meetings. In an interview on 04/16/25 at 11:10am, the Regional Nurse stated she would retrain the nursing management staff on care plans to ensure they were being updated correctly. In an interview on 04/16/25 at 11:55am the MDS nurse stated when she completed an MDS, she tried to make sure the care plan was updated to include any new areas of focus and interventions for them. Record review of the facility's Care Plan Revisions Upon Status Change Policy dated 10/24/22 stated in part: Policy: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: a. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable. b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. c. The team meeting discussion will be documented in the nursing progress notes. d. The care plan will be updated with the new or modified interventions. e. Staff involved in the care of the resident will report resident response to new or modified interventions. f. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. g. The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care. h. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs.

Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 5 residents (Resident #2) reviewed for clinical documentation. LVN-C failed to document a complete and accurate skin assessment for Resident #2 on 07/28/24. This failure could place residents at risk for incomplete or inaccurate clinical records, which could lead to miscommunication, a delay in services, or a potential decline in the resident's health. Findingd included: Record review of Resident #2's face sheet, dated 04/15/25, revealed an [AGE] year-old male with an original admitted [DATE]. Resident #2's diagnoses included Dementia (a group of symptoms affecting memory, thinking and social abilities), Cognitive Communication Deficit (communication difficulties that arise from cognitive impairments), and High Risk of Heterosexual Behavior (all unprotected heterosexual activities occurring outside of a consistent sexual relationship). Record review of Resident #2's annual MDS assessment, dated 04/08/25, revealed a BIMS score of 05, which indicated severely impaired cognition. Record review of Resident #2's care plan, initiated 08/10/23, revealed the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs; and Resident #2's care plan, initiated 07/04/24, revealed the resident needed a structured environment. Record review of Resident #2's progress note, dated 07/28/24, revealed Resident #2 slapped Resident #3 on the left buttocks. Resident #3 turned around and punched Resident #2 in the face, knocking his glasses off, and creating a superficial scratch on the bridge of Resident #2's nose and redness to Resident #2's left cheek. Another progress note, dated 07/28/24 and 08/01/24, revealed Resident #2 had triple antibiotic ointment applied to his nose. Record review of the Provider Investigation Report, dated 07/28/24 at 12:10 PM, revealed a head-to-toe assessment of Resident #2 was completed by LVN - C, and there was a superficial laceration noted to the bridge of Resident #2's nose, as well as some redness to the left cheek. Record review of Resident #2's weekly skin evaluation, dated 07/28/24 at 2:18 PM, revealed Resident #2 was re-assessed by LVN-C, and she documented Resident #2 had no abnormal skin areas or any other skin wounds or skin issues. Record review of Resident #2's physician orders, dated 07/28/24 at 6:00 PM, revealed an order to apply triple antibiotic ointment to the superficial abrasion to the bridge of Resident #2's nose. This order ended on 08/04/24. In an interview with LVN - C on 04/15/25 at 1:40 PM, she stated Resident #2 slapped Resident #3 on the buttocks, and even though Resident #2 did not mean anything by it, Resident #3 did not like to be touched, so Resident #3 hit him back in the face. She stated Resident #2 ended up with a scratch to the top of his nose and some redness to one of his cheeks. LVN - C initially stated it was a scratch with a break in the skin, but then she changed her wording and stated it was only a red mark that was left by his glasses, and the red mark was gone by the time she did the second assessment. In an interview with the ADON on 04/15/25 at 1:55 PM, she stated the triple antibiotic order began the evening of 07/28/24 and ended on 08/04/24. She stated the triple antibiotic was applied to the abrasion on Resident #2's nose. The ADON also stated maybe LVN - C, who did the initial and follow-up assessment, was not remembering correctly or maybe had just forgotten there was an actual abrasion that required triple antibiotic ointment. She stated skin assessments should be completed accurately so that residents received consistent and adequate care. In an interview with the DON on 04/14/24 at 2:35 PM, she stated Resident #3 had some PTSD from childhood sexual abuse and trauma, so he did not like to be touched by others. She stated Resident #2 was a grabber and a toucher, and he would grab or touch anyone that walked by. When he grabbed or slapped Resident #3 on the buttocks, Resident #3 just reacted instantly by hitting him in the face. She stated it caused a small scratch to the bridge of Resident #2's nose. She stated she was not sure why LVN - C had stated that it was just redness and went away a couple of hours later because it was still there that evening when the order for the triple antibiotic ointment was received to be applied to the abrasion. She agreed that skin assessments should be completed accurately so residents received consistent and adequate care. Record review of the facility's Documentation Policy, implemented 10/24/22, revealed Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. 3. Principles of documentation include but are not limited to: A. Documentation shall be factual, objective, and resident centered.

45411 Based on interview and record review, the facility failed to ensure an accurate MDS was completed for 2 of 18 residents (Resident #10 and #18) reviewed for MDS assessment accuracy. 1. The facility failed to accurately document Resident #18's pacemaker on his MDS. 2. The facility inaccurately documented that Resident #10 used restraints on her MDS. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Resident #10 Record review of Resident #10's admission record indicated she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, lack of coordination, abnormal posture, reduced mobility, and a history of falling. She was [AGE] years old. Record review of Resident #10's Quarterly MDS assessment dated [DATE] indicated: Section P - Restraints and Alarms, P0100. Physical Restraints - A. Bed rail was used less than daily. Record review of Resident #10's care plan dated 03/21/24 indicated: Problem: Resident uses DME. Resident has quarter side rails to assist with repositioning and transfers. Goal: Resident will experience no injury from the use of DME through the next review date (most recent revision date 09/25/23). Interventions: Assess for adverse effects of DME use such as incontinence, skin breakdown, decrease functional ability and confusion, and consult with physician. Ensure valid consent on chart prior to initializing restraint. Monitor for changes in mental status and changes in functional level and report to MD as needed. Record review of Resident #10's physician order summary report dated 03/21/24 indicated in part: 2 quarter side rails to assist her with bed mobility and transfers (order status active; order date 02/01/23) Resident #18 Record review of Resident #18's admission record dated 03/20/2024 indicated he was admitted to the facility on [DATE] with diagnoses of Parkinson's and pacemaker. He was [AGE] years of age. Record review of Resident #18's MDS with an ARD (assessment reference date) of 01/09/2024 did not indicate Resident #18 used a pacemaker. Record review of Resident #18's physician order report dated 3/21/24 indicated in part: Check pacemaker order status active. During an interview on 03/21/24 at 11:26 AM, the DON stated that Resident #10's bed rails were not in use as a restraint so there would not be anything in the charting system to indicate they were. She stated that the MDS nurse told her (the DON) that she had accidently checked the bed rails button in the restraint section when she was completing Resident #10's most recent quarterly MDS. The DON stated that an MDS modification had already been started to correct the error. The DON stated that the bed rails were never intended to be a restraint for Resident #10 and that she only used the bed rails for positioning and mobility while she was in bed. The DON stated she was not sure how both she and the MDS Coordinator overlooked that the restraint section of the Quarterly MDS had information checked when Resident #10 had never had that section populated before. During an interview on 03/21/24 at 12:04 PM, the MDS Coordinator said Resident #18's pacemaker should have been on the MDS, but it got missed. The MDS coordinator said they would have to update the MDS to indicate the resident had a pacemaker. During an interview on 03/21/24 at 12:05 PM, the DON said it was her responsibility to make sure the MDS's were updated and revised as needed and that she had not noticed that the pacemaker was not in the Resident #18's MDS and that it should have been. During an interview on 03/21/24 at 2:07 pm, the MDS Coordinator stated that she had no idea why she checked the bed rails box in the restraint section of Resident #10's Quarterly MDS. She stated she had always coded Resident #10 as no restraints on her past MDS assessments. She stated it was just human error. She stated she had made the correction and submitted the modification MDS for approval. The MDS Coordinator stated that type of error could affect a resident's care plan, quality measures, the type and amount of documentation to be done for or on the resident, the monitoring and daily care for the resident as well as the possible adverse effects of a resident being treated as though they had restraints when they did not. Record review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.19.1, October 2024 reflected The RAI process has multiple regulatory requirements . (1) the assessment accurately reflects the resident's status.

45399 Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 18 residents (Residents #18 and #61) reviewed for care plans in that: The facility failed to ensure Resident #18's Care Plan addressed his pacemaker. The facility failed to ensure Resident #61's Care Plan addressed her code status. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included the following: Resident #18 Record review of Resident #18's admission record dated [DATE] indicated he was admitted to the facility on [DATE] with diagnoses of Parkinson's and pacemaker. He was [AGE] years of age. Record review of Resident #18's Minimum Data Set (MDS) assessment dated [DATE] indicated in part: Brief Interview Mental Status score was 11 indicating resident had moderately impaired cognition. Record review of Resident #18's care plan revealed his pacemaker had not been care planned. Record review of Resident #18's physician order report dated [DATE] indicated in part: Check pacemaker order status active. Resident #61 Record review of Resident #61's face sheet dated [DATE], indicated he was admitted to the facility on [DATE] with diagnosis of Alzheimer's Disease, dementia, cognitive communication deficit, aphasia ( difficulty speaking), anxiety disorder( feelings of fear and anxiety), history of falls, and major depressive disorder (chronic depression) . He was [AGE] years of age. Record review of Resident #61's Minimum Data Set (MDS) dated [DATE] indicated in part: Brief Interview Mental Status = of 0 out of 15 indicating severe cognitive impairment. Record review of Resident #61's care plan revealed his code status had not been care planned. Record review of Resident #61's physician order report dated [DATE] indicated in part: CPR (Full Code). During an interview on [DATE] at 12:47 PM, the Social Worker stated that she was solely responsible for starting care plans for code status on all admissions. The Social Worker stated she was unsure why code status was not showing up in the electronic medical records under care plans. During an interview on [DATE] at 11:56 AM, the MDS Coordinator said Resident #18's pacemaker should have been care planned but it got missed. The MDS Coordinator said they would have to update the care plan. During an interview on [DATE] at 11:57 AM, the DON said it was her responsibility to make sure the care plans were updated as needed and that she had not noticed that the pacemaker was not care planned for Resident #18 and it should have been. During an interview on [DATE] at 02:02 PM, the Administrator was made aware that Resident #18's pacemaker was not care planned. The Administrator said it should have been care planned and the pacemaker not being care planned could lead to improper care of the resident. Review of facility policy Comprehensive Care Plans dated [DATE] revealed in part: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights , that includes measurable objectives and timeframes to meet a residents medical , nursing, and mental and psychological needs that are identified in the comprehensive assessment. Person centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #18 and #59) of 4 residents reviewed for infection control. 1. The facility failed to ensure CNA A washed or sanitized her hands prior to putting gloves on or changing her gloves after they became contaminated during incontinent care while assisting Resident #18. 2. The facility failed to ensure CNA B washed or sanitized her hands prior to putting gloves on or changing her gloves after they became contaminated during incontinent care while assisting Resident #59. This failure could place resident's risk for cross contamination and the spread of infection. Findings include: RESIDENT #18 Record review of Resident #18's admission record dated 03/20/2024 indicated he was admitted to the facility on [DATE] with diagnoses of Parkinson's, muscle wasting and atrophy (loss of skeletal muscle mass). He was [AGE] years of age. Record review of Resident #18's MDS dated [DATE] indicated Resident #18's BIMS score was 11 indicating the resident's cognition was moderately impaired. Urinary continence = Frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). Bowel continence = Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement). Record review of Resident #18's care plan dated 02/15/24 indicated in part: Problem: Resident has actual and or potential impairment to skin integrity r/t Parkinson's and incontinence and confusion. Goal: Resident will have no skin complications/impairments through the review date. Interventions: Apply moisture barrier cream to groin/peri area every shift until healed. Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Preventative skin care after incontinent episodes per facility protocol. C.N.A's to apply barrier cream as needed after incontinent episodes. During an observation on 03/19/24 at 11:15 AM, CNA A performed incontinent care for Resident #18. CNA A entered the resident's room and put gloves on without washing or sanitizing her hands first. CNA A performed peri-care by wiping the resident's penis and scrotum area. The resident had urinated, and the brief was wet. CNA A then removed her gloves and put on a pair of new gloves without washing or sanitizing her hands. CNA A then took a wet wipe and wiped the resident's rectal area, removed the old brief from underneath the resident and placed it in the trash. CNA A then took a clean brief fastened it to the resident, pulled his pants back on while wearing the same gloves that were used to wipe the resident's rectal area and remove the old brief. During an interview on 03/19/24 at 11:24 AM CNA A said she normally washed or sanitized her hands prior to performing patient care. CNA A said she had gotten nervous and forgotten to wash or sanitize her hands prior to putting gloves on. CNA A said she should have changed her gloves prior to touching the new brief and pulled Resident #18's pants up. CNA A said if she did not wash her hands or changed her gloves it could lead to cross contamination and spread of germs. CNA A said the failure occurred because she got nervous and missed some of the steps. Resident #59 Record review of Resident #59's admission record dated 03/21/2024 indicated resident was admitted to the facility on [DATE] with diagnosis that include Alzheimer's Disease with Early onset, Dementia, history of falling, pain, and muscle wasting and atrophy. Resident #59 was [AGE] years of age. Record review of Resident #59's MDS dated [DATE] indicated her BIMS score was 99 indicating resident was unable to be interviewed for mental status. The MDS revealed the resident had short and long-term memory problems, and her Cognitive skills for daily decision making was severely impaired. Resident #59's MDS indicated she was always incontinent of urine (no episodes of continent voiding) and always incontinent of bowel movements (no episodes of continent bowel movements). During an observation on 03/19/24 at 11:40 AM, CNA B entered Resident #59's room and donned gloves without washing hands or using hand sanitizer first. CNA B performed perineal care for Resident #59 by wiping the resident's vaginal area front to back. The resident was turned to the side and CNA B wiped the resident's bottom. CNA B removed the urine soiled brief from under the resident and discarded it in the trash. Without changing gloves, CNA B placed the clean brief under the resident. The resident was then turned to allow the brief to be adjusted. CNA B removed gloves and did not use hand sanitizer or washed hands. CNA B then pulled the resident's pants up and covered resident with a blanket. CNA B gathered and removed the trash from the room. During an interview on 03/20/24 at 01:59 PM, LVN D stated that staff should be performing hand hygiene prior to performing incontinent care. LVN D stated staff should be sanitizing their hands between glove changes between dirty and clean steps of incontinent care. LVN D stated that after incontinent care, after throwing trash away, staff should wash their hands. CNA B was unavailable for interview. During an interview on 03/21/24 at 12:08 PM, the DON said it was her expectation for staff to wash or sanitize their hands prior to putting gloves on. The DON said staff were expected to wash or sanitize their hands in between glove changes. The DON said staff were expected to change their gloves when they went from dirty to clean. The DON said if staff did not wash or sanitize their hands or changed gloves at the appropriate times it could lead to cross contamination. During an interview on 03/21/24 at 02:00 PM, the Administrator was made aware of CNA A's incontinent care observation. The Administrator said the CNA should have washed or sanitized her hands prior to putting on gloves. Th Administrator said the CNA should have changed gloves prior to touching the clean brief and Resident #18's clothes. The Administrator said the failure could lead to cross contamination and spread of germs. Record review of the facility's policy titled Perineal care dated 10/24/22 indicated in part: It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible and to prevent and assess for skin breakdown. Perineal care refers to care of the external genitalia and the anal area. Perform hand hygiene and put on gloves. If perineum is grossly soiled turn resident on side remove any fecal material with toilet paper, then remove and dis/card. Cleanse buttocks and anus, front to back; vagina to anus females, scrotum to anus in males, using a separate washcloth or wipes. Re-position resident in supine position. Change gloves if soiled and continue with perineal care. Record review of the facility's policy titled Hand hygiene dated 10/24/22 indicated in part: All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub. Staff will perform hand hygiene when indicated using proper technique consistent with accepted standards of practice. The use of gloves does not replace hand hygiene. If you task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves.

Based on observation, interview, and record review, the facility failed to provide services in the facility memory unit with reasonable accommodation of resident needs and preferences, for 6 of 19 residents (Resident # 83 (R#83), Resident #35 (R#35), Resident #414 (R#414), Resident #49 (R#49), Resident 8 (R#8) and Resident #78 (R #78)) reviewed for accommodation of needs. The facility staff did not provide R#83, R#35, R#414, R#49, R #8, and R #78 with a call light that was within reach in the female memory unit which could result in the potential outcome of being unable to call for assistance in the event of an emergency. This failure could place residents who utilized call lights at risk for not having his/her needs met. Findings included: Review of R #83's Face Sheet dated 03/01/24 documented a [AGE] year-old female admitted on [DATE] with the diagnoses of: ALZHEIMER'S DISEASE WITH EARLY ONSET, NEED FOR ASSISTANCE WITH PERSONAL CARE, REPEATED FALLS, and DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE . The resident resides in the facility memory unit. Review of R #83's Quarterly Minimum Data Set, dated dated dated [DATE] revealed R #83: -required extensive assistance with two-person physical assist for bed mobility, transfers, dressing, toilet use, and personal hygiene -had impairment on both sides of lower extremity (hip, knee, ankle, foot) Review of R #83's comprehensive care plan dated 10/23/23 documented: Resident is at risk for falls related to FRONTOTEMPORAL NEUROCOGNITIVE DISORDER ( a common cause of dementia. A group of disorders that occur when the nerve cells in the frontal and temporal lobes of the brain are lost) Gait/balance problems, Psychoactive drug use interventions: Anticipate and meet the resident's needs, Call light within reach . Observation on 02/29/24 at 8:48 AM revealed R #83 was lying in bed and was not able to get out of bed on her own. Review of R #35's Face Sheet dated 03/01/24 revealed a [AGE] year-old male admitted on [DATE] with the diagnoses of: Lack of Coordination, DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY, Dysphagia (difficulty swallowing foods or liquids arising from the throat or esophogas, ranging from mild difficulty to complete and painful blockage, hypertension, and type 2 Diabetes. The resident resides in the female memory unit. Review of R #35's Quarterly Minimum Data Set, dated dated dated [DATE] revealed R #35: -is nonverbal -required extensive assistance with two-person physical assist for bed mobility, transfers, and dressing. - COMPLETE ROTATOR CUFF TEAR OR RUPTURE OF RIGHT SHOULDER, NOT 11/07/2019 SPECIFIED AS TRAUMATIC Review of R #35's comprehensive care plan dated 02/16/24 documented: Resident is at risk for falls related to impaired balancing, impaired cognition, requires wheelchair for mobility and assistance with transfers . Interventions: Anticipate and meet the resident's needs call light within reach. Observation on 02/29/24 at 08:51 AM revealed R #35 was in her room lying in bed and the call light was pinned to the light string behind her against the wall. R #35 is not able to be interviewed. Review of R #414's Face Sheet dated 03/01/24 revealed a [AGE] year-old female admitted on [DATE] with the diagnoses of: DEGENERATIVE DISEASE OF NERVOUS SYSTEM, UNSPECIFIED, Lack of Coordination, Unsteadiness on feet, Dementia, Type 2 Diabetes, Hypertension, and Major Depressive Disorder. Review of R #414's Quarterly Minimum Data Set, dated dated dated [DATE] revealed R #414: -had clear speech, usually understood. -required extensive assistance with two-person physical assist for bed mobility and toilet use. -required supervision with one-person physical assist for transfers, dressing, and personal hygiene. Review of R #414's comprehensive care plan dated 01/13/24 documented: Resident is at risk for falls r/t impaired balancing, cognitive loss, poor safety awareness . Interventions: -Anticipate and meet the resident's needs. -call light within reach. Review of R #49's Face Sheet dated 03/01/24 documented an [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with the diagnoses of: Alzheimer's Disease, Urinary Tract Infection, Type 2 Diabetes, Anxiety, Hypertension, and lack of coordination. Review of R #49's Quarterly Minimum Data Set, dated dated dated [DATE] revealed R #49: -required extensive assistance with two-person physical assist for bed mobility, transfers, dressing, toilet use, and personal hygiene -had impairment on both sides of lower extremity (hip, knee, ankle, foot) Review of R #49's comprehensive care plan dated 01/13/24 documented: Resident is at risk for falls related to Dementia, Gait/balance problems, Psychoactive drug use interventions: Anticipate and meet the resident's needs, Call light within reach . Observation on 02/29/24 at 08:53 AM revealed R #49 was noted in her room sleeping upright. R #49 was sitting in bed with call light clipped onto itself near the wall that was behind R #49's bed. Review of R #8's Face Sheet dated 05/16/23 documented a [AGE] year-old female admitted on [DATE] with the diagnoses of: UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY, NEED FOR ASSISTANCE WITH PERSONAL CARE, URINARY TRACT INFECTION, SITE NOT SPECIFIED, DISPLACED FRACTURE OF FIFTH METATARSAL BONE, LEFT FOOT, SEQUELA ( when bones are displaced in multiple areas of there are multiple breaks on the foot), and history of falling Review of R #8's Quarterly Minimum Data Set, dated dated dated [DATE] revealed R #8: -required extensive assistance with two-person physical assist for bed mobility, transfers, dressing, toilet use, and personal hygiene. -had impairment on left sides of lower extremity (hip, knee, ankle, foot) - nonverbal Review of R #8's comprehensive care plan dated 12/16/24 documented: Resident is at risk for falls related to FRONTOTEMPORAL NEUROCOGNITIVE DISORDER ( a common cause of dementia. A group of disorders that occur when the nerve cells in the frontal and temporal lobes of the brain are lost) , Gait/balance problems, Psychoactive drug use interventions: Anticipate and meet the resident's needs, Call light within reach . Observation on 02/29/24 at 8:48 AM revealed R #8 was lying in bed and is not able to get out of bed on her own. The investigator checked to verify if the call light was within reach, and it was not. R #8. On 02/29/24 at 08:51 AM, the call light was on the nightstand approximately 5 feet away from where the resident was laying in bed . The nightstand is located at the foot of the bed. On 02/29/2024 at 11:12 AM, the call light was still on the nightstand approximately 5 feet away from where the resident was laying in bed . The nightstand is located at the foot of the bed. On February 29, 2024 at 9:14 AM interview with licensed vocational nurse (LVN A), that is assigned to the female memory unit at the nursing and rehabilitation. Per the licensed vocational nurse (LVN A), when it was brought to her attention about the six different call lights, . she stated that some residents are very active, and they move so much and they're call lights will fall often. Other residents she stated that they don't use them, and that they typically just call out when they need help. The license vocational nurse stated that she understood that regardless of whether the resident calls out or use their call button that the resident's do need to have their call button accessible to them in case of an emergency. When asked, what are the harms that could happen if a call light is not accessible to the resident, the licensed vocational nurse stated that it could result in the resident being harmed or something more serious occurring. The license vocational nurse (LVN A) stated that the reason so many call lights were probably so far away was because the C.N.A. 's will get the resident up during morning meal time or morning cleanup, and they probably forgot to put the lights back where they were located . The investigator asked the licensed vocational nurse how they would ensure this does not continue occur she stated that the staff will round more thoroughly and will make sure that during the morning time that the call lights are placed back with the resident after they are fed and changed for the day. In an interview on 03/01/24 at 8:58AM, the DON revealed call lights are used by patient to tell the staff that they need assistance. She stated, call lights should be close to the residents at all times because if the call lights are not close to the resident than they can't call for help. The DON revealed the facility policy documented that the call lights have to be within reach of the resident. She stated, The staff is taught in school and orientation to put the call light within reach and upon hire the staff shadows another staff member and during orientation the staff are shown what they are supposed to do . The Director of Nursing stated that she monitors to ensure that the call lights are accessible by rounding several times during the day in the memory unit to make sure the residents have their call lights within reach. Record review of the facility's policy for Resident Call System dated 10/13/22 documented procedure: The call light must always be positioned within reach of the resident. Return demonstrations must be used when educating the resident about call light use. If the resident is unable to demonstrate appropriated call light use, the nurse must be notified to determine an adequate alternative.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety for 1 of 1 kitchen reviewed in that: Hot food on the steam table was below the required temperature for serving The steam table was not clean The shelf on the steam table was not clean A component of the vent hood was not clean There was no cleaning checklist for the kitchen These failures could place residents at serious risk for complications from food contamination, and/or foodborne illness. Findings were: Observations of the kitchen during the initial tour with the DM on 01/31/23 at 01:30 PM revealed: the steam table had a thick yellowish crust in each of the 4 compartments. The underside of the shelf above the steam table was coated with a thick brown substance. The vent hood above the stove had thick brown droplets hanging on a pipeline that ran the length of the vent hood, above the stove and the deep fryer. Observations of lunch service food temperatures on 02/01/23 at 11:43 AM by the DM: A digital thermometer was utilized for all foods. The BBQ beef was at 175F, baked beans at 163F, pureed beans at 107F, squash at 157F, fortified soup at 163F, pureed broccoli at 146F. The DM did not immediately remove the pureed beans to reheat. During an interview with DW A and the DM to interpret, as DW A only spoke Spanish, on 01/31/23 at 1:40 PM revealed that DW A cleaned the entire kitchen on Thursdays and Fridays but could not specify what she cleans. The DM stated she asked DW A how she knew what to clean. The DM stated DW A stated to her that the previous manager told her exactly what to clean, she just never got the list. The DM stated DW A was the only one that cleaned everything, and everyone picked up after themselves. During an interview with the DM, RD, and the ADM on 02/02/23 at 09:15 AM the DM stated the baked pureed beans that were temped at 107F yesterday were removed from the steam table and reheated to 156F after this surveyor left the area. The DM could not say why she did not remove the beans immediately. The DM stated hot foods had to be held at 135F. The DM stated the kitchen did not have a cleaning log for staff to follow and initial. The DM stated everyone picked up after themselves. The ADM stated he had been at this facility for about a year. The ADM stated cleaning logs were utilized when the previous DM was employed. The ADM stated the cleaning logs had not been used since the previous DM left. The ADM stated he did not know cleaning lists were not being used by the staff. The ADM stated the DM was responsible for having cleaning logs and that he (ADM) should have followed up on it. The DM stated she had a personal log she signs off, titled, the Daily Kitchen Checklist. The Daily Kitchen Checklist had 23 items listed on it. The DM stated she checked off the items when she arrived every morning. The DM stated the staff did not know what she was doing with the checklist. The DM stated if there was something she found that had not been done, she would bring it to the staff's attention at that time. The DM stated the staff was supposed to know what to clean, and that sometimes they did not do it. The DM stated the staff was not accountable for the checklist. The DM stated the week she was out with Covid, no one checked. The DM stated the cooks were responsible for cleaning the steam table. The DM stated she placed a maintenance request to have the steam table deep cleaned. The DM stated the shelf above the steam table was part of the steam table, but the staff did not clean it. The DM stated the stuff on the shelf above the steam table could fall into the food or attract gnats. The DM and the ADM stated the maintenance man was supposed to clean the vent hood. The DM stated she put in the maintenance request to have the vent hood cleaned a couple of days ago. The ADM and the DM stated the maintenance man was supposed to clean the vent hood two times a month but had not because he was behind on his work. The ADM stated the maintenance man had been working on other issues. The DM and the ADM stated that what should be happening was scheduling-they needed to keep it (a cleaning schedule) on a daily and monthly basis. The ADM and the DM stated the staff will sign off on the daily checklist. The DM stated it was important so they wouldn't have contaminations, gnats and things falling into food. The DM stated, the residents could get sick-pretty badly. The ADM stated they would be conducting in-services on cleanliness and implementing a plan to make sure the cleaning was being done. The RD stated she did not know the staff was not using a daily checklist. During an interview with the MS on 02/02/23 at 11:32 AM the MS stated he cleaned the filters on the vent hood in between semi-annual contracted cleanings and inspections. The MS stated he did not see the dirty pipeline. The MS stated if the steamer table was cleaned regularly, the scaling would not get like that. The MS stated he was the only one working on everything and it was a lot. During an interview with the COOK on 02/02/23 at 11:40 AM, stated she had been employed at the facility for over 3 years and there was not a cleaning checklist. The COOK stated there was one they used a while ago, but it went away, and she did not know why nor did she ask anyone. The COOK stated the kitchen staff needed a checklist because they forget what to do, get lazy, and just don't do it. The COOK stated the cooks were supposed to be cleaning the steam table. The COOK also stated, I'm not gonna lie- the steam table had not been cleaned since October 2022 which she knew of. A record review of the maintenance schedule for the vent hoods revealed inspections were done on 12/14/22, 06/28/22, and 12/17/22. Scheduled maintenance was performed on 02/09/21, 08/03/21, 02/04/22, and 07/18/22. The record review of the DM's daily kitchen checklists had 23 items to be addressed daily or after each use. The checklists were dated 01/09-01/13/23, 01/16-01/21/23, 01/23-01/27/23, 12/05-12/09/22, 12/12-12/16/22, and 12/19-12/23/22- was all missing checkoffs, and the week of 01/30-02/03/23 was completely missing. Blanks/missing check marks indicated the cleaning task(s) had not been done. There were no checks for any of the weekends. These dates were the only records the DM had. The 23 items included: 1. All dishes, pots, pans and utensils . 2. Freezer, refrigerator and dishwasher temperatures are checked and recorded 3. All sinks .4. All work counters .5. Can opener .6. Steam table is cleaned and sanitized after each use 7. Dishwasher .8. Tray return window .9. Trash can .10. Bathroom .11. Dish cloths are washed .12. Sweep and mop floors daily 13. Open spills are cleaned and ovens turned off 14.wear hair restraints and clean clothing .keep hands cleaned .15. ice machine 16. All tools 17. Clean Steamer and steam table after each use 18. Mixer 19. Receiving dock 20. Slicer .21. Foods thawed properly 22. Foods cooled properly 23. Chemicals stored away from food.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for two of six residents (Resident #26 and Resident #223) who were reviewed for dignity. The facility failed to provide dignity privacy coverings for urinary catheter drainage bags to two of two residents reviewed (Resident #26 and Resident # 223) reviewed for dignity. This deficient practice could affect residents who require urinary catheters in the facility at risk for diminished quality of life, self- esteem, dignity and increase risk for isolation. The findings included: 1. Record review of Resident # 26's face sheet dated 02/01/23, documented an [AGE] year-old male admitted [DATE], with diagnoses including type 2 diabetes mellitus with hyperglycemia (high blood sugar levels), hyperlipidemia (high lipid levels in blood), and essential hypertension (high blood pressure). Record review of Resident # 26's Quarterly MDS dated [DATE], revealed he had a BIMS score of 06, indicating he had severe cognitive impairment. It also indicated he used an indwelling catheter at the time of the assessment. Record review of Resident # 26's Active physician orders dated 02/01/2023 documented: Check Foley Catheter placement every shift .check foley catheter every shift for placement May use leg strap to secure Foley in place .Foley Catheter Care every shift .Foley catheter: Change drainage bag as needed for Leaking. Record review of Resident # 26's comprehensive care plan dated 02/01/23 documented: The resident has an indwelling foley Catheter: 22Fr (French- size of the foley catheter) 30 ML (milliliters) balloon/bulb. Care plan was initiated on 01/12/23 and was revised on 02/01/23. It documented the following interventions: position catheter bag and tubing below the level of the bladder and away from entrance room door . Check tubing for kinks each shift . monitor and document intake and output as per facility policy . monitor/document for pain/discomfort due to catheter .monitor/record/report to MD for s/sx (signs and symptoms) UTI (urinary tract infection): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. In an interview and observation in Resident #26's room on 01/31/23 at 02:55 p.m. revealed Resident #26 resting in bed, awake and alert conversing with family members at his bedside. Observation also revealed the foley tube hanging off the edge of the bed and the bag laying off left side of bed on the floor exposed without a privacy dignity bag. Interview with the family members at bedside revealed they had observed the urinary drainage catheter bag on the floor exposed since they had arrived. 2. Record review of Resident # 223's face sheet dated 02/01/23, documented a [AGE] year-old male admitted [DATE], with diagnoses including type 2 diabetes mellitus with hyperglycemia (high blood sugar levels), hyperlipidemia (high lipid levels in blood), and essential hypertension (high blood pressure). Record review of Resident # 223's Quarterly MDS dated [DATE] revealed he had a BIMS score of 09, indicating his cognitive status was moderately impaired. It also indicated he used an indwelling catheter at the time of the assessment. Record review of Resident # 223's Active physician orders dated 02/01/2023 documented: Check Foley Catheter placement every shift .check foley catheter every shift for placement May use leg strap to secure Foley in place .Foley Catheter Care every shift .Foley catheter Output every shift .Foley catheter: Change drainage bag as needed for leaking . Foley catheter: irrigate foley catheter with NS or H2- as needed for leaking or hematuria . Foley Catheter: Change 18FR (French-size of the foley catheter) 30 ML (milliliters). Balloon as needed for patency, dislodgment and leaking. Record review of Resident # 223's comprehensive care plan dated 02/01/23 documented: The resident has an indwelling Catheter: 18Fr (French- size of the foley catheter) 30 ML (milliliters. Care plan was initiated on 12/20/22. It documented the following interventions: Catheter: last changed: (specify date). Change catheter (frequency) (specify size) (specify type) date initiated 12/20/22 . catheter: the resident has (specify size) (specify type of catheter) Position catheter bag and tubing below the level of the bladder and away from entrance room door. Date initiated 12/20/22 . Check tubing for kinks [# times] each shift. Date initiated: 12/20/22 .Monitor and document intake and output as per facility policy. Date initiated 12/20/22 . Monitor for s/sx (signs and symptoms) of discomfort on urination and frequency . Date initiated 12/20/22 . Monitor/document for pain/discomfort due to catheter. Date initiated 12/20/22. In an observation and interview of Resident # 223 on 1/31/23 at 03:20 p.m. resident was observed resting in bed, awake and alert, and requesting to see his nurse to check on his great toe. Observation was made that resident urinary catheter drainage bag was hanging on side rail of bed and not in privacy bag, In an interview on 01/31/23 at 03:20 p.m. with Resident #223 revealed Resident #223 was unaware the foley drainage bag was not in privacy bag. He was not sure why he had foley catheter or for how long he had it for. In an interview on 02/01/23 at 03:40 p.m. with the DON, revealed the facility did not have policies regarding foley care, indwelling foley care, foley bag care, or catheter care for male or female residents. The DON stated she would provide surveyor C with the skills checklist and their nursing procedure. In an interview on 02/02/23 at 03:30 p.m. with LVN B, LVN B stated she did observe foley drainage bag was not in privacy bag on both residents under her care (Resident #26 and Resident # 223) during her shift that day. LVN B stated, I did not know they were supposed to be in the room, I knew foley drainage bags were supposed to be in privacy bags in the hallway. LVN B stated that it was the CNA's and the nurse's responsibility to place the foley drainage bag in the privacy bag. LVN B revealed that privacy bags on urinary catheter drainage bags were in fact used for dignity. In an interview with the DON on 02/02/23 at 03:35 p.m. she stated she did observe that Resident #26 and Resident #223 did not have privacy coverings over their urinary catheter drainage bags. The DON stated that after the initial observation on 01/31/23 staff was instructed to provide privacy bags to residents with urinary catheter drainage bags. The DON mentioned that it was the CNA's and the nurse's responsibility to place the foley drainage bag in the privacy bag. The DON noted it was the responsibility of nurses and CNAs caring for the residents to care for the foley drainage bags. The DON acknowledged her responsibility to provide oversight of the care of the resident and for the in-service of the nurses and CNAs and stated she had done so on 1/31/23 after the foley drainage bag for Resident #26 was observed on the floor. She also acknowledged the failure to provide dignity to the Resident by not placing the foley drainage bag in the privacy bag. Record review of a document provided by the facility titled, Catheter Care, Urinary with a revised date 07/15, quoted in part, Place Foley catheter bag in covered pouch. Record review of a document provided by the facility titled, [Facility] RN/LVN Orientation Skills Checklist, signed and dated 08/23/22 by LVN B, urinary foley catheter, insertion/care, and proper positioning-catheter secure to leg were among the skills that were checked off on this date. Facility failed to include covering urinary drainage bag with a privacy bag in the skills checklist listed on this form . Record review of a document provided by the facility titled Clinical Competency Validation Indwelling Urinary Catheter-Insertion of, signed and dated 08/22/22 by LVN B indicated she passed the critical elements necessary to keep the drainage bag below the level of the patient's bladder and off the floor .Secure to bed frame upon orientation. Facility failed to include covering urinary drainage bag with a privacy bag in the critical elements listed on this form.

Based on observation, interview and record review. The facility failed to implement its policies and procedures that prohibit neglect of residents for one Resident (R#1) of five Residents reviewed for neglect. R #1 was not provided adaptive equipment for her wheel chair leg/foot rests. R #1 sustained a physical injury. The facility staff were aware of R #1's need for adaptive equipment and failed to develop intervention strategies to prevent physical injury. CNA "P" did not notify the charge nurse when R #1 initially expressed pain. This failure could affect 15 wheel chair dependent residents and 67 residents that required the assistance of one or two staff for transfers by placing them at risk for physical injury. The findings were: R #1's Face Sheet dated 03/09/15 revealed R #1 was a [AGE] year old female readmitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. and Dementia. R #1's Significant Change Minimum Data Set ((MDS) dated [DATE] revealed R #1 was on Hospice Care for the [DIAGNOSES REDACTED].#1 was confused, disoriented, and forgetful. R #1 had a decreased ability to make herself understood and a decreased ability to understand others. R #1 had a hearing impairment and vision impairment. R #1 was incontinent of bowel and bladder, uses mechanical lift for all transfers and was unable to perform ADL's without limited to total assistance. R #1 required limited assistance with eating. R #1 was wheelchair bound. R #1's Care Plan dated 01/24/15 revealed R #1 required assistance for all ADL's: "Extensive assistance x 1 with bed mobility, and incontinent care/toileting. Ext. assist x 2 (hoyer) for transfers, total assistance x 1 w/wheelchair mobility ..." The following approaches were to be implemented: "...Promote (R #1's) safety with ADL functions ...Provide (R #1) with appropriate assistive devices as needed. (R #1) is w/c bound and is total dependent on staff for w/c mobility." R #1's Care Plan dated 01/24/15 revealed R #1 had a history of [REDACTED]. The following approaches were to be implemented: "Provide for pressure relieving and positioning devices. Assist (R #1) carefully when providing care ..." Daily and Q (every) Shift Charting dated 03/14/15 at 9:00 a.m., revealed R #1 was up in her Wheel Chair (W/C) in the front lobby "moaning in pain noted to have swelling to Lt. ankle ...spoke with aid on the floor about resident. States that when taking resident out of dining room resident's foot slipped off foot rest and was under chair." Physician's Telephone Orders dated 03/14/15 revealed an order for [REDACTED]. Physician's Telephone Orders dated 03/14/15 at 9:01 p.m., revealed an order for [REDACTED].=pain medicine and [MEDICATION NAME]= sedative) Physician's Telephone Orders dated 03/15/15 at 8:00 p.m., revealed an order for [REDACTED].#1 to have a left ankle and leg wrap with comfort ace wrap. Physician's Telephone Orders dated 03/16/15 revealed an order for [REDACTED]. Physician's Telephone Orders dated 03/17/15 revealed an order for [REDACTED]. Review of physician progress notes [REDACTED].#1's apparent injury Left ankle eversion was swollen and ecchymosis. (Ankle eversion=ankle sprain caused by an external force) (Ecchymosis=non-raised skin discoloration from broken blood vessels) On 04/01/15 at 1:50 p.m., the Medical Director said, "According to (R #1's) X-Ray she does not have a fracture but an eversion sprain." Provider Investigation Report dated 03/16/15 at 10:00 a.m., revealed the incident involving R #1 occurred on 03/14/15 at 9:30 a.m. The report indicated R #1 was total assistance and was not interviewable. The perpetrator was identified as CNA "P". The description of the injury revealed while CNA "P" was transporting R #1 out of the dining area, R #1's foot slipped off wheel chair foot rest and onto the floor. R #1 cried out and when CNA "P" stopped the wheel chair R #1's foot was behind the foot rest. CNA "P" backed the wheel chair up and placed R #1's foot on the foot rest and wheeled R #1 to the living area. R #1 was assessed as having pain, and left foot and ankle area sustained deep tissue damage. There were no fractures based on X-Ray. The provider response was suspending CNA "P" pending investigation, all parties were notified, and pain management, care plans updated, and medical care was provided. R #1's wheel chair was screened for safety and the facility applied a foot board as an intervention to prevent R #1's feet from slipping off foot rests. Facility audited other resident wheel chairs for safety, and In serviced staff on reporting incidents, wheel chair positioning, use of foot boards for wheel chair rests/pedals, proper wheel chair transport of residents, use of mechanical lifts and abuse and neglect. "Investigation Summary... Investigator concludes that although an incident, abuse occurred, by negligent infliction of injury, with no willful intent." On 03/31/15 at 10:05 a.m., during an observation of R #1's left leg and ankle with LVN "L" present revealed R #1's left leg and ankle were swollen and was dark gray in appearance. R #1 had facial grimacing when LVN lifted R #1's leg up to remove the ace wrap. LVN "L" said she was the charge nurse for the hall R #1 was residing and was familiar with R #1's care needs. LVN "L" said she had seen R #1's foot slip off the foot rests several times but did not think this would cause injury, because when R #1's foot would fall off the foot rest, the staff would lift her foot up and place it back onto the foot rest. LVN "L" said if she thought R #1's foot slipping off the foot rest was a problem she would have made a referral for PT to evaluate. LVN "L" said she was unaware how often or even if, PT re-evaluates resident's need for adaptive equipment. On 03/31/15 at 10:40 a.m., interview with PT "K" revealed R #1's wheel chair foot rests were fully functioning and that after R #1's injury PT evaluated R #1's wheel chair for safety and determined a leg board was needed. PT ordered a device for R #1's chair to position legs correctly and prevent legs from slipping through the leg rests or falling off the foot rests. PT "K" said when the nursing staff saw R #1's feet falling off the foot rests that a referral should have been made to PT to evaluate the wheel chair for safety and adaptive equipment. On 03/31/15 at 10:55 p.m., interview with Responsible Party (RP) revealed prior to R #1's leg injury, R #1 was up in the wheel chair three times a day, was able to feed herself and R #1's appetite was fair. Since R #1's injury, the Hospice Nurse recommended that resident stay in the bed, due to the pain and discomfort associated with the injury that getting out of bed took to much energy out of R #1. The RP said prior to the injury R #1 was mobile in the wheel chair short distances by "scooting her feet." The RP said now, R #1 had a decrease in appetite and slept most of the time. On 03/31/15 at 12:55 p.m., interview with LVN "M" revealed she was also a charge nurse for the same hall R #1 resided. LVN "M" said she was the nurse on duty at the time R #1 was injured. LVN "M" said that another charge nurse witnessed the incident occur. LVN "M" said she did not feel R #1 was at risk for injury from foot rests, because R #1 "did not move around" and was total care. LVN "M" said the charge nurses should be monitoring CNAs to ensure they are providing safe transfers and care. LVN "M" said she has never witnessed R #1's feet slip off the wheel chair foot rests and since R #1's incident R #1 has had a decline in ADL functioning, because before the injury, R #1 was getting out of bed for all meals and activities. LVN "M" said now R #1 does not get out of bed at all and R #1's appetite had greatly declined. On 03/31/15 at 2:45 p.m., interview with LVN "B" revealed she was on duty when R #1 was injured. LVN "B" said "sometime" after 9:00 a.m. on 03/14/15 she heard R #1 yell out and when she looked up CNA "P" was pushing R #1 in the wheel chair and LVN "B" said to CNA "P" "watch her feet" CNA "P" stopped pushing the wheel chair and picked up the lap robe that was covering R #1's legs. LVN "B" said R #1's left foot bent behind her and on the floor under the wheel chair. CNA "P" picked R #1's foot up and placed it back on the foot rest. LVN "P" said R #1 did not make any noise when CNA "P" lifted R #1's foot onto the foot rest. LVN "B" said she left to take care of another resident and when she returned "approximately 15 minutes later" to the Nurses Station she saw LVN "M" lifting R #1's foot up and placing it back on the foot rest. LVN "B" said she noticed R #1's facial grimacing and asked LVN "M" if CNA "P" had reported to her that R #1's foot had slipped off the foot rest? LVN "M" said no, CNA "P" had not reported anything to her. LVN "B" said both she and LVN "P" saw that R #1's foot and ankle was swollen so LVN "P" said she was going to get R #1 back into bed to conduct an assessment. LVN "B" said she felt the incident could have been avoided if the CNA had lifted the blanket up to ensure R #1's feet were securely positioned on the foot rest before moving the wheel chair. On 03/31/15 at 3:15 p.m., interview with PT "K" revealed if a resident was not properly positioned in their wheel chair then their leg could come off the foot rests. PT "K" said residents that have cognition impairment would not necessarily know if their foot fell off the foot rest and residents that are dependent with wheel chair mobility should have a leg board in place to prevent legs and feet injury. PT "K" said staff should always check resident positioning prior to moving their wheel chair. PT "K" said, "To my understanding (R #1) had a blanket coving her legs, maybe the blanket was covering the foot rests making it difficult to assess positioning." On 04/01/15 at 10:05 a.m., interview with CNA "P" revealed on 03/14/15 at approximately 6:15 a.m. to 6:30 a.m. she and Nurse Aide (NA) "J" went into R #1's room to get her out of bed for breakfast. CNA "P" said R #1 made a noise as if she were in pain. CNA "P" said she was unfamiliar with R #1 because she only works part time, but NA "J" was familiar with R #1 and told CNA "P" that R #1 had arthritis and was frequently in pain. CNA "P" said when they transferred R #1 from the bed to the wheel chair via mechanical lift that she noticed R #1's foot was on the floor and not on the foot rest. CNA "P" said she lifted R #1's foot up to place it on the foot rest R #1 again made another noise like she was in pain. CNA "P" asked NA "J" if they should report to the charge nurse and NA "J" said "no" because R #1 always was in pain. CNA "P" said, "I feel really bad that I did not report it earlier because (R #1) could have been medicated for her pain." CNA "P" said she wheeled R #1 to the dining room and then after breakfast she started to wheel R #1 out of the dining room when she heard LVN "M" yell out from across the room, "hey, watch her foot". CNA "P" said she stopped the wheel chair and lifted up R #1's blanket that was covering her legs and saw that R #1's foot had fallen off the foot rest and was bent under the wheel chair. CNA "P" said she lifted R #1's foot up and placed it back on the foot rest and R #1 said, "ouch my leg hurts," CNA "P" then wheeled R #1 into the living room and was called off to tend to another resident. CNA "P" said, "It is a blessing that all this came about because now the aides are getting training they need." CNA "P" said R #1 had not gotten out of bed since the injury occurred. On 04/01/15 at 11:00 a.m., interview with NA "J" revealed on 03/14/15 "sometime after 6:00 a.m." she and CNA "P" entered R #1's room to get her up for breakfast. NA "J" said she had worked with R #1 for the past three months and was "very familiar" with her care needs. NA "J" said R #1 was asleep and had to be wakened prior to the transfer via mechanical lift. NA "J" said the transfer was uneventful and R #1 did not show signs of pain. NA "J" said between 9:00 a.m. and 9:15 a.m. she saw LVN "M" transporting R #1 back to her room, LVN "M" requested assistance in transferring R #1 back to bed. NA "J" said she and CNA "P" transferred R #1 back into bed and R #1 complained that her leg hurt. NA "J" said she saw R #1's left leg, ankle and top of foot was discolored blue and purple and swollen. NA "J" said she had seen R #1's foot fall off the foot rest many times but she lifts R #1's foot up and back on the foot rest prior to moving the wheel chair, because R #1 cannot position her own feet independently. NA "J" said R #1 never had a foot or leg board for the wheel chair prior to the incident but now has one. R #1 had not gotten out of bed since her leg injury. NA "J" was told by the charge nurses, not to get R #1 out of bed . NA "J" said staff was in serviced after R #1's leg injury on proper positioning, safe transfers and the use of leg/foot boards. NA "J" said the training was really needed because a lot of people did not know how to use a foot board or transfer a resident that had foot rests and leg rests on their wheel chair. On 04/01/15 at 12:20 p.m., interview with the DON revealed CNAs should have reported to their charge nurse R #1's feet were slipping off the foot rests instead of just placing R #1's feet back on the foot rests. The DON said R #1's injury could have been prevented and retraining of staff will be conducted. The DON said the PT department determines how a resident should be transferred. Review of facility Policy and Procedures (no date) entitled "Lifting And Transferring Of Residents ...STANDARD Residents are lifted and transferred safely in all instances. POLICY * Nurses assess and determine lifting and transfer requirements and the procedure used for each resident ...*All members of the nursing staff, nurses and nursing assistants are responsible for using good body mechanics, knowing the proper procedures and properly operating assistive devices." Review of facility Policy and Procedures (no date) entitled "Positioning In Chair/Wheelchair ...STANDARD Residents are positioned to maintain correct body alignment when seated in chair ...POLICY * Cushions, wedges, and other corrective devices for seating are properly applied after assessment and implementation by the rehabilitation department ...PROCEDURES Wheelchair ...3. Position hips, knees and feet as close to 90-90-90 position as possible. 4. Support feet by placing on footplates or adaptive cushions (foot rest and foot boards) ...Ensure positioning during transport." Review of facility Incident/Accident Management Policy and Procedure dated 10/01/2010 revealed, "...Purpose *To ensure the center's staff is employing best practice standards to the best of their ability to prevent incidents and accidents...Definitions...'Avoidable Accident' means that the facility did not: -Identify Environmental hazards... -Implement interventions... -Monitor effectiveness... Procedures: ...2. The staff member making the discovery will notify his/ her immediate Supervisor or DON/designee about the incident..." Review of facility Abuse Prevention policy and procedure dated 01/25/15 revealed; "POLICY It is the policy of this Center to maintain the resident's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, Neglect and misappropriation of property...III. Prevention A. 3. e. Education of staff related to the need to communicate any concerns that they observe or that have been reported...4. Analysis of:...d. Assessment, care planning and monitoring residents with needs...those that require heavy nursing care and/or totally dependent on staff. Care giving staff will be aware of interventions..." According to Centers of Medicare and Medicaid Services form 672 the facility had 67 residents that required the assistance of one or two staff for transfers. The facility's Wheel Chair Dependent Residents list revealed 15 residents were wheel chair bound.

Based on observation, interview and record review. The facility failed to implement its policies and procedures that prohibit neglect of residents for one Resident (R#1) of five Residents reviewed for neglect. R #1 was not provided adaptive equipment for her wheel chair leg/foot rests. R #1 sustained a physical injury. The facility staff were aware of R #1's need for adaptive equipment and failed to develop intervention strategies to prevent physical injury. CNA "P" did not notify the charge nurse when R #1 initially expressed pain. This failure could affect 15 wheel chair dependent residents and 67 residents that required the assistance of one or two staff for transfers by placing them at risk for physical injury. The findings were: Review of facility Policy and Procedures (no date) entitled "Lifting And Transferring Of Residents ...STANDARD Residents are lifted and transferred safely in all instances. POLICY * Nurses assess and determine lifting and transfer requirements and the procedure used for each resident ...*All members of the nursing staff, nurses and nursing assistants are responsible for using good body mechanics, knowing the proper procedures and properly operating assistive devices." Review of facility Policy and Procedures (no date) entitled "Positioning In Chair/Wheelchair ...STANDARD Residents are positioned to maintain correct body alignment when seated in chair ...POLICY * Cushions, wedges, and other corrective devices for seating are properly applied after assessment and implementation by the rehabilitation department ...PROCEDURES Wheelchair ...3. Position hips, knees and feet as close to 90-90-90 position as possible. 4. Support feet by placing on footplates or adaptive cushions (foot rest and foot boards) ...Ensure positioning during transport." Review of facility Incident/Accident Management Policy and Procedure dated 10/01/2010 revealed, "...Purpose *To ensure the center's staff is employing best practice standards to the best of their ability to prevent incidents and accidents...Definitions...'Avoidable Accident' means that the facility did not: -Identify Environmental hazards... -Implement interventions... -Monitor effectiveness... Procedures: ...2. The staff member making the discovery will notify his/ her immediate Supervisor or DON/designee about the incident..." Review of facility Abuse Prevention policy and procedure dated 01/25/15 revealed; "POLICY It is the policy of this Center to maintain the resident's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, Neglect and misappropriation of property...III. Prevention A. 3. e. Education of staff related to the need to communicate any concerns that they observe or that have been reported...4. Analysis of:...d. Assessment, care planning and monitoring residents with needs...those that require heavy nursing care and/or totally dependent on staff. Care giving staff will be aware of interventions..." R #1's Face Sheet dated 03/09/15 revealed R #1 was a [AGE] year old female readmitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. and Dementia. R #1's Significant Change Minimum Data Set ((MDS) dated [DATE] revealed R #1 was on Hospice Care for the [DIAGNOSES REDACTED].#1 was confused, disoriented, and forgetful. R #1 had a decreased ability to make herself understood and a decreased ability to understand others. R #1 had a hearing impairment and vision impairment. R #1 was incontinent of bowel and bladder, uses mechanical lift for all transfers and was unable to perform ADL's without limited to total assistance. R #1 required limited assistance with eating. R #1 was wheelchair bound. R #1's Care Plan dated 01/24/15 revealed R #1 required assistance for all ADL's: "Extensive assistance x 1 with bed mobility, and incontinent care/toileting. Ext. assist x 2 (hoyer) for transfers, total assistance x 1 w/wheelchair mobility ..." The following approaches were to be implemented: "...Promote (R #1's) safety with ADL functions ...Provide (R #1) with appropriate assistive devices as needed. (R #1) is w/c bound and is total dependent on staff for w/c mobility." R #1's Care Plan dated 01/24/15 revealed R #1 had a history of [REDACTED]. The following approaches were to be implemented: "Provide for pressure relieving and positioning devices. Assist (R #1) carefully when providing care ..." Daily and Q (every) Shift Charting dated 03/14/15 at 9:00 a.m., revealed R #1 was up in her Wheel Chair (W/C) in the front lobby "moaning in pain noted to have swelling to Lt. ankle ...spoke with aid on the floor about resident. States that when taking resident out of dining room resident's foot slipped off foot rest and was under chair." Physician's Telephone Orders dated 03/14/15 revealed an order for [REDACTED]. Physician's Telephone Orders dated 03/14/15 at 9:01 p.m., revealed an order for [REDACTED].=pain medicine and [MEDICATION NAME]= sedative) Physician's Telephone Orders dated 03/15/15 at 8:00 p.m., revealed an order for [REDACTED].#1 to have a left ankle and leg wrap with comfort ace wrap. Physician's Telephone Orders dated 03/16/15 revealed an order for [REDACTED]. Physician's Telephone Orders dated 03/17/15 revealed an order for [REDACTED]. Review of physician progress notes [REDACTED].#1's apparent injury Left ankle eversion was swollen and ecchymosis. (Ankle eversion=ankle sprain caused by an external force) (Ecchymosis=non-raised skin discoloration from broken blood vessels) On 04/01/15 at 1:50 p.m., the Medical Director said, "According to (R #1's) X-Ray she does not have a fracture but an eversion sprain." Provider Investigation Report dated 03/16/15 at 10:00 a.m., revealed the incident involving R #1 occurred on 03/14/15 at 9:30 a.m. The report indicated R #1 was total assistance and was not interviewable. The perpetrator was identified as CNA "P". The description of the injury revealed while CNA "P" was transporting R #1 out of the dining area, R #1's foot slipped off wheel chair foot rest and onto the floor. R #1 cried out and when CNA "P" stopped the wheel chair R #1's foot was behind the foot rest. CNA "P" backed the wheel chair up and placed R #1's foot on the foot rest and wheeled R #1 to the living area. R #1 was assessed as having pain, and left foot and ankle area sustained deep tissue damage. There were no fractures based on X-Ray. The provider response was suspending CNA "P" pending investigation, all parties were notified, and pain management, care plans updated, and medical care was provided. R #1's wheel chair was screened for safety and the facility applied a foot board as an intervention to prevent R #1's feet from slipping off foot rests. Facility audited other resident wheel chairs for safety, and In serviced staff on reporting incidents, wheel chair positioning, use of foot boards for wheel chair rests/pedals, proper wheel chair transport of residents, use of mechanical lifts and abuse and neglect. "Investigation Summary... Investigator concludes that although an incident, abuse occurred, by negligent infliction of injury, with no willful intent." On 03/31/15 at 10:05 a.m., during an observation of R #1's left leg and ankle with LVN "L" present revealed R #1's left leg and ankle were swollen and was dark gray in appearance. R #1 had facial grimacing when LVN lifted R #1's leg up to remove the ace wrap. LVN "L" said she was the charge nurse for the hall R #1 was residing and was familiar with R #1's care needs. LVN "L" said she had seen R #1's foot slip off the foot rests several times but did not think this would cause injury, because when R #1's foot would fall off the foot rest, the staff would lift her foot up and place it back onto the foot rest. LVN "L" said if she thought R #1's foot slipping off the foot rest was a problem she would have made a referral for PT to evaluate. LVN "L" said she was unaware how often or even if, PT re-evaluates resident's need for adaptive equipment. On 03/31/15 at 10:40 a.m., interview with PT "K" revealed R #1's wheel chair foot rests were fully functioning and that after R #1's injury PT evaluated R #1's wheel chair for safety and determined a leg board was needed. PT ordered a device for R #1's chair to position legs correctly and prevent legs from slipping through the leg rests or falling off the foot rests. PT "K" said when the nursing staff saw R #1's feet falling off the foot rests that a referral should have been made to PT to evaluate the wheel chair for safety and adaptive equipment. On 03/31/15 at 10:55 p.m., interview with Responsible Party (RP) revealed prior to R #1's leg injury, R #1 was up in the wheel chair three times a day, was able to feed herself and R #1's appetite was fair. Since R #1's injury, the Hospice Nurse recommended that resident stay in the bed, due to the pain and discomfort associated with the injury that getting out of bed took to much energy out of R #1. The RP said prior to the injury R #1 was mobile in the wheel chair short distances by "scooting her feet." The RP said now, R #1 had a decrease in appetite and slept most of the time. On 03/31/15 at 12:55 p.m., interview with LVN "M" revealed she was also a charge nurse for the same hall R #1 resided. LVN "M" said she was the nurse on duty at the time R #1 was injured. LVN "M" said that another charge nurse witnessed the incident occur. LVN "M" said she did not feel R #1 was at risk for injury from foot rests, because R #1 "did not move around" and was total care. LVN "M" said the charge nurses should be monitoring CNAs to ensure they are providing safe transfers and care. LVN "M" said she has never witnessed R #1's feet slip off the wheel chair foot rests and since R #1's incident R #1 has had a decline in ADL functioning, because before the injury, R #1 was getting out of bed for all meals and activities. LVN "M" said now R #1 does not get out of bed at all and R #1's appetite had greatly declined. On 03/31/15 at 2:45 p.m., interview with LVN "B" revealed she was on duty when R #1 was injured. LVN "B" said "sometime" after 9:00 a.m. on 03/14/15 she heard R #1 yell out and when she looked up CNA "P" was pushing R #1 in the wheel chair and LVN "B" said to CNA "P" "watch her feet" CNA "P" stopped pushing the wheel chair and picked up the lap robe that was covering R #1's legs. LVN "B" said R #1's left foot bent behind her and on the floor under the wheel chair. CNA "P" picked R #1's foot up and placed it back on the foot rest. LVN "P" said R #1 did not make any noise when CNA "P" lifted R #1's foot onto the foot rest. LVN "B" said she left to take care of another resident and when she returned "approximately 15 minutes later" to the Nurses Station she saw LVN "M" lifting R #1's foot up and placing it back on the foot rest. LVN "B" said she noticed R #1's facial grimacing and asked LVN "M" if CNA "P" had reported to her that R #1's foot had slipped off the foot rest? LVN "M" said no, CNA "P" had not reported anything to her. LVN "B" said both she and LVN "P" saw that R #1's foot and ankle was swollen so LVN "P" said she was going to get R #1 back into bed to conduct an assessment. LVN "B" said she felt the incident could have been avoided if the CNA had lifted the blanket up to ensure R #1's feet were securely positioned on the foot rest before moving the wheel chair. On 03/31/15 at 3:15 p.m., interview with PT "K" revealed if a resident was not properly positioned in their wheel chair then their leg could come off the foot rests. PT "K" said residents that have cognition impairment would not necessarily know if their foot fell off the foot rest and residents that are dependent with wheel chair mobility should have a leg board in place to prevent legs and feet injury. PT "K" said staff should always check resident positioning prior to moving their wheel chair. PT "K" said, "To my understanding (R #1) had a blanket coving her legs, maybe the blanket was covering the foot rests making it difficult to assess positioning." On 04/01/15 at 10:05 a.m., interview with CNA "P" revealed on 03/14/15 at approximately 6:15 a.m. to 6:30 a.m. she and Nurse Aide (NA) "J" went into R #1's room to get her out of bed for breakfast. CNA "P" said R #1 made a noise as if she were in pain. CNA "P" said she was unfamiliar with R #1 because she only works part time, but NA "J" was familiar with R #1 and told CNA "P" that R #1 had arthritis and was frequently in pain. CNA "P" said when they transferred R #1 from the bed to the wheel chair via mechanical lift that she noticed R #1's foot was on the floor and not on the foot rest. CNA "P" said she lifted R #1's foot up to place it on the foot rest R #1 again made another noise like she was in pain. CNA "P" asked NA "J" if they should report to the charge nurse and NA "J" said "no" because R #1 always was in pain. CNA "P" said, "I feel really bad that I did not report it earlier because (R #1) could have been medicated for her pain." CNA "P" said she wheeled R #1 to the dining room and then after breakfast she started to wheel R #1 out of the dining room when she heard LVN "M" yell out from across the room, "hey, watch her foot". CNA "P" said she stopped the wheel chair and lifted up R #1's blanket that was covering her legs and saw that R #1's foot had fallen off the foot rest and was bent under the wheel chair. CNA "P" said she lifted R #1's foot up and placed it back on the foot rest and R #1 said, "ouch my leg hurts," CNA "P" then wheeled R #1 into the living room and was called off to tend to another resident. CNA "P" said, "It is a blessing that all this came about because now the aides are getting training they need." CNA "P" said R #1 had not gotten out of bed since the injury occurred. On 04/01/15 at 11:00 a.m., interview with NA "J" revealed on 03/14/15 "sometime after 6:00 a.m." she and CNA "P" entered R #1's room to get her up for breakfast. NA "J" said she had worked with R #1 for the past three months and was "very familiar" with her care needs. NA "J" said R #1 was asleep and had to be wakened prior to the transfer via mechanical lift. NA "J" said the transfer was uneventful and R #1 did not show signs of pain. NA "J" said between 9:00 a.m. and 9:15 a.m. she saw LVN "M" transporting R #1 back to her room, LVN "M" requested assistance in transferring R #1 back to bed. NA "J" said she and CNA "P" transferred R #1 back into bed and R #1 complained that her leg hurt. NA "J" said she saw R #1's left leg, ankle and top of foot was discolored blue and purple and swollen. NA "J" said she had seen R #1's foot fall off the foot rest many times but she lifts R #1's foot up and back on the foot rest prior to moving the wheel chair, because R #1 cannot position her own feet independently. NA "J" said R #1 never had a foot or leg board for the wheel chair prior to the incident but now has one. R #1 had not gotten out of bed since her leg injury. NA "J" was told by the charge nurses, not to get R #1 out of bed . NA "J" said staff was in serviced after R #1's leg injury on proper positioning, safe transfers and the use of leg/foot boards. NA "J" said the training was really needed because a lot of people did not know how to use a foot board or transfer a resident that had foot rests and leg rests on their wheel chair. On 04/01/15 at 12:20 p.m., interview with the DON revealed CNAs should have reported to their charge nurse R #1's feet were slipping off the foot rests instead of just placing R #1's feet back on the foot rests. The DON said R #1's injury could have been prevented and retraining of staff will be conducted. The DON said the PT department determines how a resident should be transferred. According to Centers of Medicare and Medicaid Services form 672 the facility had 67 residents that required the assistance of one or two staff for transfers. The facility's Wheel Chair Dependent Residents list revealed 15 residents were wheel chair bound.

Based on observation, interview, and record review, the facility failed to ensure the environment remained free of accident hazards; and each resident receives adequate supervision and assistance devices to prevent accidents for one Resident (R#1) of five residents reviewed provision of adaptive equipment. -R #1 was not provided adaptive equipment for her wheel chair leg/rests. R #1 sustained a physical injury. This failure could affect 15 wheel chair dependent residents and 67 residents that required the assistance of one or two staff for transfers by placing them at risk for physical injury. The findings were: R #1's Face Sheet dated 03/09/15 revealed R #1 was a [AGE] year old female readmitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. and Dementia. R #1's Significant Change Minimum Data Set ((MDS) dated [DATE] revealed R #1 was on Hospice Care for the [DIAGNOSES REDACTED].#1 was confused, disoriented, and forgetful. R #1 had a decreased ability to make herself understood and a decreased ability to understand others. R #1 had a hearing impairment and vision impairment. R #1 was incontinent of bowel and bladder, uses mechanical lift for all transfers and was unable to perform ADL's without limited to total assistance. R #1 required limited assistance with eating. R #1 was wheelchair bound. R #1's Care Plan dated 01/24/15 revealed R #1 required assistance for all ADL's: "Extensive assistance x 1 with bed mobility, and incontinent care/toileting. Ext. assist x 2 (hoyer) for transfers, total assistance x 1 w/wheelchair mobility ..." The following approaches were to be implemented: "...Promote (R #1's) safety with ADL functions ...Provide (R #1) with appropriate assistive devices as needed. (R #1) is w/c bound and is total dependent on staff for w/c mobility." R #1's Care Plan dated 01/24/15 revealed R #1 had a history of [REDACTED]. The following approaches were to be implemented: "Provide for pressure relieving and positioning devices. Assist (R #1) carefully when providing care ..." Daily and Q (every) Shift Charting dated 03/14/15 at 9:00 a.m., revealed R #1 was up in her Wheel Chair (W/C) in the front lobby "moaning in pain noted to have swelling to Lt. ankle ...spoke with aid on the floor about resident. States that when taking resident out of dining room resident's foot slipped off foot rest and was under chair." Physician's Telephone Orders dated 03/14/15 revealed an order for [REDACTED]. Apply Voltran Gel 1% to her left ankle four times a day as needed for pain. Physician's Telephone Orders dated 03/14/15 at 9:01 p.m., revealed an order for [REDACTED].=pain medicine and Valium= sedative) Physician's Telephone Orders dated 03/15/15 at 8:00 p.m., revealed an order for [REDACTED]. An additional order was for R #1 to have a left ankle and leg wrap with comfort ace wrap. Physician's Telephone Orders dated 03/16/15 revealed an order for [REDACTED]. Physician's Telephone Orders dated 03/17/15 revealed an order for [REDACTED]. Review of physician progress notes [REDACTED].#1's apparent injury Left ankle eversion was swollen and ecchymosis. (Ankle eversion=ankle sprain caused by an external force) (Ecchymosis=non-raised skin discoloration from broken blood vessels) On 04/01/15 at 1:50 p.m., the Medical Director said, "According to (R #1's) X-Ray she does not have a fracture but an eversion sprain." Provider Investigation Report dated 03/16/15 at 10:00 a.m., revealed the incident involving R #1 occurred on 03/14/15 at 9:30 a.m. The report indicated R #1 was total assistance and was not interviewable. The perpetrator was identified as CNA "P". The description of the injury revealed while CNA "P" was transporting R #1 out of the dining area, R #1's foot slipped off wheel chair foot rest and onto the floor. R #1 cried out and when CNA "P" stopped the wheel chair R #1's foot was behind the foot rest. CNA "P" backed the wheel chair up and placed R #1's foot on the foot rest and wheeled R #1 to the living area. R #1 was assessed as having pain, and left foot and ankle area sustained deep tissue damage. There were no fractures based on X-Ray. The provider response was suspending CNA "P" pending investigation, all parties were notified, and pain management, care plans updated, and medical care was provided. R #1's wheel chair was screened for safety and the facility applied a foot board as an intervention to prevent R #1's feet from slipping off foot rests. Facility audited other resident wheel chairs for safety, and In serviced staff on reporting incidents, wheel chair positioning, use of foot boards for wheel chair rests/pedals, proper wheel chair transport of residents, use of mechanical lifts and abuse and neglect. "Investigation Summary... Investigator concludes that although an incident, abuse occurred, by negligent infliction of injury, with no willful intent." On 03/31/15 at 10:05 a.m., during an observation of R #1's left leg and ankle with LVN "L" present revealed R #1's left leg and ankle were swollen and was dark gray in appearance. R #1 had facial grimacing when LVN lifted R #1's leg up to remove the ace wrap. LVN "L" said she was the charge nurse for the hall R #1 was residing and was familiar with R #1's care needs. LVN "L" said she had seen R #1's foot slip off the foot rests several times but did not think this would cause injury, because when R #1's foot would fall off the foot rest, the staff would lift her foot up and place it back onto the foot rest. LVN "L" said if she thought R #1's foot slipping off the foot rest was a problem she would have made a referral for PT to evaluate. LVN "L" said she was unaware how often or even if, PT re-evaluates resident's need for adaptive equipment. On 03/31/15 at 10:40 a.m., interview with PT "K" revealed R #1's wheel chair foot rests were fully functioning and that after R #1's injury PT evaluated R #1's wheel chair for safety and determined a leg board was needed. PT ordered a device for R #1's chair to position legs correctly and prevent legs from slipping through the leg rests or falling off the foot rests. PT "K" said when the nursing staff saw R #1's feet falling off the foot rests that a referral should have been made to PT to evaluate the wheel chair for safety and adaptive equipment. On 03/31/15 at 10:55 p.m., interview with Responsible Party (RP) revealed prior to R #1's leg injury, R #1 was up in the wheel chair three times a day, was able to feed herself and R #1's appetite was fair. Since R #1's injury, the Hospice Nurse recommended that resident stay in the bed, due to the pain and discomfort associated with the injury that getting out of bed took to much energy out of R #1. The RP said prior to the injury R #1 was mobile in the wheel chair short distances by "scooting her feet." The RP said now, R #1 had a decrease in appetite and slept most of the time. On 03/31/15 at 12:55 p.m., interview with LVN "M" revealed she was also a charge nurse for the same hall R #1 resided. LVN "M" said she was the nurse on duty at the time R #1 was injured. LVN "M" said that another charge nurse witnessed the incident occur. LVN "M" said she did not feel R #1 was at risk for injury from foot rests, because R #1 "did not move around" and was total care. LVN "M" said the charge nurses should be monitoring CNAs to ensure they are providing safe transfers and care. LVN "M" said she has never witnessed R #1's feet slip off the wheel chair foot rests and since R #1's incident R #1 has had a decline in ADL functioning, because before the injury, R #1 was getting out of bed for all meals and activities. LVN "M" said now R #1 does not get out of bed at all and R #1's appetite had greatly declined. On 03/31/15 at 2:45 p.m., interview with LVN "B" revealed she was on duty when R #1 was injured. LVN "B" said "sometime" after 9:00 a.m. on 03/14/15 she heard R #1 yell out and when she looked up CNA "P" was pushing R #1 in the wheel chair and LVN "B" said to CNA "P" "watch her feet" CNA "P" stopped pushing the wheel chair and picked up the lap robe that was covering R #1's legs. LVN "B" said R #1's left foot bent behind her and on the floor under the wheel chair. CNA "P" picked R #1's foot up and placed it back on the foot rest. LVN "P" said R #1 did not make any noise when CNA "P" lifted R #1's foot onto the foot rest. LVN "B" said she left to take care of another resident and when she returned "approximately 15 minutes later" to the Nurses Station she saw LVN "M" lifting R #1's foot up and placing it back on the foot rest. LVN "B" said she noticed R #1's facial grimacing and asked LVN "M" if CNA "P" had reported to her that R #1's foot had slipped off the foot rest? LVN "M" said no, CNA "P" had not reported anything to her. LVN "B" said both she and LVN "P" saw that R #1's foot and ankle was swollen so LVN "P" said she was going to get R #1 back into bed to conduct an assessment. LVN "B" said she felt the incident could have been avoided if the CNA had lifted the blanket up to ensure R #1's feet were securely positioned on the foot rest before moving the wheel chair. On 03/31/15 at 3:15 p.m., interview with PT "K" revealed if a resident was not properly positioned in their wheel chair then their leg could come off the foot rests. PT "K" said residents that have cognition impairment would not necessarily know if their foot fell off the foot rest and residents that are dependent with wheel chair mobility should have a leg board in place to prevent legs and feet injury. PT "K" said staff should always check resident positioning prior to moving their wheel chair. PT "K" said, "To my understanding (R #1) had a blanket coving her legs, maybe the blanket was covering the foot rests making it difficult to assess positioning." On 04/01/15 at 10:05 a.m., interview with CNA "P" revealed on 03/14/15 at approximately 6:15 a.m. to 6:30 a.m. she and Nurse Aide (NA) "J" went into R #1's room to get her out of bed for breakfast. CNA "P" said R #1 made a noise as if she were in pain. CNA "P" said she was unfamiliar with R #1 because she only works part time, but NA "J" was familiar with R #1 and told CNA "P" that R #1 had arthritis and was frequently in pain. CNA "P" said when they transferred R #1 from the bed to the wheel chair via mechanical lift that she noticed R #1's foot was on the floor and not on the foot rest. CNA "P" said she lifted R #1's foot up to place it on the foot rest R #1 again made another noise like she was in pain. CNA "P" asked NA "J" if they should report to the charge nurse and NA "J" said "no" because R #1 always was in pain. CNA "P" said, "I feel really bad that I did not report it earlier because (R #1) could have been medicated for her pain." CNA "P" said she wheeled R #1 to the dining room and then after breakfast she started to wheel R #1 out of the dining room when she heard LVN "M" yell out from across the room, "hey, watch her foot". CNA "P" said she stopped the wheel chair and lifted up R #1's blanket that was covering her legs and saw that R #1's foot had fallen off the foot rest and was bent under the wheel chair. CNA "P" said she lifted R #1's foot up and placed it back on the foot rest and R #1 said, "ouch my leg hurts," CNA "P" then wheeled R #1 into the living room and was called off to tend to another resident. CNA "P" said, "It is a blessing that all this came about because now the aides are getting training they need." CNA "P" said R #1 had not gotten out of bed since the injury occurred. On 04/01/15 at 11:00 a.m., interview with NA "J" revealed on 03/14/15 "sometime after 6:00 a.m." she and CNA "P" entered R #1's room to get her up for breakfast. NA "J" said she had worked with R #1 for the past three months and was "very familiar" with her care needs. NA "J" said R #1 was asleep and had to be wakened prior to the transfer via mechanical lift. NA "J" said the transfer was uneventful and R #1 did not show signs of pain. NA "J" said between 9:00 a.m. and 9:15 a.m. she saw LVN "M" transporting R #1 back to her room, LVN "M" requested assistance in transferring R #1 back to bed. NA "J" said she and CNA "P" transferred R #1 back into bed and R #1 complained that her leg hurt. NA "J" said she saw R #1's left leg, ankle and top of foot was discolored blue and purple and swollen. NA "J" said she had seen R #1's foot fall off the foot rest many times but she lifts R #1's foot up and back on the foot rest prior to moving the wheel chair, because R #1 cannot position her own feet independently. NA "J" said R #1 never had a foot or leg board for the wheel chair prior to the incident but now has one. R #1 had not gotten out of bed since her leg injury. NA "J" was told by the charge nurses, not to get R #1 out of bed . NA "J" said staff was in serviced after R #1's leg injury on proper positioning, safe transfers and the use of leg/foot boards. NA "J" said the training was really needed because a lot of people did not know how to use a foot board or transfer a resident that had foot rests and leg rests on their wheel chair. On 04/01/15 at 12:20 p.m., interview with the DON revealed CNAs should have reported to their charge nurse R #1's feet were slipping off the foot rests instead of just placing R #1's feet back on the foot rests. The DON said R #1's injury could have been prevented and retraining of staff will be conducted. The DON said the PT department determines how a resident should be transferred. On 04/01/15 at 12:45 p.m., interview with Occupational Therapy Assistant OTA "A" revealed Nurses Aides were supposed to notify the charge nurse if a resident has problems maintaining safe posture in a wheel chair. OTA "A" said if staff witness a resident's foot slipping of the wheel chair foot rests then a referral should be made to PT to evaluate for adaptive equipment. OTA "A" said in her professional training she was taught to take all equipment off the wheel chair prior to transferring a resident because the resident could get their feet and legs tangled up in the leg/foot rests and cause injury. Review of facility Policy and Procedures (no date) entitled "Lifting And Transferring Of Residents ...STANDARD Residents are lifted and transferred safely in all instances. POLICY * Nurses assess and determine lifting and transfer requirements and the procedure used for each resident ...*All members of the nursing staff, nurses and nursing assistants are responsible for using good body mechanics, knowing the proper procedures and properly operating assistive devices." Review of facility Policy and Procedures (no date) entitled "Positioning In Chair/Wheelchair ...STANDARD Residents are positioned to maintain correct body alignment when seated in chair ...POLICY * Cushions, wedges, and other corrective devices for seating are properly applied after assessment and implementation by the rehabilitation department ...PROCEDURES Wheelchair ...3. Position hips, knees and feet as close to 90-90-90 position as possible. 4. Support feet by placing on footplates or adaptive cushions (foot rest and foot boards) ...Ensure positioning during transport." Review of facility Incident/Accident Management Policy and Procedure dated 10/01/2010 revealed, "...Purpose *To ensure the center's staff is employing best practice standards to the best of their ability to prevent incidents and accidents...Definitions...'Avoidable Accident' means that the facility did not: -Identify Environmental hazards... -Implement interventions... -Monitor effectiveness... Procedures: ...2. The staff member making the discovery will notify his/ her immediate Supervisor or DON/designee about the incident..." According to Centers of Medicare and Medicaid Services form 672 the facility had 67 residents that required the assistance of one or two staff for transfers. The facility's Wheel Chair Dependent Residents list revealed 15 residents were wheel chair bound.

Based on interview, record review, the facility failed to provide each resident with a care plan that must describe the services that are to be furnished with measurable objectives and timetables to meet a resident's medical and nursing needs for one Resident (R#1) of six residents reviewed for care plans. The care plan for R#1 did not address the use of the toe splint; who would put the splint on, who would remove the splint; hours on, hours off, frequency of assessments or physician notification of changes. R#1 was admitted to the hospital on [DATE] for gangrene (death of tissue, usually resulting from deficient or absent blood supply) to Right second toe. Right second toe was amputated within a week of admission to hospital. Failure to have interventions and goals in place in a Comprehensive Care Plan affected R#1 and placed two residents with splints and braces at risk for skin infections and possible amputations. The findings were: Review of R#1's Face Sheet dated 04/23/13 revealed a [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of R#1's Minimum Data Set (MDS), quarterly review assessment dated [DATE] revealed: - disorganized thinking, no rejection of care -usually understood-difficulty communicating some words... -Ability to understand others-usually understands- misses some part/intent of message - Mood behaviors are not exhibited - No impairment in upper or lower extremities; able to ambulate with walker - Functional status independent with supervision - oversight with bed mobility, transfers and ambulation - bathing with oversight help only Record review of R#1 Wound Care Specialist (WCS) evaluation dated 12/17/12: - " Unstageable wound with eschar (dead tissue) right second toe, secondary to deformity. treatment plan: Resident #1 had a Magnetic Resonance Imaging (MRI) on 12/27/12 and was diagnosed with [REDACTED]. Record review of R#1's Weekly skin assessment (WSA) sheets revealed: - 02/04/13 "presence of skin concerns: yes-R (right) foot 2nd toe; poss. (possible) osteo[DIAGNOSES REDACTED]; assessment of lower extremities-normal - 02/11/13 presence of skin concerns: yes R foot 2nd toe; type -blank; assessment of lower extremities- normal -02/18/13 presence of skin concern: yes-R foot 2nd toe; type-blank; description of RLE (right lower ext.)-Normal -other: Hammertoe (toe bent at the middle of joint, claw-like). -02/28/13 presence of skin concern: yes R foot 2nd toe; type-blank Description- RLE-normal-hammertoe Rt foot 2nd toe. " Record review of R#1's Routine Treatment Administration Record dated February 2013 revealed -R foot 2nd toe-keep w/DSD (dry sterile dressing) qd (every day) to monitor for drainage. Record review of R#1's WSA - " 03/04/13 presence of skin concerns: Yes. R foot 2nd toe; type poss. osteo[DIAGNOSES REDACTED]-description of RLE-normal -hammertoe. -03/11/13 presence of skin concerns: R foot 2nd toe- poss. hx (history) Osteo[DIAGNOSES REDACTED]- must wear toe splint to R foot 2nd toe-must wear toe splint while ambulating (walking). -03/18/13 presence of skin concerns: Yes. R foot 2nd toe assessment of RLE-normal. -03/25/13 presence of skin concerns: R foot 2nd toe-hx of Osteo[DIAGNOSES REDACTED] Description of RLE -normal.-must wear toe splint to R foot 2nd toe while ambulating. D/t (due to) hx of Osteo[DIAGNOSES REDACTED]." The skin assessments from 02/18/13 to 03/25/13 did not describe the condition of R#1 ' s R 2nd toe (hammertoe) before or after the toe splint was applied. Record review of R#1 Routine Treatment Administration Record dated March 2013 "wound care d/c'd (discontinued) 03/05/13. Toe splint to R foot 2nd toe while ambulating 6a.m.-6p.m." Record review of R#1's Care Plan dated 12/10/12 and updated 03/07/13 revealed " potential for skin breakdown...currently has an area of concern (blister) to her R 2nd toe on her right foot requiring referral to Wound Care Specialist. " R#1's Care plan revealed: - "12/17/12-CBC (complete blood count), x-ray R 2nd toe r/o (rule out) Osteo[DIAGNOSES REDACTED] chronic severe hammertoe deformity. R#1 ' s Care Plan Wound Care Specialist (WCS) notes revealed: - 12/17/12 revealed: unstageable wound with eschar (dead tissue) right second toe, secondary to deformity. treatment plan: [REDACTED] -12/20/12 MRI of Rt foot to r/o Osteo[DIAGNOSES REDACTED]. 01/02/[MEDICATION NAME](antibiotic) 500 milligram (mg) 1 po (by mouth) bid (twice a day) for [MEDICATION NAME] (preventive) measures -possible Osteo[DIAGNOSES REDACTED] ... -01/02/13 Refer pt. (patient) to orthopedic surgeon Record Review of WCS notes revealed: 01/28/13 " Osteo[DIAGNOSES REDACTED] right foot second toe. treatment plan: [REDACTED]. 2. Continue to keep right foot floated and pressure off toes... -01/31/13 " follow up x-ray to Rt foot 2nd toe d/t Osteo[DIAGNOSES REDACTED]. R#1 to remain non-ambulatory until follow up with orthopedic. -02/01/13 dedicated coned down view of the R foot second toe ... -03/04/13 Family member "A" refused follow up with ortho. (orthopedic) doctor. -03/05/13 Must wear toe splint with ambulation, may see podiatrist when in facility. " The care plan for R#1 did not address the use of the toe splint; who would put the splint on, who would remove the splint; hours on, hours off, frequency of assessments or physician notification of changes. Record review of R#1's Progress Note dated 03/05/13 revealed: "received telephone order from (orthopedic) office for 1. (Physical therapy/Occupational therapy) PT/OT to eval and treat as indicated for strengthening, 2. Per (orthopedic) ok to ambulate with rolling walker after Physical therapy/Occupational eval. 3. Must use toe splint to R foot while ambulating. 4. May see Podiatrist when in facility, RP (responsible party) aware of all orders." written per Licensed Vocational Nurse (LVN) "A". Record review telephone order for R#1 dated 3/05/13 revealed: - " Must use toe splint with ambulation. - May see podiatrist when in facility." On 05/07/13 at 2:25 p.m. attempted to interview LVN "A" by telephone, but she was not available. Record Review of R#1's Physical Therapy evaluation and plan of treatment notes with start of care 03/06/13 revealed: "Gait Analysis-deviations- patient exhibits inadequate toe clearance, inadequate trunk extension and forward lean of which are associated with the underlying causes of joint limitation and impaired proprioception (the awareness of posture, movement, and changes in [MEDICATION NAME] and the knowledge of position)." Record Review of R#1's Physician order [REDACTED]. Record review of R#1 Routine Treatment Administration record dated March 2013 "wound care d/c'd (discontinued) 03/05/13. Toe splint to Rt foot 2nd toe while ambulating 6a.m.-6p.m." Record review of Nurses Notes for R#1 from 03/25/13 to 04/02/13 did not reveal any documentation related to R#1's Rt 2nd toe. Record review of R#1 Nurses Note dated 04/02/13 revealed: "Rt foot 2nd toe [MEDICAL CONDITION] (swollen) with foul odor. Slough (dead tissue) to 3/4 top of toe. Removed toe splint..." R#1 was transferred to (local hospital). Record review of R#1's Hospital Record Consultation report dated 04/04/13 per Surgeon "J" Impression: 1. Right foot gangrene. 2. Right foot [MEDICAL CONDITION]. Record review of R#1's hospital Pre-Procedure Assessment and Post Procedure Progress Note dated 04/05/13 revealed: Right 2nd toe transmetatarsal amputation (surgical procedure to remove toe) . Post Procedure Diagnosis: [REDACTED]. During an interview on 04/22/13 at 11:50 a.m., Family member "A" stated "I saw my mother's (R#1) foot while she was in the Emergency Department on 04/02/13 and her whole foot was red, and swollen, after the surgery, my mother (R#1) keeps asking what happened to my foot? and why did I have to have my toe amputated? " During an interview on 04/23/13 at 12:00 p.m., Director of Nurse (DON) stated that R#1 had a Rt 2nd toe splint due to R#1 ' s hammertoe deformity. DON stated there was no care plan generated for R#1's toe splint and that she did not know that she needed a care plan for the toe splint. During an interview on 04/23/13 at 12:30 p.m. the Director of Physical Therapy stated that she saw R#1 for an evaluation for strengthening. The PT Director stated that R#1 always wore the toe splint when ambulating. Director stated that she would remove R#1's shoe to make sure that R#1 was wearing the toe splint. The PT Director stated that normally she would monitor the splint and plan to educate nursing and restorative aide for the care of the splint, but R#1's splint was ordered by the nursing staff, and the nurses should have been monitoring it. Director stated that she did not train the nursing or restorative nurse aide on the care R#1's splint. During an interview on 04/23/13 at 1:00 p.m. with the Administrator, he stated that R#1's toe splint was ordered by facility. He stated that the medical supply company used by facility did not have a manufacturer ' s recommendation on the toe splint and/or no other information. During an interview on 05/07/13 at 11:30 a.m. Minimum Data Set (MDS) Coordinator " H " revealed that R#1 did not show a change of condition that effected three or more activities of daily living (ADLs) within a 7 day look back window. (MDS) Coordinator " H " stated that she looked at R#1's nurses notes, MD (physician) orders, x-rays and any other documentation and it did not show that R#1 had a significant change of condition. Therefore a change of condition MDS was not done for R#1. MDS Coordinator " H " stated that the DON or the Care Plan Nurse could have written a Temporary Care Plan for R#1 for any new [DIAGNOSES REDACTED]. During an Interview on 05/07/13 at 11:35 a.m., LVN "B" revealed that the nurse was responsible for putting on any devices. LVN "B" stated that the order was written in the Treatment Administration Record (TAR). LVN "B" stated R#1's TAR read to apply splint to R#1 R 2nd toe from 6:00 a.m. to 6:00 p.m. LVN "B" stated that she would put the splint on R#1's Rt foot and described R#1's splint to the surveyor as follows: " The splint had a hard surface and a cushion that covered R#1's two toes, and that the two toes were held together with rubber- like band to the tip of the toes to secure the splint in place." LVN "B" stated that she would apply the splint in the morning but would not remove it at 6:00 p.m., because R#1 was still up in the dining room. During an interview on 05/07/13 at 1:30 p.m., CNA "G" revealed that R#1 wore her R 2nd toe splint during the night. CNA "G" stated that R#1 was still wearing her R 2nd toe splint when CNA "G" left her shift at 10:00 p.m. During an interview on 05/07/13 at 2:00 p.m., Care Plan nurse "E" revealed that she added R#1's [DIAGNOSES REDACTED]. Care plan Nurse "E" stated that she did not have any interventions or goals for R#1 on the new [DIAGNOSES REDACTED].#1's splint. Care Plan Nurse "E" stated that a care plan should have been written, but that any of the other facility nurses could have started a Temporary care plan. During an interview on 05/07/13 at 2:15 p.m., CNA "F" revealed that R#1 was scheduled for a bath on 04/01/13 during the 2:00p.m.-10 p.m. shift. CNA "F" stated that R#1 appeared agitated and refused a bath that day. CNA "F" stated that R#1 washed her own underarms, removed her pants below her knees and did her own perineal (gential and rectal area of the body)-area. CNA "F" stated that she did not remove R#1 socks or shoes to check if R#1 was wearing any device on her toes. CNA "F" stated that she had reported R#1's refusal to shower to LVN "A". During an interview on 05/07/13 at 2:30 p.m., R#1's hospital Surgeon " J " revealed that R#1's R 2nd toe was amputated on 04/05/13. He stated "the toe was very sick." The Surgeon stated that R#1's past clinical records revealed that R#1 had two positive tests that revealed R#1 had Osteo[DIAGNOSES REDACTED] of the R 2nd toe. He stated that R#1 developed Gangrene (due to restriction of blood supply) to the R 2nd toe. On 05/07/13 at 3:00 p.m., the DON stated that she had two residents in the facility that used splints. On 05/07/13 at 3:15 p.m., during the exit conference, the DON and Administrator were given the opportunity to provide additional information. None was provided.

Based on interview, record review, the facility failed to provide each resident the necessary care and services to attain or maintain the highest practical physical well being, in accordance with the comprehensive assessment for one Resident (R#1) of six residents reviewed for skin assessments and splints. The facility failed to assess and monitor the condition of the toe under the splint from 03/26/13 to 04/01/13 after a splint was placed. R#1's skin assessments were not done to monitor for any discoloration of skin, circulation, warmth of the toe and did not asesss for signs or symptoms of infection to report to physician. R#1 was admitted to the hospital on [DATE] for gangrene (death of tissue, usually resulting from deficient or absent blood supply) to Right second toe. Right second toe was amputated within a week of admission to hospital. This failure affected the quality of care for one Resident (R#1) and placed two residents at risk for developing skin infections and gangrene who used splints/braces. The findings were: Review of R#1's Face Sheet dated 04/23/13 revealed a [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of R#1's Minimum Data Set (MDS), quarterly review assessment dated [DATE] revealed: - disorganized thinking, no rejection of care -usually understood-difficulty communicating some words... -Ability to understand others-usually understands- misses some part/intent of message - Mood behaviors are not exhibited - No impairment in upper or lower extremities; able to ambulate with walker - Functional status independent with supervision - oversight with bed mobility, transfers and ambulation - bathing with oversight help only Record review of R#1 Wound Care Specialist (WCS) evaluation dated 12/17/12: - " Unstageable wound with eschar (dead tissue) right second toe, secondary to deformity. treatment plan: Resident #1 had a Magnetic Resonance Imaging (MRI) on 12/27/12 and was diagnosed with [REDACTED]. Record review of R#1's Weekly skin assessment (WSA) sheets revealed: - 02/04/13 "presence of skin concerns: yes-R (right) foot 2nd toe; poss. (possible) osteo[DIAGNOSES REDACTED]; assessment of lower extremities-normal - 02/11/13 presence of skin concerns: yes R foot 2nd toe; type -blank; assessment of lower extremities- normal -02/18/13 presence of skin concern: yes-R foot 2nd toe; type-blank; description of RLE (right lower ext.)-Normal -other: Hammertoe (toe bent at the middle of joint, claw-like). -02/28/13 presence of skin concern: yes R foot 2nd toe; type-blank Description- RLE-normal-hammertoe Rt foot 2nd toe. " Record review of R#1's Routine Treatment Administration Record dated February 2013 revealed -R foot 2nd toe-keep w/DSD (dry sterile dressing) qd (every day) to monitor for drainage. Record review of R#1's WSA - " 03/04/13 presence of skin concerns: Yes. R foot 2nd toe; type poss. osteo[DIAGNOSES REDACTED]-description of RLE-normal -hammertoe. -03/11/13 presence of skin concerns: R foot 2nd toe- poss. hx (history) Osteo[DIAGNOSES REDACTED]- must wear toe splint to R foot 2nd toe-must wear toe splint while ambulating (walking). -03/18/13 presence of skin concerns: Yes. R foot 2nd toe assessment of RLE-normal. -03/25/13 presence of skin concerns: R foot 2nd toe-hx of Osteo[DIAGNOSES REDACTED] Description of RLE -normal.-must wear toe splint to R foot 2nd toe while ambulating. D/t (due to) hx of Osteo[DIAGNOSES REDACTED]." The skin assessments from 02/18/13 to 03/25/13 did not describe the condition of R#1 ' s R 2nd toe (hammertoe) before or after the toe splint was applied. Record review of R#1 Routine Treatment Administration Record dated March 2013 "wound care d/c'd (discontinued) 03/05/13. Toe splint to R foot 2nd toe while ambulating 6a.m.-6p.m." Record review of R#1's Care Plan dated 12/10/12 and updated 03/07/13 revealed " potential for skin breakdown...currently has an area of concern (blister) to her R 2nd toe on her right foot requiring referral to Wound Care Specialist. " R#1's Care plan revealed: - "12/17/12-CBC (complete blood count), x-ray R 2nd toe r/o (rule out) Osteo[DIAGNOSES REDACTED] chronic severe hammertoe deformity. R#1 ' s Care Plan Wound Care Specialist (WCS) notes revealed: - 12/17/12 revealed: unstageable wound with eschar (dead tissue) right second toe, secondary to deformity. treatment plan: [REDACTED] -12/20/12 MRI of Rt foot to r/o Osteo[DIAGNOSES REDACTED]. 01/02/[MEDICATION NAME](antibiotic) 500 milligram (mg) 1 po (by mouth) bid (twice a day) for [MEDICATION NAME] (preventive) measures -possible Osteo[DIAGNOSES REDACTED] ... -01/02/13 Refer pt. (patient) to orthopedic surgeon Record Review of WCS notes revealed: 01/28/13 " Osteo[DIAGNOSES REDACTED] right foot second toe. treatment plan: [REDACTED]. 2. Continue to keep right foot floated and pressure off toes... -01/31/13 " follow up x-ray to Rt foot 2nd toe d/t Osteo[DIAGNOSES REDACTED]. R#1 to remain non-ambulatory until follow up with orthopedic. -02/01/13 dedicated coned down view of the R foot second toe ... -03/04/13 family member "A" refused follow up with ortho. (orthopedic) doctor. -03/05/13 Must wear toe splint with ambulation, may see podiatrist when in facility. " The care plan for R#1 did not address the use of the toe splint; who would put the splint on, who would remove the splint; hours on, hours off, frequency of assessments or physician notification of changes. Record review of R#1's Progress Note dated 03/05/13 revealed: "received telephone order from (orthopedic) office for 1. (Physical therapy/Occupational therapy) PT/OT to eval and treat as indicated for strengthening, 2. Per (orthopedic) ok to ambulate with rolling walker after Physical therapy/Occupational eval. 3. Must use toe splint to R foot while ambulating. 4. May see Podiatrist when in facility, RP (responsible party) aware of all orders." written per Licensed Vocational Nurse (LVN) "A". Record review telephone order for R#1 dated 3/05/13 revealed: - " Must use toe splint with ambulation. - May see podiatrist when in facility." On 05/07/13 at 2:25 p.m. attempted to interview LVN "A" by telephone, but she was not available. Record Review of R#1's Physical Therapy evaluation and plan of treatment notes with start of care 03/06/13 revealed: "Gait Analysis-deviations- patient exhibits inadequate toe clearance, inadequate trunk extension and forward lean of which are associated with the underlying causes of joint limitation and impaired proprioception (the awareness of posture, movement, and changes in [MEDICATION NAME] and the knowledge of position). Record Review of R#1's Physician order [REDACTED]. Record review of R#1 Routine Treatment Administration record dated March 2013 "wound care d/c'd (discontinued) 03/05/13. Toe splint to Rt foot 2nd toe while ambulating 6a.m.-6p.m." Record review of Nurses Notes for R#1 from 03/25/13 to 04/02/13 did not reveal any documentation related to R#1's Rt 2nd toe. Record review of R#1's Hospital Record Consultation report dated 04/04/13 per Surgeon "J" Impression: 1. Right foot gangrene. 2. Right foot [MEDICAL CONDITION]. Record review of R#1's hospital Pre-Procedure Assessment and Post Procedure Progress Note dated 04/05/13 revealed: Right 2nd toe transmetatarsal amputation (surgical procedure to remove toe) . Post Procedure Diagnosis: [REDACTED]. Record review of R#1 Nurses Note dated 04/02/13 revealed: "Rt foot 2nd toe [MEDICAL CONDITION] (swollen) with foul odor. Slough (dead tissue) to 3/4 top of toe. Removed toe splint..." R#1 was transferred to (local hospital). Record review of R#1's Hospital Record Consultation report per Surgeon "J" dated 04/04/13 revealed: Impression: 1. Right foot gangrene. 2. Right foot [MEDICAL CONDITION]. Record review dated 04/05/13 of R#1's hospital Pre-Procedure Assessment and Post Procedure Progress Note revealed: Right 2nd toe transmetatarsal (surgical procedure to remove toe) amputation. Post Procedure Diagnosis: [REDACTED]. During an interview on 04/22/13 at 11:50 a.m., Family member "A" stated "I saw my mother's (R#1) foot while she was in the Emergency Department on 04/02/13 and her whole foot was red, and swollen, after the surgery, my mother (R#1) keeps asking what happened to my foot? and why did I have to have my toe amputated? " During an interview on 04/23/13 at 12:00 p.m., Director of Nurse (DON) stated that R#1 had a Rt 2nd toe splint due to R#1 ' s hammertoe deformity. DON stated there was no care plan generated for R#1's toe splint and that she did not know that she needed a care plan for the toe splint. During an interview on 04/23/13 at 12:30 p.m. the Director of Physical Therapy stated that she saw R#1 for an evaluation for strengthening. The PT Director stated that R#1 always wore the toe splint when ambulating. Director stated that she would remove R#1's shoe to make sure that R#1 was wearing the toe splint. The PT Director stated that normally she would monitor the splint and plan to educate nursing and restorative aide for the care of the splint, but R#1's splint was ordered by the nursing staff, and the nurses should have been monitoring it. Director stated that she did not train the nursing or restorative nurse aide on the care R#1's splint. During an interview on 04/23/13 at 1:00 p.m. with the Administrator, he stated that R#1's toe splint was ordered by facility. He stated that the medical supply company used by facility did not have a manufacturer ' s recommendation on the toe splint and/or no other information. During an interview on 05/07/13 at 11:30 a.m. Minimum Data Set (MDS) Coordinator " H " revealed that R#1 did not show a change of condition that effected three or more activities of daily living (ADLs) within a 7 day look back window. (MDS) Coordinator " H " stated that she looked at R#1's nurses notes, MD (physician) orders, x-rays and any other documentation and it did not show that R#1 had a significant change of condition. Therefore a change of condition MDS would was not done for R#1. MDS Coordinator " H " stated that the DON or the Care Plan Nurse could have written a Temporary Care Plan for R#1 for any new [DIAGNOSES REDACTED]. During an Interview on 05/07/13 at 11:35 a.m., LVN "B" revealed that the nurse was responsible for putting on any devices. LVN "B" stated that the order was written in the Treatment Administration Record (TAR). LVN "B" stated R#1's TAR read to apply splint to R#1 R 2nd toe from 6:00 a.m. to 6:00 p.m. LVN "B" stated that she would put the splint on R#1's Rt foot and described R#1's splint to the surveyor as follows: " The splint had a hard surface and a cushion that covered R#1's two toes, and that the two toes were held together with rubber- like band to the tip of the toes to secure the splint in place." LVN "B" stated that she would apply the splint in the morning but would not remove it at 6 p.m. because R#1 was still up in the dining room. During an interview on 05/07/13 at 1:30 p.m., CNA "G" revealed that R#1 wore her R 2nd toe splint during the night. CNA "G" stated that R#1 was still wearing her R 2nd toe splint when CNA "G" left her shift at 10:00 p.m. During an interview on 05/07/13 at 2:00 p.m. with Care Plan nurse "E" revealed that she added R#1's [DIAGNOSES REDACTED]. Care plan Nurse "E" stated that she did not have any interventions or goals for R#1 on the new [DIAGNOSES REDACTED].#1's splint. Care Plan Nurse "E" stated that a care plan should have been written, but that any of the other facility nurses could have started a Temporary care plan. During an interview on 05/07/13 at 2:15 p.m. with CNA "F" revealed that R#1 was scheduled for a bath on 04/01/13 during the 2:00 p.m.-10:00 p.m. shift. CNA "F" said that R#1 appeared agitated and refused a bath that day. CNA "F" stated that R#1 washed her own underarms, removed her pants below her knees and did her own perineal (gential and rectal area of the body)-area. CNA "F" stated that she did not remove R#1 socks or shoes to check if R#1 was wearing any device on her toes. CNA "F" stated that she had reported R#1's refusal to shower to LVN "A". During an interview on 05/07/13 at 2:30 p.m., with R#1's hospital Surgeon " J " revealed that R#1 ' s R 2nd toe was amputated on 04/05/13. He stated "the toe was very sick." The Surgeon stated that R#1's past clinical records revealed that R#1 had two positive tests that revealed R#1 had Osteo[DIAGNOSES REDACTED] of the Rt 2nd toe. He stated that R#1 developed Gangrene (due to restriction of blood supply) to the R 2nd toe. On 05/07/13 at 3:00 p.m., the DON stated that she had two residents in the facility that used splints. On 05/07/13 at 3:15 p.m., during the exit conference, the DON and Administrator were given the opportunity to provide additional information. None was provided.