Every finding on record at Mesquite Village Wellness & Rehabilitation

Based on observations, interviews, and record reviews, the facility failed to ensure that the residents' environment remained free of hazards as was possible for three of eight Residents (Resident #2, #3 and #4) reviewed for accident hazard. The facility failed to ensure that Resident #4 did not have a container of disinfectant wipes on his bedside table on 07/08/26. The facility failed to ensure that Resident #2 did not have a container of Clorox disinfectant wipes, Fantastik Disinfectant multipurpose cleaner spray, and a bottle of Fabuloso cleaning liquid on his bedside table on 07/08/26. The facility failed to ensure that Resident #3 did not have Lysol air sanitizer aerosol can and a bottle of nail polish remover on her bedside table 07/08/26. These deficient practices placed the residents at risk for accidental injury, misuse and, exposure to hazardous chemicals.Findings included: Record review of Resident #4's Face Sheet, dated 07/08/26, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses of Schizoaffective Disorder, Bipolar Type, Violent Behavior. Record review of Resident #4's Significant change in condition MDS Assessment, dated 05/28/26, revealed the resident had a BIMS score of 15 (indicating no cognitive decline). The MDS Assessment indicated that he had medically complex conditions, and was mostly independent with ADL's and functional ability. During an observation and interview on 07/08/26 at 9:50 a.m. with Resident #4, it was observed that she had a container of disinfecting wipes. She stated she ordered and used the wipes to sanitize her surroundings. Record review of Resident #2's Face Sheet, dated 07/08/26, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of Schizoaffective Disorder, Bipolar Type (breaks from reality with extreme mood swings) Record review of Resident #2's admission MDS Assessment, dated 06/16/26 revealed a BIMS score of 14 (cognitively intact). The admission MDS Assessment indicated that he had medically complex conditions and was primarily independent. During an observation and interview on 07/08/26 at 9:55 a.m. with the Housekeeping Supervisor, a container of Clorox wipes, bottle of Fabuloso cleaning liquid, and Fantastik disinfectant cleaner were noted on Resident #2's bedside table. He stated that the items should not be in the resident's room. He stated that the facility policy was that no hazardous items should be stored in the residents' rooms. He stated that they should be locked in designated areas out of reach of the residents. He stated that the reason for keeping them away from the residents was to make sure they did not swallow harmful chemicals and cause harm to themselves. He stated that it could mess up their intestines if swallowed or make a wound worse if it got on their skin. He stated that he had not noticed the items in Resident #2's room before now. He stated that if any housekeeping staff found any hazardous substances, they will usually reported to him. Record review of Resident #3's Face Sheet, dated 07/08/26, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses of mild cognitive impairment (transitional stage between normal age-related memory loss and more serious conditions like dementia) and Type 2 Diabetes (high blood sugar). Record review of Resident #3's Quarterly MDS Assessment, dated 05/13/26, revealed the resident had a BIMS score of 15 (indicating no cognitive impairment). The MDS Assessment indicated he had medically complex conditions. Record review of Resident #3's Comprehensive Care Plan, dated 12/21/25, revealed the resident has an ADL self-care performance deficit. During an observation on 07/08/26 at 10:20 a.m. it was observed that Resident #3 had Lysol air sanitizer, and Equate nail polish remover on her bedside table. During an interview on 07/08/26 at 10:25 a.m. with Housekeeper M, she stated that the facility policy was that no hazardous items should be stored in the resident's room. She stated that she had not noticed any hazardous items in Resident #3's room. She stated that she reported any items not allowed in the rooms to her supervisor who took care of it. She stated that the residents could inhale or drink the items especially if they were confused. She stated that the chemicals could cause neurological issues, stomach issues or burn the resident's skin. During an interview on 07/08/26 at 12:47 p.m. with the ADON, she stated that the residents should not have any hazardous items in their rooms. She stated that they removed them and labeled them with the resident's name and returned the items to their family and educated them to not bring those items. She stated that it could be ingested by the residents or other residents who wander. She stated that the chemicals could be poisonous and interact with their medications and could land the resident in the hospital for poisoning. She stated that all staff were responsible for making sure the hazardous items were not in the residents' rooms. During an interview on 07/08/26 at 1:26 p.m. with CNA R, she stated that the facility policy as that hazardous items should not be in the residents' room. She stated that if she notices any hazardous items she reports it to the nurse in charge. She stated that she has not noticed any harmful items in Resident #3's room. She stated the resident went out shopping yesterday and may have bought the items. She stated that any hazardous items can harm the residents. She stated that ingesting any chemicals will land the resident in the hospital. She stated that all staff are responsible for making sure there are no harmful items in the residents' rooms. During an interview on 07/08/26 at 1:50 p.m. with CNA C, she stated that the facility policy is that no hazardous items should be in the residents' room, she stated that the residents go out to the store to buy them, she stated she is supposed to notify the nurse when she finds them. She stated that she had not noticed any such items in any residents' rooms. She stated that inhaling the fumes or drinking any hazardous chemicals can cause harm or induce an allergic reaction for the resident or roommate. During an interview on 07/08/26 at 2:11 p.m. with RN M, she stated that the facility policy is that no harmful chemicals should be allowed in the resident's room. She stated that all nurses, CNAs, and housekeeping staff are responsible for making sure that no harmful chemicals are stored in the residents' room. She stated that some of the chemicals may be flammable and since they have residents that are cognitively impaired, they might get a hold of it and drink the chemicals. She stated that the chemicals can cause breathing issues, burns, allergic reactions and even death. During an interview on 07/08/26 at 2:32 p.m. with the DON, he stated that the facility policy is that all cleaning material should have an MSDS (medical safety data sheet) and the sheets should specify what chemicals are contained in the cleaning chemicals and how to treat them. He stated that they remove any hazardous chemicals from the residents room and notify the family to come get them. He stated that he has not noticed any of the chemicals observed in any residents' rooms. He stated that the residents can accidentally ingest the chemicals which can make them sick. He stated that all staff are responsible for making sure that no dangerous chemicals are stored in the residents' rooms. The facility did not supply any hazardous items storage policy as requested during the investigation on 07/08/2026 at 11:40 a.m.

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for two of eight residents (Residents #4, and #3) reviewed for medication storage. 1.The facility failed to ensure Resident #4's Trimicolone ointment 0.5% was not on top of the resident's side table on 07/08/26. 2.The facility failed to ensure Resident #3's melatonin gummies, melatonin tablets and Asper cream lidocaine cream were not on her bedside table on 07/08/26 These failures could place residents at risk of misuse of medications and possible adverse reactions.Findings included: Record review of Resident #4's Face Sheet, dated 07/08/26, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses of Schizoaffective Disorder, Bipolar Type, Violent Behavior. Record review of Resident #4's Significant change in condition MDS Assessment, dated 05/28/26, revealed the resident had a BIMS score of 15 (indicating no cognitive decline). The MDS Assessment indicated that he has medically complex conditions, and mostly independent with ADL's and functional ability. Record review of Resident #4's physician's order date 04/06/26 revealed and order for Triamcinolone Acetonide External Cream 0.5 % (Triamcinolone Acetonide (Topical)) Apply to affected areas topically two times a day for rash on feet, leg, and back. During an observation and interview on 07/08/26 at 9:50 a.m. with Resident #4, it was observed that she had a tube of Trimicolone ointment 0.5% on her nightstand. She stated that the ointment was in the same place, and no one had told her it should not be on her table. She stated that the cream was prescribed for her and the nurse was the one who applied the cream on her and left it on her nightstand. She stated it had always been done that way. She stated she was not able to recall which nurse, that it was a few of them who tended to her at different times. Record review of Resident #3's Face Sheet, dated 07/08/26, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnosed of mild cognitive impairment (transitional stage between normal age-related memory loss and more serious conditions like dementia) and Type 2 Diabetes (high blood sugar). Record review of Resident #3's Quarterly MDS Assessment, dated 05/13/26, revealed the resident had a BIMS score of 15 (indicating no cognitive impairment). The MDS Assessment indicated that he has medically complex conditions. Record review of Resident #3's Comprehensive Care Plan, dated 12/21/25, revealed the resident has an ADL self-care performance deficit. Record review of Resident #3's physician order date 10/04/25 revealed an order for Salonpas External Patch 3.1-6-10 % (Camphor-Menthol-Methyl Salicylate) Apply to lower back topically as needed for pain. During an observation on 07/08/26 at 10:20 a.m. it was observed that Resident #3 had melatonin gummies, melatonin tablets, Asper cream lidocaine cream on her bedside table. During an interview on 07/08/26 at 12:47 p.m. with the ADON, she stated that the residents should not have medications in their rooms. She stated that no resident in the facility is assessed to self-administer medications at this time. She stated that the residents can overdose if they have an order from the physician already and that the medications can interact with other medications they are taking. She stated that they can overdose or have an allergic reaction which can lead to hospitalization or even death. She stated that the nursing staff are responsible for making sure that the residents do not have medications in their rooms by checking daily and doing an inventory during admission, educate the family and residents about why they should not have medications on them. During an interview on 07/08/26 at 1:26 p.m. with CNA R, she stated that no medication should be in the residents' rooms. She stated that if the residents brought a medication in it should be given to the nurse and have it labeled with the resident's name. She stated that all medication should be ordered by the physician even for over the counter. She stated that taking medication unsupervised could harm the residents. She stated that all medications should be documented by the nurse. She stated that if she found medication in a resident room, she reported it to the nurse. During an interview on 07/08/26 at 1:50 p.m. with CNA C, she stated that no medication should be stored in the residents' rooms. She stated that she had not noticed any medication in Resident #4's room. She stated that self-administering medication by residents can be hazardous especially if they have dementia. She stated they could get sick, have an allergic reaction or even be sent to the hospital if the resident takes medications inappropriately. During an interview on 07/08/26 at 2:11 p.m. with RN M, she stated that no residents should have medications in their rooms, and if medications are found during rounds, they are removed. She stated that if the resident wants to have a medication, they are assessed for self-medication and notify the physician to get an order if approved. She stated that the assessment is to make sure that the resident is alert and oriented and understands the dosing and side effects of the medication they are taking. She stated that if an assessment is not done, the residents can overdose themselves with the medication. She stated that neither Resident #3 and Resident #4 have had an assessment for self-administration of medication. During an interview on 07/08/26 at 2:32 p.m. with the DON, he stated that no medication should be at the resident's bedside, except those who have been assessed to self-administer medication and have a physician order. He stated that if the staff is not aware of the medication the resident is taking, it cannot be recorded and they could double dose them. He stated that overdose could decrease the resident's level of consciousness and make them lethargic. Record review of the facility's policy Medication Administration Policy/Procedure - Nursing Clinical, revised May 2025, reflected POLICY: It is the policy of this Facility, medication shall be administered as prescribed by the resident's physician, nurse practitioner, or physician's assistant . procedure . 1. Only licensed medical and nursing personnel or other lawfully authorized staff members may prepare, administer, and record medication administration. Record review of the facility's policy titled, Medication Storage in the Facility P & P, dated March 2025 reflected, Policy: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations . 2. Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized to administer medications. Record review of the facility's policy / procedure titled, Medication Storage Nursing Manual-Nursing Care dated 01/2026 reflected: PurposeTo establish standards that safeguard residents by preventing unauthorized access tomedications and ensuring compliance with applicable federal and state pharmacy regulations.Policy1. Medications must be stored securely to prevent unauthorized access, diversion, loss, contamination, or misuse.2. All medications will be stored in accordance with physician orders, pharmacy labeling, manufacturer recommendations, and applicable federal and state regulations.3. Medication carts, rooms, cabinets, and controlled substance compartments must remain locked at all times unless under direct and continuous supervision of authorized personnel.4. Only authorized, licensed staff may access medication storage areas.

Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of eight residents (Resident #5) reviewed for respiratory care. The facility failed to ensure Resident #5's oxygen nasal canula and BIPAP mask were properly stored on 07/08/26. These failures could place residents at risk of respiratory infection, respiratory complications, and not having their respiratory needs met.Findings Include 1. Record review of Resident #5's face sheet, dated 07/08/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with the following: Chronic Respiratory Failure (when the lungs cannot adequately supply oxygen or take out carbon dioxide from the blood) and Obstructive Sleep Apnea (collapse of upper airway during sleep) Record review of Resident #5's admission MDS Assessment, dated 06/15/26, reflected moderately impaired cognition with a BIMS of 14 (cognitively intact). The MDS Assessment indicated that he had medically complex conditions. Record review of Resident #5's Comprehensive Care Plan, dated 06/16/26, reflected that the resident had oxygen therapy related to CHF and one of the interventions was: The resident has O2 via nasal 2 Liters per minute continuously and as needed. The care plan dated 06/18/26 revealed the resident is resistive to care and refuses to use BIPAP at night with interventions to Allow to make decisions about treatment regime, to provide sense of control. Record review of Resident #5's Physician's Order, dated 06/09/26, revealed BiPAP Settings (IPAP-18: EPAP 6:fi02%-35) atbedtime for Sleep Apnea as needed, order dated 06/11/26 revealed O2 3 liters per minute via nasal cannula every shiftrelated to CONGESTIVE HEART FAILURE, Change Respiratory Tubing, Mask, Bottled Water, clean filter every 7 days continuous related to CONGESTIVE HEART FAILURE check O2 daily and change tubing every 7 days. During an observation and interview on 07/08/26 at 10:00 a.m. with Resident #5, revealed his oxygen tube was lying on the oxygen concentrator and the BIPAP mask was in an open drawer. Both items were observed open to air and not bagged. Resident #5 was unable to verbalize when asked if he knew it should be bagged, he only nodded his head. During an interview on 07/08/26 at 12:47 p.m. with the ADON, she stated that the BIPAP should be washed, wiped and stored in a bag when not in use and the bag was changed weekly and dated. She stated the oxygen tubing is changed weekly and should be bagged when not in use. She stated that bagging the oxygen tube and BIPAP mask prevents infection. She stated that if not bagged dust particles or bacteria can get in their nasal tracks and cause pneumonia or other respiratory infection. She stated that the nursing staff, including the CNAs, are responsible for making sure the oxygen tube and CPAP mask are stored correctly when not in use. During an interview on 07/08/26 at 1:26 p.m. with CNA R, she stated that oxygen tubes and CPAP masks should be bagged when not in use. She stated that if it's found exposed or on the floor the nurse is notified to make sure it is changed. She stated that not bagging the oxygen tube and the CPAP mask could be a cause of infection or make an already infection worse for the residents. During an interview on 07/08/26 at 1:50 p.m. with CNA C, she stated that the facility policy is that the oxygen tube and the BIPAP mask should be bagged when not in use. She stated that they need to be bagged for infection control and prevent dirt, debris or insects from getting into them. She stated that they could breathe germs in their lungs and cause respiratory problems long-term. During an interview on 07/08/26 at 2:11 p.m. with RN M, she stated that stated that the oxygen tube and the CPAP mask should always be bagged, she stated that any respiratory apparatus should always be bagged when not in use. She stated that they should be bagged for infection control. She stated that the nurses are responsible for making sure that respiratory apparatus are bagged when not in use. She stated that if the if the resident uses a contaminated breathing apparatus, it could cause allergies or worsen their respiratory issues. During an interview on 07/08/26 at 2:32 p.m. with the DON, he stated that all oxygen tubes and BIPAP mask should be store in a bag when not in use. He stated that the nursing staff is responsible for making sure they are bagged and they make rounds for the residents that are independent to make sure they are putting their oxygen tubes in a bag when they are not in use. He stated that bagging the oxygen tubes prevents and decreases any incidents of infection. Record review of the facility's policy / procedure titled, Oxygen Administration Nursing Manual dated 06/2020 reflected: Infection ControlB. Oxygen items will be stored in a plastic bag at the resident's bedside to protect theequipment from dust and dirt when not in use.

Based on observation, interview and record review, the facility failed to implement Federal, State, and local laws and regulations regarding smoking, smoking areas, and smoking safety and their own smoking policy for one (Resident #1) of 8 residents reviewed for smoking and compliance. The facility failed to implement their smoking policy regarding Resident #1's noncompliance with smoking on 07/08/26. Resident #1 had smoking paraphernalia in his possession. This failure could affect residents' safety by smoking in other areas than the designated area which could lead to an unsafe smoking environment.Findings included: Review of Resident #1's Face Sheet dated 07/08/26 revealed the resident was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses of Mild cognitive impairment (intermediate stage of memory and thinking decline), and Tobacco use. Record review of Resident #1's Quarterly MDS Assessment, dated 07/26/26, revealed the resident had a BIMS score of 14 (indicating no cognitive impairment). The MDS Assessment indicated that he has medically complex conditions. Record review of Resident #1's Comprehensive Care Plan, dated 01/08/26, revealed I use of tobacco products, smoking,chewing, or snuff, with goal I will be free of tobacco related injuries through next review and intervention of: 1) I will be supervised by a nursing facility staff member when I smoke, 2) I will smoke only during the designated times determined by the facility whensupervision will be provided, 3) I will smoke only in designated smoking areas, 4) Me/ my RP will be provided with the facility's smoking policy and will demonstrate understanding of consequences of any non-adherence to the facility's smoking policy(which could even result in my discharge from the facility for continued nonadherence to facility's smoking policy.), 5) My smoking /tobacco supplies are to be kept in the smoking supply box at the nurse's station/med room, 6) My smoking/tobacco supplies will be returned to the smoking supply box at the nurse's station/med room at the end of each smoke break, 7) Staff will assist in notifying my family when I need smoking supplies. During an observation and interview on 07/08/26 at 10:05 a.m. with Resident #1, 3 cigarette packs were observed on his bedside table. There was 2 empty cigarette packs and 1 full pack of cigarettes, he stated that he usually had his cigarettes on his table and no one had an issue with it. He stated he got them from the store when he goes out of the facility. During an interview on 07/08/26 at 12:47 p.m. with ADON, she stated that residents who smoke are not allowed to have any cigarettes in their possession, all cigarettes are supposed to be in a locked box and smoking is at designated times. She stated that all staff are responsible for making sure that no residents have cigarettes in their rooms. If noticed they are removed and stored in the appropriate lockbox, notify the RP and educate the residents. She stated that it is a hazard and could start a fire, they could burn themselves or other residents. During an interview on 07/08/26 at 1:26 p.m. with CNA R, she stated that residents are not allowed to have cigarettes or lighters in their rooms. She stated that the items should be stored in a locked box with the residents' names and made available during designated smoke times. She stated that if the residents light a cigarette in their room, it could be a fire hazard and if they have oxygen, it could cause an explosion that can harm him and other residents. During an interview on 07/08/26 at 1:50 p.m. with CNA C, she stated that no residents should have cigarettes in their rooms. She stated they are usually locked in a secure box till supervised smoking times by staff. She stated that she notifies the nurse if she finds any cigarette in the resident's room. She stated that is a fire hazard if they light the cigarette, if they drop cigarette or fall asleep while smoking. During an interview on 07/08/26 at 2:11 p.m. with RN M, she stated that no residents are allowed to have cigarettes in their rooms, she stated that they should be in a lock box located at the nursing station. She stated that all staff are responsible for making sure the residents don't have cigarettes in their rooms. She stated that if the residents have cigarettes in their rooms, it could be a hazard, they can burn themselves or others. During an interview on 07/08/26 at 2:32 p.m. with the DON, he stated that no resident should have cigarettes on their person, cigarettes were always stored in a lockbox behind the nurses' station where the nurses can monitor. He stated that the residents having cigarettes in their rooms is a fire hazard. He stated that the residents have access to their individual lockboxes with keys and are supervised by the nurses during smoke times posted at the nurses' station. He stated that all staff should report to the charge nurse if they find cigarettes in the resident's room. He stated he is not sure how Resident #1 got the cigarettes in his room. Record review of the facility's policy / procedure titled, Smoking by Residents Nursing Manua-Nursing Administration dated 06/2020 reflected: PurposeTo respect resident choice to smoke and to maintain a safe healthy environment for both smokersand non-smokers.PolicyI. Smoking is not allowed anywhere inside the Facility.II. The Facility permits smoking only in the area(s) designated by the Facility's Safety Committee.III. The Facility discourages smoking by residents and ensures that those residents who choose tosmoke do so safely.IV. Residents who want to smoke will be assessed for their ability to smoke safely prior to beingallowed to smoke in these areas.V. Residents who are not able to smoke safely will be accompanied by Facility Staff while smoking.VI. This policy applies to the use of both cigarettes and e-cigarettes.IX. All smoking materials will be stored in a secure area to ensure they are kept safe.

Based on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for five of fifteen resident rooms (room [ROOM NUMBER], #2, #3, #4, and #5) on Hall 4, and two of three shower rooms observed for cleanliness. The facility failed to ensure Resident room [ROOM NUMBER], #2, #3, #4, and #5 on Hall 4 were thoroughly cleaned and sanitized. The facility failed to ensure the shower room on Hall 4 and the shower room near the nurses' station was thoroughly cleaned and sanitized. These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.Findings included:During an interview on 06/16/26 at 9:45 a.m., Complainant #1 stated when she visited the resident's room, it was always dirty and unclean. She stated they always had to clean the resident's room and the bathroom because it was filthy. She stated all the shower rooms were filthy and had feces on the floor, and they refused to bathe the resident in them. During an observation on 06/16/26 at 9:55 a.m., the shower room on Hall 4 revealed a large trash bag of dirty clothes and towels sitting on top of the toilet seat, and there were wet towels lying on the floor near the toilet. The toilet had dark brownish stains along the bottom of the toilet base. The trash can was overflowing with trash. The floor had trash, dark grayish stains, and a large puddle of dirty water circling the drain. There was a box on the floor with dirty adult briefs and other trash.During an observation on 06/16/26 at 10:00 a.m., the shower room near the nurses' station revealed the shower drains had a dark grayish and white substance on top of the drains and there was a rust-like substance circling the drains. The shower chair and shower bed had white soap scum over the top surface of them. The toilet seat had a brownish stain on the top surface. The shower bench had black stains on the top surface. A syringe dispenser had black and brownish dirt all over the top of it. In an interview and observation on 06/16/26 at 10:01 a.m., the DON was in the shower room near the nurse's station, he was observed gathering towels that were left in the shower room. He stated housekeeping was responsible for thoroughly cleaning the shower rooms and the CNAs were responsible for cleaning after they had completed showering a resident. The DON stated if the shower rooms are not thoroughly cleaned it could spread germs to the residents.During an observation on 06/16/26 at 10:34 a.m., room [ROOM NUMBER] reflected the room floor had dark substances on the floor near the resident's bed. The room floor had white tissue near a nightstand. The air conditioning unit had dirt and dust on the front panel of the unit, and the air filter had thick dust on it. The bathroom floor had brownish stains all over the center portion of the floor, the corners of the floor, and around the toilet. There was a white object, used to measure urine output, on the floor with brownish stains on the inside of it. During an observation on 06/16/26 at 10:37 a.m., room [ROOM NUMBER] reflected the room floor had built up dirt in the corners of the door frame and corners of the floor. The air conditioning unit had dirt and dust on the front panel of the unit, and the air filter had thick dust on it. The floor of the room had dark substances near the resident's bed. The bedside table near the resident's bed had [NAME] stains along the base of the table. The bathroom floor had brownish and green substances near and around the toilet. During an observation on 06/16/26 at 10:38 a.m., room [ROOM NUMBER] reflected the air conditioning unit had dirt and dust on the front panel of the unit. The bedside table near the resident's bed had [NAME] stains along the base of the table. The floor of the room had dark substances near the resident's bed and around a floor mat. During an observation on 06/16/26 at 10:41 a.m., room [ROOM NUMBER] reflected the air conditioning unit had dirt and dust on the front panel of the unit. The bathroom floor had brownish stains in the corners, the center, and around the toilet. During an observation on 06/16/26 at 10:48 a.m., room [ROOM NUMBER] reflected the air conditioning unit had dirt and dust on the front panel of the unit. An air mattress on the bed near the entrance of the room had brownish stains on the top surface off the mattress and it had a strong urine smell. The floor of the room had black and brownish substances near the resident's bed and near a nightstand. The bathroom floor had brownish and grayish stains in the corners of the floor, under the bathroom sink, and around the toilet. During an interview on 06/16/26 at 10:59 a.m., the Housekeeping Supervisor stated he was responsible for cleaning the rooms on Hall 4 and housekeeping was responsible for cleaning the shower rooms. He stated they cleaned the shower rooms once a day and cleaned them every two weeks. He stated they were responsible for cleaning the entire resident room, including the bathrooms and the air conditioning units. He stated they completed deep cleaning every other day. He was shown pictures of the concerns observed in Resident room [ROOM NUMBER], #2, #3, #4, and #5 on Hall 4, and two of three shower rooms. He stated they were responsible for cleaning the areas mentioned in the rooms and shower rooms. He stated the areas not thoroughly cleaned could lead to an infection. During an interview on 06/16/26 at 11:10 a.m., Housekeeping M stated she was responsible she cleaning the shower room across from the nurses' station and the rooms on Hall 1 and 5. She stated she cleaned the shower room daily. She stated the floor tech sometimes pressure washed the floors, but she did not know how frequently. She was shown photos of the concerns observed in the shower rooms and she stated she cleaned the shower room daily and deep cleaned them every 2 or 3 days. During an interview on 06/16/26 at 11:20 a.m., the Administrator was shown photos of the concerns observed in Resident room [ROOM NUMBER], #2, #3, #4, and #5 on Hall 4, and the shower rooms on Hall 4 and near the nurse's station. She stated the areas of concern should be thoroughly cleaned because it could impact the residents' quality of life. Review of the facility's policy on Resident Rooms and Environment, dated 08/2020, revealed To provide residents with a safe, clean, comfortable and homelike environment. The Facility provides residents with a safe, clean, comfortable, and homelike environment. Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. Facility Staff aim to create a personalized, homelike atmosphere, paying close attention to the following: A. Cleanliness and order

Based on interview and record review, the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for two of seven residents (Resident #1, Resident #2) reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #2 was free from abuse by Resident #1. This failure could place residents at risk for abuse or neglect that could lead to serious harm.Findings included: Record review of Resident #1's face sheet, dated 05/05/26, reflected a [AGE] year-old male was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: acute osteomyelitis (severe bone infection), non-pressure chronic ulcer of unspecified heel and midfoot, type 2 diabetes (high blood sugar), protein-calorie malnutrition (a severe nutritional deficiency resulting from inadequate intake of protein and calories), schizoaffective disorder (a chronic mental health condition that combines symptoms of schizophrenia (such as hallucinations, delusions, or disorganized thinking) with a major mood disorder, such as bipolar or unipolar (depressive) disorder), muscle weakness (a reduction in physical strength), end stage renal disease (final, irreversible state of kidney failure), dysphagia (pain, choking, or food feeling stuck in the throat), lack of coordination (clumsy, unsteady, and uncoordinated muscle movements), abnormal posture and cognitive communication deficit (impairment in communication). Record review of Resident #1's Quarterly MDS assessment, dated 03/17/26, reflected BIMS score of 11, which indicated moderate cognitive impairment. The MDS assessment under Section GG-Functional Abilities, reflected Resident #1 needed setup or clean-up assistance with eating and oral hygiene, substantial assistance with toileting, partial assistance with shower and bathing, and supervision with dressing and hygiene. The MDS assessment under Section E-Behaviors, reflected Resident #1 did not exhibit any physical, verbal or other behavioral symptoms towards others. Record review of Resident #1's care plan, revised 04/01/26, reflected Resident #1 at risk for physical behavior related to dementia by evidence of hitting another resident in the face/eye. Interventions included: sending to psych ED for evaluation and treatment, analyzing key times, places circumstances, triggers, and what de-escalates behavior and document, assessing and addressing contributing sensory deficits, assessing and anticipating resident's needs, cognitive assessment, providing physical and verbal cues to alleviate anxiety; giving positive feedback back, assisting verbalization of source of agitation, assisting to set goals for more pleasant behavior, encourage seeking out staff member when agitated, evaluating side effects of medications, giving resident as many choices as possible about care and activities. Record review of Resident #1's progress note LVN B, dated 03/30/26 at 2:45 PM, reflected the following: The writer was at the nurse station, when another staff member drew attention to [Resident #1] in the hallway who was about hit [Resident #2]. [Housekeeper A] ran to the hallway. Immediate intervention was initiated to prevent further physical contact and ensure the safety of both residents. [This writer] after separated both patients, I asked him what happened, [Resident #1] bust out laughing, He said Oh I hit [Resident #2], and nothing can be done about it. Both [residents] were separated immediately. Skin assessment was completed. [Resident #2] he had no skin issue vitals were B/P 129/84, P 79, 02 97 room air, pain 0, temperature 97.8. Administrator, DON, ADON, MD, POA were notified. [Resident #1] was placed on 1 on 1. We continued to follow the plan of care. [sic] Record review of Resident #1's progress note by RN A, dated 05/04/26 at 3:00 PM, reflected the following: Resident witnessed [Resident #1] hit another resident in the back while looking out the door in the TV room. [Resident #1] hit the other resident twice in his back and threatened to hit another resident. Resident #1 stated, 'Yeah, I hit him'. Residents separated immediately. Administrator notified immediately, DON, MD and RP notified, one on one initiated. Skin assessment completed, no new skin issues noted, continue plan of care. Record review of Resident #2's face sheet, dated 05/05/26, reflected a [AGE] year-old male that was admitted to the facility on [DATE]. Resident #2 had diagnoses which included: type 2 diabetes (body resists insulin or fails to produce enough), chronic pulmonary edema (gradual accumulation of fluid in the lung's air sacs), dementia (decline in mental ability), major depressive disorder (a serious, common mental health condition characterized by persistent, severe low mood, loss of interest in activities and physical/cognitive symptoms lasting at least two weeks), fracture of neck of right femur, abnormal posture, protein-calorie malnutrition (a severe nutritional deficiency resulting from inadequate intake of protein and calories), vitamin b deficiency (body lacks sufficient levels of B vitamins), age related osteoporosis (a condition where bones lose density and strength, accelerating after age [AGE] as bone breakdown outpaces formation), lack of coordination (muscle movements are clumsy or unsteady), impulse disorders (mental health conditions characterized by an inability to resist urges, behaviors, or impulses that may harm oneself or others), depression (a common, serious medical illness causing persistent sadness, loss of interest, and physical symptoms that interfere with daily life), cognitive communication deficit (difficulty with verbal or non-verbal communication), delusional disorder (a serious mental health condition characterized by the presence of one or more non-bizarre delusions-false, fixed beliefs-lasting for at least one month), acute kidney failure (a sudden, rapid loss of kidney function-often within hours or days-leading to waste, toxin, and fluid buildup in the body), congestive heart failure (a chronic, progressive condition where the heart muscle is too weak or stiff to pump blood efficiently), muscle weakness, hyperlipidemia (high levels of fats) and weakness. Record review of Resident #2's Quarterly MDS assessment, dated 03/07/26, reflected a BIMS score of 4 which indicated severely impaired cognition. The MDS assessment under Section GG-Functional Abilities, reflected Resident #2 needed clean-up assistance with eating, supervision with oral hygiene and upper body dressing, partial assistance with toileting hygiene, showering, and lower body dressing and substantial assistance with putting and taking off footwear and personal hygiene. The MDS assessment under Section E-Behaviors, reflected Resident #2 did not exhibit any physical, verbal or other behavioral symptoms towards others. Record review of Resident #2's care plan, revised 04/01/26, reflected Resident #2 had a risk of redness with puffiness to left eye due to another resident hitting him in his eye. Interventions included: Identifying potential causative factors and eliminating/resolving when possible, informing/instructing staff of causative factors and measures to prevent bruises, monitoring location, size of redness with puffiness and reporting to MD. Record review of Resident #2's progress note by RN A, dated 03/30/26 at 3:12 PM, reflected the following: Resident Nurse was informed by another employee that [Resident #2] was about to be hit by [Resident #1]. Nurse went there quickly to prevent it immediately. Intervention was initiated to separate both [residents] to prevent any physical contact. [Resident #2] said, He swung his hand and hit my face, I was about to swing mine but missed it. I was on the hallway, he was saying bitch words to me on the hallway, I told him, I don't like it, that's when he started to swing his hand. Nurse separated both residents. Immediately we noticed redness on the left eye and slide [sic] swelling noted under the left eyelid. [Resident #2] was assisted to his room. Skin assessment was completed, we only saw the redness in the eye, and swelling under his eyelid. MD, Administrator, DON, POA were notified. MD gave a new order for Skull series to assess for possible fracture. Xray order was placed. Vital signs were B/P 132/80, P 73, 02 98 room air, pain 0, temp 97.7. We placed iced pad on the left eyelid, [there] was no bleeding. [Resident #2] was asked if he wanted to go to his room. [Resident #2] denied and assisted to the nurse's station. We continued to follow the plan of care. [sic] Record review of Resident #2's progress note by LVN B, dated 05/04/26 at 5:00 PM, reflected the following: [Resident #2] noted in wheelchair in TV room looking out of the doors, when [Resident #1] in a wheelchair hit [Resident #2] in his back 2 times, residents immediately separated. [Resident #2] was unable to verbalize what happened. Administrator notified, skin assessment completed, no skin issues noted. DON, MD and RP notified, continue plan of care. Record review of Resident #2's radiology results report, examination date 03/30/26, reflected the following in part: Procedure: SkullInterpretation:Reason for Study: Localized swelling, mass and lump, headFindings: The visualized skull and facial bone demonstrate no acute fracture. No joint dislocation. Unremarkable soft tissues. The nasal bone appears intact. Conclusion: 1. No obvious or acutely displaced fracture. 2. A CT is recommended for better sensitivity if symptoms persist or worsen. In an interview on 05/05/26 at 11:21 AM, Resident #1 stated he and Resident #2 were watching tv in the tv common area. Resident #1 stated he rolled up on Resident #2 and punched Resident #2 in the face with a closed fist. Resident #1 stated after he punched Resident #2, Resident #2 put up his hands. Resident #1 stated Resident #2 stated he did not hit back. Resident #1 also stated staff were passing lunch trays during that time. Resident #1 stated he did not know how staff found out, but staff separated them. Resident #1 stated he hit Resident #2 because he felt Resident #2 was a child molester. Resident #1 stated he seen it in his file but did not identify what file. In an interview on 05/05/26 at 11:33 AM, Resident #2 stated he was trying to remember the incident. He stated he did not remember. Resident #2 then stated he had been hit with a fist in his chest. Resident #2 stated he did not know who the other resident was that hit him. Resident #2 stated he did not have any marks. Resident #2 stated he felt safe and was not afraid of anyone at the facility. On 05/05/26 at 1:46 PM, an attempt call to Housekeeper C but no answer. The operator stated mailbox was full and unable to leave a message. Housekeeper A had not called back by exit. In an interview on 05/05/26 at 3:04 PM, the Administrator stated Resident #1 and Resident #2 had not previously had any altercations prior to 03/03/26. She stated she received information about the incident while still in the building. The Administrator stated the residents were separated, assessed and notified RP's, MD and PD. The Administrator stated the facility was currently working on transferring Resident #1 to a group home. The Administrator stated Resident #1 would be transferred on 05/06/26. She also stated additional training was done with staff regarding resident to resident altercations, abuse and neglect, and how to handle residents with schizophrenia and dementia. In an interview on 05/05/26 at 4:38 PM, Resident #3 stated on 05/04/26 around lunchtime, he was sitting facing the tv and Resident #2 was facing outside. He stated Resident #1 went up and hit Resident #2 on his back two times. He stated Resident #2 told Resident #1 that he better be glad he did not hit him back. Resident #3 stated there were no words exchanged between the residents prior to the incident. Resident #3 stated there was no staff in the tv room at the time. He stated staff were walking around. He stated when he called there were 3 or 4 staff that came to assist. Resident #3 stated staff separated Resident #1 and Resident #2, then took Resident #1 out of the room. In an interview on 05/05/26 at 4:55 PM, the DON stated he was in the building during the incident but received the information afterwards. The DON stated Resident #1 was the aggressor. The DON stated Resident #1 felt like he knew Resident #2 from out in the community. Resident #1 alleged Resident #2 was a child molester and that was why he hit him. The DON stated he spoke to Resident #1 about keeping his hands to himself. The DON also stated the residents were separated immediately and assessed Resident #2. The DON stated Resident #2's eye had some redness as if it was irritated but not swollen. The DON stated that the redness was gone within 48 hours. The DON stated they were in the process of having Resident #1 transferred to a group home. Record review if the facility's policy titled, Abuse Prevention and Prohibition Program, revised 08/2020, reflected in part the following: Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements.Policy:Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property.A. Definitions for the meaning of key terms used in this policy.II. The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. This policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial wellbeing.

Based on interviews and record reviews the facility failed to ensure in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for one (Resident #1) of 12 residents reviewed for Medical records. The facility failed to ensure the IDT or MDS Coordinator added Resident #1's Pressure Injury on buttocks, unstageable diagnosis to his EMR profile, after he was [BH1] diagnosed on [DATE] with it and prior to his discharge on [DATE]. This failure could affect all residents by placing them at risk of getting missed care and treatments if no one were aware of their diagnosis, which could lead to decreased health and psycho-social well-being. Findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] by RN W revealed, a [AGE] year-old male who admitted [DATE]. He had a BIMS score 15 (no cognitive impairment) and had upper and lower extremity impairment on both sides and dependent - helper did all effort for all ADL's. He was always incontinent with bladder and frequently incontinent with bowel and he had medically complex conditions. His diagnoses was Malnutrition, depression, Amyotrophic lateral sclerosis, adjustment disorder, GERD, other lack of coordination, chronic pain, dysphagia. Skin Conditions: At risk of developing pressure ulcers/injuries, no skin conditions. Record review of Resident #1's MARs/TARs dated 12/01/24 - 12/19/24 revealed, Ammonium Lactate external cream 12% apply to both lower extremities topically two times a day for dry skin (start date 12/12/24 - DC date 12/20/24). Hydrocortisone External lotion 2.5% topical apply to skin topically two times a day for itchy areas resident able to state where itch is occurring (start date 03/05/24 and DC date 12/20/24). Apply zinc oxide to buttock as needed for wound (start date 05/26/24 and DC date 12/20/24). Mupirocin external ointment 2% apply to affected areas to RLE topically two times a day for skin infection until 12/22/24, apply to RLE x 10 days (start date 12/13/24 - DC date 12/20/24. Record review of Resident #1's Order Recap Report printed 08/14/25 revealed, Resident may be seen by Wound care Dr. V, for evaluation and treatment. every 7 day(s) for open areas noted on baseline skin assessment Verbal 09/27/2024 start 09/28/2024 and DC 12/20/2024 by Doctor J. Apply zinc oxide to buttock as needed for Wound (started 05/26/24 - 12/20/24) by Doctor J. Ammonium Lactate External Cream 12 % (Lactic Acid (Ammonium Lactate)) Apply to both lower extremities topically two times a day for dry skin (start 12/12/24 - 12/20/24). Hydrocortisone External Lotion 2.5 % (Hydrocortisone (Topical)) Apply to Skin topically two times a day for itchy areas Resident able to state where itch is occurring (started 03/05/24 - 12/20/24). Mupirocin External Ointment 2 % (Mupirocin) Apply to affected areas to RLE topically two times a day for skin infection until 12/22/2024 Apply to RLE x 10 days (start 12/13/24 - 12/20/24). Record review of Resident #1's Care plans printed and date initiated 03/18/23 revealed, Resident #1 have bowel incontinence related to immobility & Amyotrophic Lateral Sclerosis: Interventions: check resident every two hours and assist with toileting as needed, provide loose fitting, easy to remove clothing, provide pericare after each incontinent episode and see care plans on mobility, ADL's, Cognitive deficit, communication. And date initiated 04/24/23 - Resident #1 have potential impairment to skin integrity related to impaired mobility and incontinence; he prefers to have incontinent pad in recliner chair: Interventions: avoid scratching, and keep hands and body parts from excessive moisture. Educate resident/family/caregivers of causative factor and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface.(Resident #1 did not have a Care plan for pressure injuries anywhere in his EMR profile). Record review of Resident #1's Progress Note by NP B dated 01/31/25 revealed, Diagnosis, Assessment and Plan - Assessment ICD Codes L89.300 Pressure injury of buttock, unstageable. Plan Discussed with Nursing & patient Apply zinc oxide in area and cover with dressing. Try to offload pressure to area. Record review of Resident #1's Nurses Note dated 01/31/2024 at 09:41 am by LVN A revealed, Reopened area about resident Left buttock area about 0.2x0.2cm. NP B here notified. New order noted -apply zinc oxide QD until healed. RP notified. Record review of Resident #1's Nurses note dated 05/26/2024 at 10:17 pm by LVN C revealed, Resident said the buttocks wound are healed. MD notified and changed zinc oxide cream qd to PRN. Call light in reach. Record review of Resident #1's Nurses note dated 07/08/2024 at 09:22 am by Nurse D revealed, Nurse asked about buttocks abrasion and resident stated it is healing. Will continue to monitor. Record review of Resident #1's Nurses note dated 07/10/2024 1:17 pm by Nurse D revealed, Nurse asked resident about buttocks wound after his shower and resident verbalized it is healing. Record review of Resident #1's Nurses Notes dated 07/10/2024 at 10:09 pm by RN E revealed, Nurse cont. to monitor wound to buttocks, no s/s of infection noted. Resident stable, alert and oriented x 4 with no s/s of pain or distress noted at this time. Vitals within normal range. Call light within reach. Will continue with care plan. Record review of Resident #1's Nurses Notes dated 07/23/2024 at 2:36 pm by Nurse D revealed, Nurse did wound care treatment per residents request because both residents buttocks cheeks skin was irritating him. Record review of Resident #1's Nurses Notes dated 09/16/2024 at 8:07 pm by LVN E revealed, Resident requested for wound consult for pressure wound to buttock. MD notified, waiting for response. Resident stable, alert and oriented x 4 with no s/s of pain or discomfort noted at this time. Vitals within normal range, call light within reach, will continue with care plan. Record review of Resident #1's Nursing Notes dated 09/26/2024 at 10:47 pm by Former DON F revealed, Baseline skin assessment completed. Noted open areas to sacral area. Refer to wound care doctor to evaluate and treat. Continue to monitor. Record review of Resident #1's Nurses Note dated 09/27/2024 at 2:36 pm by Former DON F revealed, Follow up to baseline skin assessment findings. Resident was referred to [Wound care] Dr. for eval and treatment. Face sheet and medication list faxed, order is in the system. Record review of Resident #1's Nurses Notes dated 11/03/2024 at 1:30 pm by LVN C revealed, Apply zinc oxide to buttock as needed for Wound Full shower provided. Excoriation and peeling skin to buttocks. No bleeding. BP=115/80, P=76, T=97.6, O2 SAT (saturation)=98, ROOM AIR, R=18. Will monitor. Record review of Resident #1's Weekly Skin Observation Tool dated 12/03/24 revealed, Does the resident have any observed skin issues? Yes- 3.Excoriation to buttocks: Dry skin to lower extremities, shoulders, thighs, abdomen, shoulders, calves; Eczema on abdomen. Healing blister to right inner thigh. Interview on 08/18/25 at 10:21 am, NP I stated he was the NP for Doctor J and saw Resident #1 before he discharged the facility December 2024. He stated oh yes he remembered Resident #1 very well, he used a tablet to communicate with and had ALS because he could not talk (speak). He stated he discharged to another place. He stated he saw Resident #1 once or twice before he discharged this facility in December 2024. He stated he did a head to toe assessment and his legs were swollen and he ordered a water pill for him to start taking. He stated Resident #1 had a couple of skin issues, a wound on butt and rash on his lower leg. He stated the only issues Resident #1 had was his legs were swollen and he had the wound on his buttock. Interview on 08/19/25 at 9:44 am, NP I stated when he assessed Resident #1 in December 2024, he could not remember the size of his butt wound but there was no odor or draining. He stated Resident #1 had a wound in the crack of his butt area. He stated Resident #1 had wound care orders but said ‘Let's make changes to his orders' and added the mupirocin ointment for his butt crack wound. Interview on 08/19/25 at 12:24 pm, the Administrator stated she would have to review Resident #1's records and was not aware the pressure injury diagnosis was not added to Resident #1's EMR profile. Interview on 08/19/25 at 1:16 pm, Doctor J stated Resident #1 had some skin issues on his legs and a wound on his bottom January 2024 and sometime in May 2024. He stated Resident #1 was diagnosed with a pressure wound of his sacral area and that the Wound Care Doctor had treated it. He stated he did not know that Resident #1 had not been assessed by the Wound Care Doctor. Interview on 08/19/25 3:47 pm, DON O stated he was not sure why his pressure injury was not added to his medical records because he was not working here at the time. Interview on 08/19/25 at 4:38 pm, MDS P stated she was the person who updated the resident's diagnosis in the EMR. She stated when the Facility Doctors diagnosed a resident they should be added to the resident's medical record. She stated she looked at the residents progress notes from the facility doctors and outside doctors to add diagnoses. She stated she was responsible for ensuring the diagnoses were added to the EMR. She stated if the diagnoses were not added to the EMR the staff wound not know what was going on with the resident. She stated not adding the diagnoses could cause anything to happen like infections and hospitalizations. Interview on 08/20/25 at 12:46 pm, MDS P stated she went over the resident's documentation weekly by using a calendar to check five residents per day to review their nurses notes, doctor's notes and hospital records and psychiatric records for any new additions to the resident's EMR profile. She stated if the diagnosis were not added, the resident could have a change of condition and need to go to the hospital or get infections. She stated the resident might receive improper care or not get the right treatment for a skin issue. Interview on 08/20/25 at 4:21 pm, DON O stated not being sure why Resident #1's pressure Ulcer of buttock diagnosis was not added to his medical record and if the doctor put it on a progress note, it should have been added. He stated Resident #1's pressure ulcer diagnosis should have been added to his diagnosis profile and been care planned. He stated not having a diagnosis added to a resident records runs the risk of the diagnosed condition not being treated. Interview on 08/21/25 at 4:57 pm, the Administrator stated the MDS Coordinator was responsible for ensuring medical records were accurate. Interview on 08/21/25 at 5:42 pm ADON G stated she was not sure why Resident #1's pressure ulcer of buttock diagnoses was not added to his EMR profile. She stated she was not sure of the timeframe diagnosis should be add and would assume within a couple of days depending on what it is. Record review of the Facility's Medical records policy was requested 08/19/25 at 5:14 pm and 08/21/25 at 5:24 pm and the Administrator stated the facility did not have one.

Based on interviews and record reviews the facility failed to ensure they provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of 12 residents reviewed for Pharmacy services. The facility failed to ensure LVN H and LVN X gave Resident #1 his Ammonium Lactate ointment on his lower legs as prescribed by his doctor on [DATE], [DATE], [DATE], [DATE] and [DATE][BH1] prior to discharge on [DATE]; Subsequently, the nurses stated it was unavailable with no documentation as to why. This failure could affect all residents by placing them at risk of going without their medications which could cause a resident to have a decline in health and psycho-social well-being.Findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] by RN W revealed, a [AGE] year-old male who admitted [DATE]. He had a BIMS score 15 (no cognitive impairment) and had upper and lower extremity impairment on both sides and dependent - helper did all effort for all ADL's. He was always incontinent with bladder and frequently incontinent with bowel and he had medically complex conditions. His diagnoses was Malnutrition, depression, Amyotrophic lateral sclerosis, adjustment disorder, GERD, other lack of coordination, chronic pain, dysphagia. Skin Conditions: At risk of developing pressure ulcers/injuries, no skin conditions. Record review of Resident #1's Order Recap Report printed [DATE] revealed, Apply zinc oxide to buttock as needed for Wound (started [DATE] - [DATE]) by Doctor J. Ammonium Lactate External Cream 12 % (Lactic Acid (Ammonium Lactate) Apply to both lower extremities topically two times a day for dry skin (start [DATE] - [DATE]). Hydrocortisone External Lotion 2.5 % (Hydrocortisone (Topical)) Apply to Skin topically two times a day for itchy areas Resident able to state where itch is occurring (started [DATE] - [DATE]). Mupirocin External Ointment 2 % (Mupirocin) Apply to affected areas to RLE topically two times a day for skin infection until [DATE] Apply to RLE x 10 days (start [DATE] - [DATE]). Record review of Resident #1's Care plans printed [DATE] and date initiated [DATE] revealed, Resident #1 have bowel incontinence related to immobility & Amyotrophic Lateral Sclerosis: Interventions: check resident every two hours and assist with toileting as needed, provide loose fitting, easy to remove clothing, provide pericare after each incontinent episode and see care plans on mobility, ADL's, Cognitive deficit, communication. And date initiated [DATE] - Resident #1 have potential impairment to skin integrity related to impaired mobility and incontinence; he prefers to have incontinent pad in recliner chair: Interventions: avoid scratching, and keep hands and body parts from excessive moisture. Educate resident/family/caregivers of causative factor and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Record review of Resident #1's MARs/TARs dated [DATE] - [DATE] revealed , Ammonium Lactate external cream 12% apply to both lower extremities topically two times a day for dry skin (start date [DATE] - DC date [DATE]). Hydrocortisone External lotion 2.5% topical apply to skin topically two times a day for itchy areas resident able to state where itch is occurring (start date [DATE] and DC date [DATE]). Apply zinc oxide to buttock as needed for wound (start date [DATE] and DC date [DATE]). Mupirocin external ointment 2% apply to affected areas to RLE topically two times a day for skin infection until [DATE], apply to RLE x 10 days (start date [DATE] - DC date [DATE]. Record review of Resident #1's MAR/TARS dated [DATE] revealed, Ammonium Lactate External Cream 12 % (Lactic Acid Ammonium Lactate) Apply to both lower extremities topically two times a day for dry skin apply ammonium lactate -Start Date- [DATE] 6:00 pm -D/C Date- [DATE] 10:09 am. It was coded other/see nurses notes: unavailable for the dayshift on [DATE], [DATE], [DATE], [DATE] and [DATE] and night shift on [DATE] was coded hold/see nurses notes. Record review of Resident #1's Nurses Note dated [DATE] at 1:32 pm by LVN H revealed, Several dry yellow crusted over areas to BLE observed MD made aware will continue to implement current plan of care. Record review of Resident #1's Nurses Note dated [DATE] 10:15 am LVN H revealed, New order furosemide 20 mg 1 tab x 10 days Bactroban apply to affected area to RLE BID x 10 days ammonium lactate cream apply to BLE - NP I. Record review of Resident #1's Nurses Note dated [DATE] at 1:41 pm by LVN H revealed, Ammonium Lactate External Cream 12 % Apply to both lower extremities topically two times a day for dry skin apply ammonium lactate NA. Record review of Resident #1's Nurses Notes dated [DATE] at 8:36 pm by LVN X revealed, Ammonium Lactate External Cream 12 % Apply to both lower extremities topically two times a day for dry skin apply ammonium lactate medication unavailable. Record review of Resident #1's Nurses note dated [DATE] at 11:52 am by LVN H revealed, Ammonium Lactate External Cream 12 % not available. Record review of Resident #1's Nurses note dated [DATE] at 12:51 pm by LVN H revealed, Ammonium Lactate External Cream 12 % Apply to both lower extremities topically two times a day for dry skin apply ammonium lactate not available. Record review of Resident #1's Nurses noted [DATE] at 10:09 am by LVN H revealed, Ammonium Lactate External Cream 12 % not available to administer noted. Record review of Resident #1's Nurses note dated [DATE] at 9:09 am by LVN H revealed, Ammonium Lactate External Cream 12 % Apply to both lower extremities topically two times a day for dry skin apply ammonium lactate not available. Interview on [DATE] at 10:21 am, NP I stated he was the NP for Doctor J and saw Resident #1 before he discharged the facility [DATE]. He stated oh yes he remembered Resident #1 very well, he used a tablet to communicate with and had ALS because he could not talk (speak). He stated he discharged to another place. He stated he saw Resident #1 once or twice before he discharged this facility in [DATE]. He stated he did a head to toe assessment and his legs were swollen and he ordered a water pill for him to start taking. He stated Resident #1 had a couple of skin issues, a wound on butt and rash on his lower leg. He stated the only issues Resident #1 had was his legs were swollen and he had the wound on his buttock. Interview on [DATE] at 9:44 am, NP I stated when he assessed Resident #1 in [DATE], he could not remember the size of his butt wound but there was no odor or draining. He stated Resident #1 had a wound in the crack of his butt area. He stated Resident #1 had wound care orders but said ‘Let's make changes to his orders' and added the mupirocin ointment for his butt crack wound. Interview on [DATE] at 10:00 am, LVN H stated honestly she could not remember if Resident #1 had a wound care consult or treatment order because he was here a while ago in 2024. She stated she could not remember if she put any dressings on his lower leg but something was being put on it. She stated she never talked to the Wound care Doctor about Resident #1 and he was not seen by the Wound care Doctor. She stated for the ammonium lactate it was a possibility the pharmacy was saying it was an over the counter or cost too much and was not really sure. She stated Resident #1 probably had some ammonium lactate that was expired she was not really sure. She stated the NP back when Resident #1 was here was NP I. Interview on [DATE] at 12:24 pm, the Administrator stated the DON and Pharmacist did the monthly medication reconciliation of the resident's Doctor's orders to determine if there were any discrepancies. She stated if a resident was prescribed medication, the nurses needed to call the Doctor if it was unavailable. She stated the nurses needed to see if there was an alternate medication they could get or be put on hold. She stated If a resident were prescribed medication and not given she was not sure what could happen to the resident. Interview on [DATE] at 12:31 pm, DON O stated after review he stated there was no documentation on why the ammonium lactate was unavailable. He stated he was not sure why the ammonium lactate was not given to Resident #1 in [DATE]. He stated he would check to see why it was not given and unavailable. Interview on [DATE] at 1:01 pm, ADON G stated the staff needed to ensure the residents orders were followed through on. She stated it was the nurses responsibility to ensure the orders were done. She stated every month nurse management reviewed all of the residents physician orders that was then signed by the doctors sign. She stated the facility's Pharmacist came to the facility monthly to review the resident's medications and signed off on review of the medications. She stated the Pharmacist reviewed the medication findings with DON O of any concerns. She stated Resident #1 had a skin disorder of dry and scaly skin and had a rash in [DATE] and could not remember where it was. She stated she was not sure why Resident #1's ammonium sulfate was unavailable and would have to look in the computer. Interview on [DATE] at 1:16 pm, Doctor J stated Resident #1 had some skin issues on his legs and a wound on his bottom [DATE] and sometime in [DATE]. He stated none of the staff called him about any issues with Resident #1's ammonium lactate order being unavailable and it was not discontinued. He stated typically if the nurses could not get a medication was because it was not in stock or not covered by the insurance, then they would get another medication for the residen. Interview on [DATE] 3:47 pm, DON O stated for the ammonium lactate, he spoke to the dayshift nurse LVN H and she said it was not available. He stated he was not sure why LVN H did not contact Resident #1's Doctor/NP or pharmacy. He stated LVN H said she did not contact the Doctor or pharmacy because she felt like Bactroban and ammonium lactate were the same. He stated if the medication was not available the nurse should have called to see if it was a hold and ask the pharmacy for an alternate medication. He stated the nurses should have talk to him if they didn't have the ammonium lactate. Interview on [DATE] 4:15 pm, ADON G stated Resident #1 discharged this facility [DATE]. She stated the nurse said Resident #1's ammonium lactate was unavailable and after she spoke to LVN H she said it was not available. She stated LVN H should have notified Doctor J to get a substitute medication and let nurse management aware to assist with ensuring the resident received his medication. Record review of ADON G's email dated [DATE] at 3:52 pm revealed, I'm unaware of the resident not receiving ammonia lactate medication. The mar shows the other shifts administered cream except for the 6-2 shift with LVN H. The charge nurse communicates between the doctors regarding skin issues. 12/10 & [DATE] show in the nurses' notes that the charge nurse communicated skin issues with the MD. The charge nurses are responsible for communication; they complete skin assessments and notifications. Interview on [DATE] at 4:51 pm, the Administrator stated she was not aware Resident #1 was not given his ammonium lactate for several days before he discharged [DATE], because it was unavailable. She stated the pharmacist reviewed the medication and doctors reviewed the documentation. She stated the clinical team was responsible for ensuring the medications were accurately being given. She stated she was not sure who was ultimately responsible for ensuring the medications were accurate. Interview on [DATE] at 4:21 pm, DON O stated if a resident's medication was not available the nurse needed to call the Doctor and pharmacy for further guidance. He stated if the medication was not in stock the nurses should call the Doctor to see if there was an equivalent available. He stated he was not able to determine why Resident #1 did not get the ammonium lactate twice per day. He stated LVN H said the ammonium lactate was not available and said he was not sure if LVN H did not look in the medication cart if the ointment was missing she should have called the Doctor and/or pharmacy to see if there was some type of insurance issue. He stated they did a 1:1 training with LVN H because of this issue. He stated he could see RN E gave the ammonium lactate to Resident #1 at night and LVN H was aware if the medication were not available she should have made an attempt to get it then told himself or the ADON about it to address. He stated the physician orders were supposed to be followed and the nursing staff worked under the Doctors. He stated they could not do anything arbitrarily and do something different than what the Doctor ordered. Interview on [DATE] at 4:57 pm, the Administrator stated she was not sure why Resident #1 did not get the ammonium lactate ointment for his legs. She stated some nurses gave Resident #1 the ointment and others did not.[ She stated for Medication administering the ADON and DON were responsible for ensuring the services were being done. Record review of LVN H's Record of in-service dated [DATE] by DON O revealed, If medications aren't available, it is the charge nurses responsibility to call pharmacy. Meds (Medications) can be pulled from E-kit if not available. MD notification must be made so med (medication) can be placed on hold and/or change to an alternative. and this document was signed by LVN H. Record review of the facility's Medication and Administration Policy Revised [DATE] revealed, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 2. The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related function. 4. Medications are administered in accordance with prescriber orders, including any required timeframe.

Based on interviews and record reviews the facility failed to ensure the Comprehensive Care plan was reviewed and revised after each assessment, including both the comprehensive and quarterly review assessments for one (Resident #1) of 12 residents reviewed for Care plans. The facility failed to ensure their IDT or MDS [BH1] Coordinator added Resident #1's ICD Code L89.300 Pressure injury of buttock, unstageable diagnosis to his care plan when on 01/31/24, he was diagnosed with an unstageable pressure injury of buttock and prior to his discharge on [DATE]. This failure could affect all residents by placing them at risk of not having a complete profile which could result in inadequate care and result in a decrease in health and psycho-social well-being.Findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] by RN W revealed, a [AGE] year-old male who admitted [DATE]. He had a BIMS score 15 (no cognitive impairment) and had upper and lower extremity impairment on both sides and dependent - helper did all effort for all ADL's. He was always incontinent with bladder and frequently incontinent with bowel and he had medically complex conditions. His diagnoses was Malnutrition, depression, Amyotrophic lateral sclerosis, adjustment disorder, GERD, other lack of coordination, chronic pain, dysphagia. Skin Conditions: At risk of developing pressure ulcers/injuries, no skin conditions. Record review of Resident #1's Order Recap Report printed 08/14/25 revealed, Resident may be seen by Wound care Dr. V, for evaluation and treatment. every 7 day(s) for open areas noted on baseline skin assessment Verbal 09/27/2024 start 09/28/2024 and DC 12/20/2024 by Doctor J. Apply zinc oxide to buttock as needed for Wound (started 05/26/24 - 12/20/24) by Doctor J. Ammonium Lactate External Cream 12 % (Lactic Acid (Ammonium Lactate)) Apply to both lower extremities topically two times a day for dry skin (start 12/12/24 - 12/20/24). Hydrocortisone External Lotion 2.5 % (Hydrocortisone (Topical)) Apply to Skin topically two times a day for itchy areas Resident able to state where itch is occurring (started 03/05/24 - 12/20/24). Mupirocin External Ointment 2 % (Mupirocin) Apply to affected areas to RLE topically two times a day for skin infection until 12/22/2024 Apply to RLE x 10 days (start 12/13/24 - 12/20/24). Record review of Resident #1's Care plans printed 08/21/25 and date initiated 03/18/23 revealed, Resident #1 have bowel incontinence related to immobility & Amyotrophic Lateral Sclerosis: Interventions: check resident every two hours and assist with toileting as needed, provide loose fitting, easy to remove clothing, provide pericare after each incontinent episode and see care plans on mobility, ADL's, Cognitive deficit, communication. And date initiated 04/24/23 - Resident #1 have potential impairment to skin integrity related to impaired mobility and incontinence; he prefers to have incontinent pad in recliner chair: Interventions: avoid scratching, and keep hands and body parts from excessive moisture. Educate resident/family/caregivers of causative factor and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. (Resident #1 did not have a pressure injury care plan). Record review of Resident #1's Progress Note by NP B dated 01/31/24 revealed, Diagnosis, Assessment and Plan - Assessment ICD Codes L89.300 Pressure injury of buttock, unstageable. Plan Discussed with Nursing & patient Apply zinc oxide in area and cover with dressing. Try to offload pressure to area. Record review of Resident #1's Nurses Note dated 01/31/2024 at 9:41 am by LVN A revealed, Reopened area about resident Left buttock area about 0.2x0.2cm. NP B here notified. New order noted -apply zinc oxide QD until healed. RP notified. Record review of Resident #1's Nurses Notes dated 09/16/2024 at 8:07 pm by LVN E revealed, Resident requested for wound consult for pressure wound to buttock. MD notified, waiting for response. Resident stable, alert and oriented x 4 with no s/s of pain or discomfort noted at this time. Vitals within normal range, call light within reach, will continue with care plan. Record review of Resident #1's Nursing Notes dated 09/26/2024 at 10:47 pm by Former DON F revealed, Baseline skin assessment completed. Noted open areas to sacral area. Refer to wound care doctor to evaluate and treat. Continue to monitor. Record review of Resident #1's Nurses Notes dated 11/03/2024 at 1:30 pm by LVN C revealed, Apply zinc oxide to buttock as needed for Wound Full shower provided. Excoriation and peeling skin to buttocks. No bleeding. BP=115/80, P=76, T=97.6, O2SAT=98, ROOM AIR, R=18. Will monitor. Record review of Resident #1's Weekly Skin Observation Tool dated 12/03/24 revealed, Does the resident have any observed skin issues? Yes- 3.Excoriation to buttocks: Dry skin to lower extremities, shoulders, thighs, abdomen, shoulders, calves; Eczema on abdomen. Healing blister to right inner thigh. Interview on 08/14/25 at 1:59 pm, LVN A stated Resident #1 did not have any wounds but he had redness on his buttock and zinc oxide cream was used to treat it last year 2024. Interview on 08/14/25 at 2:21 pm, CNA K stated Resident #1 the nurses applied cream on his left buttock because he had a small wound on it last year 2024. Interview on 08/14/25 at 2:38 pm, CNA L stated Resident #1 had scratches on his right buttock, it was a shear that started last year (2024) sometime. Interview on 08/14/25 at 2:55 pm, CNA M stated Resident #1 had a wound on his bottom, he developed a wound after his shower one day she noticed it. She stated his nurses would put some cream and covered with dressing. She stated Resident #1's wound on his bottom was the size of a quarter last year 2024. Interview on 08/18/25 at 10:21 am, NP I stated he was the NP for Doctor J and saw Resident #1 before he discharged the facility December 2024. He stated oh yes he remembered Resident #1 very well, he used a tablet to communicate with and had ALS because he could not talk (speak). He stated he discharged to another place. He stated he saw Resident #1 once or twice before he discharged this facility in December 2024. He stated he did a head to toe assessment and his legs were swollen and he ordered a water pill for him to start taking. He stated Resident #1 had a couple of skin issues, a wound on butt and rash on his lower leg. He stated the only issues Resident #1 had was his legs were swollen and he had the wound on his buttock. Interview on 08/19/25 at 9:44 am, NP I stated when he assessed Resident #1 in December 2024, he could not remember the size of his butt wound but there was no odor or draining. He stated Resident #1 had a wound in the crack of his butt area. He stated Resident #1 had wound care orders but said ‘Let's make changes to his orders' and added the mupirocin ointment for his butt crack wound. Interview on 08/19/25 at 1:16 pm, Doctor J stated Resident #1 had some skin issues on his legs and a wound on his bottom January 2024 and sometime in May 2024. He stated Resident #1 was diagnosed with a pressure wound of his sacral area. Interview on 08/20/25 at 11:28 am, CNA T stated she started working at this facility the spring of 2024 and saw Resident #1's butt sore but did not talk to anyone about it. Interview on 08/20/25 at 11:49 am, CNA M stated she first noticed Resident #1 had a butt wound last year, last summer August or September 2024. Interview on 08/20/25 at 12:01 pm, LVN N stated Resident #1 had a sore with a dressing on his coccyx and was kind of not sure of the size. She stated she forgot because it had been so long ago last year 2024. She stated she was not aware he had a wound care consult. Interview on 08/20/25 at 3:21 pm, CNA R stated she remembered Resident #1, he had a sore on his butt more like circular and sometime would see just a little blood coming from it last year 2024. Interview on 08/22/25 at 4:16 pm, former CNA U stated Resident #1 had a wound and noticed it when she started working at that facility last September 2024 up until he discharged this facility. Interview on 08/20/25 at 12:46 pm, MDS P stated the timeframe for completing care plan she was not sure. She stated for new diagnosis she would create a care plan and discuss in the IDT meeting. She stated she was not sure why Resident #1's pressure injury diagnosis was not care planned because she was not the MDS Coordinator at that time. She stated she went over the resident's documentation weekly by using a calendar to check five residents per day their nurses notes, doctor's notes and hospital records and psychiatric records for any new additions to the resident's EMR profile. She stated if the diagnosis were not added the resident could have a change of condition and need to go to the hospital or get infections. She stated the resident might receive improper care, not get the right treatment for skin issue. She stated they had 14 days to revise care plan as soon as she was aware of the new diagnosis. Interview on 08/21/25 at 4:57 pm, the Administrator stated the MDS Coordinator was responsible for ensuring medical records were accurate and care plans are updated. She stated the timeframe for inputting new diagnosis into care plans was 14 days. Record review of the Facility's Care Plan Policy Revised March 2022 revealed, Policy Statement: The Interdisciplinary team is responsible for the development of the care plan. Policy Interpretation and Implementation: 1. Resident care plans are developed according to the timeframes and criteria established by 483.21 and 2. Comprehensive person centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT).

Based on interviews and record reviews the facility failed to ensure the residents received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the resident's clinical condition demonstrated that they were unavoidable for one (Resident #1) of 12 residents reviewed for Wound care services. The facility failed to ensure Resident #1 was free from pressure injuries and on 01/31/24 he developed a pressure injury of buttock, unstageable and wound care treatments were started. Subsequently, on 09/27/24 Resident #1's Dr./NP ordered for him to get a wound care consult because he had an open sacral wound, however it was not completed because ADON G said he did not have a wound. Additionally, Resident #1 was never assessed by the Wound care doctor prior to his discharge on [DATE] and from 09/02/24 to 12/17/24 there was 34 times the CNA's coded Resident #1's skin observations as red, discoloration and open. This failure could place all residents at risk of getting wounds or skin issues if the Dr./NP orders were not followed, which could cause continued skin issues and result in health decline and decreased psycho-social well-being. The findings included: Interview on 08/19/25 at 2:33 pm, Wound care Dr. V stated he had not been to this facility in a while and was not familiar with seeing Resident #1. He stated he was the wound care doctor at this facility from 08/14/24 to 12/18/24 and he had no discussions with the staff about Resident #1. He stated he was very diligent on documenting each resident and he had no consults with this resident. He said he did not take a look at Resident #1 and not document it. Interview on 08/14/25 at 5:46 pm, Resident #1 sitting up in bed at a 30 degree level and via the use of an eye gazing tablet to generate speech. He stated while he was at [The previous Nursing Facility] they did not refer him to the wound care doctor after he developed a wound on his butt. He stated they were not doing any treatments to attempt to heal it and he still had the wound on his butt when he left that facility. Record review of Resident #1's Quarterly MDS assessment dated [DATE] by RN W revealed, a [AGE] year-old male who admitted [DATE]. He had a BIMS score 15 (no cognitive impairment) and had upper and lower extremity impairment on both sides and dependent - helper did all effort for all ADL's. He was always incontinent with bladder and frequently incontinent with bowel and he had medically complex conditions. His diagnoses was Malnutrition, depression, Amyotrophic lateral sclerosis, adjustment disorder, GERD, other lack of coordination, chronic pain, dysphagia. Skin Conditions: At risk of developing pressure ulcers/injuries, no skin conditions. Record review of Resident #1's Discharge instruction by LVN H dated 12/19/24 , revealed he discharged this facility with no in home care or services, to another Healthcare Center.current treatments, G-tube, medications and skin treatments, catheter care. Record review of Resident #1's Order Recap Report printed 08/14/25 revealed from 03/25/24 to 12/20/2024: Resident may be seen by Wound care Dr. V, for evaluation and treatment. every 7 day(s) for open areas noted on baseline skin assessment Verbal 09/27/2024 start 09/28/2024 and DC 12/20/2024 by Doctor J. Apply zinc oxide to buttock as needed for Wound (started 05/26/24 - 12/20/24) by Doctor J. Ammonium Lactate External Cream 12 % (Lactic Acid-Ammonium Lactate) Apply to both lower extremities topically two times a day for dry skin (start 12/12/24 - 12/20/24). Hydrocortisone External Lotion 2.5 % (Hydrocortisone (Topical)) Apply to Skin topically two times a day for itchy areas Resident able to state where itch is occurring (started 03/05/24 - 12/20/24). Mupirocin External Ointment 2 % (Mupirocin) Apply to affected areas to RLE topically two times a day for skin infection until 12/22/2024 Apply to RLE x 10 days (start 12/13/24 - 12/20/24). Record review of Resident #1's Care plans Printed 08/21/25 and date initiated 03/18/23 revealed, Resident #1 have bowel incontinence related to immobility & Amyotrophic Lateral Sclerosis: Interventions: check resident every two hours and assist with toileting as needed, provide loose fitting, easy to remove clothing, provide pericare after each incontinent episode and see care plans on mobility, ADL's, Cognitive deficit, communication. And date initiated 04/24/23 - Resident #1 have potential impairment to skin integrity related to impaired mobility and incontinence; he prefers to have incontinent pad in recliner chair: Interventions: avoid scratching, and keep hands and body parts from excessive moisture. Educate resident/family/caregivers of causative factor and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. (Resident #1's Care Plans was not updated and there were no revised care plans for Pressure injury and ointment treatments). Record review of Resident #1's EMR revealed from 01/31/24 to 12/19/24, there were no wound care consults progress notes anywhere in the resident's records. Record review of Resident #1's Progress Note by NP B dated 01/31/24 revealed, Diagnosis, Assessment and Plan - Assessment ICD Codes L89.300 Pressure injury of buttock, unstageable. Plan Discussed with Nursing & patient Apply zinc oxide in area and cover with dressing. Try to offload pressure to area. Record review of Resident #1's Nurses Note dated 01/31/2024 at 9:41 am by LVN A revealed, Reopened area about resident Left buttock area about 0.2x0.2cm. NP B here notified. New order noted -apply zinc oxide QD until healed. RP notified. Record review of Resident #1's Nurses note dated 03/18/2023 at 5:55 pm by LVN A revealed, Resident is 36 Yrs (years) old admitted to [This Facility] under the care of Dr./NP. Arrived in facility via wheelchair accompanied by parent and transported by family. Alert and oriented x 3. Respiration even and unlabored. Skin warm and dry to touch. Noted rashes all over resident body. contractures noted to resident fingers. Resident noted with G/Tube and condom catheter. resident on continue feeding (formula) 1.4 at 100ml/hr. cont. Able to make needs known. Denies pain or discomfort at this time. Shower given. Ate 50% of his dinner. Message left for Dr. to call. Record review of Resident #1's Nurses note dated 05/26/2024 at 10:17 pm by LVN C revealed, Resident said the buttocks wound are healed. MD notified and changed zinc oxide cream qd to PRN. Call light in reach. Record review of Resident #1's Nurses note dated 07/08/2024 at 09:22 am by Nurse D revealed, Nurse asked about buttocks abrasion and resident stated it is healing. Will continue to monitor. Record review of Resident #1's Nurses note dated 07/10/2024 1:17 pm by Nurse D revealed, Nurse asked resident about buttocks wound after his shower and resident verbalized it is healing. Record review of Resident #1's Nurses Notes dated 07/10/2024 at 10:09 pm by RN E revealed, Nurse cont. to monitor wound to buttocks, no s/s of infection noted. Resident stable, alert and oriented x 4 with no s/s of pain or distress noted at this time. Vitals within normal range. Call light within reach. Will continue with care plan. Record review of Resident #1's Nurses Notes dated 07/23/2024 at 2:36 pm by Nurse D revealed, Nurse did wound care treatment per residents request because both residents buttocks cheeks skin was irritating him. Record review of Resident #1's MARs/TARs dated 09/01/24 - 09/30/24 revealed, Hydrocortisone External lotion 2.5% topical apply to skin topically two times a day for itchy areas resident able to state where itch is occurring (start date 03/05/24 and DC date 12/20/24). Apply zinc oxide to buttock as needed for wound (start date 05/26/24 and DC date 12/20/24). Record review on Resident #1's CNA Point of Care skin observations from 09/02/24 to 12/17/24 revealed coding for Item value 1 Red area - Item value 2. Discoloration and item value 4. open area was coded 34 times by various CNA's. Record review of Resident #1's Nurses Notes dated 09/16/2024 at 8:07 pm by LVN E revealed, Resident requested for wound consult for pressure wound to buttock. MD notified, waiting for response. Resident stable, alert and oriented x 4 with no s/s of pain or discomfort noted at this time. Vitals within normal range, call light within reach, will continue with care plan. Record review of Resident #1's Weekly Skin Observation Tool dated 09/22/24 revealed, 1. Does the resident have any observed skin issues? Yes- 3.Excoriation to buttocks: old scars to both hands, dry skin to lower extremity, shoulders (rear), thighs, and right calf; Eczema on abdomen, thigh and rear lower legs. Treatment in progress. Record review of Resident #1's Nursing Notes dated 09/26/2024 at 10:47 pm by Former DON F revealed, Baseline skin assessment completed. Noted open areas to sacral area. Refer to wound care doctor to evaluate and treat. Continue to monitor. Record review of Resident #1's Nurses Note dated 09/27/2024 at 2:36 pm by Former DON F revealed, Follow up to baseline skin assessment findings. Resident was referred to [Wound care] Dr. for eval and treatment. Face sheet and medication list faxed, order is in the system. Record review of Resident #1's Weekly Skin Observation Tool dated 09/29/24 revealed, Does the resident have any observed skin issues? Yes- 3.Excoriation to buttocks: old scars to both hands, dry skin to lower extremity, shoulders (rear), thighs, and right calf; Eczema on abdomen, thigh and rear lower legs. Resident may be seen by Wound care Dr. V. Record review of Resident #1's MARs/TARs dated 10/01/24 - 10/31/24 revealed, Hydrocortisone External lotion 2.5% topical apply to skin topically two times a day for itchy areas resident able to state where itch is occurring (start date 03/05/24 and DC [BH7] [S(8] date 12/20/24). Apply zinc oxide to buttock as needed for wound (start date 05/26/24 and DC date 12/20/24). Record review of Resident #1's Weekly Skin Observation Tool dated 10/06/24 revealed, Does the resident have any observed skin issues? Yes- 3.Excoriation to buttocks: old scars to both hands, dry skin to lower extremity, shoulders (rear), thighs, and right calf; Eczema on abdomen, thigh and rear lower legs. Record review of Resident #1's Weekly Skin Observation Tool dated 10/20/24 revealed, Does the resident have any observed skin issues? Yes- 3.Excoriation to buttocks: old scars to both hands, dry skin to lower extremities, shoulders (rear), thighs, and right calf; Eczema on abdomen, chafing rash between thighs. ABD Pad in place. Record review of Resident #1's Weekly Skin Observation Tool dated 10/27/24 revealed, Does the resident have any observed skin issues? Yes- 3.Excoriation to buttocks: old scars to both hands, dry skin to lower extremities, shoulders (rear), thighs, and right calf; Eczema on abdomen. Old blister to right inner thigh. Record review of Resident #1's MARs/TARs dated 11/01/24 - 11/30/24 revealed, Hydrocortisone External lotion 2.5% topical apply to skin topically two times a day for itchy areas resident able to state where itch is occurring (start date 03/05/24 and DC date 12/20/24). Apply zinc oxide to buttock as needed for wound (start date 05/26/24 and DC date 12/20/24). Record review of Resident #1's Nurses Notes dated 11/03/2024 at 1:30 pm by LVN C revealed, Apply zinc oxide to buttock as needed for Wound Full shower provided. Excoriation and peeling skin to buttocks. No bleeding. BP=115/80, P=76, T=97.6, O2SAT=98, ROOM AIR, R=18. Will monitor. Record review of Resident #1's Weekly Skin Observation Tool dated 11/03/24 revealed, Does the resident have any observed skin issues? Yes- 3.Excoriation to buttocks: old scars to both hands, dry skin to lower extremities, shoulders (rear), thighs, and right calf; Eczema on abdomen, Old blister to right inner thigh. Record review of Resident #1's Weekly Skin Observation Tool dated 11/10/24 revealed, Does the resident have any observed skin issues? Yes- 3.Excoriation to buttocks: Flaky dry skin to lower extremities, shoulders (rear), thighs, and right calf, abdomen. Record review of Resident #1's MARs/TARs dated 12/01/24 - 12/19/24 revealed, Ammonium Lactate external cream 12% apply to both lower extremities topically two times a day for dry skin (start date 12/12/24 - DC date 12/20/24). Hydrocortisone External lotion 2.5% topical apply to skin topically two times a day for itchy areas resident able to state where itch is occurring (start date 03/05/24 and DC date 12/20/24). Apply zinc oxide to buttock as needed for wound (start date 05/26/24 and DC date 12/20/24). Mupirocin external ointment 2% apply to affected areas to RLE topically two times a day for skin infection until 12/22/24, apply to RLE x 10 days (start date 12/13/24 - DC date 12/20/24 Record review of Resident #1's Weekly Skin Observation Tool dated 12/03/24 revealed, Does the resident have any observed skin issues? Yes- 3.Excoriation to buttocks: Dry skin to lower extremities, shoulders, thighs, abdomen, shoulders, calves; Eczema on abdomen. Healing blister to right inner thigh. Record review of Resident #1's Weekly Skin Observation Tool dated 12/10/24 revealed, Does the resident have any observed skin issues? Yes- 2. 41) Right lower leg (front). 3. Several dry yellow crusted over areas to BLE. Record review of Resident #1's Change in Condition dated 12/10/24 by ADON G and LVN H revealed, The Change In Condition/s reported on this CIC Evaluation are/were: Other change in condition At the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP 122/75 - 12/10/2024 10:22 Position: Sitting r/arm - Pulse: P 78 - 12/10/2024 10:22 Pulse Type: Regular - RR: R 18 - 12/10/2024 10:22, - Temp: T 97.6 - 12/10/2024 10:22 Route: Forehead (non-contact), - Weight: W 134.2 lb - 12/6/2024 15:03 Scale: Bath - Pulse Oximetry: O2 97 % - 12/10/2024 10:23 Method: Room Air - Blood Glucose: Resident/Patient is in the facility for: Long Term Care Primary Diagnosis is: (blank) Relevant medical history is: (blank) Code Status: **Code Status:***FULL CODE*** Advance directives are: (blank), Resident/Patient had the following medications changes in the past week: Resident/Patient is on Coumadin/warfarin: No, The result of last INR: Date: (blank), Resident/Patient is on anticoagulant other than warfarin: (blank), Resident/Patient is on: (blank) Outcomes of Physical Assessment : Positive findings reported on the resident/patient evaluation for this change in condition were: - Mental Status Evaluation: No changes observed, - Functional Status Evaluation: No changes observed, - Behavioral Status Evaluation: - Respiratory Status Evaluation: (blank), - Cardiovascular Status Evaluation:(blank), - Abdominal/GI Status Evaluation: (blank), - GU/Urine Status Evaluation: (blank), - Skin Status Evaluation: Rash, - Pain Status Evaluation: Does the resident/patient have pain? (blank), - Neurological Status Evaluation: (blank), Nursing observations, evaluation, and recommendations are: (blank), Primary Care Provider Feedback : Primary Care Provider responded with the following feedback: A. Recommendations: no new orders, B. New Testing Orders:(blank), C. New Intervention Orders:(blank). Comments: (blank). Record review of Resident #1's Weekly Skin Observation Tool dated 12/17/24 revealed, Does the resident have any observed skin issues? Yes- 2. 34) Left thigh (front). 3. Multiple scabbed area to BLE; treatment in place. Record review of Resident #1's Weekly Skin Observation Tool dated 12/19/24 revealed, Does the resident have any observed skin issues? Yes- 2. Other (specify) BLE. 3. Multiple scabs on BLE. Interview on 08/14/25 at 1:59 pm, LVN A stated Resident #1 did not have any wounds but he had redness on his buttock and zinc oxide cream was used to treat it last year 2024. Interview on 08/14/25 at 2:21 pm, CNA K stated she could not remember when but while Resident #1 was at the facility, the nurses applied cream on his left buttock because he had a small wound on it last year 2024. Interview on 08/14/25 at 2:38 pm, CNA L stated Resident #1 had scratches on his right buttock, it was a shear that started last year (2024) sometime. Interview on 08/14/25 at 2:55 pm, CNA M stated Resident #1 had a wound on his bottom, he developed a wound after his shower one day she noticed it when he was at the facility. She stated his nurses would put some cream on it and covered it with dressing. She stated Resident #1's wound on his bottom was the size of a quarter last year 2024. Interview on 08/15/25 at 12:32 pm, Former DON F stated she used to be the DON at this facility about a year ago and did not remember anything about the residents including Resident #1. Interview on 08/15/25 at 1:19 pm, LVN N stated Resident #1 had skin breakdown on his butt that was the size of a quarter. She stated the nurses put dressing on it last year 2024. Interview on 08/15/25 at 2:17 pm, RN E stated he worked the overnight shift and yes Resident #1 had a wound on his bottom the nurses did treatment and dressings on last year 2024. Interview on 08/15/25 at 3:20 pm ADON G stated Resident #1 had really dry scaly skin and he had a topical cream that was used. She stated when Resident #1 considered (thought) he had a wound, but he was told he did not have one on his buttock that she could remember. She stated she talked to him all the time through a computer he used because he was not able to verbalize his needs. She stated he had a chronic skin condition and his skin cream was applied after his showers. She stated he had a shearing of his buttocks that healed in two weeks last year 2024. She stated Resident #1 discharged the facility and he did not have any wounds. She stated LVN H was the nurse who discharged him and December 2024 and he had no skin issues. Interview on 08/15/25 at 5:20 pm, DON O stated Resident #1 spoke to him on occasion and said he was going to get those staff but he did not go into any detail. He stated Resident #1 had no skin issues and said he saw his skin 11/24/25 because he worked that day on the floor. He stated Resident #1 had dry skin issues and had no shearing either before he discharged [DATE]. He stated he spoke to Resident #1 weekly to check on him with how things were going and he did not have any complaints about anything. Interview on 08/18/25 at 10:21 am, NP I stated he was the NP for Doctor J and saw Resident #1 before he discharged the facility December 2024. He stated oh yes he remembered Resident #1 very well, he used a tablet to communicate with and had ALS because he could not talk (speak). He stated he discharged to another place. He stated he saw Resident #1 once or twice before he discharged this facility in December 2024. He stated he did a head to toe assessment and his legs were swollen and he ordered a water pill for him to start taking. He stated Resident #1 had a couple of skin issues, a wound on butt and rash on his lower leg. He stated the only issues Resident #1 had was his legs were swollen and he had the wound on his buttock. Interview on 08/19/25 at 9:44 am, NP I stated when he assessed Resident #1 in December 2024, he could not remember the size of his butt wound but there was no odor or draining. He stated Resident #1 had a wound in the crack of his butt area. He stated Resident #1 had wound care orders but said ‘Let's make changes to his orders' and added the mupirocin ointment for his butt crack wound. Interview on 08/19/25 at 10:00 am, LVN H stated honestly she could not remember if Resident #1 had a wound care consult or treatment order because he was here a while ago in 2024. She stated Resident #1 did not have a wound on his bottom or infection on his leg and could not remember if she put any dressings on his lower leg but something was being put on them. She stated she never talked to the Wound care Doctor about Resident #1 and he was not seen by the Wound care Doctor. Interview on 08/19/25 at 10:29 am, LVN A stated Resident #1's buttock was excoriated and his skin peeled off that was treated with zinc oxide cream last year 2024. She stated his skin was peeling when they wiped him off. She stated they also used triamcinolone ointment on his skin. She stated she admitted Resident #1 and took him straight to the shower because of the rash on his legs and all over skin. She stated she could not recall Resident #1 being seen by the Wound Care Doctor. She stated Resident #1 never asked to see the wound care Doctor and he did not have a wound on his leg. She stated he had excoriation which was a whitish in color and no shearing on his butt. Interview on 08/19/25 at 12:17 pm, RN E stated Resident #1 had a butt wound and was not sure when but it was last year 2024. He stated it was always covered up with a dressing the size of 1.5 cm x 1 cm (about 1/2 size of dollar bill ). He stated he applied cream on his arms and could not remember which side the wound dressing was on. He stated he applied cream on both of his legs for dry skin but not his wound on him buttock because they did the treatment and dressing on the dayshift. He stated he could not remember if Resident #1 had a wound care consult. Interview on 08/19/25 at 12:24 pm, the Administrator stated she was not aware Resident #1 had a wound care referral when he was at this facility. She stated her expectation was for the nurses to identify if it appeared to be a wound they would notify the Doctor for a wound care referral. Interview on 08/19/25 at 12:31 pm, DON O stated he did not think Resident #1 had an order for a wound care consult and did not think he needed one because he did not have a wound. He stated ADON G or himself sent the wound care referrals to the wound care Doctor. He stated zinc oxide was not for an open wound and was a barrier cream. He stated he was not sure who called for the zinc oxide order for Resident #1. He stated if a resident had an order for a wound care consult they should follow the order to get the would care Doctor to evaluate the resident. He stated he was not sure why NP I said Resident #1 had a wound on his buttock. He stated why would Resident #1 have a wound care consult if he did not have a wound. He stated after reviewing Resident #1 records, he did not have a wound care order while he (Resident #1) was here. Interview on 08/19/25 at 1:01 pm, ADON G stated the staff needed to ensure the residents orders were followed through on. She stated it was the nurses responsibility to ensure the orders were done. She stated Resident #1 did not have a wound care consult because his wound healed before the Wound care Doctor came back to the facility for rounds. She stated the Wound care Doctor came once per week. She stated Resident #1 had an abrasion on his buttock that had healed because barrier cream was applied to his bottom. She stated they continued to put barrier cream on his bottom for his comfort and said Resident #1 had a skin disorder of dry and scaly skin. She stated she knew about Resident #1's wound care order but he did not have a wound so he did not need to be seen by the wound care doctor, She stated Resident #1 had a rash in December 2024 and could not say where it was. Interview on 08/19/25 at 1:16 pm, Doctor J stated Resident #1 had some skin issues on his legs and a wound on his bottom January 2024 and sometime in May 2024. He stated Resident #1 was diagnosed with a pressure wound of his sacral area and that the Wound Care Doctor had treated it. He stated he did not know that Resident #1 had not been assessed by the Wound Care Doctor. He stated the staff had changed so much at the facility and was not sure who he spoke to about it. He stated he never discontinued Resident #1's wound care order because he needed to see the Wound care Doctor for his skin issues. He stated no one had ever said Resident #1 did not need the Wound consult. He stated he expected the resident's wound care consults to be done in order to keep their skin issues from getting worse. Interview on 08/19/25 at 3:01 pm, ADON G stated Resident #1's Wound care consult order was not discontinued while he was at this facility in case another wound came up. She stated when the Wound care Doctor was at the facility and passing through doing rounds she told him Resident #1 did not have a wound and he said okay and did not see him. She stated she would have to look and see if she had spoken to Doctor J and NP I about Resident #1 having a wound on his buttock. She stated in December 2024, LVN H contacted Resident #1's Doctor about his rash and could not remember the location of it. Interview on 08/19/25 3:47 pm, DON O stated he checked again in the EMR and Resident #1 did not have a wound care consult order. He stated he was not really sure why Resident #1 did not see the Wound care Doctor and if he had a wound care consult, maybe Wound care Dr. V saw him and may not have documented seeing him. He stated he was not sure why his pressure injury was not added to his medical records because he was not working here at the time. He stated he had not spoken to NP I about Resident #1's butt wound yet. He stated the nurses called anything a wound, like skin tears and abrasions and wound was just a term they used. He stated nothing could happen to the resident if they did not get a wound care consult if they already had wound care orders. He stated the Doctors signed off and changed the medications as needed and if a resident had a stage 3 or higher wound they would refer the resident to the wound care doctor. He stated the nurses used the word wound loosely because eschar and skin tears were not the same and a lot of the staff were not able to tell what a real wound was. He stated the last time he saw Resident #1's buttock was right before Thanksgiving November 2024 or before he discharged [DATE] He stated the nursing staff have had wound care trainings earlier this year February 2025 or March 2025. He stated some of the nurses was still classifying everything as a wound and said they were currently educating the nurses on identifying wounds. Interview on 08/19/25 4:15 pm, ADON G stated Resident #1 discharged this facility she believed 12/20/24. She stated sometimes she rounded with the wound care Doctor and other times the DON or charge nurse did. She stated the Charge Nurses did their own skin assessments of their assigned residents. She stated she had not spoken to NP I and Doctor J about them saying Resident #1 had a wound on his buttock. Record review of an email dated 08/19/25 at 3:52 pm by ADON G revealed, Wound Consult is a standing order for possible wounds. If wounds are healed before or if not an actual wound, the wound doctor is contacted verbally, in person, or on the phone. In this case, the wound doctor was Wound care Dr. V, and he was informed verbally while doing rounds at the facility., The wound consult order remains as a standing order. The wound order was discontinued when the resident d/c from the facility on 9/20/204 [sic].The charge nurse communicates between the doctors regarding skin issues. 12/10 & 12/11/25 [sic] show in the nurses' notes that the charge nurse communicated skin issues with the MD. The charge nurses are responsible for communication; they complete skin assessments and notifications. Interview on 08/19/25 at 4:38 pm, MDS P stated she could not recall Resident #1 having a wound care order or pressure ulcer and once Resident #1 asked her to put cream around his face. She stated the expectations for when the residents had wound care referrals was for the nurses to contact the wound care Doctor. She stated not having wound care consults could cause a resident to have an adverse effect depending on the resident's orders. She stated the staff would not know what was going on with the resident and probably could not treat them properly. Interview on 08/19/25 at 4:51 pm, the Administrator stated the nurse management DON O and ADON G were responsible for scheduling wound care consults. Interview on 08/20/25 at 3:21 pm, CNA R stated she remembered Resident #1, he had a sore on his butt more like circular and sometimes would see just a little blood coming from it last year 2024. She stated she told the nurse after they lifted him and transferred him to the bedside commode and saw it initially in 2024. She stated in December 2024 she documented the redness of his wound in the EMR. She stated she never talked to nurse management because she just reported his sore to his nurse for that shift. She stated she told LVN S in 2024 about Resident #1's sore and she said okay and went to look at it. She stated the sore on his butt had its good days and bad days and did not always bleed and said the sore did not have any odor but was about 1/2 inch in size. She stated she saw LVN C, LVN S and LVN N doing treatments on it. She stated she worked nights and thought ADON G and DON O were aware of the sore on his butt because Resident #1 informed everybody about it. She stated she never spoke to ADON G or DON O about his butt sore because she talked the nurses about it. Interview on 08/20/25 at 11:28 am, CNA T stated she started working at this facility the spring of 2024 and saw Resident #1's butt sore but did not talk to anyone about it. She stated she was not sure if ADON G and DON O knew about his butt wound. She stated in October 2024 or November 2024, Resident #1's butt wound stuck to his pants because it bled a lot when they pulled down his pants. She stated she told LVN C and after Resident #1 was showered then LVN C came and cleaned and put cream on his butt wound. She stated he had the butt wound for a while and all the way up to the time he discharged this facility. She stated Resident #1 did not have any pain from the wound. She stated CNA L and herself gave him showers and CNA L also saw the sore bleeding. She stated after she finished Resident #1's shower she would fill out the shower sheet and sign it and then the nurse would put the shower sheet into the drawer at the nursing station. Interview on 08/20/25 at 11:49 am, CNA M stated she first noticed Resident #1 had a butt wound last year, last summer august or September 2024. She stated the nurses knew Resident #1 had a butt wound because after he showered the nurses had to put cream on it. She stated she saw LVN A, LVN C, LVN H put cream on it. She stated she documented his butt wound on the shower sheets and thought the nurses documented in the nurses notes. She stated Resident #1 had dry skin on the bottom of legs and his butt wound bled a little bit at times. She stated the last time Resident #1's butt wound bled was a couple of times before he discharged this facility. She stated the time his butt wound bled, she completed the shower sheet, then the nurse put the cream on it. She stated sometimes Resident #1 did not have a dressing on it and if it drained, a dressing was put on it. She stated she was not sure if the nurse managers were aware of his butt wound but the shower sheets were completed and the nurse put them in the drawer at the nurses station. Interview on 08/20/25 at 12:01 pm, LVN N stated Resident #1 had a sore with a dressing on his coccyx and was kind of not sure of the size. She stated she forgot because it had been so long ago last year 2024. She stated she was not aware he had a wound care consult. Interview on 08/22/25 at 4:16 pm, former CNA U stated Resident #1 had a wound and noticed it when she started working at that facility last September 2024 up until he discharged this facility. She stated when she would give him a shower, she would pat the area of his butt really softly. She stated she did not see Resident #1's butt sore healed. She stated at times his butt wound bled a little bit and was about the size of a quarter. She stated she spoke to the nurses and they put dressing and cream on it and added LVN C was good about putting the dressing on his wound. She stated she did not see other nurses doing the skin treatments after he showered but LVN C. She stated sometimes Resident #1 was in pain because of the butt wound. She stated DON O started working there and he was not too talkative and did not say hello to the CNA's and would just walk by them, so she never talked to him about anything. She stated she did not see ADON G to talk about Resident #1's wound but did talk to the nurses about it. Interviews on 08/21/25 b[TRUNC

Based on interviews and record reviews the facility failed to ensure they provided care included but was not limited to assessing, evaluating, planning and implementing resident care plan and responding to resident's needs for one (Resident #1) of 12 residents reviewed for Nursing services. 1.The facility failed to ensure ADON G referred Resident #1 to the Wound care Doctor after he was diagnosed with an open sacral wound on 09/27[BH1] [BH2] /24 and prior to discharge on [DATE]. 2.The facility failed when ADON G stated she was aware of the Physician's order dated 09/27/24 for a wound care consult for Resident #1 but felt he did not have a wound on his buttock so she did not follow the Doctor's order from 09/27/24 to 12/19/24. These failures could affect all residents by placing them at risk of continued wound issues and infections if Doctor's orders were not followed, which could result in a decrease in health and psycho-social well-being. Findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] by RN W revealed, a [AGE] year-old male who admitted [DATE]. He had a BIMS score 15 (no cognitive impairment) and had upper and lower extremity impairment on both sides and dependent - helper did all effort for all ADL's. He was always incontinent with bladder and frequently incontinent with bowel and he had medically complex conditions. His diagnoses was Malnutrition, depression, Amyotrophic lateral sclerosis, adjustment disorder, GERD, other lack of coordination, chronic pain, dysphagia. Skin Conditions: At risk of developing pressure ulcers/injuries, no skin conditions. Record review of Resident #1's Order Recap Report printed 08/14/25 revealed, Resident may be seen by Wound care Dr. V, for evaluation and treatment. every 7 day(s) for open areas noted on baseline skin assessment Verbal 09/27/2024 start 09/28/2024 and DC 12/20/2024 by Doctor J. Apply zinc oxide to buttock as needed for Wound (started 05/26/24 - 12/20/24) by Doctor J. Ammonium Lactate External Cream 12 % (Lactic Acid (Ammonium Lactate)) Apply to both lower extremities topically two times a day for dry skin (start 12/12/24 - 12/20/24). Hydrocortisone External Lotion 2.5 % (Hydrocortisone (Topical)) Apply to Skin topically two times a day for itchy areas Resident able to state where itch is occurring (started 03/05/24 - 12/20/24). Mupirocin External Ointment 2 % (Mupirocin) Apply to affected areas to RLE topically two times a day for skin infection until 12/22/2024 Apply to RLE x 10 days (start 12/13/24 - 12/20/24). Record review of Resident #1's Care plans printed 08/21/24 and date initiated 03/18/23 revealed, Resident #1 have bowel incontinence related to immobility & Amyotrophic Lateral Sclerosis: Interventions: check resident every two hours and assist with toileting as needed, provide loose fitting, easy to remove clothing, provide pericare after each incontinent episode and see care plans on mobility, ADL's, Cognitive deficit, communication. And date initiated 04/24/23 - Resident #1 have potential impairment to skin integrity related to impaired mobility and incontinence; he prefers to have incontinent pad in recliner chair: Interventions: avoid scratching, and keep hands and body parts from excessive moisture. Educate resident/family/caregivers of causative factor and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Record review of Resident #1's Nurses Note dated 01/31/2024 at 09:41 am by LVN A revealed, Reopened area about resident Left buttock area about 0.2x0.2cm. NP B here notified. New order noted -apply zinc oxide QD until healed. RP notified. Record review of Resident #1's Nurses note dated 05/26/2024 at 10:17 pm by LVN C revealed, Resident said the buttocks wound are healed. MD notified and changed zinc oxide cream qd to PRN. Call light in reach. Record review of Resident #1's Nurses note dated 07/08/2024 at 09:22 am by Nurse D revealed, Nurse asked about buttocks abrasion and resident stated it is healing. Will continue to monitor. Record review of Resident #1's Nurses note dated 07/10/2024 1:17 pm by Nurse D revealed, Nurse asked resident about buttocks wound after his shower and resident verbalized it is healing. Record review of Resident #1's Nurses Notes dated 07/10/2024 at 10:09 pm by RN E revealed, Nurse cont. to monitor wound to buttocks, no s/s of infection noted. Resident stable, alert and oriented x 4 with no s/s of pain or distress noted at this time. Vitals within normal range. Call light within reach. Will continue with care plan. Record review of Resident #1's Nurses Notes dated 07/23/2024 at 2:36 pm by Nurse D revealed, Nurse did wound care treatment per residents request because both residents buttocks cheeks skin was irritating him. Record review of Resident #1's MARs/TARs dated 09/01/24 - 09/30/24 revealed, Hydrocortisone External lotion 2.5% topical apply to skin topically two times a day for itchy areas resident able to state where itch is occurring (start date 03/05/24 and DC date 12/20/24). Apply zinc oxide to buttock as needed for wound (start date 05/26/24 and DC date 12/20/24). Record review of Resident #1's Nurses Notes dated 09/16/2024 at 8:07 pm by LVN E revealed, Resident requested for wound consult for pressure wound to buttock. MD notified, waiting for response. Resident stable, alert and oriented x 4 with no s/s of pain or discomfort noted at this time. Vitals within normal range, call light within reach, will continue with care plan. Record review of Resident #1's Nursing Notes dated 09/26/2024 at 10:47 pm by Former DON F revealed, Baseline skin assessment completed. Noted open areas to sacral area. Refer to wound care doctor to evaluate and treat. Continue to monitor. Record review of Resident #1's Nurses Note dated 09/27/2024 at 2:36 pm by Former DON F revealed, Follow up to baseline skin assessment findings. Resident was referred to [Wound care] Dr. for eval and treatment. Face sheet and medication list faxed, order is in the system. Record review of Resident #1's MARs/TARs dated 10/01/24 - 10/31/24 revealed, Hydrocortisone External lotion 2.5% topical apply to skin topically two times a day for itchy areas resident able to state where itch is occurring (start date 03/05/24 and DC date 12/20/24). Apply zinc oxide to buttock as needed for wound (start date 05/26/24 and DC date 12/20/24). Record review of Resident #1's MARs/TARs dated 11/01/24 - 11/30/24 revealed, Hydrocortisone External lotion 2.5% topical apply to skin topically two times a day for itchy areas resident able to state where itch is occurring (start date 03/05/24 and DC date 12/20/24). Apply zinc oxide to buttock as needed for wound (start date 05/26/24 and DC date 12/20/24). Record review of Resident #1's Nurses Notes dated 11/03/2024 at 1:30 pm by LVN C revealed, Apply zinc oxide to buttock as needed for Wound Full shower provided. Excoriation and peeling skin to buttocks. No bleeding. BP=115/80, P=76, T=97.6, O2SAT=98, ROOM AIR, R=18. Will monitor. Record review of Resident #1's MARs/TARs dated 12/01/24 - 12/19/24 revealed, Ammonium Lactate external cream 12% apply to both lower extremities topically two times a day for dry skin (start date 12/12/24 - DC date 12/20/24). Hydrocortisone External lotion 2.5% topical apply to skin topically two times a day for itchy areas resident able to state where itch is occurring (start date 03/05/24 and DC date 12/20/24). Apply zinc oxide to buttock as needed for wound (start date 05/26/24 and DC date 12/20/24). Mupirocin external ointment 2% apply to affected areas to RLE topically two times a day for skin infection until 12/22/24, apply to RLE x 10 days (start date 12/13/24 - DC date 12/20/24. Interview on 08/14/25 at 1:59 pm, LVN A stated Resident #1 did not have any wounds but he had redness on his buttock and zinc oxide cream was used to treat it last year 2024. Interview on 08/14/25 at 2:21 pm, CNA K stated Resident #1 the nurses applied cream on his left buttock because he had a small wound on it last year 2024. Interview on 08/14/25 at 2:38 pm, CNA L stated Resident #1 had scratches on his right buttock, it was a shear that started last year (2024) sometime. Interview on 08/14/25 at 2:55 pm, CNA M stated Resident #1 had a wound on his bottom, he developed a wound after his shower one day she noticed it. She stated his nurses would put some cream and covered with dressing. She stated Resident #1's wound on his bottom was the size of a quarter last year 2024. Interview on 08/15/25 at 3:20 pm ADON G stated Resident #1 had really dry scaly skin and he had a topical cream that was used. She stated when Resident #1 considered (thought) he had a wound, but he was told he did not have one on his buttock that she could remember. She stated she talked to him all the time through a computer he used because he was not able to verbalize his needs. She stated he had a chronic skin condition and his skin cream was applied after his showers. She stated he had a shearing of his buttocks that healed in two weeks last year 2024. She stated Resident #1 discharged the facility and he did not have any wounds. She stated LVN H was the nurse who discharged him and December 2024 and he had no skin issues. Interview on 08/18/25 at 10:21 am, NP I stated he was the NP for Doctor J and saw Resident #1 before he discharged the facility December 2024. He stated oh yes he remembered Resident #1 very well, he used a tablet to communicate with and had ALS because he could not talk (speak). He stated he discharged to another place. He stated he saw Resident #1 once or twice before he discharged this facility in December 2024. He stated he did a head to toe assessment and his legs were swollen and he ordered a water pill for him to start taking. He stated Resident #1 had a couple of skin issues, a wound on butt and rash on his lower leg. He stated the only issues Resident #1 had was his legs were swollen and he had the wound on his buttock. Interview on 08/19/25 at 9:44 am, NP I stated when he assessed Resident #1 in December 2024, he could not remember the size of his butt wound but there was no odor or draining. He stated Resident #1 had a wound in the crack of his butt area. He stated Resident #1 had wound care orders but said ‘Let's make changes to his orders' and added the mupirocin ointment for his butt crack wound. Interview on 08/19/25 at 1:01 pm, ADON G stated the staff needed to ensure the residents orders were followed through on. She stated it was the nurses responsibility to ensure the orders were done. She stated Resident #1 did not have a wound care consult because his wound healed before the Wound care Doctor came back to the facility for rounds. She stated the Wound care Doctor came once per week. She stated Resident #1 had an abrasion on his buttock that had healed because barrier cream was applied for his bottom. She stated they continued to put barrier cream on his bottom for his comfort and said Resident #1 had a skin disorder of dry and scaly skin. She stated she knew about Resident #1's wound care order but he did not have a wound so he did not need to be seen by the wound care Doctor, She stated Resident #1 had a rash in December 2024 and could not say where it was. Interview on 08/19/25 at 1:16 pm, Doctor J stated Resident #1 had some skin issues on his legs and a wound on his bottom January 2024 and sometime in May 2024. He stated Resident #1 was diagnosed with a pressure wound of his sacral area and that the Wound Care Doctor had treated it. He stated he did not know that Resident #1 had not been assessed by the Wound Care Doctor. He stated the staff had changed so much at the facility and was not sure who he spoke to about it. He stated he never discontinued Resident #1's wound care order because he needed to see the Wound care Doctor for his skin issues. He stated no one had ever said Resident #1 did not need the Wound consult. He stated he expected the resident's wound care consults to be done in order to keep their skin issues from getting worse. Interview on 08/20/25 at 11:28 am, CNA T stated she started working at this facility the spring of 2024 and saw Resident #1's butt sore but did not talk to anyone about it. Interview on 08/20/25 at 11:49 am, CNA M stated she first noticed Resident #1 had a butt wound last year, last summer august or September 2024. Interview on 08/20/25 at 12:01 pm, LVN N stated Resident #1 had a sore with a dressing on his coccyx and was kind of not sure of the size. She stated she forgot because it had been so long ago last year 2024. She stated she was not aware he had a wound care consult. Interview on 08/20/25 at 3:21 pm, CNA R stated she remembered Resident #1, he had a sore on his butt more like circular and sometime would see just a little blood coming from it last year 2024. Interview on 08/22/25 at 4:16 pm, former CNA U stated Resident #1 had a wound and noticed it when she started working at that facility last September 2024. Interview on 08/20/25 at 4:21 pm, DON O stated the physician orders were supposed to be followed and the nursing staff worked under the Doctors. He stated they could not do anything arbitrarily and do something different than what the Doctor ordered. Interview on 08/21/25 at 4:57 pm, the Administrator stated ADON G and DON O could not override what the Doctor's orders were. She stated the Doctors orders superseded what ADON G and DON O thought and they should also follow the Doctor's orders to ensure the residents received proper treatment. Interview on 08/21/25 at 5:42 pm, ADON G stated she had a training about wound care from DON O yesterday (08/19/25) and another wound care training by text from the RN Consultant today (08/20/25). She stated if it is a wound and the resident had a wound care consult order, she was going to make sure the referral was sent to the Wound Care Doctor. She stated she was going to send it to the Wound care Doctor regardless of what she thought because it was a Doctor's order. Record review of the Facility's QAPI policy dated February 2020 revealed, Policy Statement: This facility shall develop, implement, and maintain an ongoing, facility wide, data-driven QAPI Program that is focused on indicator of the outcomes of care and quality of life for our residents. Policy Interpretation and implementation: 1. Provide a means to measure current and potential indicators for outcomes of care and quality of life. 2. Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. Authority 1. The owner and/or governing board (body) of our facility is ultimately responsible for the QAPI program. Implementation:1. The QAPI Committee oversees implementation of our QAPI Plan, which is the written component describing the specifics of the QAPI program, how the facility will conduct its QAPI functions, and the activities of the QAPI Committee.

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 in the facility's only kitchen reviewed for food safety.1. The facility failed to ensure food items in the freezer were labeled with the item description (handwritten or manufacturer's label), had the received by date, the opened date and/or the consume by or expiration by dates.2. The facility failed to ensure food items in the dining room were labeled with the item description (handwritten or manufacturer's label), had the received by date, the opened date and/or the consume by or expiration by dates.3. The facility failed to ensure dietary staff wore proper hairnets while working in the kitchen.These failures could place residents at risk for food-borne illness and cross contamination.Findings Include:Observation of the side-side refrigerator on 08/05/2025 at 9:01 am revealed the following:- 1 large bag of tater tots (shredded potatoes) sealed with no item description label or distinguishing date.- 1 large bag of steak fries sealed with no item description label or distinguishing date.- 2 clear beverage dispensers sitting on counter in dining room which appeared to be iced tea and lemonade with no item description label or distinguishing date.- [NAME] A wearing a hair net on his beard with 3 holes.Interview with the DM on 08/05/2025 at 9:09 am, revealed she is responsible for labeling and staff does it when she's unavailable. She stated she puts red first out stickers on items that need to be used before the other items. The DM is responsible for dietary services at the facility.Observed [NAME] A on 08/05/2025 at 9:20 am washing dishes and wearing a hair net on his beard with 3 holes.Interview with [NAME] A on 08/05/2025 at 9:21 am he stated everyone is responsible for doing the dishes and cooking. [NAME] A was informed he had holes in the hairnet. He stated he did not know and replaced the hairnet.The policy for hairnets was requested but was not provided.Record review of the facility's Food Storage Policy, dated 2018, states, Store frozen foods in moisture-proof wrap or containers that are labeled and dated.Review of the U.S. FDA Food Code 2022 reflected: Definitions 3. Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program for 1 of 1 facility reviewed for pests in that: Gnats were observed in multiple areas of the facility: Hall100, Hall 400, and Hall 500. This failure could affect residents by placing them at an increased risk of exposure to pests and vector-borne diseases and infections. Findings included: Observation on 08/05/2025 at 9:17 a.m. revealed room [ROOM NUMBER] had three gnats crawling in the bathroom sink. Observation on 08/05/2025 at 9:18 a.m. revealed room [ROOM NUMBER] had five gnats crawling in the bathroom sink. Observation on 08/05/2025 at 9:30 a.m. revealed a medication cart on Hall 400 had three gnats crawling on top of the cart. Observation on 08/05/2025 at 9:32 a.m. revealed room [ROOM NUMBER]B had six gnats crawling on the bedside table. Observation on 08/05/2025 at 10:07 a.m. revealed room [ROOM NUMBER] a gnat flew in the room. Observation on 08/05/2025 at 10:23 a.m. revealed a gnat in the hallway flew outside of room [ROOM NUMBER]. Observation on 08/05/2025 at 10:45 a.m. revealed on Hall 500 there was three gnats on the wall near the doorway to room [ROOM NUMBER]. Further observation revealed three gnats crawling it the [NAME] in room [ROOM NUMBER]. Observation on 08/05/2025 at 10:52 a.m. a gnat flew outside of room [ROOM NUMBER]. In a confidential group meeting on 08/06/2025 at 10:00 a.m. with eleven residents revealed eleven residents stated there was a pest control problem concerning gnats. The Gants were in their bathrooms and rooms. The eleven-resident stated they had mentioned this to staff and the pest control man had come to the facility and treated the drains, but the gnat problem had not improved. In an interview on 08/07/2025 at 8:15 a.m. with MA A revealed he had not seen any gnats. MA A stated if he did see pest, he would report to the Maintenance Man. MA A stated there was a book at the nurse's station you can write your sittings in, but I just tell the Maintenance man. In an interview on 08/07/2025 at 8:45 a.m. with LVN C revealed she would tell the Administrator and the Maintenance man, if she saw pest. LVN C stated she would write it the book at the nurse's station, but she had not written anything in the book. In an interview and record review on 08/07/2025 at 10:30 a.m. with the Maintenance Man and a review of the pest control book at the nurse's station revealed the pest control company comes one time a month. The Maintenance Man stated the pest control company had told him that as long as the residents, keep plants and food in their rooms there will gnats. The maintenance man stated there had been no plan put in place to follow-up on the concerns, but he would call the pest control company back out again. Record review of the Pest control logs at the nurse's station with the maintenance man dated 04/2025 through 08/2025 revealed one mention of gnats. There was no further documentation to review. In an interview on 08/07/2025 at 11:10 a.m. with the Administrator revealed she was not aware of a pest problem in the resident's rooms. The Administrator stated the time of the year and the season it was not unusual to have pest. The Administrator stated she would see that the problem was addressed now that she was aware of the pest. Record review of facility provided pest control log revealed, in part, dates and treatments as follows:Treatment dates and services performed: 7-14-2025-Kitchen and Nurse's station had accumulation of food product from damaged goods noted. Instructed staff to remove food product to prevent attraction by pests. evidence of employees eating outside of cafeteria noted and my attract pests. Please instruct the staff do not take food outside of cafeteria area, and no open top drinks. In the dining hall the insect trap lights are not working properly.schedule serve, and the units have been unplugged.6-11-2025-treated hallways, reception, breakroom, conference room, kitchen, and restrooms. There is a small fly issue (gnats coming from the drains in the dish sink. Instructed employees to regularly clean this sink out to help. Also, rooms need to bed cleaned. Floors are sicky and this attracts gnats/small flies. 5-14-2025-treated main public restrooms, front lobby, breakroom, kitchen, dining room, nurse's station, and exterior parameters. Serviced fly light stations in the hallways.Species listed in treatment: Flies, rodents, follow-up on bed bugs, mice. insect lights not working in dining room, repaired and drain in the kitchen has built up grease, told facility to clean out the drain in kitchen sink will attract pest. In an interview 08/07/2025 at 11:00 a.m., the Administrator confirmed prior to exit 08/07/2025 there was no policy or procedure for pest control for the facility.

Based on observations, interviews, and record review the facility failed to ensure that residents had suitable, nourishing meals and snacks outside of scheduled meal service time for 1 of 1 facility reviewed. -The facility failed to ensure snacks were prepared, provided, and offered to residents after breakfast, lunch, and dinner.This failure could affect all residents who received meals served from the facility's only kitchen by placing residents at risk for, unplanned weight loss, and side effects from medication given without food, and diminished quality of life.Findings Included:In a confidential group meeting on 08/06/2025 at 10:05am 6 out of 14 residents stated the facility did not offer or pass out snacks after each mealtime. 6 out of 14 residents stated the facility stopped offering and passing out snacks about three months ago. The residents' stated snacks were not offered or passed this morning after breakfast. The residents stated they wanted snacks to be offered after each meal or always have the snacks visible after each meal. In an interview with LVN F on 08/06/2025 at 10:30am she stated snacks came from the kitchen at 10:00am and the snack tray sat out at the nurse's station. She stated it was the aide's responsibility to offer and pass out snacks to residents. She stated snacks were kept at the nurse's station or in the nourishment room. She stated snacks were passed out this morning at 10:00am to residents by the aides. Observation of the nurse's station on 08/06/2025 at 10:35am revealed no snack tray or snacks present at the nurse's station.Observation of the nourishment room on 08/06/2025 at 10:37am revealed the nourishment room was stocked with only shakes. Observation of the nurse's station on 08/06/2025 at 2:00 pm revealed no snacks or snack tray at the nurse's station.Observation of the nurse's station on 08/06/2025 at 2:10 pm revealed no snacks or snack tray at the nurse's station.Observation of the nurse's station on 08/06/2025 at 2:30 pm revealed no snacks or snack tray at the nurse's station.Observation of the nurse's station on 08/07/2025 at 10:00am revealed no snacks or snack tray at the nurse's station. In an interview with DA G on 08/06/2025 at 10:54am she stated it was the DA's responsibility to prepare snacks for residents. She stated the DA's prepared snacks in the evening so residents could receive their nighttime snacks. She stated the DA's prepared peanut butter and jelly sandwiches and cookies for the residents. She stated once the DAs were done preparing snacks; the snacks were out at the nurse's station. She stated snacks were not provided to residents during the day shifts but if staff or residents requested a snack during the day, the kitchen would prepare a snack. She stated she was unsure what staff was responsible for passing out snacks to residents. In an interview with the DM on 08/06/2025 at 10:55am she stated each shift, the kitchen prepared snacks for the residents. She stated snack times was 10:00am, 2:00pm, and 8:00pm. She stated during the day shifts residents received shakes as their snacks. She stated kitchen staff provided snacks such as peanut butter and jelly sandwiches, cookies, and/or pudding for residents as a nighttime snack. She stated the kitchen closed at 7:30pm and the snacks were prepared and sat out at the nurse's station before the kitchen closed. She stated she was unsure who was responsible for passing out snacks to residents once the tray was brought to the nurse's station. In an interview with Resident #44 on 08/06/2025 at 11:00am she stated snacks were not passed or offered to her this morning. She stated last night and the night before, snacks were not passed out or offered to her. She stated she never received or was offered snacks after any meals. In an interview with CNA H on 08/06/2025 at 11:12am she stated residents were supposed to receive snacks after each meal and it was the aide's responsibility to offer and pass out snacks to residents. She stated she did not offer or pass out snacks this morning. She stated she did not observe snacks at the nurse's station this morning. She stated she could not recall the last time she observed snacks at the nurse's station. She stated if a resident requested a snack, she would let the kitchen staff know and kitchen staff would prepare a snack. She stated when snacks were available, the kitchen prepared peanut butter and jelly sandwiches, cookies, or crackers. She stated snacks not offered or provided to residents could cause the residents to not receive the proper nutrition or hydration. In an interview with Resident #20 on 08/06/2025 at 11:19am she stated snacks were not offered or passed out this morning. She stated snacks were never offered or passed out during the day shifts. She stated snacks were provide consistently at night but the snack that was provided at night were peanut butter and jelly sandwiches. She stated she did not like peanut butter jelly sandwiches and there were no other snacks available, and staff did not offer anything else. She stated the sandwiches were kept at the nurse's station at night and staff did not pass out sandwiches unless residents asked. She stated last night and the night before the peanut butter and jelly sandwiches were on a tray at the nurse's station.In an interview with Resident #40 on 08/06/2025 at 1:04pm he stated he did not receive a snack after breakfast this morning and he never does. He stated he did not receive or was offered a snack last night or the night before. He stated about 3 months ago, was the last time he was offered or received a snack at night. In an interview with Resident #32 on 08/06/2025 at 1:15pm she stated snacks were not offered or passed out. She stated she did not receive a snack this morning or last night. She stated sometimes at night peanut butter and jelly sandwiches were left at the nurse's station but not passed out or offered to residents. She stated she only observed peanut butter and jelly sandwiches at the nurse's station.In an interview with Resident #18 on 08/06/2025 at 3:10pm he stated the facility only offered snacks at night. He stated the only snack offered at night were peanut butter and jelly sandwiches. He stated he did not eat peanut butter and jelly sandwiches and was never offered other snack options. He stated peanut butter and jelly sandwiches were offered last night and the night before. He stated snacks were never offered during the day. In an interview with the ADM on 08/07/2025 at 11:42am she stated snacks were provided to residents frequently. She stated snacks were provided mid-morning and evenings. She stated it was dietary's responsibility to prepare and distribute snacks to residents. She stated dietary prepared peanut butter and jelly sandwiches, and it was the nursing staff responsibility to pass out and offer snacks to residents. She stated she did not receive complaints or grievances about residents not receiving or being offered snacks. She stated residents were offered three meals daily to ensure the residents are receiving the plenty nutrients. She stated she was unsure how residents would be affected if snacks were not provided or offered. In an interview with the AD on 08/07/2025 at 11:55am she stated snacks were provided and kept at the nurse's station at 10:00am and 2:00pm. She stated the snack trays was stocked with a variety of snacks such as peanut butter and jelly sandwiches and bananas. She stated dietary prepared the snacks and it was the aide's responsibility to pass out snacks. She stated during monthly resident council meetings; residents never expressed a concern about not receiving or being offered snacks. She stated she gave out snacks to residents from activities or from donations. Record review of grievance logs from May 2025-August 2025 revealed no complaints regarding snacks not being provided or offered. Record review of resident council meeting minutes from January 2025- August 2025 revealed no complaints regarding snacks not being provide or offered. Record review of the facility's Texture Modified Snacks dated 2018 Policy Statement: The facility will ensure that texture appropriate snacks are available and provided to all residents. 1. Nutrition and Foodservice will provide snacks each night for all residents including residents with orders for a puree diet. 5. All snacks ordered at 10:00am and 2:00 pm will be dated and labeled with the resident's name and will be the appropriate texture for their current diet order.

Based on observation, interview and record review, the facility failed to ensure residents' right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 3 (Residents #10, #12, and #36) of 4 residents reviewed for call lights.1. The facility failed to ensure Resident #10 had their call light within reach while resident was in their wheelchair.2. The facility failed to ensure Resident #12 had their call light within reach while in their bed.3. The facility failed to ensure Resident #36 had their call light within reach while in their bed.This failure had the potential to affect residents who were unable to call staff for assistance, placing them at risk for falls, incontinence episodes, unmanaged pain, delayed treatment during a potential medical emergency, and emotional distress due to feelings of helplessness or fear.Findings Included:Record review of Resident #10's face sheet dated August 7, 2025, revealed a [AGE] year-old female who admitted to the facility on [DATE], with diagnoses of type 2 diabetes mellitus without complications (means a person has been diagnosed with type 2 diabetes, but the condition has not yet resulted in any additional health problems like nerve damage or stroke), other asthma (general term for asthma), acute kidney failure, dysphagia, oropharyngeal phase (a swallowing disorder characterized by difficulty moving chewed food from the mouth through the pharynx and into the esophagus.) and hemiplegia and hemiparesis following cerebral infarction (hemiplegia is characterized by paralysis on one side, while hemiparesis involves weakness on one side. Both conditions result from impaired communication between the brain and muscles.)Record review of Resident #10's annual MDS assessment, dated June 26, 2025, section C revealed a BIMS score was 12 out of 15 which indicated moderate cognitive impairment. The initial MDS assessment section GG further revealed Resident #10 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for upper body dressing, and sit to lying (the ability to move from sitting on side of bed to lying flat on the bed), partial/moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for toileting hygiene shower/bathe self, lower body dressing, putting on/taking off footwear, chair/bed-to-chair transfer, and toilet transfer. Review of section H revealed Resident #10 is frequently urinary incontinent. Record review of Resident #10's care plan initiated on June 18, 2025, states Resident #10 was at risk for falls and an intervention for this focus area was to ensure the resident's call light was within reach.Observation on 08/05/2025 at 9:58 AM Resident #10 was sitting in their wheelchair, legs elevated on bed, call light was on floor next to their bed. The resident was not asked about the call light.Observation on 08/06/2025 at 9:23 AM Resident #10 was sitting in their room in their wheelchair, away from the bed. Call light was attached to their bed. The resident was not asked about the call light.Record review of Resident #12's face sheet dated August 5, 2025, revealed an [AGE] year-old male who originally admitted on [DATE], with diagnoses of Type 2 diabetes mellitus with other circulatory complications (refers to the development of cardiovascular issues, like heart disease or stroke, as a consequence of type 2 diabetes), muscle weakness, lack of coordination (voluntary movements are not smooth or well-coordinated), acquired absence of eye (he loss of an eye due to injury, disease, or surgical removal), unspecified abnormalities of gait and mobility (various walking difficulties), unspecified dementia, major depression disorder, major anxiety disorder, and Alzheimer's disease.Record review of Resident #12's quarterly MDS assessment, dated June 10, 2025, section C revealed a BIMS score of 3 out of 15 which indicates severe cognitive impairment. The quarterly MDS assessment section GG further revealed Resident #12 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement), and upper and lower body dressing (the ability to dress and undress above and below the waist; including fasteners, if applicable). Review of section H revealed Resident #12 is always urinary incontinent (no episodes of continent voiding) and bowel incontinent (no episodes of continent bowel movements).Record review of Resident #12's care plan, initiated November 14, 2024, revised on June 17, 2025, states Resident #12 was at risk for falls and an intervention for this focus area was to ensure the resident's call light was within reach and Resident #12 needs prompt response to all requests for assistance.Observation on 08/06/2025 at 1:40 PM Resident #12 was lying in bed with their covers on. He stated he was okay and didn't need anything, but they had to repeat the answer 2 times due to speaking in a whisper. Call light was same position as it was on 08/05/2025 at 10:25 AM. The resident was not asked about the call light.Record review of Resident #36's face sheet dated August 7, 2025 revealed a [AGE] year-old male who admitted on [DATE], with diagnoses of hemiplegia, unspecified, affecting the right dominant side (a medical condition where the right side of the body experiences paralysis or weakness due to unspecified brain or spinal cord damage, and the affected individual is right-handed), muscle weakness (generalized) (a condition where muscle weakness is not localized to a specific area of the body but affects multiple muscle groups or the entire body), chronic obstructive pulmonary disease, vascular dementia, unspecified combined systolic (congestive) and diastolic (congestive) heart failure (a condition where the heart struggles to pump blood effectively due to issues with both the contraction (systolic) and relaxation (diastolic) phases of the heart muscle), muscle wasting and atrophy, not elsewhere classified, affecting multiple sites (muscle wasting is not specifically localized to one area, but rather affects multiple parts of the body), unspecified convulsions (specific type of convulsion is unknown), and age-related physical debility (a decline in physical function and reserve as people age, leading to increased vulnerability and difficulty coping with stressors).Record review of Resident #36's quarterly MDS assessment dated [DATE], section C revealed a BIMS score of 14 out of a 15 indicates intact cognitive function. The quarterly MDS section GG further revealed Resident #36 showed an impairment on their upper extremity (shoulder, elbow, wrist, hand). Resident #36 required substantial/maximal assistance (helper does more than half the effort) for toileting hygiene, lower body dressing, sit to lying (the ability to move from sitting on side of bed to lying flat on the bed), lying to sitting on side of bed (the ability to move from lying on the back to sitting on the side of the bed), and chair/bed-to-chair transfer (the ability to transfer to and from a bed to a chair or wheelchair). Resident #36 required partial/moderate assistance (helper does less than half the effort) for upper body dressing and personal and oral hygiene. Review of section H revealed Resident #36 is always urinary incontinent (no episodes of continent voiding) and bowel incontinent (no episodes of continent bowel movements).Record review of Resident #36's care plan date initiated on November 3, 2021, and revised August 9, 2023, target date October 14, 2025, states Resident #36 is at risk for falls and an intervention for this focus area was to ensure the resident's call light was within reach and Resident #36 needs prompt response to all requests for assistance.Observation on 08/05/2025 at 10:55 AM CNA D opened the door to Resident #36 room, closed the door behind him and less than a minute later CNA D left Resident #36's room and closed the door behind him. Resident #36 was observed lying in bed with blanket on. He was able to answer close ended questions, when he spoke, it was in a soft whisper. The call light was on the floor under the bed. (The resident was not asked about the call light.)Observation on 08/06/2025 at 9:45 AM Resident #36 was lying in bed. The call light was in same position as it was on 08/05/2025 at 10:55 AM.Interview on August 7, 2025, at 11:01 AM CNA I said the call light policy says all call lights should be answered quickly and kept within residents' reach at all times. If a call light was found on the floor or out of reach, she would pick it up and put it next to the resident. She added, residents who were unable to reach their call light would not be affected in any way because room rounds were done every two hours, and all call lights were always within reach of the resident.Interview on August 7, 2025, at 11:07 AM CNA J said the call light policy says all call lights were supposed to be within reach of residents She has never seen a call light on the floor or in an improper location, but if she did, she would immediately place it within the resident's reach. If a resident was not in their room, the call light should be attached to their bed. She stated she does room rounds every two hours or as needed. She noted that if a resident cannot access their call light, it could negatively impact their emotional well-being.Interview on August 7, 2025, at 11:12 AM CNA K stated that call lights should always be within arm's reach of residents. If a call light was not in the proper location, she moves it next to the resident. She reported conducting room rounds every two hours or as needed and noted that if a resident cannot reach their call light, it could impact them both emotionally and physically.Interview on August 7, 2025, at 11:15 AM CNA D said the call light policy says the call light should be by the resident for them to reach it. He said he's never observed a call light out of reach of a resident and if he did, he would move it within reach of the resident. He said if a resident was unable to reach their call light, they could become scared and worried.Interview on August 7, 2025, at 11:22 AM the DON said the facility did not have a call light policy. He said he hasn't observed call lights on the floor. He said call lights were supposed to be positioned within reach of the resident and when residents were put to bed the staff was to make sure the call light was within reach of the resident. When the resident was not in their bed or bedroom the call light was supposed to be attached to their bed.Interview on August 7, 2025, at 11:33 AM the Administrator said the facility doesn't have a call light policy. She said she's never observed a call light on the floor or out of reach of a resident. She said staff does room rounds every two hours or as needed. When residents were put to bed it's staff's job to make sure the call light was within reach.

Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (Resident #20, #31 and #35) of five residents observed for infection control in that: MA B failed to disinfect the blood pressure cuff (to measure the blood pressure) in between vital sign checks for Resident #20, and Resident #31. CNA D failed to change their soiled gloves and wash hands during incontinent care to Resident #35. This failure could place residents at risk for spread of infection through cross-contamination. Findings included: Review of Resident #20's quarterly MDS[VT1] assessment, dated 07/22/2025, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with the following diagnoses: hypertension (high blood pressure), diabetes (high sugar), and heart failure (weak heart). Resident #20 BIMs[VT2] score of 11 indicated the resident had moderate cognitive impairment and required assistance from one staff for activities of daily living. Review of Resident #20's the consolidated physician orders dated August 2025 reflected: order dated 05/08/2025, metoprolol Succinate ER (extended release) (high blood pressure) tablet 50mg one tab by mouth one time a day. Further review revealed physician orders to check blood pressure every shift. Review of Resident #31's quarterly MDS assessment, dated 06/06/2025, reflected she was a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: hypertension (high blood pressure) and Cerebral accident (stroke). Resident BIMs score of 9 indicated the resident had moderate cognitive impairment and required assistance from one staff for activities of daily living. Review of Resident #31's consolidated physician orders dated July 2025 reflected: order dated 12/07/2022, amlodipine (blood pressure) 10mg give one tab by mouth one time a day, hydrochlorothiazide tab (for high blood pressure) 12.5mg give one tab by mouth daily, and lisinopril tablet (high blood pressure) 20mg give one tab by mouth daily. Further review revealed physician orders to check blood pressure every shift, prior to giving blood pressure medications. Review of Resident #35's quarterly MDS assessment, dated 05/25/2025, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with the following diagnoses: Hypertension (high blood pressure), and heart failure (heart is weak). Resident BIMs score of 11 indicated the resident had moderate cognitive impairment and required assistance from one staff for activities of daily living. Observation on 08/05/2025 at 8:58 a.m. revealed MA A during medication pass went to the medication cart and started preparing to perform medication administration for Resident #20. MA A took the blood pressure cuff (machine to check blood pressure) to check her blood pressure. MA B did not clean the machine prior to or after using on Resident #20, with Sani Wipes. MA B did use hand gel on his hands prior to collecting supplies. MA B left the room went back to the cart, used hand sanitizer documented on the resident's clinical record and began to prepare for the next medication pass. Observation on 08/05/2025 at 9:07 a.m. revealed MA B during medication pass went to the medication cart and started preparing to perform medication administration for Resident #31. MA B took the blood pressure cuff to check her blood pressure. MA B did not clean the machines prior to or after using on Resident #31. MA B did use hand gel on his hands prior to collecting supplies. MA B left the room, went back to the cart removed, used hand sanitizer documented on the resident's clinical record and began to prepare for the medication pass. Observation of incontinence care on 08/05/2025 at 1:44 p.m. with Resident #35 revealed CNA D did not use hand gel in the hallway and entered the room. CNA D did not wash his hands placing on gloves, CNA D took the clothing protector that Resident #35 was holding and wiped the resident's mouth. CNA D unfastened the resident's brief tabs and wiped the pubic area with a disposable wipe, discarding the wipe in the trash bag. CNA D wiped the genitals, discarding the wipe in the trash bag. CNA D wiped the shaft of the penis and discarding the wipe in the trash bag, and then cleaned the head of the penis and discarding the wipe in the trash bag. CNA D positioned Resident #35 on his right side with the help of another staff member. CNA D wiped the rectal area that was soiled with bowel movement and discarded the wipe, using another wipe CNA D completed cleaning the rectal area of bowel movement, discarding the wipe. CNA D wiped the right buttocks, which was soiled with urine, discarding the wipe. Repositioning Resident #35 with his soiled gloves to his left side, CNA D cleaned the left buttocks, which was soiled with urine, discarding the wipe. CNA D assisted, with his soiled gloves, the other staff member to reposition Resident #35 on his back. CNA D with his soiled gloves took the clothing protector and wiped Resident #35's mouth, then placed the dirty clothing protector in the linen barrel. CNA D disposed of the dirty brief, the other staff member gave CNA D directions to take off his soiled gloves and wash his hands, as she pulled the clean brief up underneath the resident with clean hands and gloves and fastened the brief. CNA D then assisted the other staff member, pulled the clean sheet up on the resident and continued to assist the other staff member to straighten Resident #35's clothing and his linens and blanket on the bed. CNA D removed his gloves in the room and did not wash his hands. In an interview on 08/05/2025 at 2:00 p.m. with CNA D revealed he normally takes care of Resident #35 on his own, but the other staff member wanted to help (ADON). The CNA stated this confused him and made him nervous because she kept giving him instructions, so I forgot to sanitize and wash my hands and change my gloves when they were dirty. CNA D stated he had in-service concerning infection control and hand washing. The CNA stated if you do not change your gloves and wash your hands you can spread infections. In an interview on 08/06/2025 at 9:02 a.m. with DON revealed all direct care staff must clean equipment, including blood pressure cuffs, after having contact with each resident. The DON stated they have Sani wipes available on all medication and treatment carts. The DON stated if the staff was not cleaning the equipment appropriately this could spread germs to themselves and the residents. Further interview with the DON revealed that the staff should always wash hands before placing on gloves and then change the gloves after washing hands between clean and dirty process when performing incontinent care. If they do not do this it can spread infection to themselves and others. In an interview on 08/06/2025 at 9:30 a.m., MA A stated he was to clean all equipment that was used before and after use on each resident, to prevent the spread of infection. MA A stated the blood pressure cuff must be cleaned after each usage. I guess I did not clean it in front of you, I got to talking and forgot. MA A did state that he had used hand sanitizer before and after using the blood pressure cuff. Review of the in-services given in the past three months reflected an in-service dated June10th, 2025, for infection control and cleaning of equipment. MA A and CNA D had attended the meeting. Review of the facility's policy Infection Control Plan dated revised October 2018, reflected, The facility has established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection . b. maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors , and the general public. f. provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment.

Based on observation, interview and record review, the facility failed to ensure the Nutrional supplements were given as the physician had ordered to meet the Nutrional needs of two residents (Resident #21 and #26) of five residents observed. 1. MA B administered Resident #21's Med pass 2.0 (nutritional supplement) without measuring the correct amount. The physician order read to administer 60 ml (2 ounces); the MA administered 4 ounces. 2. MA B administered Resident #26's Med Pass 2.0 (nutritional supplement) without measuring the correct amount. The physician order read to administer 90 ml 93 ounces); the MA administered 4 ounces. These failures could affect the residents, by placing them at risk for not receiving their therapeutic dosage medications as ordered by the physician and decreased healthFindings included: Observation on 08/05/2025 at 3:27 p.m. during a medication pass revealed MA B administered Resident #21's Med Pass 2.0 (nutritional supplement) without measuring the correct amount of supplement to be given. MA B took the Med pass carton and poured the entire, unmarked glass full and gave to the resident to drink. Further observation reflected 4 ounces on the bottom of the plastic cup. MA B did not measure the correct amount of the oral supplement and gave 2 ounces over the ordered amount. Review of Resident #21's current physician orders, dated 08/05/2025, revealed house supplement (Med pass 2.0) three times a day 60 ml (equals 2 ounces). Review of Resident #21's MAR dated 08/01/2025 revealed the House Supplement (Med pass 2.0) 60ml was given at 3:00 p.m. Observation on 08/05/2025 at 3:33 p.m. during a medication pass revealed MA B administered Resident #26's Med Pass (nutritional supplement) without measuring the correct amount to be given. MA B took the Med pass carton and poured the entire, unmarked glass full and gave to the resident to drink. Further observation reflected 4 ounces on the bottom of the plastic cup. MA B did not measure the appropriate amount that was ordered by the physician. MA B should have been given 3 ounces but instead gave 1 ounces over the ordered amount. Review of Resident #26's current physician orders, dated 08/05/2025, revealed house supplement (Med pass 2.0) three times a day 90 ml (equals 3 ounces). Review of Resident #26's MAR dated 08/01/2025 revealed the House Supplement (Med pass 2.0) 90ml was given at 3:00 p.m. Interview with MA B on 08/05/2025 at 3:40 p.m. revealed she did not realize that the supplement needed to be measured, she just fills the cup and gives it to them. It was nutritional so the more they take the better for them. MA B stated she thought there was some marked cups (graduated cups) on another cart, but she just used the cups on the cart. She did not realize that this could create a problem for the resident, she would have to start measuring the amount or find those cups. Interview with the DON on 08/07/2025 at 11:30 a.m. revealed that the staff were supposed to administer all medications that were ordered, including supplements as the physician has ordered. The staff has graduated cups available to measure supplement or water. If more than or less than was given to the resident, it could cause problems with the nutritional base. The DON stated that the staff had annual competency testing with himself or the pharmacy, when it becomes there annual time it is tracked through the Inservice system. The DON stated he was the one who did the follow-up on who is due. Review of the facility policy and procedure titled Documentation of Medication Administration: dated November 2022 reflected, 3. Medication administration incudes, as a minimum: b.strength of drug; c. dosage; d. route of administration; .

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 including both the comprehensive assessment and quarterly review assessments for one (Resident #1) of four residents were reviewed for comprehensive care plans. The facility failed to review and revise Resident #1's care plan quarterly and after each assessment. This failure could affect residents by placing them at risk for not having their individual needs met. Findings included: Record review of Resident #1's Face Sheet printed 01/07/2025, reflected a [AGE] year-old male who was admitted to the facility initially 09/29/2017 and readmitted on [DATE] with diagnoses to include but not limited to end stage renal disease (gradual loss of kidney function), history of open wound left foot, type 2 diabetes with mellitus with foot ulcer (is a chronic condition that happens when you have persistently high blood sugar levels), peripheral vascular disease (slow and progressive disorder of the blood vessels). Record review of Resident #1's annual MDS, dated [DATE], reflected a BIMS score of 11 which indicated moderate impairment. Review of section GG indicated Resident #1 was dependent on staff for ADL's. Review of section M0150 indicated Resident #1 was at risk for pressure ulcers. Record review of Resident #1s care plan revised 01/9/2024 reflected, Resident #1 resisted care, taking medications, eating food from facility kitchen at times, showers/ADL care and attending dialysis. Resident #1 refused therapy on several occasions. Interventions included encourage as much participation/interaction by the resident as possible during care activities and give clear explanation of all care activities prior to and as they occur. Review of Resident #1's care plan conference revealed the last care plan was held 06/13/2024. Interview on 01/07/2024 at 2:17 PM with the Social Worker revealed care plan conferences were conducted every 3 months. The Social Worker stated the last care plan meeting should have been in September however was not completed due to an oversight. The Social Worker stated he was not working at the facility in September however would review resident files to ensure care plan meetings were being held quarterly. The Social Worker stated care plan meetings needed to be completed so that residents or responsible party would be updated on resident care. The Social Workers stated he was working on ensuring care plan conferences were done at the same time as the MDS. Interview on 01/08/2024 at 2:30 PM with the Administrator revealed the Social Worker was responsible for ensuring the care plan meetings were held quarterly. The Administrator stated the care plan meeting was likely missed due to the facility being in transition between Social Workers. The Administrator stated she was not sure if other care plan meetings were missed during that time. The Administrator stated she did not think there was a risk to residents due to care plan meetings not being completed due to any changes of condition being discussed in morning and evening meetings. Review of the policy Care Plans, Comprehensive person- Centered revised December 2016 The Interdisciplinary Team must review and update the care plan. At least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents for 1 (Resident #1) of 3 residents reviewed for elopement risk. On 05/08/24 around 2:00 PM, Resident #1 was found 1/4 of a mile from the facility walking on the sidewalk of a two-lane road going into a residential area, after he had eloped from the facility while wearing a wander guard and at the facility for respite care. The non-compliance was identified as PNC. The IJ began on 05/08/24 and ended on 05/10/24. The facility had corrected the non-compliance before the survey began. This failure could place residents who used wander guard at risk for serious injuries. The findings were: Record review of Resident #1's face sheet, dated 05/07/24, revealed that Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), Dementia (a general term for impaired ability to remember, think, or make decisions), Glaucoma bilateral (A group of eye conditions that can cause blindness, both eyes), and Conductive-hearing Loss, bilateral (soundwaves are disrupted anywhere along the pathway to the tympanic membrane). Record review of Resident #1's MDS assessment, dated 05/08/24 revealed a BIMS score of 99 which denoted a staff assessment of mental status, Resident #1 was indicated to have a memory problem, and was found to be severely impaired for daily decision making and disorganized thinking. Record review of Resident #1's May 2024 Physician orders revealed an order dated 05/07/24 that stated Monitor wander guard to left ankle every shift for placement. Elopement risk. Record review of Resident #1's Care Plan dated 05/07/24 revealed The resident is an elopement risk/wanderer related to Alzheimer's diagnosis. The Care Plan Goal stated, The resident's safety will be maintained through the review date. The Care Plan Interventions stated, Distract resident from wandering by offering diversions, structured activities, food, conversation, television, book. Record review of Resident #1's progress notes dated 05/07/24 at 1:53 PM Orders-Administrative stated, Monitor wander guard to-left ankle-every shift for placement. Elopement risk .every shift related to Alzheimer's disease. Record Review of Resident #1's progress notes. 05/07/24 at 3:53 PM written by ADON stated, Resident [#1] admit from home hospice care Diagnosis, Alzheimer's, respite care x 5 days, alert and oriented x2, confused and wanders asking where is his car. Verbal consent given to place wander guard to left ankle by a resident representative. Record review of Resident #1's progress notes dated 05/08/24 at 5:38 PM written by LVN J stated that At approximately 1:00 PM DON was notified by staff that they were unable to locate resident [#1] during last round on first shift. DON in facility and assisted with search. Elopement plan of action initiated. Facility and premises search initiated, resident headcount performed, and multiple parties notified including MD, Family, hospice, and Administrator. Resident has a wander guard in place to left ankle and is high risk for wandering. Resident found safe wandering in neighborhood behind nursing facility and EMT/911 on the scene. No injuries noted, no emotional distress noted, no treatments, medications, or meals missed. Resident [#1] checked out by EMT/911 on the scene and escorted back to facility by 911 on stretcher. Head to toe assessment performed and no new skin issues noted. All vitals WNL and Resident [#1] denies pain. Record review of the weather archive website (timeanddate.com) for the weather at the location of the facioity on 05/08/24 reflected that the temperature on 05/08/24 was documented to be 88 degrees Fahrenheit at 1:50 PM and 90 degrees Fahrenheit at 2:53 PM. Record review of an in-service, dated 05/08/24, facilitated by ADON and entitled Staff Education on Door Entry with objectives identified as; All staff enter and exit out/in of front entrance door, Do not enter/exit out of any other exit doors on any of the halls, Ensure doors are closed behind you, Response to door alarms (staff). The in-service was signed by 55 employee including ADON. Record review of an in-service, dated 05/08/24, facilitated by ADON and entitled Wandering/Elopement Emergency Procedure with objectives identified as; Wandering/Elopements, Emergency Procedure, Elopement Binder location on/at Nurses station. The in-service was signed by 55 employees including ADON. Record review of an in-service, dated 05/08/24, facilitated by ADON and entitled Missing Resident Drill, with objectives listed as; Actual Missing Resident Drill. The in-service was signed by 55 employees including ADON. Record review of the facilities PIR, dated 05/14/24, revealed on 05/08/24 at 2:15 PM that .while nursing staff were completing final round prior to the end of their shift, they noted Resident [#1] was not in his room nor in center . Assessment was completed on 05/08/24 at approximately 2:15 Pm by ADON and a head-to-toe assessment was completed. No injuries noted. Provider response was emergency procedure of missing person initiated. All available staff searched inside and the immediate vicinity of the center. Resident located in neighborhood near center. Once resident located and brought back to center, resident placed on one-to-one observation. Family members notified. Medical Doctor notified. Hospice notified. Head-to-toe assessment completed. Door alarm provider notified to complete visit to ensure door alarms functioning properly. Resident headcount performed throughout center to ensure no other residents were missing, no other residents noted missing. In-services related to: Missing Resident, Entry and Exit of staff, Emergency Procedures related to missing residents, and elopement binder location. Additional exit door alarms purchased for hallway exit doors. Based on staff interviews it could not be determined how resident was able to elope from center. Ad-Hoc QAPI meeting completed. Wander risk assessments updated on all residents at risk for elopement. Record review of Exit Door Safety Monitoring Logs dated from 05/09/24 to 05/30/24 revealed that all exits were monitored by staff every 2 hours for alarm function and that each door were secure. Record review of a document identifies as an invoice for a door alarm company dated, 05/10/24 revealed that a new wander guard system and bracelets were purchased, installed, and tested at the facility. Record review of a document entitled AD-Hoc QAPI Meeting, dated 05/08/24 at 3:00 PM revealed that the QAPI committee met with all attendants required participating. During an interview with ADON on 06/25/24 at 11:07 AM, ADON revealed that Resident #1 had been at the facility for respite, and that Resident #1 had somehow gotten out of the facility at shift change. Resident #1 did not have his wander guard on him when he was located outside of the facility. That Resident #1 must have somehow got his wander guard off and was possible let out by a family member. She stated that the doors all alarm if the bar was pressed too long or if the door was opened without the keypad code. In an observation and interview on 06/25/24 at 12:21 PM with the Maintenance Manager it was observed that all entry/exit points in the facility had doors that were secure, had functioning alarms and were posted with notices that that alarms will sound if door was opened. Wander guard monitors were noted to be mounted at each exit. The Maintenance Manager stated that all the wander guard monitors had been replaced with new ones on 05/10/24. During an interview on 06/26/24 at 9:13 AM CNA B stated that she had attended all of the in-services related to Resident #1's elopement. She stated that she pays a lot more attention to doors. She identified where the elopement binder was and what it was used for. She stated that the staff did two-hour checks on all of the doors. She stated 5 different ways to redirect residents that wandered and to report such behavior to a nurse. During an interview on 06/26/24 at 9:21 AM CNA C stated that that she had attended all of the in-services that were related to Resident #1elopement. She identified five different ways to redirect residents that wander. She stated that the elopement binder was marked Elopement and was located at the nurse's station and it contained all of the procedures to follow if a resident elopes. She stated that the staff had to do 2-hour checks on all of the exits for a while. During an interview on 6/26/24 at 9:29 AM CNA D stated that he had attended all of the in-services related to Resident #1's elopement. He stated that he had learned some new ways to redirect residents that wander, and he named five different ways to redirect residents that wander. He stated that the Elopement binder with all of the instructions about elopements was located behind the nurse's station. During an interview on 06/26/24 at 2:36 PM LVN B stated that the staff all had to conducted 2 hour checks on all exits, that she had attended all of the in-services related to Resident #1's elopement. She stated that all residents identified as wander/elopement risk had been reassessed and all wander guards are checked every shift, sometimes more. She stated that the CNA's have all been very good at telling the nursing staff if there are any exit seeking behaviors. During an interview on 06/26/24 at 2:44 PM MA E revealed that he had attended all of the in-services related to Resident #1's elopement. He stated that he had worked with Resident #1 for the day that Resident #1 was at the facility, and that he had seen the nurses and CNA's redirect Resident #1 several times and that he had redirected Resident #1 also. He stated that the Elopement binder had all of the elopement protocols in it and that the binder was located behind the nurse's station. He was able to identify 5 ways to redirect wandering residents. During an interview on 6/26/24 at 3:45 PM CNA F she had been working the day that Resident #1 had eloped, she stated that it had been scary and that they all had gone looking for him. She stated that they found him about 10 minutes after they started looking for him and that he had been found just around the corner from the facility. She stated that she had attended all of the in-services related to Resident#1's elopement, she was able to name 5 different ways to redirect wandering residents. She was able to name what was in the Elopement binder and where it was located . A record review of the facility's policy titled Wanderer Management, Monitoring System & Resident Elopement Protocol, last reviewed date 01/2023 , reflected Purpose: To provide a system to alert staff that a resident may be attempting leave the facility. Policy: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible . Procedures: 4. Residents identified as risk for elopement shall be provided one of the following: a. Door alarms on exit doors. b. A personal safety device that alerts staff of resident effort to leave the facility. c. Signaling device to the arm or angle or as permitted by the manufacturer . The noncompliance was identified as past noncompliance IJ. The noncompliance began on 05/08/2024 and ended on 05/10/2024 when wander risk assessments for all residents identified as wander risk and wander guard bracelets were checked for placement on 05/08/24. In-services regarding Elopement Risk with all staff were initiated on 05/09/24 and completed on 05/10/24. Exit Door alarms were checked every two hours 05/08/24 to 05/30/24. Wander guard bracelet system replaced, and new bracelets distributed to at risk residents completed on 05/10/24.

Based on interviews, and record reviews, the facility failed to obtain from hospice the most recent hospice plan of care specific to each patient needs for 1 of 3 residents (Resident #59) reviewed for hospice services. The facility failed to ensure Resident #1' s hospice care was care planned. This failure could place residents at risk of needs not being met. Findings include : Record review of Resident #1's electronic face Sheet, dated 02/29/24, revealed she was a 73 -year-old female admitted on [DATE] with diagnosis that included malignant neoplasm of corpus uteri (endometrial cancer), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs. Review of Resident #1's Comprehensive Care Plan dated on 11/21/23 reflected no care plan for hospice care. Record review of Resident #1's doctor order dated 1/22/24 revealed patient admitted to hospice on 1/22/24. Interview on 02/29/24 at 2:40PM with the DON revealed hospice care plans are kept in PCC and it would be the MDS nurse who would make sure the care plan included hospice services. Interview on 02/29/24 on 2:56 PM with the MDS coordinator revealed IDT meetings were conducted daily to discuss changes to resident care. She stated the care plan was updated as needed and quarterly and annually. She stated if a resident was receiving hospice services it should be documented on the care plan. The MDS Coordinator stated the risk of not updating the care plan would be staff would not have a full picture of the resident care. Interview on 02/29/24 at 3:30PM with the administrator revealed the IDT team discusses needs of the residents daily and stated if a resident was on hospice it would need to be documented on the care plan. The Administrator was not sure why Resident #1's care plan did not contain the hospice information. The administrator stated there was not a risk to the resident due to hospice services not being documented on the care plan due to hospice being in the building 3-5 times a week and there being a hospice binder. Review of the facility policy Charting and documentation revised July 2017 All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.