Every finding on record at Marshall Manor West

Based on observation, interview, and record review the facility failed to provide the appropriate care and services to prevent urinary tract infections to the extent possible for 1 of 2 residents reviewed for indwelling catheters. (Resident #9) -Resident #9 had a urinalysis specimen obtained on 01/30/26 due to complaint of discomfort from lower abdomen to his penis and cloudy urine. The facility staff did not follow up on obtaining results and Resident #9 continued with signs of a possible UTI. This failure could place residents at risk of not receiving the required level of care and possible sepsis. Findings included:Record review of a face sheet dated 02/04/26 indicated Resident #9 was a [AGE] year-old male admitted on [DATE]. His diagnoses included multiple sclerosis (a chronic condition where the immune system mistakenly attacks the protective covering of nerve cells), urinary retention (when the bladder (where urine is stored) doesn't empty when a person pees), urogenital implants (a medical device that is surgically placed within the male's penis to treat various conditions), neuromuscular dysfunction of bladder (when an injury or disease interrupts the electrical signals between the nerves that control bladder function), benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland), and history of urinary tract infections (an infection in the kidneys, ureters, bladder, or urethra). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #9 had moderately impaired cognition and he had an indwelling catheter. Record review of a care plan revised on 11/13/25 indicated Resident #9 had an indwelling foley catheter and was at risk for frequent UTIs, dislodgement, or other complications. Interventions included monitor for and report foul smelling, turbid urine, low-grade temp, blood in tubing or drainage bag, urine is no longer straw colored, etc.; monitor for and report inflammation or signs of infection in the area around the catheter. Signs of infection include pus or irritated, swollen, red, or tender skin; and monitor for and report to MD pain or cramps for a prolonged period, urine stops for 2 or 3 hours, bloody urine, urine that is cloudy, irritation around the abdominal opening, signs of infection such as fever or chills, an unusual, strong smelling discharge, urinary spasms, which cause sharp pains in the lower abdomen. Record review of Nurse Notes for Resident #9 indicated the following entries:* on 01/29/26 at 04:00 p.m., he reported pain radiating from the lower abdomen/stomach down to his penis; and* on 01/30/26 at 09:20 a.m., he allowed the nurse to assess his lower abdomen which was slightly distended and he complained of pain when touched. His catheter tubing had cloudy urine sediment. Hospice was contacted and an order was received for urinalysis with culture and sensitivity for complaint of lower abdominal pain. Hospice indicated they would have their laboratory to run the urine test. Record review of a Physician's Telephone Orders form indicated Resident #9 had an order dated 01/30/26 for UA /c C&S c/o lower abdominal pain. Record review of Nurse Notes for Resident #9 indicated the following entries:* on 01/30/26 at 10:30 a.m., the urine sample was collected from Resident #9 and placed in the refrigerator for pick up; * on 01/30/26 at 02:30 p.m., his catheter had amber colored urine flowing into the drainage bag; * on 01/31/26 at 12:30 a.m., there was no documentation of laboratory results received;* on 01/31/26 at 01:00 p.m., his catheter had dark colored urine and there was no documentation of laboratory results received;* on 01/31/26 at 03:15 p.m., his catheter had cloudy urine and there was no documentation of laboratory results received;* on 02/01/26 at 10:00 a.m., hospice nurse was contacted because Resident was complaining of abdominal pain; urine to catheter drainage bag thick, appeared mucous tinged, and copious; he complained of being cold with temperature assessed at 97.8 degrees; and there was no documentation of laboratory results received;* on 02/01/26 at 11:20 a.m., hospice nurse was at the facility, spoke with Resident family member and family member said abdominal pain from upcoming gallbladder surgery; hospice nurse notified MD about the Resident's upcoming surgery; there was no documentation of resident urine being assessed and addressed; and there was no documentation of laboratory results received;* on 02/01/26 at 06:00 p.m., his catheter had cloudy urine in the tubing and there was no documentation of laboratory results received;* on 02/02/26 at 09:00 a.m., urine to catheter tubing noted thick and yellow and there was no documentation of laboratory results received; and * on 02/02/26 at 11:00 a.m., hospice nurse at facility, no new orders, and awaiting C&S. There was no indication any initial laboratory results were received. During an observation on 02/02/26 at 11:02 a.m. Resident #9 was resting in bed. He had a catheter bag on the right side of the bed. There was thick yellow/white colored mucous appearing urine noted in catheter bag tubing. During an observation and interview on 02/03/2026 at 10:59 a.m. Resident #9 had urine in his catheter bag tubing with thick, turbulent, yellow colored sediment, with dark amber streaks. The Tx Nurse said the urine in the catheter tubing did look bad like he may have an infection. She said there was a specimen obtained for urinalysis on Friday (01/30/26) but did not know if the results were back yet. During an interview on 02/03/2026 at 11:10 a.m. LVN D said Resident #9 had an order for a UA with C&S on 01/30/26 and the specimen was obtained. She said hospice had sent the same day. She had not received anything back yet on Resident #9's urinalysis. She said she had not followed up with the hospice nurse on the results at this time. During an interview on 02/03/2026 at 02:45 p.m. the DON said they received the order for the urinalysis on Friday (01/30/26), the specimen was obtained, and hospice picked up the specimen to send to their lab. She said they had to send the specimen off to their lab who just received the specimen today (02/03/26). She said she had not followed up on the specimen report as well as the charge nurses. She said because of the delay they had received a stat (fast, quickly, immediately) order today (02/03/26) to obtain the specimen and to send to their lab so they would have a result tonight. She said a delay in getting lab results could be a delay of treatment. She said this could result in the resident's infection progressing into sepsis (a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) and could possibly cause death. Record review of a Physician's Telephone Orders form indicated Resident #9 had an order dated 02/03/26 for UA /c Reflex to PCR. During an interview on 02/03/26 at 03:22 p.m. the IP said she was not aware Resident #9 had not had the results of the urine specimen returned. She said she had not followed up with the CN, the hospice nurse, or the laboratory about the results. She said she was to follow up when residents had suspected infections or infections. She said an untreated urinary infection could lead to sepsis. During an interview and record review on 02/03/2026 at 5:15 p.m. the DON provided a lab result dated 02/03/26. The results indicated Resident #9 was positive for leukocyte esterase (an enzyme produced by white blood cells-presence usually means infection), nitrites (usually indicate a bacterial urinary tract infection), or catalase (it did not specify which one) and positive for catalase bacteria screen (an enzyme that can be detected in urinary tract infections). She said they should be getting the remaining results this evening or tomorrow and would provide to surveyor. She said the physician did not want to place the resident on any antibiotic at this time. Record review of a laboratory result dated 02/03/26 indicated Resident #9's urine was dark yellow colored (should be clear, yellowed colored), 3+ blood (normal level would be negative), 2+ protein (normal level would be negative), 3+ leukocyte esterase (normal level would be negative, and positive for catalase bacteria screen (normal level would be negative). Record review of the Antibiotic Stewardship - Staff and Clinician Training and Roles policy dated Policy Statement: The facility will educate and train staff and practitioners about the facility Antibiotic Stewardship Program, including appropriate prescribing, monitoring, and surveillance of antibiotic use and outcomes. Policy Interpretation and Implementation:Nursing and Direct Care Licensed Staff:1. Nurses will receive initial orientation and ongoing training on:. c. How to utilize the standardized assessment and communication tool for residents suspected of having an infection;.f. Specific information that should be reported to the physician or provider upon identifying signs and symptoms of possible infection;. Record review of the facility's undated Urinary Tract Infection Protocol indicated the following: When a resident is suspected of having a urinary tract infection or Physician has requested an order for urinalysis the Charge Nurse must take the following steps.1. If resident is continent of urine request a clean catch urine specimen; if resident is continent but has some cognitive deficit the Charge Nurse must assist in obtaining urine specimen.2. If resident is incontinent request order for in and out cath.3. Store urine on ice or in specimen refrigerator until urine is collected by the lab; because most lab draws are collected in the early am, 10/6 shift is responsible for collecting urine specimens.I. Symptomatic urinary tract infection One of the following criteria must be met:.2. The resident has an indwelling catheter and has at least two of the following signs or symptoms:(a) fever (38 CJ or chills,(b) new flank or suprapubic pain or tenderness,(c) change in character of urine, (d) worsening of mental or functional status.II. When there is a patient history of urinary infection within the past three weeks and where there may be a relapse from the previous urinary infection and / or antibiotic resistance. The facility had not received the final laboratory results prior to the survey team exiting the facility.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation in that: The facility failed to ensure the fryer was clean and free of debris.The facility failed to ensure baking sheets did not have brown and black colored buildup and debris of particles on the outside.The facility did not ensure skillets did not have brown and black colored buildup on the inside and outside.The facility failed to ensure a pack of cigarettes, and a fly swatter was not stored under the cutting boards touching the oven mittens.The facility failed to maintain cleanliness of the floor in the kitchen prep area.The facility failed to ensure dietary staff had all their hair in the hair restraints. The facility failed to ensure the Maintenance Supervisor wore a beard restraint while in the kitchen.The facility failed to ensure the dishwasher had an internal temperature starting at 80 degrees Fahrenheit then ended at 110 degrees Fahrenheit after 3 attempts on 02/02/2026 at 8:45 a.m. These failures could place residents at risk of foodborne illnesses. Findings include: During an observation and initial tour of the kitchen on 02/02/2026 at 8:45 a.m. - the fryer had thick layers of brown and yellow colored crusted debris along the outside of the fryer. The fryer had black and brown debris above the frying baskets.- 13 baking sheets had brown and black colored buildup and debris particles on the outside on the outside.- 4 skillets had brown and black colored buildup and debris particles on the outside on the outside.- one pack of cigarettes and a fly swatter were stored on the kitchen prep table under 4 cutting boards touching 2 oven mittens.- there was brown colored debris on the floor throughout the kitchen prep area, under the refrigerator, freezers and pan/pot storage.- Dietary aide B, Dietary C, and [NAME] D had loose hair hanging from the front and back of the hair restraint during meal preparation. During an initial tour observation and interview on 02/02/20206 at 8:45 a.m. the dishwasher had an internal temperature started at 80 degrees Fahrenheit and ended at 110 degrees Fahrenheit after 3 attempts. During an interview on 02/02/2026 at 9:00 a.m. with the DM she said the dishwasher's temperature must be at the manufacturer's recommendation of 120 degrees for the dishes to be sanitized. She said the chemicals they use to sanitize the dishes require the water in the dishwasher to be at a minimum of 120 degrees. She said the potential risk was cross contamination. During an observation and follow-up kitchen tour on 02/02/2026 at 10:00 a.m., the Maintenance Supervisor entered the kitchen without a beard restraint while assessing kitchen equipment. During an interview with the Maintenance Supervisor on 02/02/2026 at 10:05 a.m., the Maintenance Supervisor said he should have worn a beard restraint while in the kitchen. He said he was in a rush to look the refrigerator and forgot. He said wearing an beard restraint would ensure hair did not fall into the food.During an interview with the DM on 02/02/2026 at 11:00 a.m. she said all staff were responsible for cleaning the kitchen and she expected the kitchen to be cleaned after each meal service at a minimum. She said the fryer should not have built- up food particles on it. She said all baking sheets, pots, and skillets should be free of debris, grease and buildup to avoid potential risk of cross contamination. She said she could not recall the last time it was cleaned. The DM said cigarettes should never be stored in the kitchen prep area. She said the cigarettes were from an employee. She said the fly swatter should not be stored under the cutting boards touching the oven mittens. She said she was not aware that the cigarettes nor fly swatters were under the cutting boards. The DM said all employees have been educated on wearing hair restraints and beard restraints for facial hair while in the kitchen to avoid hair potentially getting in the food. She said the new hair nets the facility order rising from their heads, making it easier for hair to escape. She said she would have to ensure staff readjust nets as needed. She said she expected staff to follow policy and procedure while in the kitchen and while handling food. During an interview with [NAME] A on 02/02/2026 at 11:35 a.m. she said the fryer should be cleaned after use and could not recall the last time it was cleaned. [NAME] A said she could not recall how long the fryer had the debris on it nor how long the baking sheets/ skillets had built up on it. She said all kitchen staff were responsible for ensuring all kitchen cooking equipment was cleaned after use to prevent the potential of cross contamination. During an interview with the Administrator on 02/02/2026 at 11:45 a.m. he said he expected the kitchen to be clean and free of debris. He said the pans and skillets should be free of buildup to prevent the potential transfer to the food. He said personal items should not be stored in the kitchen prep area. He said hair should be restrained while in the kitchen, including facial hair to prevent hair from getting into the food. The Administrator said the manufacturer's instructions for the dishwasher's temperature should be followed to ensure the dishes are being sanitized correctly. The administrator said if dishes were not washed at 120 degrees, the residents can potentially be harmed by cross contamination. Record review of the manufacturer's recommendation. It says for water temperature to be at a minimum of 120 degrees for the dishes to be sanitized. Record Review of the facility policy titled: Sanitization dated: October 2008 indicated in part: Policy StatementThe food service area shall be maintained in a clean and sanitary manner.Policy Interpretation and ImplementationAll kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects.All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair.Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. Record review of the facilitys policy titled Sanitization revision dated October 2008 indicated in part: Policy Statement: The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions.Dishwashing machines must be operated using the following specifications:High-Temperature Dishwasher (Heat Sanitization)Wash temperature (150 - 165 F) for at least forty-five (45) seconds;Rinse temperature (165 - 180 F) for at least twelve (12) seconds. Low-Temperature Dishwasher (Chemical Sanitization)Wash temperature (120 F);Final rinse with 50 parts per million (ppm) hypochlorite (chlorine) for at least 10 seconds

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that facility was free of pests and rodents for 1 of 1 kitchen. The facility did not maintain an effective pest control program to ensure the facility was free of roaches in the kitchen. This failure could place residents at risk for an unsanitary environment and a decreased quality of life.The findings included: During an observation of the facility's kitchen on 02/02/2026 at 11:16 a.m., During lunch meal prep there was approximately one dime size light brown roach crawling from the stove area to where pan sheets were stored in the kitchen. During an observation on 02/03/2026 at 11:00 a.m. there was approximately a half quarter inch roach crawling on the shelf above where food was being pureed. The DM grabbed the roach with a napkin and discarded it. During an interview on 02/03/2026 at 12:05 p.m. with the DM she said they had a roach issue in the past. She said the roach issue had gotten better. She said they had regular pest control that would come to the facility regularly to address general pests and insects. The DM said having roaches in the kitchen potentially could get resident's sick. She said food was covered to ensure food was safe. During an interview on 02/03/2026 at 3:00 p.m. with the Administrator he said he had pest control come out routinely, every 2 weeks and as needed. He said cross contamination would be the potential risk associated with roaches in the kitchen. He said it was all staff's responsibility to notify him if pests or insects were seen so he could call the pest control to come and spray outside the scheduled visits. Record review of the facility's pest control records for 2026 indicated the pest control company visited the facility every two weeks and had last visited the facility on 01/05/2026 to treat pests and insects. The kitchen was last treated for general pests on 01/05/2026. On the report it stated Treated and inspected A wing and kitchen for general pests. No issues at this time. Record review of the facility policy tilted: Sanitization revision date: October 2008 indicated in- part Policy StatementThe food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and ImplementationAll kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects.

Based on interview, and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 5 of 9 dietary staff reviewed for food handler's certificates. The facility failed to have current food handler's certificates for five kitchen staff until surveyor intervention on 02/02/2026. (Cook-A, Dietary Aide B, Dietary Aide C, Dietary Aide D, Dietary Aide E.) This failure could place residents at risk for food borne illness. The findings included: Record review on 02/04/2026 of Kitchen hire dates indicated: [NAME] A was hired 11/07/2024- Did not have a food handler's certificate until 02/02/2026. Dietary Aide B was hired 11/1/2018- Did not have a food handler's certificate until 02/02/2026. Dietary Aide C 10/14/2024-Did not have a food handler's certificate until 02/02/2026. Dietary Aide D was hired 07/15/2025- Did not have a food handler's certificate until 02/02/2026. Did not have a food handler's certificate until 02/02/2026-Did not have a food handler's certificate until 02/02/2026. Dietary Aide was hired 07/19/2024-Did not have a food handler's certificate until 02/02/2026.Record review of the Dietary Staff's Food Handler Certificates indicated Cook-A, Dietary Aide B, Dietary Aide C, Dietary Aide D, Dietary Aide E had Food Handler Certificates dated 02/02/2026 as the date they had completed the training for the certificate. During an interview on 02/02/2026 at 1:10 p.m. with the DM she said she could not produce the food handlers license for Cook-A, Dietary Aide B, Dietary Aide C, Dietary Aide D, Dietary Aide E that was issued before 02/02/2026 (after surveyor's intervention). She said the employees could not remember their passwords to access their license online. She said she did not have a paper copy of their licenses because she knew they had one. She said she was responsible for ensuring the food handlers were current. Review of the Texas Food Code indicated the following in part: The Texas Department of State Health Services (TXDSHS) requires that all food employees must successfully complete an accredited food handler training course within 30 days of employment. The training courses teach employees about food safety, including good hygiene practices and how to avoid cross-contamination.

Based on observations, interviews and record reviews the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 1 of 20 residents (Resident #42) reviewed for diet preferences. The facility failed to ensure Resident # 42's vegetarian dietary preferences were met. This failure could place residents at risk of their preferences not being considered.Findings included: Record review of Resident #42's face sheet dated 02/02/2026 indicated a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses of - myocardial infarction (heart attack), generalized muscle weakness and lack of coordination, depression, heart failure.Record review of Resident #42's Quarterly MDS dated she had a BIMS score of 15 indicating she was cognitively intact. Record review of Resident #42's care plan revision dated 01/15/2026 indicated there was no diet listed nor a vegetarian diet listed. Resident #42's food allergies was listed Chamomile, Chocolate, Eggplant, Potato, Lanolin, [NAME] oil, and lemon flavoring.Record review of Resident #42's Order summary dated 02/04/2026 indicated a regular diet with regular texture and thin consistency. The order summary listed her diet as Cardiac that was ordered since 12/08/2025. There was no vegetarian diet listed in the orders. Record review of Resident #42's social service progress note dated 12/29/2025 indicated Resident #42's family member made a complaint related to resident's dietary restrictions/ wishes are not being honored. Her specific diet is not complete or nutritious enough.Record review on 02/19/2026 of Resident #42's list of foods she likes, dislikes, and is allergic to. -Grilled cheese-Vanilla pudding-Butterscotch pudding-Sweet potatoes-Squash-Onions-Broccoli- Salad-Ranch dressing-Beans-Rice-Cornbread-Cheetos-Apples-Peaches-Peanut butter crackers-Eggs-Grits-Toast-Biscuits-Tuna-Salmon-Impossible burgers-Mac n cheese-Black beans- No meat-No potatoes-No chocolate-No rosemary-No tomatoesPlease pick multiple for meals- Written and signed by DM. Record review of Resident #42's dietician initial assessment progress notes dated 12/19/2025 indicated Resident #42 had a diet of vegetarian. The Dietician wrote The resident is vegetarian, and DM has a detailed list of likes/ dislikes and food intolerances and continue diet/ POC. Record review of Resident #42's meal tray card non-dated indicated she had a cardiac/ renal diet. During an observation and interview 02/03/2026 at 5:50 p.m. Resident #42 was served shredded lettuce (no topping), a bag of corn chips (on the plate next to the shredded lettuce), side of green beans, side of fruit and juice. Resident #42 stated would you eat this? Now you see what I've been dealing with since December. How is this supposed to be nutritious?During an interview with the DON on 02/03/2026 at 6:00 p.m. she said the plate Resident #42 received did not meet her expectations. She said Resident #42 should never have been served plain lettuce with corn chips. She said she was aware that the resident did not eat meat but would eat salmon and tuna. She said she did not know about the written complaint that was written by Resident #42's family member. She said there was no order for Resident #42's preference for a vegetarian diet. During an interview with the Administrator on 02/03/2026 at 6:10 p.m. he said the evening meal Resident #42 was served did not align with his expectations. He said no one in the facility should be served that. He said the vegetarian diet was a preference not a diet ordered by the physician. He said the DM had ordered items off the list of food Resident #42 would eat. He said he followed up more than once on the food complaint when he received it and ensured Resident #42's preferences were met. He said she liked the food's and had no complaints since. He said the associated potential risk was Resident #42's food preferences would not be met.During an observation and interview with Resident #42 (DM present) on 02/04/2026 at 9:30 a.m. Resident #42 showed the surveyor and DM a picture that was time stamped- December 12, 2025, at 5:44 p.m. depicted a bowel of raw broccoli, ice cream, and juice for her dinner tray. A picture was taken on December 28, 2025, at 12:39 p.m. depicted a main dish of brussels sprouts (no sides). Resident #42 stated I am angry and frustrated because I keep telling the staff the over -and -over what I can and cannot eat. My family had to bring food up here for me to eat so I would have something to eat. I've gone hungry before because I did not want to eat the raw broccoli they served me with a side ice cream. They can just get me a spoon and peanut butter, and I'll eat that. Resident #42 told the DM that she knows she orders foods for her but her staff does not carry out the serving part. She said she did not know why she was served brussels sprouts because it wasn't on the list that was provided to the facility. During an interview on 02/04/2026 at 1:00 p.m. with the Dietician, she said Resident #42 asked for a vegetarian diet but would eat tuna and salmon. She said she had verbally educated the DM on what a vegetarian diet was and how to accommodate residents on that diet. She said Resident #42 was the only resident that had a vegetarian diet preference. She said it was important for the facility to take residents diet preferences into consideration when meal planning because it is their right. Record review of facility policy tilted : Resident Food Preferences revision date: November 2015 indicated in-part: Policy StatementIndividual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent.Policy Interpretation and ImplementationUpon the resident's admission (or within twenty-four (24) hours after his/her admission) the Dietitian or nursing staff will identify a resident's food preferences.When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes.Nursing staff will document the resident's food and eating preferences in the care plan.The Dietitian and nursing staff, assisted by the Physician, will identify any nutritional issues and dietary recommendations that might be in conflict with the resident's food preferences.The Dietitian will discuss with the resident or representative the rationale of any prescribed therapeutic diet. The Physician and Dietitian will communicate the risks and benefits of specialized therapeutic vs. liberalized diets.Therapeutic diets will be ordered only after the resident/representative agrees with and consents to such a diet.The resident has the right not to comply with therapeutic diets.If the resident refuses or is unhappy with his or her diet, the staff will create a care plan that the resident is satisfied with and agrees to comply with.Documenting that a resident is refusing meals due to non-compliance with diet orders is not appropriate.The Food Services Department will offer a variety of foods at each scheduled meal, as well as access to foods throughout the day and night.The facility's Quality Assessment and Performance Improvement (QAPI) Committee will periodically review issues related to food preferences and meals to try to identify more widespread concerns about meal offerings, food preparation, etc.

Based on interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 10 residents (Resident #42) reviewed for care plans. The facility failed to complete a comprehensive care plan for Resident #42's diet preferences on 12/19/2025 for Resident #42 when she was initially assessed by the Dietitian. This failure could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services. Findings included: Record review of Resident #42's face sheet dated 02/02/2026 indicated a [AGE] year-old female that was admitted to the facility on [DATE] with diagnosis: myocardial infarction (heart attack), generalized muscle weakness and lack of coordination, depression, heart failure.Record review of Resident #42's Quarterly MDS assessment dated reflected she had a BIMS score of 15 indicating her cognition was intact. Record review of Resident #42's care plan revised 01/15/2026 indicated there was no diet listed nor a vegetarian preference listed. Resident #42's food allergies were listed as, Chamomile, Chocolate, Eggplant, Potato, Lanolin, [NAME] oil, and lemon flavoring.Record review of Resident #42's Order summary dated 02/04/2026 indicated a regular diet with regular texture and thin consistency. The order summary listed her diet as Cardiac that was ordered since 12/08/2025. Record review of Resident #42's social service progress note dated 12/29/2025 indicated Resident #42's family member made a complaint that resident's dietary restrictions/ wishes are not being honored. Her specific diet is not complete or nutritious enough.Record review on 02/04/2026 of Resident #42's list of foods she likes, dislikes, and is allergic to.-Grilled cheese-Vanilla pudding-Butterscotch pudding-Sweet potatoes-Squash-Onions-Broccoli- Salad-Ranch dressing-Beans-Rice-Cornbread-Cheetos-Apples-Peaches-Peanut butter crackers-Eggs-Grits-Toast-Biscuits-Tuna-Salmon-Impossible burgers-Mac n cheese-Black beans- No meat-No potatoes-No chocolate-No rosemary-No tomatoesPlease pick multiple for meals- Written and signed by DM. Record review of Resident #42's dietician initial assessment progress notes dated 12/19/2025 indicated Resident #42 had a diet of vegetarian. The Dietician wrote The resident is vegetarian, and DM has a detailed list of likes/ dislikes and food intolerances and continue diet/ POC. During an interview on 02/03/2026 at 4:30 p.m. with the Administrator, he said the care plan should include Resident #42's diet preferences. He said they couldn't meet every preference but could make reasonable accommodations. He said her diet preferences were more of a presbyterian diet because she ate tuna and salmon. He said Resident #42's food preferences not care planned could lead to her being happy. During an interview on 02/03/2026 at 6:00 p.m. with the DON, she said the facility included residents' food/diets preferences on the care plan. She said Resident #42's care plan should have had her preferences listed. She said the nurses and herself were responsible for updating the care plans. She said Resident #42's food preferences were oversight. Record review of the facility's undated policy entitled Comprehensive Resident Centered Care Plans indicated in- part: Intent: The care plan will contain information about the physical, emotional/ psychological, psychosocial, spiritual, educational and environmental needs as appropriate. Updating Care Plans:1. Care plans are modified between care plan conference when appropriate to meet the resident's current needs, problems, and goals.3. The Care Plan will be updated and/ or revised for the following reasons: a. Significant change in the resident's condition.b. A change in planned interventions.c. Goals are obtained and new goals established to meet current resident needs and/or goals.d. New diagnosis, new medications, or abnormal labs.4. Any revisions, additions, or deletion to the plan of care will be dated and initialed. Resident/ Resident Reprehensive Involvement: Residents are involved in decisions regarding the provision of care.

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 stove. The facility failed to ensure the rear 2nd, 3rd, and 5th burners ignited when the knobs were turned on. The rear 2nd, 3rd, and 5th would not ignite when the knobs were turned until the 3rd try on 02/02/2026 at 9:18 a.m. These failures could place the residents at risk of a fire and cross contamination. Findings included: During an initial tour observation and interview on 02/02/20206 at 9:18 a.m. The rear 2nd, 3rd, and 5th burners on the stove would not ignite when the knobs were turned on until the 3rd time. No smell of gas was noted by the staff when it was turned on. The pilots' light remained on, and the front burners were working. During an interview on 02/02/2026 at 9:25 a.m. the DM said she was not aware the rear 2nd, 3rd, and 5th burners were not lighting because staff had cooked on them that morning. She said they had not had any issues with the stove prior to 02/02/2026. She said she would have someone come out and check it. During an interview on 02/02/2026 at 9:45 a.m. the Administrator said he was not aware that the burners were not igniting. He said he had not had any reports that the oven was igniting. He said he would get it maintenance that day. Record Review of the facility policy titled: Sanitization dated: October 2008 indicated in part: Policy StatementThe food service area shall be maintained in a clean and sanitary manner.Policy Interpretation and Implementation2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair.

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the residents' practicable physical, mental, and psychosocial well-being for 1 (Resident #45) of 10 residents reviewed for care plans. The facility failed to develop and implement a person-centered PICC Line IV care plan with interventions for Resident #45. This failure could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services.Record review of Resident #45's Face Sheet, dated 02/03/26 indicated a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with urinary tract infection and mycoplasma pneumonia (Bacteria that causes respiratory infection). Record review of Resident #45's Quarterly MDS Assessment, dated 12/09/2025, indicated the resident's cognition was intact with a BIMS score of 15. Record review of Resident #45's Care Plan, dated 11/12/25, indicated there were no care plans for PICC line dressing care, flushing, or for IV antibiotic.Review of Resident #45's Physician Order, dated 01/28/26, indicated Sodium Chloride 0.9% solution 50ml with Cefepime 2 gm, inject 2gm into the vein every 12 hours for 3 days diagnosis mycoplasma pneumonia. There were no orders for PICC line flushes.Record review of Resident #45's MAR/TAR, dated 01/26, indicated there was no documentation to indicate administering PICC line dressing, flushes, or for IV antibiotic.During an interview on 02/03/26 at 2:29 PM, the MDS nurse said Resident #45's care plan should have been revised on 01/28/26 when the order was obtained for the IV antibiotic. The MDS Nurse, when asked if Resident #45 had a care plan for the IV PICC line checked the resident's medical record and said there were no care plans related to the IV or Flushing. She stated either the ADON or DON was responsible for updating care plans. The MDS Nurse said all information about a resident was to be care planned. She stated the interdisciplinary team, and all staff was to follow what was documented on the plan of care for each resident, and if IV flushes were not on the care plan, there was a possibility if a nurse reviewed the care plan, the nurse may not know how to use the IV line.In an interview on 02/03/26 at 2:00 p.m., the DON stated there should be a care plan on Resident #45's chart about the PICC line with interventions to flush before connecting the IV bag with antibiotics and after. She said there should also be interventions on when to change the dressing and what to assess, like check for signs and symptoms of infections. She said everything done for the resident should have care plan. She said the nurses might know what to do, but there should be a care plan so the staff would be insync with the resident's care. The DON said the MDS nurse was responsible for care plans, and she (DON) reviewed the care plans for completeness.In an interview on 02/04/2026 at 3:00 p.m., the Administrator stated the expectation was care plans to be in place to make sure the staff were doing the care correctly. Record review of the facility's undated policy entitled Comprehensive Resident Centered Care Plans indicated in- part: Intent: The care plan will contain information about the physical, emotional/ psychological, psychosocial, spiritual, educational and environmental needs as appropriate. Updating Care Plans:1. Care plans are modified between care plan conference when appropriate to meet the resident's current needs, problems, and goals.3. The Care Plan will be updated and/ or revised for the following reasons: a. Significant change in the resident's condition.b. A change in planned interventions.c. Goals are obtained and new goals established to meet current resident needs and/or goals.d. New diagnosis, new medications, or abnormal labs.4. Any revisions, additions, or deletion to the plan of care will be dated and initialed.

Based on observation, interview, and record review, the facility failed to ensure the right to formulate an advance directive was provided for 1 of 4 residents reviewed for resident rights. (Resident #51) The facility failed to ensure Resident #51, who was listed as DNR (Do Not Resuscitate), had a valid Out-of-Hospital Do Not Resuscitate (OOH-DNR) form that was not missing required information or the witness signature and date. This failure could place residents at risk of lifesaving procedures being performed against their wishes resulting in bruising, broken ribs, electrical shocking of the heart, having a tube placed in the throat and provided artificial breathing methods, and possibly being brought back to life in an unaware and unresponsive state. Findings included:Record review of Resident #51's admission record, dated [DATE], indicated a [AGE] year-old female initially admitted on [DATE] and readmitted on [DATE]. Her diagnoses included dementia (loss of cognitive functioning), dysphagia (difficulty swallowing), dysphasia (impairment in the production of speech resulting from brain disease or damage), osteoarthritis (protective cartilage that cushions the ends of the bones wears down over time), and muscle weakness. Advance directive indicated DNR (Do Not Resuscitate). Record review of Resident #51's quarterly MDS assessment dated [DATE] indicated Resident #51 had minimal difficulty hearing, she had unclear speech, she was rarely/never able to make herself understood, she sometimes understood others, and she had severely impaired cognition and was unable to be interviewed. Record review of Resident #51's care plan indicated Resident #51 and her family requested she have a DNR status and long-term goal-initiated date of [DATE] and revision date of [DATE]. Interventions included if resident was found unresponsive with no palpable pulse or no respirations, do not initiate CPR, facility RN to pronounce and advanced directives would be reviewed by care plan team quarterly and prn. Record review of Resident #51 physician orders dated [DATE] indicated Resident #51 was a DNR. Record review Resident #51's OOH-DNR form dated [DATE] indicated the the date of birth section was blank; Section C labeled, Declaration by qualified relative of the adult person adult child box was checked signed and dated [DATE]. Section labeled TWO WITNESSES indicated, Witness #2 signed, dated [DATE], two years prior to the qualified relative signed the DNR indicating the qualified relative signature was not witnessed. The bottom of the form indicated All persons who have signed above must sign below, acknowledge that this document has been properly completed. The bottom of the form was not signed by witness #1 or witness #2. During an observation on [DATE] at 9:30 a.m. Resident #51 was lying in her bed in her room. She was unable to answer the interview questions. Attempted to contact Resident #51's responsible party on [DATE] at 11:10 a.m. and 1:15 p.m. with message requesting a return call; no returned call received. During an interview on [DATE] at 1:15 p.m., SS E said that she was responsible for assisting with OOH DNR. She said that she did not know that the witnesses had to sign the bottom of the OOH DNR form under All persons who have signed above must sign below, acknowledging that this document has been properly completed until awhile back. She said when she was notified of the witness signatures required at the bottom of the OOH DNR, she reviewed the current residents with OOH DNRs and must have missed Resident #51's not being signed or completed correctly. She said if the form was not completed correctly, that made it null and void. She said she would notify the facility staff and DON immediately and contact Resident #51's responsible party to have a new OOH DNR completed. The SS E said she would check all the DNRs for proper completeness of signatures and dates. The SS E said a resident's wishes may not have been followed if their advance directive was not completed. SS E verified there were no additional advance directives for Resident #51. During an interview on [DATE] at 2:15 p.m., the DON said Advance Directives were reviewed by the social worker to ensure accuracy. The DON said Advance Directives should be completed thoroughly to include dates that the document was witnessed and signed. The DON said she was made aware of the incomplete OOH-DNR on Resident #51 by SS E and the current OOH DNR was incomplete which would meant Resident #51 was a full code (staff would have to initiate CPR). The DON said it was important for Advance Directives to be completed thoroughly to ensure the documents were legally binding. The DON said the negative outcome would be that the resident could have CPR performed on them against their wishes. The DON said she would ensure the advance directive for Resident #51 was updated as soon as possible. Record review of a Do Not Resuscitate Order back page instructions read, .the OOH-DNR order Must be signed and dated by two competent adult witnesses who have witnessed either the competent adult person making his or her signature in section A.The original or copy of a fully and properly completed OOH-DNR order or the presence of an out of hospital DNR device on a person is sufficient evidence of the existence of the original out of hospital DNR order and either one shall be honored by responding health care professionals. Record review of the facility policy undated Do Not Resuscitate Order policy indicated: . It is the policy of the facility to honor Do Not Resuscitate Orders in accordance to State and Federal regulations .

Based on interviews and record reviews, the facility failed to ensure development and implementation of an effective discharge planning process that focused on the resident's discharge goals for 1 (Resident #15) of 10 residents reviewed for care plans. The facility failed to develop and implement a person-centered discharge care plan with interventions for Resident #15. This failure could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services.Findings Record review of Resident #15's admission record dated 02/03/2026 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of dementia (loss of cognitive functioning), cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), memory deficit following a stroke, COPD (chronic obstructive pulmonary disease-a lung disease that blocks airflow making it difficult to breathe), malignant neoplasm (cancer) of prostate. Record review of an admission MDS assessment dated [DATE] indicated Resident #15 had a BIMS score of 07 which indicated a severe cognitive impairment. He required partial to moderate assistance with self-care ADLs such as toileting, bathing, and was independent with his mobility. He had behaviors of disorganized thinking. He had active discharge planning already occurring for the resident to return to the community with no referral made to the local contact agency due to resident declined referral. Record review of Resident #15's care plan, revised 10/22/2025, indicated he had a risk for elopement. The care plan did not indicate Resident #15 had a care plan implemented or developed for discharge plans or resident's preference and potential for future discharge. Record review of Resident #15's physicians order dated 01/30/2026 indicated ok for discharge to home/community. Record review of Resident #51's psychosocial assessment dated [DATE] indicated Resident #15 expectation for discharge was to discharge to the community at another facility or community. The comments indicated he was admitted for long term placement, but Resident #51's family does have a goal to take him home if able. Record review of Resident #51's psychosocial assessment dated [DATE] indicated Resident #15 discharge assessment included: expectation for discharge was to discharge to the community at another facility or community, active plans for resident to return to community, discharge was a feasible goal and referral was made. During an interview and observation on 02/02/2026 at 10:26 a.m., Resident #15 said he was being discharged from the facility soon. Resident #15's family member entered the room and stated that Resident #15 had a plan to discharge on [DATE], but it was delayed waiting for approval or paperwork for the home health referral and acceptance. Resident #15 and family member (facility nurse) said the discharge plan was to return home with the family member, and supervision and monitoring would be provided. Resident #15 and the family member said they had care plan meetings and discussions with the facility staff regarding discharging home and safe discharge processes and was waiting for new discharge date . During an interview on 02/02/2026 at 11:00 a.m., LVN M stated she was the nurse for Resident #15, and he had physician orders for discharge, but it was postponed due to awaiting paperwork for approval for home health and a safe discharge assessment. During an interview on 02/04/2026 at 10:00 a.m., the MDS Coordinator stated it was the job of the DON and herself to update all care plans. She stated she received a psychosocial assessment from the social services department and entered the information into the EMR to create the MDS. She said from the data entered, the MDS care plans were generated. She said she was unsure how she missed developing and implementing the care plan and interventions for discharge on Resident #15. She said Resident #15's comprehensive care plan should have discharge plans. During an interview on 02/04/2026 at 10:15 a.m., SS E said she performed social services responsibilities under the corporate SW. She said she discussed discharge planning during her psychosocial assessments that she completed on admission, quarterly and as the need arose. She said she completed the psychosocial assessment on paper and gave it to the MDS Coordinator for it to be entered in the EMR as part of the MDS. She said she was aware Resident #15 had planned to return home or into the community with family, and she worked with home health services that were within his insurance network to start when he was discharged . During an interview on 02/04/2026 at 11:00 a.m., the DON stated Resident #15 had planned discharge the end of January 2026, but due to him being admitted as an elopement risk, the facility wanted Resident #15 to remain at the facility for 180 days with no elopement issues to provide a safe discharge to the home/community. She said Resident #15 and the family agreed on the delayed discharge and were waiting for approval for home health services. She said she could not think of a negative outcome for discharge planning not being on the care plan, but the facility and staff should follow state regulations and policy, and it is required that discharge plans be on the care plan. During an interview on 02/04/2026 at 02:00 p.m., the Administrator said he expected staff to follow facility policies and to update and revise residents' care plans to accurately reflect the residents' needs. Record review of the facility's undated policy titled 'Comprehensive Care Planning indicated Intent: It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessments, planning, treatment, service and intervention. It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharge for each resident. The care plan will contain information about the physical, emotional/psychological, psychosocial, spiritual, educational and environmental needs as appropriate. 2. The facility will 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 are identified in the comprehensive assessment. The comprehensive care plan must describe the following a. The services that are to be furnished to attain or maintain the residence highest practical physical mental and psychosocial well-being; . d. In consultation with their resident and their resident's representative(s): i. the residence goals for admission and desired outcomes. ii. The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities for this purpose. Iii. Discharge plans in the comprehensive care plan as appropriate in accordance with the requirements. Updating care plans: 6. Discharge planning concerns will be identified by all disciplines through ongoing assessment. The licensed nurse will make appropriate referrals to the interdisciplinary team members as necessary.

Based on observation, interview, and record review, the facility failed to administer parenteral fluids consistent with professional standards of practice and in accordance to physician orders for 1 of 1 (Resident #45) residents reviewed for parenteral (delivery of medications through injection)/IV (intravenous: administering fluids or medications directly into a vein) fluids. The facility failed to ensure Resident #45 had orders to flush the IV before and after medication administration. This failure could place residents receiving IV medications at risk for injury, infections, IV infiltration, clogging, and pain,. Findings included: Record review of Resident #45's Face Sheet dated 02/03/26 indicated a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with urinary tract infection and mycoplasma pneumonia (bacteria that causes respiratory infections). Record review of Resident #45's Quarterly MDS Assessment, dated 12/09/2025, indicated the resident was cognitively intact with a BIMS score of 15. Record review of Resident #45's Care Plan, dated 11/12/25, indicated there were no care plans for PICC line dressing care, flushing or for IV antibiotic. Review of Resident #45's Physician Order, dated 01/28/26, indicated Sodium Chloride 0.9% solution 50ml with Cefepime 2 gm, inject 2gm into the vein every 12 hours for 3 days diagnosis mycoplasma pneumonia., there were no orders for PICC line flushes.Record review of Resident #45's MAR/TAR, dated 01/26, indicated there were no documentation to indicate for administering PICC line dressing flushes or for IV antibiotic. During an interview on 02/03/26 at 2:29 PM, LVN N said before connecting the IV, the PICC line should be flushed to ensure the line was patent and would not get clogged. When asked if Resident #45 had orders for flushing and dressing changes, LVN N checked the resident's medical record and said there were no orders for flushing and dressing changes and there should be an order. In an interview on 02/03/26 at 2:00 p.m., the DON stated there should be an order on the Resident #45's chart about flushing the PICC line before connecting the IV bag with antibiotics and after. She said there should also be orders on when to change the dressing and what to assess and check for signs and symptoms of infections. She said everything done for the resident should have orders. She said the nurses might know what to do, but there should be orders so the staff would be insync with the residents' care. The DON said, for example, if there was no order when to flush the IV line, the staff would not be able to flush the IV because it would not be on the resident's eTAR/MAR. She said she already started an in-service. In an interview on 02/04/2026 at 3:00 p.m., the Administrator stated the expectation was that orders would be in place to make sure the staff were doing the care correctly. He said the DON already started an in-service. Record review of the facility's policy Central Venous and Midline Catheter Flushing 2001 MED-PASS, Inc., revised April 2016 indicated Purpose: The purposes of this procedure are to maintain patency of midline and central venous catheters. Flushing Protocol 1. Flush catheters at regular intervals to maintain patency AND before and after the following.administering of medication.

Based on observations, interviews, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 1 of 22 resident (Resident #37) reviewed for storage and labeling of medications. -Resident #37 had medications Nyquil cold & flu 12 oz bottle and Cloraseptic spray (Red) 6 oz bottle opened and used at the bedside. This failure could place residents at risk for misuse of medication, overdose, drug diversions, adverse reactions of medications, and not receiving the therapeutic benefit of medications.The findings include: Record review of Resident #37's face-sheet dated 02/04/26 indicated he was a [AGE] year-old male, admitted to facility on 10/03/25. His diagnosis included: Allergic rhinitis(seasonal allergies). Record review of Resident #37's admission MDS dated [DATE] indicated in part:- understood or understands others and had clear speech-BIMS score= 9 of 15, indicating moderately impaired cognitively for decision making Record review of Resident #37's electronic record indicated there was no Care Plan addressing may keep medications at bedside and no care plan to self-administer medications. Further review of the electronic record revealed Resident #37 did not have a Self-Administration Medication Assessment initiated or completed. Record review of Resident #37's consolidated report of current Physician orders dated 1/2026 and 2/2026 indicated no scheduled or PRN order for Nyquil cold & flu, Cloraseptic spray, self-administer medications or to leave at bedside. Observation during initial tour, on 02/02/26 at 9:30 a.m. indicated Resident #37 was not in the room and the door was open. On his bedside nightstand was an opened and used 9 ml bottle of Nyquil liquid, with no pharmacy label. On the bedside table was an opened and used bottle of chloroseptic with no pharmacy label. Observations on 02/02/26 at 2:45p.m. revealed Resident #37 was not in the room. The door was open and on bedside nightstand was the same bottle of Nyquil liquid, and on the bedside table was the same used bottle of chloroseptic red. During an interview on 02/03/2026 at 9:10 a.m. with LVN-N she said no resident should have medications at their bedside. She said she did not know of any residents having medications in their rooms. She said a physician's order must be on file for the resident to receive the medication as well as to self-administer medications. She said a resident could take inappropriate amounts of the medication or another resident could wonder in the room and get the medication and take it. She said residents could have an allergic reaction or become ill from taking unprescribed medication. During an interview on 02/03/26 at 9:18 a.m. MA-L said she's not aware of any resident having medications in their room. She said a resident can make themselves sick by taking unprescribed medications. She said all medications must have a physician's order and be given by a nurse or medication aide. Interview on 02/03/26 at 9:30 a.m. with the DON while at the Nurses station revealed she was aware of the mediations Nyquil & chloroseptic at Resident #37's bedside but could not remember who told her. The DON said her expectation was for nursing staff to follow facility policy and procedure and not leave medications at the bedside. The DON said Resident #37 would need a doctor's order and medication self-administration assessment completed before he would be able to keep meds at the bed side and administer them himself. The DON revealed she would have to look in the computer to see if Resident #37 had an order or med assessment, after looking in the computer the DON told surveyor that Resident #37 did not have an order for mediations or to leave medications at bedside and no self-administer medication assessment had been done for Resident #37. The DON said leaving medications at the bedside puts residents at risk of not taking properly or giving it to someone else to take, but that she (DON) felt Resident #37 was cognitively intact enough to take the medication correctly and would need to have a MD order or Self-Med Assessment first. The DON agreed that Residents in the facility must have a doctor's order to receive medications and that no resident can keep medication in their rooms and were not allowed to self-medicate. She stated there must be a physician's order to leave the medication at the bedside and an order for the resident to self-medicate. During and observation and interview on 02/03/26 at 10:00 a.m. indicated Resident #37 was in his room sitting on the side of his bed. When asked what does he use the Nyquil and chloroseptic for and how often does he use it, Resident #37 said that he uses the Nyquil at night for a cough and the chloroseptc for numbing a sore tooth in that back of his mouth and that his family member brought it for him approximately 3 weeks ago. Resident #37 said he did not report it to the nurses because the medication can be bought from the drug store without a Doctor's prescription and didn't see any point in it. When asked if he stored the medications in a different area Resident #37 said I keep it out like that very much like you see it there is not much room here to put things. Interview on 02/03/26 at 12:00pm with RP for Resident #37 indicated she had no concerns with the Medications Resident #37 was taking and was to meet with the facility for a quarterly meeting. The RP said she was the person responsible for bringing in the medications Nyquil and chloroseptic and she had done so approximately 3-4 weeks ago. The RP revealed she had not notified the nurses about the medications because she was not aware that she had to tell them since the medications were over-the-counter medications. The RP also said no one from the facility had contacted her about the medications, or that they could not be left out unattended at the bedside. During an interview on 02/04/26 beginning at 3:02 p.m., the Administrator stated his expectations were that all medications were left with the nurse unless the resident was assessed to self-administer. The Administrator stated the nursing department head was responsible for monitoring and overseeing. The Administrator stated it was important to ensure medications were not left at bedside for resident safety. Record review of the facility's policy titled, Medication Access and Storage, revised 05/2007 reflected . It is the policy of this facility to store all drugs and biological in locked compartments . Record Review of Pharmacy Policy & Procedure Manual 2003 titled Bedside storage of medications indicated, 10. All nurses and aides are required to report to the charge nurse on duty any mediations found at the bedside not unauthorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of this procedure and related policy when necessary.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 1 of 3 residents reviewed for transfers. (Residents #1)The facility failed to keep Resident #1 free from injury after he was improperly transferred by CNA A on 10/19/25 causing extensive bruising to his chest and multiple rib fractures.This failure resulted in the identification of an Immediate Jeopardy (IJ) on 10/21/25 at 11:35 a.m. While the IJ was removed on 10/22/25 at 11:30 a.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.This failure could place residents at risk of injury from accident and hazards.Record review of the face sheet dated 10/20/25 revealed Resident #1 was a [AGE] year-old male. Resident #1 was initially admitted on [DATE] with diagnoses including dementia, abnormalities of gait and mobility, and assistance with personal care. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #1 was usually understood and sometimes understood others. The MDS indicated a BIMS was not conducted due to Resident #1 being rarely to never understood. The MDS indicated Resident #1 required moderate assistance with chair/bed-to-chair transfers. Record review of the care plan last revised on 08/25/25 indicated Resident #1 had a poor transfer status related to age, diminished strength, diminished sensation, and problems with vision and/or hearing. The care plan indicated an intervention dated 06/11/25 for Resident #1 to be transferred with a mechanical lift and 2-person assistance. Record review of a Nurses Note for Resident #1 dated 10/19/25 at 11:00 p.m. by LVN B indicated, .Res (Resident #1) noted (with) large swollen and bruised are to (left upper) chest area and bruising mid chest area. (Resident #1) also has discoloration to (left upper) area. (Skin tear) to (right) arm with transparent dressing. Record review of a Nurses Note for Resident #1 dated 10/20/25 at 4:30 a.m. by LVN B indicated, Area to mid chest more darker area, larger than when first found. Record review of an Emergency Medicine Note dated 10/20/25 at 11:35 a.m. indicated, (Resident #1).presented to the Emergency Department with chest bruising.he has chest swelling and bruising, which he seems to attribute to being picked up by a 300 pound guy. The time of onset is uncertain but he states he was picked up yesterday; he experiences pain only when pressure is applied to the area. No history of falling is reported.He denies any acute fall or trauma. The author of the note was the Emergency Department Physician. Record review of an ED (emergency department) Note indicated, .Family called, to update, family stated (Resident #1) been telling her they pick him up and it hurts. The note was signed by the emergency room RN. Record review of Intake Report Child Protective Service dated 10/20/25 at 12:21 p.m. indicated, .(Resident #1) is unable to walk or transfer independently.On 10/20/25 (Resident #1) was brought to the ER (emergency department) from the nursing home for bruising to his chest wall. (Resident #1) was found to have bruising all throughout his upper chest extending across both shoulders. The bruising was black, purple, and yell in coloration and appeared to be in multiple stages of healing and associated swelling throughout. (Resident #1) denied any recent falls or trauma and was echoed by the nursing home. When (Resident #1) was alone, he stated that there is a man at the facility that is 300 pounds who regularly picks him up incorrectly. (Resident #1) stated that the man will pick him up by his body under his arms despite (Resident #1) having a hoyer lift that should be used. (Resident #1) stated that he frequently tells this person being picked up that way hurts, but that his complaints are ignored. It is uncertain if there is only one person lifting (Resident #1) incorrectly as his memory is not always accurate., and information that he's shared with family in the past about the man who lift him incorrectly has not lined up with that person's schedule or presence at the facility. The reporter was the hospital emergency department Health Unit Assistant. Record review of CT Chest results dated 10/20/25 at 12:43 p.m. for Resident #1 indicated, .Left 11 and 12 posterior (back of the body) lateral (side, away from the middle of the body) rib fractures may be recent or subacute (recent onset). Right 10th and 11th lateral rib fractures appear recent/subacute. Old sternal fracture.Impression: Left 11 and 12 rib and right 10th and 11th rib fractures appear recent/subacute.Record review of hospital records dated 10/20/25 indicated, .Primary Diagnosis.Contusion (bruising) of chest wall. There was a note that indicated, .Please take caution when helping patient transfer. The note was signed by the Emergency Department Physician on 10/20/25 at 1:39 p.m. There was a photograph of Resident #1 included in the hospital records. The photograph showed extensive dark bruising to the left and right upper chest and a dark bruise to the left upper arm. The report indicated, Problem List and Treatment Plan:.(Resident #1) presented with chest wall swelling, bruising, and localized tenderness following recent physical handling, without a history of fall or trauma.Exam revealed chest wall bruising and swelling. The records indicated, .Diagnoses.Contusion of chest wall.Traumatic injury of rib. During an interview on 10/20/2025 at 2:51 p.m., the hospital Emergency Department Health Unit Assistant said Resident #1 was brought to the emergency department with bruising across the top of his chest. She said he denied any falls or any other injuries. She said he was brought to the emergency department by transport van. She said the bruising went from shoulder to shoulder. She said staff had gone in the room to ask him what happened, and he said a 300-pound man always picked him up to move him from the wheelchair to the bed. She said Resident #1's family member told them she had witnessed CNA A transferring the resident yesterday (10/19/25) and not use the mechanical lift. She said the family member said Resident #1 had been complaining to her that a CNA had been picking him up to transfer him and it hurt. She said the family member said Resident #1 had asked the CNA to not to pick him up the way he was picking him up.During an interview on 10/20/25 at 3:00 p.m., the Emergency Department Physician said he had evaluated Resident #1 the emergency department. He said Resident #1 had extensive bruising across his chest and had some rib fractures. He said some of the rib fractures could be older injuries. He said Resident #1 said that a 300-pound man had been lifting him up. The Emergency Department Physician said he did not feel anyone had done anything malicious to the resident. He said he felt maybe someone had been picking the resident up from behind with their arms around the chest and they had been overly rough.During an interview on 10/20/25 at 3:05 p.m., Resident #1's family member said CNA A had been transferring Resident #1 and not using the mechanical lift. The family member said on 10/19/25, she had witnessed CNA A picking up the resident with his hand under the resident's arms. She said CNA A transferred Resident #1 from the couch to the wheelchair. She said CNA A was in front of the resident when he transferred the resident.During an observation and interview on 10/20/25 at 3:07 p.m., Resident #1 was sitting in a wheelchair in his room. There was a mechanical lift pad under him. Resident #1 denied pain. The resident had dark purple bruising across the upper left chest and across the upper right chest. There was also a dark purple bruise with a skin tear on the upper left arm. The bruising to the chest and arm appeared to be new. He said he was injured by CNA A picking him up under his arms. He said CNA A had picked him up more than once.During an interview on 10/20/25 at 3:20 p.m., the Emergency Department RN said she was Resident #1's nurse in the emergency department. She said she was very concerned about the bruising to Resident #1's chest. She said she did ask Resident #1 if anyone had abused him. She said he denied abuse. She said he did say that someone had been picking him up like a baby and it hurt. She said she felt the bruising was in various stages of healing and his cat scan results showed rib fractures.During an interview on 10/20/2025 at 3:46 p.m., CNA A said Resident #1 was a regular resident of his. He said he was the CNA for Resident #1 on 10/19/25. CNA A said they usually used a mechanical lift to transfer Resident #1 to prevent what has happened yesterday (10/19/25). CNA A said 10/19/25 the mechanical lift pad was not available and was not under Resident #1 in the wheelchair. CNA A said, on 10/19/25, he did transfer Resident #1 without using the mechanical lift. CNA A said he used a gait belt. CNA A said he transferred Resident #1 from the wheelchair to the couch, from the couch back to the chair for dinner, and then from the chair to the bed. CNA A said he used the gait belt for all three transfers. CNA A said Resident #1 was often combative. CNA A said on 10/19/25, Resident #1 was not combative. CNA A said Resident #1 was scared he was going to fall and pressed himself against him. CNA A said when he went to put Resident #1 to bed on 10/19/25, he took Resident #1's shirt off and he had a skin tear to his arm and there was a little patch of discoloration to his nipple area. CNA A said in the past, they had used a gait belt to transfer Resident #1. CNA A said recently Resident #1 declined. CNA A said using a gait belt was just not safe for Resident #1 anymore, so they had started using a mechanical lift.During an interview on 10/20/25 at 4:15 p.m., Resident #1's family member said on 10/19/25, CNA A did not use a gait belt to transfer Resident #1. The family member said CNA A lifted Resident #1 under his arms and tight to his body and transferred him from the wheelchair to the couch and then later back from the couch to the wheelchair. The family member said CNA A was not the only one transferring Resident #1 this way. The family member said other CNAs were doing the same thing. The family member said Resident #1 had broken his sternum in a car accident about 12 years ago.During an interview on 10/21/2025 at 8:12 a.m., Resident #1 said on 10/19/25, CNA A did not use a gait belt to transfer him. Resident #1 said CNA A used his hands to carry him to the next room.During an interview on 10/21/25 at 3:03 p.m., CNA D said on the night of 10/19/25, she was rounding with another CNA and found bruising to Resident #1's chest. She said he had small bruising in the middle of his chest and both sides of the upper chest was bruised. She said Resident #1 said, That Big Ole Boy did it. She said she reported it to the nurse and the nurse reported it to the DON and Administrator. She said Resident #1 required two-person assistance with a mechanical lift for transfers.During an interview on 10/21/2025 at 3:45 p.m., LVN B said she was Resident #1's nurse the night of 10/19/25. She said she assessed Resident #1. She said the bruising was mostly on the left breast and appeared to be swollen. She said there was some discoloration in the middle of his chest. She said Resident #1 said that a Big Ole Boy did it. She said she asked him again what happened, and LVN B stated what Resident #1 said made no sense. She said she then reported the bruising to the DON so it could be investigated.During an interview on 10/22/25 at 11:03 p.m., the DON said she was notified of the bruising to Resident #1's chest after 11:00 p.m. on 11/19/25. She said she immediately reported the bruising to the Administrator. She said when she got to the facility, she assessed the resident. She said he denied abuse to her. She said CNA A was then suspended on 10/20/25. She said he was then terminated on 10/21/25 due to improper transfer.During an interview on 10/22/25 at 12:08 p.m., the DON said when she interviewed Resident #1 on the morning of 10/20/25, Resident #1 told her a 300-pound man had picked him up and moved him from one room to the other. She said she then called CNA A. She said CNA A told her he transferred Resident #1 three different times on 10/19/25. She said CNA A told her that he had used the gait belt to transfer the resident. She said CNA A said Resident #1 did not appear to have any pain. She said CNA A did tell her that Resident #1 had a skin tear to his arm and he had notified the nurse. She said she spoke to Resident #1's family member and she told her that CNA A did not used the gait belt. She said Resident #1 had been a two-person transfer with a mechanical lift since 06/14/25. She said she would have expected Resident #1 to have been transferred with two staff members using a mechanical lift. She said residents who were not transferred appropriately could lead to injury. During an interview on 10/22/25 at 12:30 p.m., the Administrator said he interviewed Resident #1. He said Resident #1 told him a 300-pound man had picked him up and carried him to bed. He said CNA A should have used two staff members and a mechanical lift to transfer Resident #1 on 10/19/25. The Administrator said a resident not being transferred appropriately had the potential to lead to an injury. Record review of an Assisting With Transfers and Reposition facility policy dated 05/02/18 indicated, .Purpose: Safely handle, reposition, transfer and protect Resident and staff from injury during transfers and repositioning.Mechanical lifts are used to transfer resident who: are totally dependent (non-weight bearing) or weigh more than 100 lbs.are too heavy for staff to transfer.For bed to wheelchair/chair or wheelchair/chair to bed transfers Stand and Pivot transfers with transfer belts (gait belts) for those resident whose: legs are strong enough to bear some weight (partial weight bearing, the resident is cooperative and can follow directions, the resident can assist with the transfer. The Administrator was notified of an IJ on 10/21/25 at 11:35 a.m. and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 10/21/25 at 5:15 p.m. and included the following:1. Description of Immediate Jeopardy SituationThe facility failed to ensure Resident #1 was protected from accident hazards during transfers. On 10/19/25, CNA A performed improper manual transfers without the required mechanical lift. As a result, Resident #1 sustained extensive bruising and bilateral rib fractures. This deficient practice resulted in Immediate Jeopardy because it had the potential to cause serious injury and did cause actual harm.________________________________________2. Immediate Actions Taken to Remove Jeopardy Administrator and DON were retrained by Regional Nurse consultant on Free of Accidents/Supervision/Devices and the importance of accurately identifying transfer status. Completed 10/21/2025 at 12:30 p.m. On 10/20/25 at 12:30 a.m., CNA A was immediately removed from resident care and suspended pending investigation. CNA A was terminated on 10/21/2025 at 12:10 p.m. Beginning at 12:45 p.m. on 10/21/25, the DON initiated a facility-wide audit of all residents requiring transfer assistance to ensure transfer methods were accurate and safe. All Care plans were updated with ADL status as well as the amount of staff members. On admission therapy screens for safe transfer status. Rescreens are performed after any change of condition or decline. Initiated 10/21/2025 12:45 p.m. Completed 10/21/2025 5:00 p.m. Licensed nurses completed head-to-toe skin and injury assessments on all residents to identify any additional injuries. Initiated 10/21/2025 12:30 p.m. Completed 10/21/2025 5:00 p.m. The RN Supervisor notified Resident #1's physician and family of the incident and injuries. Initiated 10/21/2025 12:40 p.m. Completed 10/21/2025 12:41 p.m. All CNA and nursing staff were immediately, or prior to next shift, re-educated on safe transfer procedures, use of gait belts, and use of mechanical lifts. Staff were also inserviced about following care plans on amount of assistance with each ADL such as transfers. Staff were inserviced on the risk of injury of not transferring residents correctly. Staff were inserviced on not to lift resident under arms or pull on their clothing or limbs. Initiated 10/21/2025 12:30 p.m. Completed 10/21/2025 5:00 p.m. 3. Identification of Residents at RiskAll residents requiring staff assistance for transfers were identified through review of the MDS, care plans, and transfer assessments. Each resident was evaluated to determine current transfer status and ensure appropriate assistive device was in use. No additional injuries were found during head-to-toe skin assessments.________________________________________4. Systemic Measures Implemented to Prevent Recurrence Mandatory education and return demonstrations on safe transfers, mechanical lift operation, and two-person assistance policy were conducted immediately, or prior to the next shift, for all direct care staff by the DON/ADON/Designee. Initiated 10/21/2025 12:30 p.m. Completed 10/21/2025 5:00 p.m. DON/ADON/Designee verified and updated transfer status in EMR system for all residents to reflect accurate transfer assistance requirements. Initiated 10/21/2025 12:30 p.m. Completed 10/21/2025 5:00 p.m. DON revised New admission Procedure to include required transfer evaluation and documentation by licensed nursing staff upon admission before any transfer occurs. Initiated 10/21/2025 12:30 p.m. Completed 10/21/2025 5:00 p.m. DON/ADON/Designee reviewed and updated Care plans to ensure transfer interventions matched resident needs. Initiated 10/21/2025 12:30 p.m. Completed 10/21/2025 5:00 p.m. A process was implemented requiring licensed staff to immediately update transfer status on the resident care plan after any change in conditions. The licensed staff will then update the resident's ADL sheet and flag and communicate through 24 hour report for oncoming staff. Initiated 10/21/2025 12:30 p.m. Completed 10/21/2025 5:00 p.m.________________________________________ 5. Monitoring to Ensure Ongoing ComplianceThe DON/ADON/Designee will complete daily audits for 14 days on all resident transfers to ensure: Correct transfer method is used Proper assistive device (Hoyer, sit-to-stand, gait belt) is in place EMR system documentation matches transfer method Audit results will be reviewed daily during clinical meetings and reported to the Administrator. Any non-compliance will result in immediate staff re-education and corrective action. After the 14-day period, weekly audits will continue for 30 days to ensure sustained compliance.________________________________________6. Completion DateAll immediate corrective actions were initiated on 10/21/25 and ongoing monitoring will continue as outlined. The surveyor's verification of the Plan of Removal from 10/22/25 was as follows:Record review of Safety and Supervision of Residents in-service indicated, .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes.When accident hazards are identified, the QAPI/Safety Committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible.Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable.Our individualized, resident-centered approach safety addresses safety and accident hazards for individual residents.Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include.Safe lifting and Movement of Residents. The in-service indicated that the Administrator and DON were educated by the Regional Nurse Consultant on 10/21/25. The in-service indicated the Certified Occupational Therapist Assistant and the Physical Therapist Assistant were then educated by the DON. Record review of the employee file for CNA A indicated CNA A was hired on 12/17/24. The employee file included a Personal Change Notice. The notice indicated CNA A was terminated on 10/21/25. The reason for termination was improper transfer. The notice indicated CNA A was not eligible for rehire. Record review of a Resident List Report indicated on 10/21/25, the DON completed an audit of all residents to ensure transfer methods were accurate and safe. Record review of 10 of 51 residents care plans indicated each care plan had been updated with the ADL status as well as the amount of staff members needed for transfer. Care plans were reviewed on 10/22/25 for Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, and Resident #14. Each reflected the ADL status as well as the amount of staff members needed for transfers. Record review of 10 of 51 residents skin assessments indicated residents had been assessed head to toe. Skin assessments were reviewed on 10/22/25 Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, and Resident #14 on 10/21/25. There were no concerns.Record review of a Nurse's Notes for Resident #1 indicated physician was notified of the bruising on 10/19/25 at 11:16 p.m. by LVN B.Record review of a Nurse's Note for Resident #1 indicated call was placed, and a message was left for Resident #1's power of attorney on 10/19/25 at 11:28 p.m. by LVN B.Record review of Hoyer, Two Person Hoyer (Mechanical) Lift Check Off forms indicated 26 nurses and CNAs were re-educated on safe transfer procedures on 10/21/25. Record review of Clinical Skills Checklist and Competency Evaluation forms indicated 26 nurses and CNAs were re-educated on safe transfer procedures using a gait belt on 10/21/25. Record review of a Staff In-Service Training titled, Safe Resident Transfers & Following Care Plan Instructions dated 10/21/25 indicated 38 nurses and CNAs were in-serviced on .correct transfer method and assistive device every time.Never lift a resident under their arms or pull on their clothing or limbs.Never transfer alone if the care plan says 2-person assist or mechanical lift required.Shortcutting or guessing a transfer method is never allowed.If a resident seems different during a transfer, STOP and NOTIFY THE NURSE immediately.A nurse must reassess the resident and update the transfer status and care plan before transfer continues.Why This Matter: Prevents serious injuries.Keeps Resident safe.Meets federal regulation.Protects your CNA license and your job.Required by state law and facility policy.Transfers must always be done safely, correctly, and according to the care plan.STOP-THINK-ASK-GET HELP. Record review of 10 or 51 residents' electronic medical records accessed on 10/22/25 between 7:30 a.m. and 11:30 a.m. indicated Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, and Resident #14's record reflected accurate transfer assistance requirements.Record review of an Assisting with Transfers and Reposition facility policy revised on 10/21/25 and signed by the Administrator, DON, and ADON indicated, .Safely handle, reposition, transfer and protect Resident and staff from injury during transfers and repositioning.Upon admission readmission or change in condition, the charge nurse will assess the residents' transfer status and document on the Resident Data Collection Form. Nursing can review Therapy notes from the hospital, previous facility, family, etc. Revision 10/21/25: Charge nurse will then communicate the transfer status to floor staff via the Baseline Care plan and the ADL sheet.The Charge nurse will also notify assigned nursing assistant of transfer status verbally and document transfer status on Nurse Aide's Information Sheet and care plan.The facility charge nurse will assess residents whose transfer status has changed due to decline or improvement and notify nursing assistant of change in transfer status and document status change on Nurse Aide's information sheet. During an interview on 10/21/25 at 2:20 p.m., CNA A said he had been terminated by the Administrator and that he was told his license was being referred. During interviews conducted on 10/22/25 beginning at 8:45 a.m. through 10:30 a.m., 29 of 38 CNAs and nurses in-serviced (LVN B, CNA D, Restorative Aide E, CNA F, CNA G, CNA H, Restorative Aide J, CNA K, CNA L, CNA M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, Restorative Aide T, CNA U, CNA V, CNA W, LVN X, LVN Y, LVN Z, the ADON, the MDS Nurse, LVN BB, LVN CC, LVN DD, and LVN B) were interviewed. All said they were educated on safe resident transfers and following the care plan. Each said educated on using the correct transfer method and assistive device every time. They said they were educated on never lifting a resident under their arms or pull on their clothing or limbs, never transfer alone if the care plan says 2-person assist or mechanical lift required. They said they were not to guess on the transfer method. They said when a resident declined the CNAs were to notify the nurse. The nurse must then reassess the resident and update the transfer status and care plan. They each said this was to prevent injury of the resident. During interviews conducted on 10/22/25 beginning at 8:45 a.m. through 10:30 a.m., 13 of 26 CNAs and nurses in-serviced (Restorative Aide E, CNA F, CNA G, CNA H, Restorative Aide J, CNA K, CNA U, LVN X, LVN Y, LVN Z, the ADON, LVN AA, and Restorative Aide T) indicated they had been checked off in-person on safe transfer procedures for mechanical lift transfers and gait belt transfers. Each staff member was able to verbalize step by step instructions on how to identify the type of transfer each resident required and how to safely perform a mechanical lift transfer or a gait belt transfer. During an interview on 10/22/25 at 9:50 a.m., the Certified Occupational Therapist Assistant said the DON had in-serviced herself and the Physical Therapist Assistant on 10/21/25 concerning screening each resident on admission for safe transfer status and re-screening residents after any change of condition or decline. She said she then assisted in re-educating staff on safe mechanical lift and gait belt transfers. During an interview on 10/22/25 at 10:25 a.m., the ADON said she had been in-serviced by the DON on 10/21/25 on safe transfer techniques, to assess a resident with a decline and update their care plan to reflect accurate transfer requirements, risk of injury for not transferring residents correctly, and not lifting a resident under the arms or pulling or their clothing or limbs. She said after she was re-educated, she then assisted in head-to-toe assessments of each resident and re-educating other staff. During an interview on 10/22/25 at 10:44 p.m., the Administrator said on 10/21/25, he was trained by the Regional Nurse on Safety and Accidents. He said on 10/19/25 at approximately 11:00 p.m. or 11:30 p.m. He was notified of the bruising to Resident 1's chest. He said the DON called and told him at that time. He said the DON suspended CNA A the next morning after determining he may have improperly transferred Resident #1. The Administrator said on 10/21/25 at 12:10 p.m. he called CNA A, and he was terminated. He said CNA A had not returned to the facility at any time after the injury was discovered. During an interview on 10/22/25 at 11:03 p.m., the DON said she was trained on re-assessing, transfer statuses, and appropriate transfer statuses. She said she was trained on preventing injuries of the residents. She said the Regional Nurse in-serviced herself and the Administrator. She said CNA A was suspended on 10/20/25. She said he was then terminated on 10/21/25 due to improper transfer. She said she, the Administrator, and the Patient Care Advocate rounded on each resident to see if they had injuries or any concerns regarding CNA A. She said no concerns were identified. She said on the week of 10/07/25, she had audited each resident's chart and documented how much assistance each resident required for transfers. She said on 10/21/25 she reviewed this audit to make sure it was correct, and nothing needed to be updated. She said head-to-toe assessments were conducted of each resident in the facility on 10/21/25 by herself, the ADON, two nurses, and the wound care nurse. She said no injuries were found. She said she checked off the ADON, Restorative Aide J, and two therapy staff members. She said they then in-serviced the CNAs and the nurses. She said nurses and CNAs that were not present, were in-serviced over the phone and would be checked off in person when they return to work at the facility. She said if a resident had a status change, the care plan would be updated, and the CNAs would be notified prior to any transfers. She said if she or the MDS nurse was not present, the charge nurse would update the care plan, notify the aide, and update the nurse aide information sheet.During an interview on 10/22/2025 at 11:25 a.m., the MDS Coordinator stated she was aware of the in-service done related to transferring safety. She said to always use 2 people with a mechanical lift and two people with gait belt transfer if their care plan stated that was what was needed. She stated the nurses could update the resident care plan for change of condition on transfer status or they could let her know what needed to be corrected, and she would correct it.On 10/22/25 at 11:30 a.m., the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and a severity level actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interviews and record reviews, the facility failed to implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the residents' practicable physical, mental, and psychosocial well-being for 1 (Resident #2) of 10 residents reviewed for care plans.The facility failed to implement a person-centered fall prevention care plan with interventions for Resident #2 to meet medical, nursing, mental and psychosocial needs.The facility failed to implement added interventions of providing a therapy evaluation, failed to drop the seat of his wheelchair, and failed to add non-skid material to wheelchair after fall resulting in fracture. These failures could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services.Record review of an undated face sheet revealed Resident #2 was an [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of traumatic subarachnoid hemorrhage (a type of brain injury where bleeding occurs in the space between the brain and the thin membrane covering it), hemiplegia (paralysis of one side of the body), and convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of muscles and associated especially with brain disorders).Record review of an admission MDS assessment dated [DATE] revealed Resident #2 had a BIMS of 12 which indicated a mild cognitive impairment. Resident #2 required partial to moderate assistance with ADLs such as toileting, transfer, and bathing. Resident #2 had 1 fall with major injury, had a seizure disorder, and had verbal and other behaviors 4 to 6 days per week.Record review of a care plan conference worksheet dated 10/02/2025 revealed a care plan conference was held with Resident #2 and his family members along with the DON, ADON, Administrator and Social Worker to discuss Resident #2's recent fall. The worksheet revealed interventions agreed upon by the family for therapy to evaluate Resident #2's wheelchair to drop the seat.Record review of a care plan dated 10/03/2025 titled History of Falls with major injury stated Resident #2 leaned forward to lock his wheelchair and fell out of his wheelchair. His interventions were listed as therapy evaluation for a restorative program, non-skid material to seat, and x ray of bilateral hips related to complaint of pain. Facility failed to follow interventions of therapy evaluation, and non-skid material to seat of wheelchair.During an interview on 10/20/2025 at 10:00 a.m., Family Member #1 of Resident #2 stated they attended a care plan meeting on 10/02/2025 after a fall that caused a fractured hip. She stated they discussed therapy evaluating Resident #2 for safety and to drop his seat. Family Member #1 stated therapy never evaluated Resident #2 even after they confirmed his hip fracture, he had surgery and returned to the facility, nor did they drop his seat to increase his safety. Family Member #1 stated that put Resident #2 at risk for a repeat fall with a surgically repaired fracture.During an interview on 10/20/2025 at 11:00 a.m., LVN C stated she was the nurse for Resident #2 when he fell. She stated Resident #2 was in his wheelchair and reached forward, locking his brakes and slid in slow motion to the floor. She stated she was surprised he had a fracture from the fall because it was a slow soft fall. LVN C stated the interventions were for Resident 2 to be evaluated by therapy, Resident #2's wheelchair seat was to be dropped to prevent him from sliding out when locking his brake. LVN C stated Resident #2 was to have nonskid material in his seat as well. LVN C stated she was told therapy could not evaluate him because of his payer source. LVN C stated she never saw Resident #2 in a wheelchair with a drop seat or nonskid material in his chair.During an interview on 10/22/2025 at 10:00 a.m., the MDS Coordinator stated it was the job of the DON and herself to update all care plans. She stated she was unsure how she missed adding the care plan interventions for a therapy evaluation and a dropped seat for safety. She stated she was also uncertain why the intervention of nonskid material to the chair was not carried out. She stated it was the job of the entire facility to read the care plans and carry out the interventions.During an interview on 10/22/2025 at 11:00 a.m., the DON stated Resident #2 was private pay and had no funding for therapy services. She stated a restorative nursing plan was written for Resident #2. She stated it was initiated 10/13/2025 when he returned from the hospital where he had surgery on his hip. She stated therapy had to evaluate him and drop his seat if it was a safe intervention and they would have provided the nonskid material to put in his chair, but because he was not evaluated before he went to the hospital on [DATE], he had not gotten the nonskid material. She stated not following interventions decided on during the care plan meeting could have resulted in further injury to the residents from another fall. During an interview on 10/22/2025 at 11:30 a.m., the Administrator stated it was important to follow interventions decided on by the IDT (interdisciplinary team). He stated it was important because the interventions were put in place to keep the residents healthy and safe. The Administrator stated Resident #2 had a care plan meeting on 10/02/2025 following a fall that injured the resident. He stated it was decided that therapy would evaluate him for safety in his wheelchair. Resident #2 was not evaluated by therapy because he was private pay, and the cost had to be approved by the family. Resident #2 eventually went to the hospital to have surgery on his fractured hip. The Administrator stated therapy evaluated him for a restorative program when he returned from the hospital, but he was not evaluated for a dropped seat or nonskid material for his wheelchair.Record review of the facility's policy dated 07/20/2021 titled 'Comprehensive Care Planning revealed The facility will 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 are identified in the comprehensive assessment.services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility will establish, document, and implement the care and services to be provided for each resident to assist in attaining or maintaining his or her highest practical quality of life.

Based on observation, interview, and record review, the facility failed to ensure that the menu was followed for the lunch meal on 11/04/24 and 11/05/24 for 2 of 2 meals (the lunch service) reviewed for nutritional adequacy. The facility did not serve fried chicken, as planned, with the lunch meal on 10/04/2024 nor informed residents that a substitute would be used. The facility failed to serve Salisbury steak with the lunch meal on 10/05/2024 nor informed residents that a substitute would be used. These failures could affect all residents in the facility by placing them at risk of not receiving adequate nutritive food value needed to promote/maintain health. Findings included: Record review of a Sample Menu Substitution List dated 11/04/2024 to 11/05/2024 showed that on 11/04/2024 fried chicken was scheduled and substituted with fajita chicken. The Menu shows that on 11/05/2024 Salisbury steak was scheduled and substituted with steak. Record review of a facility food menu shows that on 11/04/2024 fried chicken was scheduled to be prepared. Shows that on 11/05/2024 that Salisbury steak was scheduled to be prepared. During an observation and interview on 11/05/2024 at 12:38 p.m., the Dietary Manager said that they would not have traditional Salisbury steak today. She said that they served an alternate provided by Sysco. She said that alternate is sliced beef. She said the box she was provided said Salisbury Steak. It was observed while testing a food tray that sliced roast beef was served as Salisbury steak. During an interview on 11/05/2024 at 12:50 p.m., Resident #50 stated that he did not like the food he was given today. He said he did not know what the meat was that was served. He said it was not any kind of Salisbury steak he has eaten before. During an interview on 11/05/2024 at 12:58 p.m., Resident #17 said she did not eat the meat on her plate. She said she didn't like the beef she was served. She said she likes the Salisbury steak that is made from a hamburger patty. She said that she didn't like what she was served today it was a tough piece of beef that had gravy on it. She said she ate the rest of her plate. During an interview and observation on 11/05/2024 at 1:02 p.m., Resident #47 said she did not try the roast beef to see if it was any good. She said that it did not look like what Salisbury steak normally looks like. She said it was a slice of beef and not a patty. She said if it doesn't look good it would not touch her lips. She said she ate the rest of her food, and it tasted fine. It was observed that Resident #47 did not eat any of her sliced beef. During an interview on 11/05/2024 at 1:04 p.m., Resident #4 said he enjoyed the food that he was served today but he would have preferred if it was the Salisbury steak that was on the menu. He said he ate everything but would have wanted to be informed if they did not have real Salisbury steak. During an interview on 11/05/24 3:20 p.m., the Dietary Manager, said the food supplier representative told her they were out of stock of the regular Salisbury Steak. She said they will order extra cases of Salisbury steak for this season since they would be serving it more often in the Fall/Wintertime. She said she had the conversation with the food representative last Monday October 28th, 2024. She said the food supplier delivered the sliced beef that was served today Tuesday October 29th, 2024. She said the kitchen served sliced roast beef today as Salisbury Steak. She said what they served today was delivered last Tuesday October 29th, 2024. She said they had a substitute menu list that shows steak as today's substitute. She said if an item was not available, and it will be substituted they do not tell the residents the substitute will be served. During an interview on 11/06/2024 at 10:50 a.m. with the Dietary Manager she said each morning she displays the daily menu on the walls in various locations for residents to see. She said that substitutions are not displayed. She said that residents would not be informed if a substitution will be used and the menu that is displayed is not updated to reflect that a substitution was used. She said that residents do not make orders for their food choice and that if a substitute was desired by a resident the resident themself would need to request the substitution to the kitchen. She said that if a food became unavailable that was planned through their supplier residents would not be notified of that fact even though the menu remained the same. During an interview on 11/06/24 at 01:25 p.m., the Director of Nurses said she expects that kitchen staff follow menus and notify residents their options for substitutions. She said that residents would be placed at risk of losing weight and quality of life loss if they are given foods that were not appetizing to them and their choices. During an interview on 11/6/2024 at 1:50 p.m., the Administrator said he expects that kitchen staff notify residents when a substitution will be made to their menu. He said that it may be a quality-of-life issue for residents if they are receiving food they do not like. Requested a policy regarding menus and substitutions on 11/06/24. Facility provided policy did not have a section that specifically addressed notifications of meal substitutions.

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 kitchen sanitation in that: 1. Chicken, contained in plastic, was being thawed on a stovetop with hot water. 2. Tater Tots, shredded lettuce, iceberg lettuce, cheese, and an unknown food item was not labeled or dated. 3. Kitchen stove was not kept free of carbon buildup, grease, and food particles. These deficient practices could place residents who received meals from the kitchen at risk for food borne illness. The findings included: During an observation on 11/4/24 at 9:05 a.m . it was observed that tater tots, shredded lettuce, iceberg lettuce, cheese, and an unknown food item were not labeled and dated. It was observed that kitchen staff was thawing a large block of chicken in its plastic packaging inside a large pot with water. The water was simmering and appeared to be near boiling point. It was observed that the cooking stove top and the stainless-steel backing had grease and food particles layered on the surfaces. During an interview on 11/06/24 at 10:21 a.m., the Dietary Manager said that food should not be dethawed by placing it in boiling water while still in its plastic on the stovetop. She said the frozen chicken should have been placed on the bottom shelf of a refrigerator or placed in a sink underwater with water continuously flowing and agitating the water. She said that improper thawing could cause foodborne illness. She said food should be labeled and dated as it was placed into the refrigerator or freezer. She said that when food was opened and placed back into the refrigerator it should be labeled and dated as well. She said it was the responsibility of kitchen staff to ensure that food was labeled and dated. She said residents could be placed at risk of foodborne illness if they eat spoiled food. She said that the stove top should be cleaned regularly. She said that there should not be a buildup of food and grease in the stove top or the stove backing. During an interview on 11/06/24 at 01:25 p.m., the Director of Nurses said she expects that kitchen staff to thaw meat properly as meat that was prepared unproperly would place residents at risk for foodborne illness. She stated that kitchen staff should have labeled and dated the food items that were stored in the kitchen. She stated that she expects kitchen staff to clean the cooking surfaces in the kitchen. During an interview on 11/06/24 at 01:50 p.m., the Administrator said he expected that his kitchen staff thaw meat according to state regulations. He said that he expected staff to label and date food stored in the kitchen. He said that residents could be placed at risk for foodborne illness if they consumed meat that was not prepared or stored properly. He stated that the kitchen should be maintained and cleaned. He said that grease and food particles should be cleaned from cooking surfaces. Review of the facility document dated 2019, Meat and Vegetable Preparation provided by the Dietary Manager revealed: Meats and vegetables will be prepared to conserve maximum nutritive value, to develop and enhance flavor and appearance, and to prevent foodborne illness Meat will be defrosted using safe thawing methods (never at room temperature): In the refrigerator in a drip proof container, and in a manner that prevents cross contamination. In the sink, submerging the item under cold water (<70 F) that is running fast enough to agitate and float off loose ice particles. Review of the facility document dated 2019, General Sanitation of Kitchen provided by the Dietary Manager revealed: Food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule Cleaning and sanitation tasks for the kitchen will be outlined in a written cleaning schedule. Tasks will be assigned to be the responsibility of specific positions. Frequency of cleaning for each task will be defined. Methods and materials/cleaning compounds to be used for cleaning/sanitizing will be written for each task. Employees will be trained on how to perform cleaning tasks.

Based on observation, interview, and record review, the facility failed to ensure that each resident who was incontinent of bowel/bladder and each resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections, for 1 of 4 residents (Resident #29) reviewed for indwelling urinary catheters (is a thin, hollow tube that is inserted into the bladder to drain urine). The facility failed to ensure Resident #29's foley catheter bag (is a device that drains urine (pee) from your urinary bladder into a collection bag outside of your body when you can't pee on your own) was changed as ordered on 10/15/24 (12am). The facility failed to ensure Resident #29's supra-pubic catheter (is a tube that drains urine from the bladder through a small incision in the lower abdomen) was changed as ordered on 10/16/24 (nights) Theses failures could place residents at risk for urinary tract infections. Findings included: Record review of Resident #29's face sheet dated 11/06/24 indicated Resident #29 was an [AGE] year-old male admitted to the facility on [DATE] and 04/26/22 with diagnoses including dementia (is a chronic condition that causes a decline in mental abilities, such as thinking, remembering, and reasoning, that interferes with daily life), retention of urine (is a condition that prevents the bladder from emptying completely), urinary tract infection (is a bacterial infection that affects the urinary tract, which includes the bladder, urethra, and kidneys), and obstructive (is a urinary tract disorder that occurs when urine flow is obstructed, either structurally or functionally) and reflux (is a condition where urine flows backward from the bladder into the ureters and sometimes the kidneys) uropathy. Record review of Resident #29's annual MDS assessment dated [DATE] indicated Resident #29 was understood and usually understood others. Resident #29 had a BIMS score of 10 which indicated moderate cognitive impairment. Resident #29 had an indwelling catheter. Record review of Resident #29's care plan revision date 11/05/24 indicated Resident #29 has a history of BPH (is a noncancerous condition that causes the prostate gland to enlarge) and now had a suprapubic catheter due to obstructive uropathy and was at risk for frequent UTIs, dislodgement, or other complications. Intervention included change foley catheter once a month and change bag twice a month. Record review of Resident #29's medication review report dated 11/06/24 indicated: *Change foley catheter bag twice a month at bedtime. Change foley catheter bag on the 15th and 30th of the month. Ordered date 11/30/20. *Supra-pubic catheter 16 french/10 cc bulb changed every 4 weeks, every night shift starting on the 16th and ending on the 16th every month. Ordered 04/26/23. Record review of Resident #29's Treatment Administration Record dated 10/01/24-10/31/24 indicated: *Change foley catheter bag twice a month at bedtime (12 am). Change foley catheter bag on the 15th and 30th of the month. Ordered date 11/30/20. The TAR did not reflect administration on the 15th but on the 20th (LVN J). *Supra-pubic catheter 16 french/10 cc bulb changed every 4 weeks, every night shift starting on the 16th and ending on the 16th every month. Ordered 04/26/23. The TAR did not reflect administration on the 16th but on the 20th (LVN J). Record review of the Nursing Staff assigned to Resident #29 on 10/15/24 and 10/16/24, provided by the DON on 11/06/24 indicated: *10/15/24: 2pm-10pm (LVN K), 10pm-6am (LVN J) *10/16/24: 2pm-10pm (LVN C), 10pm-6am (LVN L) During an observation on 11/04/24 at 1:45 p.m., Resident #29 was lying in bed. On Resident #29's wheelchair, bedside his bed, a catheter bag was hanging from it. On 11/06/24 at 10:33 a.m., attempted to contact LVN L by phone. A voicemail was left with contact information. A return phone call was not received prior or after exit. On 11/06/24 at 10:50 a.m., attempted to contact LVN K by phone. Unable to leave message. On 11/06/24 at 10:53 a.m., attempted to contact LVN C by phone. A voicemail was left with contact information. A return phone call was not received prior or after exit. During an interview on 11/06/24 at 10:43 a.m., LVN J said Resident #29 got his catheter bag changed more than twice a month. She said Resident #29's catheter bag leaked, or the resident messed the bag spout up when he tried to empty the bag himself. She said Resident #29's catheter and bag were changed on or around the 15th or 16th of October 2024. She said Resident #29's catheter and bag needed to be changed as ordered to prevent an infection. During an interview on 11/06/24 at 11:58 a.m., the DON said expected nursing staff to follow physician orders. She said she expected nursing staff to document if an order could not be completed, on the ordered day. She said if was important to change Resident #29's catheter and bag as ordered to prevent an infection. She said when the resident's catheter and/or bag was not changed as ordered, it placed the resident at risk for developing an infection. She said the DON was responsible for ensuring physician orders were being followed. She said she at the end of the month, she randomly reviewed resident's MAR/TARs to monitor medication and treatment administration. During an interview on 11/06/24 at 1:02 p.m., LVN K said she recalled helping another nurse change Resident #29's catheter. She said she could not remember the exact day Resident #29's catheter was changed. She said it was possible Resident #29's catheter did not get changed on the scheduled day because he refused sometimes. During an interview on 11/06/24 at 1:10 p.m., AS#1 said that the facility locked supplies like catheters and the catheter bags on the night shift and weekends. AS#1 said sometimes the facility did not have the supplies on hand to change the catheter and catheter bags on schedule. During an interview on 11/06/24 at 2:19 p.m., the ADM said the charge nurse was responsible for changing resident's catheter and bag. He said charge nurses should document on the MAR/TAR and nurse's notes when completed. He said research indicated indwelling catheter should not be changed often. He said he could not say the resident was at risk for an infection if it was not changed as ordered. He said the resident was at risk for an infection if the catheter was not changed for a long period of time. Record review on an undated facility's Indwelling Urinary Catheter Use policy indicated .a resident who enters the facility without an indwelling catheter is not catharized unless the resident's clinical condition demonstrates that catheterization was necessary . The policy did not address changing the bag or catheter.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 2 of 6 residents reviewed for care plans. (Resident #6 and Resident #29) The facility failed to ensure Resident #6's vision impairment and use of eyeglasses were care planned. The facility failed to ensure Resident #29's hearing impairment was care planned. These failures could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services. Findings included: Record review of Resident #6's face sheet dated 11/06/24 indicated Resident #6 was a [AGE] year-old female admitted to the facility on [DATE] and 05/02/18 with diagnoses including dementia (is the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), cognitive communication deficit (is a condition that makes it difficult to communicate due to a brain injury or other underlying cognitive issues), and age related physical debility (is weakness caused by an illness, injury, or aging). Record review of Resident #6's quarterly MDS assessment dated [DATE] indicated Resident #6 was sometimes understood and sometimes understood others. Resident #6 had moderately impaired vision with use of corrective lenses. Resident #6 was rarely/never understood and was unable to complete the BIMS assessment. Resident #6 had short-and-long term memory problem and moderately impaired cognitive skills for daily decision making. Record review of Resident #6's care plan received on 11/06/24 did not reflect a care plan problem addressing moderately impaired vision with use of corrective lenses. During an observation on 11/04/24 at 12:45 p.m., Resident #6 was in the dining room eating lunch. Resident #6 did not have eyeglasses on. During an observation on 11/05/24 at 9:45 a.m., Resident #6 was in the facility's television room. Resident #6 was asleep in her wheelchair with no eyeglasses visualized. During an observation and interview on 11/05/24 at 3:00 p.m., Resident #6's was in the television room. Resident #6 was in her wheelchair with no eyeglasses visualized. Resident #6 answered basic questions but got confused when questioned about her vision. During an interview on 11/05/24 at 3:10 p.m., the DON said Resident #6 had several pairs of eyeglasses. She said Resident #6 did wear her eyeglasses but also liked to claim other people eyeglasses were hers. She said she found Resident #6's prescribed eyeglasses in her purse. Record review of Resident #29's face sheet dated 11/06/24 indicated Resident #29 was an [AGE] year-old male admitted to the facility on [DATE] and 04/26/22 with diagnoses including dementia (is a chronic condition that causes a decline in mental abilities, such as thinking, remembering, and reasoning, that interferes with daily life), and retention of urine (is a condition that prevents the bladder from emptying completely). Record review of Resident #29's annual MDS assessment dated [DATE] indicated Resident #29 was understood and usually understood others. Resident #29 had moderate difficulty hearing and no hearing aids. Resident #29 had a BIMS score of 10 which indicated moderate cognitive impairment. Resident #29's care area assessment summary triggered communication. Record review of Resident #29's care plan provided on 11/06/24 did not reflect Resident #29's moderate difficulty hearing and no hearing aids. During an observation and interview on 11/04/24 at 1:45 p.m., Resident #29 was lying bed. Resident #29 did not understand the interview questions until the surveyor spoke loudly and slowed my speech. During an interview on 11/05/24 at 4:00 p.m., Resident #29 said he was hard of hearing but did not want hearing aids. During an interview on 11/05/24 at 4:05 p.m., LVN K said Resident #29 was hard of hearing. She said the facility had attempted to send him to a doctor for it, but he refused. During an interview on 11/06/24 at 11:05 a.m., the MDS Coordinator said she was responsible for resident's care plans. She said Resident #6 and Resident #29's vision and hearing deficit should be on their care plan. She said if the vision and hearing deficit was triggered on the MDS then it should be care planned. She said Resident #6 had vision problems and wore eyeglasses. She said she did not know Resident #29 was hard of hearing. She said social service normally handled resident's vision and hearing needs. She said she would communicate with social service to see what interventions needed to be added for Resident #29. She said a resident's care plan was important, so everyone was aware of the resident's needs. She said when things were not care planned, it placed residents at risk for not getting theirs needs met. During an interview on 11/06/24 at 11:58 a.m., the DON said the facility developed care plans by looking at the resident's history, talked to the family, assessment by facility staff, and the MDS. She said Resident #6 and Resident #29's vision and hearing deficit should be on their care plans. She said it was important to have a resident hearing problem on their care plan to know how to communicate with them and how the communicate with the staff. She said the vision problem needed to be on the care plan to know if the resident required special assistance due to decrease vision. She said it placed resident at risk for falls if their vision needs were not addressed. She said the MDS Coordinator and DON were responsible for the resident's care plan. She said the IDT should oversee the care planning process. During an interview on 11/06/24 at 2:19 p.m., the ADM said the DON and MDS Coordinator were responsible for the resident's care plans. He said Resident #6 and Resident #23's vision and hearing deficit should be care planned. He said it was important to care plan those problems to know how to interact with the residents. He said it was important because vision and hearing affected the resident quality of life and care. He said the DON and MDS Coordinator were also responsible for overseeing the care planning process. Record review of an undated facility's Care Planning-Resident policy indicated .each resident has a Resident Care Plan that is current, individualized, and consistent with medical regimen .a functional nursing assessment is conducted by using the Minimum Data Set (MDS) form .

Based on interview, and record review the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers based on the comprehensive assessment for 1 of 2 Residents (Resident #12) whose record were reviewed for skin integrity. The facility failed to ensure Resident #12 received and/or documented wound care on the evening shift of 10/19/24 and 10/20/24. This failure could place residents at risk for developing pressure ulcers and could contribute to developing avoidable pressure ulcers. Findings included: Record review of Resident #12's face sheet dated 11/06/24 indicated Resident #12 was a [AGE] year-old female admitted on [DATE] and 10/18/24 with diagnoses including dementia (is a chronic condition that causes a decline in mental abilities, such as thinking, remembering, and reasoning, that interferes with daily life), pressure ulcer of sacral region (is a skin injury that forms on the sacrum, a bony area of the lower back and spine), and enterocolitis (is a condition that involves inflammation of the small and large intestines, or digestive tract) due to clostridium difficile (is a bacterium that can cause diarrhea, colitis, and other symptoms). Record review of Resident #12's annual MDS assessment dated [DATE] indicated Resident #12 was understood and usually understood others. Resident #12 had a BIMS score of 01 which indicated severe cognitive impairment. Resident #12 was at risk of developing pressure ulcer/injuries. Record review of Resident #12's care plan dated 10/21/24 indicated Resident #12 had a skin concern: Unstageable coccyx. Intervention included administer medication and supplements as needed. Record review of Resident #12's hospital discharge summary dated 10/18/24 indicated start Venelex ointment (is an ointment that's used on the skin to cover wounds). Apply topically two times daily. Record review of Resident #12's Medication Record dated October 2024 indicated Start Venelex ointment, apply topically 2 times daily. Use as directed. Dated 10/18/24. The medication record indicated Day which was highlighted, and Evening was not highlighted. No initials were noted for evening shift on 10/19/24 and 10/20/24. Record review of Resident #12's nurse's notes by LVN G, dated 10/19/24 at 12:10 a.m., indicated .this nurse [LVN G] makes weekend supervisor [RN H] aware of dressing to coccyx and bilateral heels .and that drsgs [dressings] looked fresh and intact .supervisor verbalized understanding and states 'we should leave them in place for now if intact to help .protect from any C.diff getting into wounds . Record review of Resident #12's nurse's notes by LVN M, dated 10/20/24 at 1:30 a.m., indicated .drsgs [dressings] intact to coccyx and bilateral heels . Record review of Resident #12's nurse's notes by LVN M, dated 10/20/24 at 5:10 a.m., indicated .tx [treatment] to coccyx and bilateral heels done per RN supervisor [RN H] . On 11/06/24 at 11:05 a.m., attempted to contact LVN M by phone. Unable to leave message. LVN M did not return call prior or after exit. During an interview on 11/06/24 at 11:09 a.m., WCN F said when a resident with a pressure ulcer was admitted the charge nurse was responsible to complete an assessment, call the PCP to relay findings and discuss treatment orders from the hospital. She said if the PCP approved of the treatment orders from the hospital, the charge nurse place the order on the TAR and physician order slip. She said Resident #12's treatment order was for twice a day. She said AM or days was done by the 6am-2pm shift and the evening was done by 2-10 pm shift. She said on the weekends, the weekend supervisor was responsible for dressing changes. She said the weekend supervisor usually arrived around midnight and completed dressing changes around 8-9 am. She said the weekend supervisor reviewed the treatment book and charge nurses informed him of wound dressing changes that were due. She said when a treatment was done, it should be charted in the nurse's notes and the MAR/TAR. She said it was important to document on the MAR/TAR when a treatment was done so everyone knew it was completed. She said on Resident #12's TAR, it appeared the treatment for her coccyx was only done once but the nurse's note said the dressing was clean, dry, and intact. She said it was important for Resident #12 to receive her treatment twice a day to decrease the risk of infection and help with wound healing. She said if Resident #12's coccyx dressing was not done as ordered, she was at risk for an infection and decreased healing. During an interview on 11/06/24 at 11:23 a.m., LVN G said she did not remember if Resident #12's wound dressing was changed on her shift. She said she worked the 2pm-10pm shift. She said when a treatment was done it was supposed to be charted on the resident's MAR/TAR. She said if the treatment order was scheduled for twice a day, it was supposed to be done on the morning shift and evening shift. She said the evening shift was 2pm-10pm shift. She it was important for Resident #12's wound dressing to be changed as ordered to control the drainage. She said if a resident's dressing was not changed as ordered then the wound could get infected and worsen. During an interview on 11/06/24 at 11:55 a.m., RN H said he was the weekend supervisor for the facility. He said he knew which treatments needed to be complete from reviewing the treatment book. He said when he completed the treatment, he placed his initials on the TAR/MAR. He said he normally completed the treatments after the residents got up in the morning. He said if Resident #12 had an order for a treatment he probably did it. He said he did not know why 10/19/24 and 10/20/24 were not initialed. He said if something was not documented then it was not done. He said Resident #12's treatment needed to be done twice a day because that was how it was ordered. He said it did not help the resident if the treatment was not done as ordered. During an interview on 11/06/24 at 11:58 a.m., the DON said she expected the nursing staff to follow the physician orders and document when treatments were done. She said nursing staff should document on the MAR/TAR and nurse's notes. She said the weekend supervisor or the resident's nurse were responsible for wound dressing changes. She said the treatments needed to be done as ordered to prevent infection and worsening of the wound. She said the WCN and DON should oversee that the wound care treatment orders were being followed. During an interview on 11/06/24 at 2:19 p.m., the ADM said the charge nurse and weekend supervisor were responsible for wound dressing changes on the weekend and evening shift. He said he expected nursing staff to follow the physician orders and document when the treatment was done. He said nursing staff should document on the TAR and nurse's notes when the treatment was done. He said if the resident's treatments were not done as ordered, the wound could worsen. She said the WCN and DON should oversee that the wound care treatment orders were being followed. Record review of an undated facility's Pressure Ulcer Treatment policy indicated .residents with pressure ulcers receive necessary treatment and services to promote healing prevent infection and reduce the likelihood of new ulcers developing .

Based on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 4 residents (Resident #07) reviewed for resident rights in that: The facility failed to provide a catheter privacy bag for Residents #07 while sitting in main living room at facility with other residents on 11/5/2024. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth. Findings included: 1.Record review of a face sheet for Resident #07 dated 2/20/2024, indicated Resident #07 was a [AGE] year-old female who was readmitted on [DATE] with the diagnoses of encephalopathy (A medical term used to describe a disease that affects brain structure or function. It causes altered mental state and confusion.), Intellectual disabilities (a condition that limits intelligence and disrupts abilities necessary for living independently), dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities), and conversion disorder with seizures (a condition where a mental health issue disrupts how your brain works). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #07 was rarely or never understood and BIMS score unable to be recorded indicating Resident #07 was severely cognitively impaired. Resident #07 was dependent for all ADL's (Activities of Daily Living). Record review of a care plan for ADLs, last updated 12/15/2017, indicated Resident #07 required max assist with all ADL's due to cognition related to mental retardation, unsteady gait/balance, daily bowel, and bladder incontinence. During an observation on 11/4/2024 at10:25 AM, Resident #07 was sitting up in wheelchair in her room with door open with catheter bag hanging below wheelchair without a privacy bag with yellow urine observed in the catheter bag. During an observation on 11/5/2024 at 10:13 AM, Resident #07 was sitting in the main living room on Hall C seated in her specialty wheelchair with catheter bag without a privacy cover hanging below her wheelchair. During the observation, staff and other residents were passing by and 1 other resident observed in the TV room with Resident #07. During an observation on 11/5/2024 at 10:43 AM, Resident #07 was sitting in the main living room on hall C in her wheelchair with catheter bag hanging below the wheelchair. The catheter bag was dated 10/31/2024 with urine facing the toward the front of the wheelchair. During an interview on 11/6/2024 at 11:07 AM, CNA A said residents who have a catheter should have a privacy cover over the catheter bag. CNA A said the nursing staff were responsible for keeping the catheter bags covered. She said if she observed a resident without a catheter bag cover, she would notify the nurse. CNA A said a resident may not feel comfortable if other residents were eating or drinking with a catheter bag exposed or make a resident feel bad if their catheter was exposed. During an interview on 11/6/2024 at 1:00 PM, LVN C said the facility has privacy covers for catheter bags. LVN C said if a resident comes from the hospital with a catheter, they sometimes do not have privacy covers. LVN C said she did not think you could change the catheter bags, but the staff could use a leg bag if a resident was up. LVN C said if a resident remained in their room and did not leave, they would still need a privacy bag. LVN C said a resident could be embarrassed if they did not have the proper cover over their catheter. LVN C said it could also bother other residents if they observed a catheter while eating or in a main room together. She said if a resident had a catheter that looked nasty, it could change a person's appetite. During an interview on 11/6/2024 at 1:24 PM, the ADON said the residents should have catheter covers on their catheter. The ADON said sometimes residents will go out to the hospital and they return with a different type of catheter. She said the facility nursing staff would change out the resident's catheter bag and place one from the facility's catheter bags with the privacy cover. The ADON said it was important to have the privacy covers on the catheters for privacy. She said a resident could be self-conscious if they had a catheter where other could see. She said if a resident was unable to voice their need for privacy bag, the staff should anticipate their need. During an interview on 11/6/2024 at 1:44 PM, the DON said she expected the nurses to change out the catheter bags to the facility's catheter bag with privacy cover. The DON said it depended on the resident, but it could be a dignity issue. She said she felt a reasonable person would feel embarrassed if their catheter bag was exposed. She said it may cause other persons in the public setting to lose their appetite. The DON said Resident #07 leaves her room, and she did have a new catheter bag after returning from hospital on 11/3/2024. During an interview on 11/6/2024 at 2:06 PM, the ADM said he expected the Resident #7 to have a privacy bag on her catheter. The ADM said it was the responsibility of the charge nurse to change out the catheter bags when a resident returns from the hospital. Review of a policy dated 9/2/2015 titled Indwelling Urinary Catheter Use revealed Purpose: A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary. 8. Catheter care: c. Utilization drainage bag holders/covers when resident is out of room to provide dignity. Review of a policy dated July 1, 2002, titled Dignity: The Quality or State of being worthy, honored or esteemed revealed .a resident is treated with respect, consideration, and recognition as an individual. The facility now becomes the resident's home; therefore, remember each resident has a right to A dignified existence. The facility must promote care in a manner and environment that enhances each resident's dignity and respect in full recognition of his/her individuality.

Based on observation, interview, and record review, the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment was provided related to COVID-19. (CNA I, Housekeeper E, Floor Tech H, and CNA P) The facility did not provide designated staff to work on the COVID-19 (a new respiratory disease which can cause mild to severe illness with most severe illness in adults [AGE] years and older) unit as indicated in their policy. CNA I, Housekeeper E, and Floor Tech H worked both the COVID-19 unit and the non-COVID-19 unit. CNA P did not take measure to prevent the spread of infection when she entered Resident #21's room who was on contact isolation. An Immediate Jeopardy (IJ) situation was identified on 05/01/20. While the IJ was removed on 05/03/20, the facility remained out of compliance at a level of potential for more than minimal harm with a scope identified as a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for being exposed to COVID-19, health complications, and death. Findings included: 1. During an observation on 04/30/20 at 2:45 p.m., CNA I was working as a restorative aide on the non-COVID-19 halls. During an interview on 05/01/20 at 10:47 a.m., LVN K said CNA I was currently working in the COVID-19 ward with them but did not always work back here. During an interview on 05/01/20 at 10:55 a.m., CNA I said provided restorative therapy on the COVID-19 unit that morning to her assigned residents. She said she worked all halls every day because she was not designated on any hall. CNA I said she used the main entrance and re-entered general population halls after doffing PPE. 2. A face sheet dated 5/1/20 indicated Resident #21 was admitted [DATE], her [DIAGNOSES REDACTED]. During an observation on 04/28/20 at 12:00 p.m., Resident #21 was in her room and no signage was posted on the outside of her door indicating she was on isolation, but there was a PPE station set up outside of her room and biohazard boxes set up inside her room with discarded PPE visible inside. During an interview on 04/28/20 at 12:10 p.m., LVN N said Resident #21 returned from the hospital on contact isolation after being tested for COVID-19 and staff were to wear mask, gown, and gloves into her room. During an interview on 04/28/20 at 12:15 p.m., the DON said Resident #21 was not diagnosed with [REDACTED].#21 was in respiratory isolation until her results were obtained. During an observation and interview on 04/28/20 at 12:36 p.m., CNA P was noted to be wearing a surgical mask when she entered Resident #21's room with her lunch tray, she put the tray on the overbed table and exited the room without donning PPE, she did not sanitize her hands before or after entering the room. CNA P said she did not know what kind of isolation Resident #21 was in but probably should have worn a gown. CNA P said she was assigned to other residents on the general population hall. During an interview on 04/30/20 at 3:18 p.m., the DON said staff working on the COVID-19 hall were designated to only work on the unit and not allowed to re-enter general population halls. During an interview on 04/30/20 at 5:07 p.m., Housekeeping Supervisor G said the housekeepers and floor techs cleaned the non-COVID-19 and the COVID-19 units. She said the staff completed their duties on COVID-19 ward then exited for the day through the exit designated for the ward and returned the next day through the front entrance. Housekeeping Supervisor G said as of 4/29/20 Housekeeper E and Floor Tech H were designated to only clean on the COVID-19 ward and to eliminate further possible cross contamination. During an observation and interview on 05/01/20 at 9:43 a.m., Housekeeper F was interviewed via a translator, CNA O. Housekeeper F was cleaning rooms on the general population hall A and said she cleaned the entire facility including the COVID-19 ward. She said she cleaned on the COVID-19 ward that same day. This investigator asked CNA O to confirm the translation indicating Housekeeper F entered the COVID-19 ward this morning and then continued to clean the general population halls. CNA O repeated the question and Housekeeper F confirmed her statement, she affirmed and shrugged at this surveyor. Housekeeper F said she wore the appropriate PPE on the COVID-19 ward and utilized a mask, gown, and gloves on the general population halls. During an interview on 05/01/20 at 9:55 a.m., the administrator said Housekeeper F did not speak English, the translator misunderstood, and did not think she had entered the COVID-19 ward. During an interview on 04/28/20 at 11:10 a.m., the administrator said the secured unit was designated as the COVID-19 ward because the initial confirmed positive case was identified in the secured unit and it lent itself to being able to control access. During an interview on 04/28/20 at 11:10 a.m., the DON said residents who were symptomatic with COVID-19 symptoms, residents with known exposure to a resident or staff who tested positive for COVID-19, and/or residents who returned from an evaluation outside of the facility were placed in droplet isolation on the general population halls. The DON said staff were not designated to care only for the isolated residents unless their COVID-19 results were positive, then they were relocated to the COVID-19 ward. The CDC website at <https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html> accessed 5/13/20 indicated, .Dedicate Space in the Facility to Monitor and Care for Residents with COVID-19. Dedicate space in the facility to care for residents with confirmed COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19. Assign dedicated HCP to work only in this area of the facility. Have a plan for how residents in the facility who develop COVID-19 will be handled (e.g., transfer to single room, prioritize for testing, transfer to COVID-19 unit if positive). Closely monitor roommates and other residents who may have been exposed to an individual with COVID-19 and, if possible, avoid placing unexposed residents into a shared space with them. Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options may include placing the resident in a single-person room or in a separate observation area, so the resident can be monitored for evidence of COVID-19. Residents could be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their exposure (or admission). Testing at the end of this period could be considered to increase certainty that the resident is not infected. If an observation area has been created, residents in the facility who develop symptoms consistent with COVID-19 could be moved from their rooms to this location while undergoing evaluation . According to: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html, with a revision date of 03/07/2020, Defining Risk Exposure: Low-risk exposures generally refer to brief interactions with patients with COVID-19 or prolonged close contact with patients who were wearing a facemask for source control while HCP were wearing a facemask or respirator. A Policies and Practices-Infection Control policy revised 01/04/2011 indicated: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infection. This facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and the general public alike. The objectives of our infection control policies and practices are to: a. Prevent, detect, investigate, and control infections in the facility; b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public; c. Establish guidelines for implementing Isolation Precautions, including Standard and Transmission-based Precautions; d. Establish guidelines for the availability and accessibility of supplies and equipment necessary for Standard Precautions; e. Maintain records of incidents and corrective actions related to infections; f. Provide guidelines for the safe cleaning and reprocessing of reusable resident care equipment. On 05/01/2020 at 11:20 a.m., the administrator and DON were notified of the Immediate Jeopardy (IJ) situation, a completed IJ template was provided to the facility for the above failures, and a Plan of Removal was requested. On 05/01/2020 at 6:36 p.m., the administrator was notified the facility's Plan of Removal was accepted, and included: Facility nurses will continue to monitor for symptoms of COVID 19 in all residents who are not exhibiting any symptoms of COVID 19 every shift and report any symptoms immediately to DON. The DON will then coordinate any presumptive residents' move to the COVID Presumptive Unit until testing and their status can be determined. Upon notification of a positive case on the Presumptive COVID Unit the charge nurse will immediately notify the DON. The DON will coordinate the move of the resident with positive results onto the COVID Unit. If any resident tests negative for COVID 19 on the COVID Presumptive Unit, the resident will be moved back to their original room. ADON will coordinate schedule of all COVID and COVID Presumptive dedicated staff to ensure no crossover of COVID and COVID Presumptive employees dedicated to the COVID unit from working on the COVID free unit. DON will monitor schedule daily to ensure compliance. On 5/1/20, asymptomatic resident (Resident #36) was moved to the COVID presumptive unit with dedicated staff pending the outcome of his test after his roommate tested positive on 5/1/20. On 5/1/20, all staff working on the COVID units were re-in serviced on the procedures for entering and exiting the unit as well as the screening procedures by the DON. The ADON will conduct the same in-service with all staff working outside the unit on 5/1/20. The COVID unit nurse will monitor all dedicated HCP to ensure they are entering and exiting only through the established route. Any problems will be immediately reported to the administrator. On 5/1/20, ADON in serviced all nursing staff to report any symptoms of COVID-19 immediately to the DON. Administrator will monitor for compliance daily with the DON and Housekeeping supervisor to review schedules and any new onset of symptoms of COVID-19 and any coordinated resident moves to ensure appropriate placement and dedicated staff compliance. The surveyor's verification of the Plan of Removal on 05/02/2020 was as follows: Residents who were identified as being positive for COVID-19 were separated from residents who were identified as negative for COVID-19 and were placed in the hall B of the facility and residents with potential exposure to of symptomatic of COVID-19 were separated on hall C with designated staff. Observations were made to ensure staff were wearing appropriate PPE and there was no staff identified working multiple halls. Staff observations were made to ensure that all staff were wearing appropriate PPE throughout the facility. Further observations revealed that staff members were washing their hands with soap and water and/or using hand sanitizer. The front entrance to the facility had sufficient PPE supplies for staff or essential personnel to enter the building premises. Further observations revealed that there was an attendant at the front desk who was conducting temperature checks and a questionnaire for COVID-19 symptoms. During an interview on 05/02/20 at 1:00 p.m., LVN M said she received in-service training prior to her shift starting this morning regarding the procedures for entering and exiting the unit as well as the screening procedures by the ADON and to report any symptoms of COVID-19 immediately to the DON. During an interview on 05/02/20 at 1:06 p.m., CNA O said she received in-service training prior to her shift starting this morning regarding the procedures for entering and exiting the unit as well as the screening procedures by the ADON and to report any symptoms of COVID-19 immediately to the DON. During an interview on 05/02/20 at 1:10 p.m., CNA W said she received in-service training prior to her shift starting this morning regarding the procedures for entering and exiting the unit as well as the screening procedures by the ADON and to report any symptoms of COVID-19 immediately to the DON. During an interview on 05/02/20 at 1:15 p.m., CNA Y said she received in-service training prior to her shift starting this morning regarding the procedures for entering and exiting the unit as well as the screening procedures by the ADON and to report any symptoms of COVID-19 immediately to the DON. During an interview on 05/02/20 at 1:38 p.m., LVN Z said she received in-service training prior to her shift starting this morning regarding the procedures for entering and exiting the unit as well as the screening procedures by the ADON and to report any symptoms of COVID-19 immediately to the DON. During an interview on 05/02/20 at 1:48 p.m., Housekeeper AA said she received in-service training prior to her shift starting this morning regarding the procedures for entering and exiting the unit as well as the screening procedures by the ADON and to report any symptoms of COVID-19 immediately to the DON. She said she did not work on the COVID-19 wards. During an interview on 05/02/20 at 4:34 p.m., LVN K said she received in-service training prior to her shift starting this morning regarding the procedures for entering and exiting the unit as well as the screening procedures by the DON and to report any symptoms of COVID-19 immediately to the DON. On 5/3/20 at 12:15 p.m., the DON was informed the IJ was removed; however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to provide necessary treatment and services based on a comprehensive assessment to prevent development and worsening of pressure injuries for 3 of 3 residents reviewed for pressure injuries. (Resident #s 1, 2, 3) Resident #1 was admitted without a pressure injury, but was at moderate risk for the development of a pressure injury. He developed a stage 4 pressure injury on his heel. The facility did not provide pressure relief for Resident #1's heel. Resident #2 was admitted without a pressure injury. She developed a stage 3 pressure injury on her left buttock. The facility did not provide a pressure relief cushion for Resident #2 when she was out of bed. Resident #3 had a Stage 3 pressure injury on his left knee stump that worsened. The facility did not provide pressure relief per the plan of care. This failure could place 4 residents with pressure injuries at risk for developing new pressure injuries and decline in existing pressure injuries. Findings included: 1. A face sheet dated 11/18/16 indicated Resident #1 admitted on [DATE]. Physician orders [REDACTED].#1, readmitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #1's cognition was severely impaired. He was totally dependent on staff for bed mobility, transfers, and toileting, and was always incontinent of bowel and bladder. Resident #1 had two unstageable pressure injuries at the time of this assessment. A skin care plan initiated 7/28/15 indicated Resident #1 was at risk for skin breakdown. Staff were to elevate his calves on pillows or use positioning devices to relieve heel pressure as needed and off-load his heels frequently while he was in the wheelchair. A pressure injury care plan dated 8/21/16 indicated Resident #1 had a pressure injury on his left heel and was to wear a multi-podus boot when out of bed. Staff were to assist with off-loading his heels every two hours or as needed. A Braden scale assessment dated [DATE] indicated Resident #1 was at a moderate risk for skin breakdown. The wound care flow sheets for Resident #1, completed by the treatment nurse, indicated the following: Left heel pressure injury *On 8/2/16 - Resident #1 developed a pressure injury, measuring 8 x 7 cm, described as a blister with even margins, and brown surrounding tissue. *On 8/15/16 - blister measuring 15 x 11 cm. with uneven margins and brown surrounding tissue. *On 9/6/16 - unstageable pressure injury measuring 12.8 x 10.8 cm. with yellow scant drainage, uneven margins, and tanish surrounding tissue. The open area measured 3 x 3.2 cm. *On 9/26/16 - deep tissue injury measuring 6 x 9.3 cm. with scant yellow drainage, unattached edges, and pink surrounding tissue. *On 10/24/16 - wound type not specified, measuring 11.2 x 6.2 cm. with scant yellow drainage, unattached edges, and pink surrounding tissue. *On 10/31/16 - in the hospital *On 11/8/16 - wound type not specified, measuring 7.1 x 9.2 cm. with scant blood sanguineous drainage, 95% slough, and pink surrounding tissue. *On 11/14/16 - wound type not specified, measuring 7.4 x 8.5 cm. with slough on the left side, and a red beefy wound bed. There was scant blood sanguineous drainage, wound margins intact, and pink surrounding tissue. A hospital wound healing center physician order [REDACTED].#1 had a stage 4 pressure injury on an unspecified heel and a multi-podus splint boot was to be applied to Resident#1s left foot. During an observation on 11/17/16 at 10:29 a.m., Resident #1 was sitting in a Geri chair with no boot on his left heel. His left foot was wrapped with a bandage. The resident's feet were not off-loaded and were not on a pressure-relieving cushion. During an observation on 11/18/16 at 8:39 a.m., Resident #1 was in bed with his left foot on a pillow, but his heel was not off-loaded. During an interview 11/18/16 at 8:47 a.m., the treatment nurse said Resident #1 had a stage 4 pressure injury on his left heel. She said the wound was recently debrided in the hospital. During an observation with the treatment nurse on 11/18/16 at 9:04 a.m., Resident #1 had an open left heel pressure injury measuring 8 cm x 8.2 cm. The wound bed was pink with moderate drainage. There was yellow slough along the upper edges of the wound bed. His heel was not off-loaded before the treatment nurse began her treatment. 2. A face sheet dated 11/18/16 indicated Resident #2 admitted on [DATE]. Physician orders [REDACTED].#2, readmitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident 2's cognition was severely impaired and she was totally dependent on staff for bed mobility, transfers, and toileting. She was always incontinent of bowel and bladder. Resident #2 had no pressure injuries at the time of this assessment. A Braden scale assessment dated [DATE] indicated Resident #2 was at a mild risk for skin breakdown. A skin care plan initiated 10/6/15 indicated Resident #2 had a history of [REDACTED]. A wheelchair pressure relieving cushion was to be applied to Resident #2 ' s chair when she was out of bed. A pressure injury care plan dated 11/7/16 indicated Resident #2 had a stage 3 on her left buttock. The interventions indicated if the pressure injury was a stage 2 or greater, a pressure relieving device was to be used in the wheelchair. During an observation and interview on 11/17/16 at 10:21 a.m., Resident #2 was sitting in a Geri-chair without a pressure relieving cushion. The treatment nurse said hospice was supposed to have ordered a pressure-relieving cushion for Resident #2, but it had not arrived yet. The wound care flow sheets for Resident #2, completed by the treatment nurse, indicated the following: Left buttock pressure injury *On 11/7/16 - Resident #2 developed a pressure injury, measuring 3.5 x 3.8 cm, wound bed pink and surrounding tissue was dark fragile. *On 11/14/16 - measuring 5.1 x 4.2 cm, wound bed beefy red with drainage and surrounding tissue was dark fragile. During an observation and interview with the treatment nurse on 11/18/16 at 9:36 a.m., Resident #2 had an open left buttock pressure injury that measured 3.8 cm x 5.6 cm with a pink wound bed. The outer-perimeter of the wound was dark brown. The treatment nurse said Resident #2's wound bed was 75% slough. She said Resident #2 had a stage 3 facility acquired pressure injury. 3. Physician orders [REDACTED].#3, readmitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. A Braden scale assessment dated [DATE] indicated Resident #3 was at a high risk for skin breakdown. The most recent MDS assessment dated [DATE] indicated Resident #3's cognition was severely impaired. He was totally dependent on staff for bed mobility, transfers, and toileting, and was always incontinent of bowel and bladder. Resident #3 had one stage 3 pressure injury at the time of this assessment. A skin care plan initiated 1/6/16 indicated Resident #3 was at risk for altered skin integrity, had a history of [REDACTED]. The care plan interventions included a wheelchair pressure relieving cushion when out of bed if Resident #3 was at a high risk for skin breakdown. The wound care flow sheets for Resident #3 completed by the treatment nurse, indicated the following: Right knee stump pressure injury- Right knee pressure injury- *On 7/25/16 - Resident #3 had a stage II pressure injury, measuring .8 x .9 cm, with brown surrounding tissue. *On 8/2/16 - stage II measuring .8 x 1 cm, with brown surrounding tissue. *On 8/8/16 - stage II measuring .5 x .8 cm, with brown surrounding tissue. *On 8/15/16 - stage II measuring .8 x .6 cm, with brown surrounding tissue. *On 8/22/16 - stage II measuring .9 x .8 cm, with brown surrounding tissue. *On 8/29/16 - stage II measuring .5 x .6 cm, with brown surrounding tissue. *On 9/6/16 - stage II measuring .5 x .8 cm, with brown surrounding tissue. *On 9/12/16 - stage II measuring .6 x .8 cm, with brown surrounding tissue. *On 9/19/16 - stage II measuring .6 x .5 x .1 cm, with serous drainage and brown dry surrounding tissue. *On 9/26/16 - pressure injury measuring .5 x .5 cm, with pink dry surrounding tissue. *On 10/3/16 - pressure injury measuring .5 x .5 cm, with dry surrounding tissue. *On 10/10/16 - scab measuring .6 x .6 cm, with brown surrounding tissue. *On 10/17/16 - scab measuring .5 x .5 cm, with brown surrounding tissue. *On 10/24/16 - scab measuring .5 x .5 cm, with brown surrounding tissue. *On 10/31/16 - yellowish wound bed forming on scab measuring .7 x .7 cm, with brown surrounding tissue. *On 11/7/16 - yellowish wound bed forming on scab measuring .9 x .9 cm, with brown surrounding tissue. *On 11/14/16 - yellow slough to wound bed measuring 1.1 x 1.1 cm, with brown surrounding tissue. During an observation and interview on 11/18/16 at 9:24 a.m., Resident #3 had a pressure injury on his right knee. The pressure injury was a small circular open area with 90% yellow slough in the wound bed. The size of the pressure injury was approximately the size of the end of a Q-tip. The treatment nurse said the pressure injury was a stage 3 because the wound was past the dermis and consisted of slough. During an observation on 11/18/16 from 8:44 a.m. to 9:31 a.m., Resident #3 was sitting in a Geri-chair without a pressure relieving cushion. During an interview on 11/18/16 at 10:11 a.m., the DON said she expected staff to use pressure reducing pads in the wheelchairs and Geri-chairs for residents with a low Braden score and residents who were care planned for the pressure-reducing pads. She said a resident ' s heel should be floated off the pillow and not resting on the pillow at all in order for it to be considered off-loaded. An undated Pressure Ulcer Policy indicated use pressure reducing devices to relieve pressure and use elbow and heel protectors if needed. The website, www.npuap.org <http://www.npuap.org>, accessed 12/5/16 indicated the following: Pressure Injury:A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 3 Pressure Injury: Full-thickness skin lossFull-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue lossFull-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. The CMS Form 672 dated 11/17/16 indicated 4 residents had pressure injuries.