Every finding on record at Nans Pointe Rehabilitation and Nursing

Based on record review, interviews, and policy review, the facility failed to ensure a signed bed hold were included in the transfer to the hospital for three of four residents (Resident (R) 44, R12, and R73) reviewed for hospitalization out of 24 sample residents. This failure had the potential of not relaying pertinent medical and demographic information to the receiving hospital. Findings include: 1.) Review of R44'sadmission Record located in the electronic medical record (EMR) under the Profile tab revealed R44 was initially admitted to the facility on [DATE] with diagnoses including diabetes mellitus. Review of R44's Progress Notes, dated 06/29/26, revealed R44 had been sent to the emergency room after a syncopal episode while in rehabilitation. Review of R44's admission Minimum Data Set (MDS) with an Assessment Reference date (ARD) of 04/12/26, revealed R44 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated R44 had moderate cognitive impairment. Review of R44's discharge MDS located in the EMR under the MDS tab with an ARD of 06/29/26, revealed R44 was discharged to a short-term general hospital with the anticipation of readmission to the facility. Review of R44's EMR revealed there was no documentation of the signed bed hold for the 06/29/26 discharge. 2. Record review of R12's admission Record located under the Profile tab of the EMR revealed an admission date of 03/05/25. R12 had a diagnosis of chronic kidney disease. Record review of R12's quarterly MDS with an ARD of 04/18/26 revealed R12 had a BIMS score of three out of 15 which indicated severe cognitive impairment. During a record review of R12's Progress Notes located under the Progress Notes tab of the EMR, there was no documentation a written notice of transfer was provided to R12 or R12's resident representative and there was no documentation of a signed bed hold when R12 was transferred to the hospital on [DATE]. 3. Review of R73's admission Record, located in the EMR under the Profile tab revealed R73 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure, aphasia, dysphasia, acute kidney failure, sepsis, and anemia. Review of R73's admission MDS with an ARD of 02/03/26 revealed a BIMS score of five out of 15 which indicated R73 was severely cognitively impaired. Review of the EMR did not identify a transfer notice or bed hold provided to the resident or responsible party. A review of the progress notes located in the EMR under the Progress Notes tab revealed a nurse's note dated 04/05/26 stating that R73 was sent to the hospital related to a malfunctioning catheter. Another note, dated 04/059/26, revealed R73 was admitted to the hospital related to Acute Kidney Injury (AKI) and Urinary Tract Infection (UTI). During an interview on 07/10/26 at 9:23 AM, the Administrator confirmed there was no signed bed hold for R44's discharge. In a follow up interview at 1:01 PM, the Administrator stated the bed holds are not signed, the forms are just put in the packet that is sent with the resident. He could not find all the transfer summaries. During an interview on 07/10/26 at 2:24 PM, the Admissions Director (AD) stated the bed hold form is placed in the packet that is sent out with the resident. She added she does follow them up with a phone call but does not get them signed. Review of facility policy titled Transfer and Discharge (including AMA), dated 12/01/22, indicated It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered.Provide notice of bed hold policy to the resident and representative at the time of transfer, as possible but no later than 24 hours of the transfer.

Based on observations, record review, interviews, and policy review, the staff failed to wash or sanitize the hands of the residents before a meal and failed to wash or sanitize their own hands while serving the residents their meals for one of four survey days. These failures had the potential to increase the prevalence and spread of foodborne illness and infection for residents served by staff we well as the facility failed to process and store laundry and environmental cleaning items in a safe and sanitary manner to prevent the development and transmission of communicable diseases and infections. Specifically, the facility stored clean resident care and housekeeping items, including bolster pads, used for resident positioning, microfiber cloths, microfiber cleaning pads, dust mops, and clean mop heads, within an area designated for the processing of soiled laundry. This practice created the potential for cross-contamination of clean items through exposure to contaminated laundry and environmental pathogens. This deficient practice had the potential to affect all 118 current residents residing in the facility.Findings include: 1. During a meal observation on 07/08/26 at 11:47 AM the Social Service Assistant and Activities Assistant (AA) were observed to serve meals to the 14 residents sitting in the dining room. The two staff were observed to prepare the meal by opening their drinks, taking lids off of the food setting up the silverware and helping resident adjust their chairs without washing or sanitizing their hands between each resident. The two staff members were observed to bring resident into the dining room and set up their meals without washing their hands. During an interview on 07/08/26 at 12:50 PM the Social Service Assistant stated that he was asked to help at the last minute and just didn't think about washing his hands and probably should have. During an interview on 07/08/26 at 12:55 PM the Activity Assistant (AA)stated that he was pulled into help at the last minute. The AA stated that he had just started working at the facility two weeks ago and did not think to wash his hands. During an interview on 07/09/26 at 11:10 AM the Registered Dietitian (RD) stated that all staff should be washing their hands when assisting resident and help the residents wash or sanitized their hands for the meal. The RD stated that there are new employees, but they should know to wash their hands when assisting the residents. During an interview on 07/09/26 at 11:28 AM the Dietary Manager (DM) stated staff should be washing their hands and the hands of the residents when helping with the meals. The DM stated all staff are expected to wash their hands when assisting resident with anything. A review of the facility's policy titled, 12/01/22, indicated that all staff working in all areas of the facility will perform proper hand hygiene to prevent the spread of infection to residents, staff, and visitors. 2. During observation of the laundry room on 07/09/26 at 12:10 PM, Housekeeping (HSKP) 2 was observed removing and sorting soiled laundry from plastic bags and placing the items into a washing machine. HSKP2 was wearing disposable gloves but no additional personal protective equipment. During the sorting process, soiled laundry was observed repeatedly coming into contact with HSKP2's exposed forearms. Further observation revealed a metal shelving unit located on the soiled side of the laundry room. The shelving unit contained clean items, including bolster pads used for resident positioning, microfiber cloths, microfiber cleaning pads, dust mops, and clean mop heads. The shelving unit was uncovered and not physically separated from the area where soiled linen and clothing were being sorted and processed. As a result, clean items were stored in a location where they could become contaminated through exposure to soiled laundry and airborne particles generated during the sorting process. During an interview on 07/09/26 at 12:10 PM, the [NAME] confirmed the clean mopheads, bolster pads, dust mop, micro cloths, micro cleaning pads should be stored on the clean side in laundry. During an interview on 07/09/26 at 12:20 PM, Housekeeping (HSKP)2 stated, We have gowns, I just didn't put one on, I should have. During an interview on 07/10/26 at 2:10 PM, the Housekeeping Director (HD) stated, She is a new employee, and she should have been wearing personal protective equipment while working with the dirty laundry. Review of the facility policy titled, Soiled Linen and Trash Containers dated 12/01/2022 revealed. Policy: Soiled linen and trash collection receptacles shall not exceed 32 gallons in capacity and shall meet all Life Safety Code requirements (LSC 101, 2012 edition, section 18.7.5.7). Policy Explanation and Compliance Guidelines . 8. Staff shall wear appropriate personal protective equipment when handling soiled linen or trash .

Based on observation and interview, the facility failed to have adequate equipment to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area. Specifically, the call light system did not function in two of 24 resident (Resident (R) 82 and R129) and the facility did not provide residents in these rooms an adequate alternate means to communicate with nursing staff. Findings include: 1. During an interview on 07/08/26 at 12:45 PM R82 stated she had had her call light on since right after breakfast because she had a headache and needed some medication. R82 stated her outside light was not working and she had told staff several times, but no one had fixed it. An observation of the call light panel in her room revealed the light activated. An observation of the light outside the room revealed the light was not on. An observation of the call light panel at the nurse's station was conducted on 07/08/26 at 12:50 PM revealed the call light from R82's was red, blinking with an audible beep coming from the panel. Licensed Practical Nurse (LPN)4 was sitting at the desk with her back to the light panel. She did not respond to the light. Several other staff members walked into the station and out without noticing the light. An observation on 07/08/26 at 1:31 revealed LPN2 sitting in front of the call light panel without noticing the light or the sound of the call light in room [ROOM NUMBER]. LPN 2 was observed to respond to several call lights on the opposite side of the nursing station when an outside light was activated. At 1:34 PM, R82 was observed to come to the nurse's station and ask for her medication. The call light remained on. During an interview on 07/08/26 at 1:41 PM LPN2 was asked if she had noticed the call light which was still alerting on the panel. LPN2 stated she did not notice the call light or hear the beeping coming from the call light panel. During an interview on 07/08/26 at 1:47 PM the Director of Nursing (DON) was alerted to the call light still blinking on the call light panel. The malfunctioning light was pointed out to the DON. The DON stated he had not been notified of any broken or malfunctioning lights and if they had broken lights then a bell would be provided to alert the nurses. The call light was then turned off in the resident's room by staff. The call light had been alerting staff at the nurse's station for 57 minutes before staff went to the resident's room to turn it off. During an interview on 07/08/26 at 1:55 PM the Environmental Service Director (EVD) stated that a fire in room [ROOM NUMBER] had shorted out some of the wiring and they were not sure if it had affected the call lights. 2. Review of R129's admission Record located under the Profile tab of the electronic medical record (EMR) indicated R129 was admitted to the facility on [DATE] with the diagnosis of osteoarthritis. Review of R129's Progress Notes located under the Progress Notes tab of the EMR dated 07/06/26 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R129 was cognitively intact. During an observation on 07/07/26 at 11:39 AM, the call light box was absent from where it would normally be located in the wall behind R129's bed. Subsequent interview with R129 at that time confirmed the call light had not worked since she was admitted to the room on 07/02/26 and it had been removed from the wall. R129 revealed she had been given a hand bell to ring. Further observation revealed R129 had a silver hand bell with a red handle sitting on the bedside table. R129 picked up the bell and rang it. After 15 minutes, no one responded to the bell. R129 stated she had to yell to get help and that was not always effective as she was not always heard. R129 revealed she was bedfast and dependent upon staff for Activities of Daily Living (ADLs). Review of R129's Task located under the Task in the EMR dated 07/02/26 through 07/10/26 indicated R129 was dependent in toileting. During an observation on 07/10/26 at 9:03 AM, R129 was resting in bed working on some beading. R129 reported she had already rung her bell some time ago (i.e., 10 minutes), the silver bell with the red handle. R129 said the staff either do not respond or they poke their heads in the door and say they will be right back then they never come back. R129 also revealed she had not been offered a different room with a call light that was functional. During an observation at 9:04 AM, R129 rang the bell. At 9:15 AM, there was no response so R129 rang the bell again. Observation of the nurses' station at that time revealed there were no staff present in area around R129's room or at the nurses' station. At 9:22 AM, an unidentified staff member was observed taking a tray of food into R129's room; 19 minutes after R129 was observed ringing the bell and 29 minutes after she reported she had rung the bell the first time. During that time, no staff were observed checking on R129. During an observation on 07/10/26 at 10:43 AM, R129 rang the bell and reported she was incontinent and needed to be changed. At 10:53 AM, R129 rang the bell again as there was no response to when she rang the bell at 10:43 AM. At 11:02 AM, Housekeeping (HSKP)1, with a clipboard, stopped at R129's door for approximately two seconds but did not go in or talk to R129 before walking down the hall. At 11:04 AM, R129 rang the bell again and the Housekeeping Manager (HM) was going by the door and went in and asked R129 if she needed anything. R129 said she needed to be changed. HM told R129 she would get help then walked down the hall about 75 feet and talked to three staff members. At 11:05 AM, HSKP1 walked back up the hallway. Interview with HSKP1 revealed she was on fire watch and her responsibilities included checking for smoke, fire, and trash that could catch fire. HSKP1 revealed she did not ask the residents if they needed assistance. At 11:06 AM, HM came back and told R129 she had reported to the staff that she needed help then left. At 11:11 AM, R129 rang the bell again. Certified Nurse Aide (CNA)6 was standing right outside the door and did not respond. At 11:13, CNA6 entered R129's room and R129 told her she needed to be changed 30 minutes after R129 had first rang the bell. During an interview on 07/10/26 at 9:11 AM, Certified Nurse Assistant (CNA)2 revealed they were to respond to the call light as soon as we hear it or see it go off. When I inquired if CNA2 could hear R129's bell since the call light was not working, CNA2 stated she did not hear it. CNA2 stated they were supposed to check on the residents every 15 minutes, but this was not documented anywhere. During an interview on 07/10/26 at 10:48 AM, the Director of Nursing (DON) reported the facility call system was an audible/visible system. The DON said staff responded to the call light when the resident pushed the button on the call cord that was connected to a box in the wall. This set off an audible alarm at the control center on the wall at the nurses' station and a light above the resident's room door would light up. The DON said the staff were notified that R129's call light was not working and that she had a bell and that staff should be able to hear it. The DON stated that there was no visual alert for R129 and the bell they gave her was not a dependable alert system as staff were not always available to hear it. The DON was not aware if R129 had been offered a different room with a functioning call light. During an interview on 07/10/26 at 11:27 AM, the Environmental Services Director (EVD) confirmed that R129's call light was not working. The EVD reported the air conditioner unit in the room next to R129's had caught fire a couple of months ago and shorted out the wiring in that room and R129's room. The EVD said he had entered a repair request in TELS, the maintenance system that schedules work requests with area technicians, and they are waiting on a tech who can repair low voltage wiring as the wiring is bad. THE EVD revealed The TELS system alerts the maintenance scheduling service to schedule the specific type of technician needed (low voltage) and the EVD was waiting to hear back from them. The EVD confirmed they do have rooms available that have functional call lights. Review of the facility policy Call Lights: Accessibility and Timely Response revised 12/01/22 revealed the following, The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response .

Based on record review, interviews, and review of the facility policy, facility failed to provide incontinence care in a timely manner for one of one resident (Resident (R) 129) reviewed for activities of daily living (ADLs) out of a total sample of 24 residents. This failure to provide timely incontinence care places residents at increased risk of urinary tract infections and skin breakdown. Findings include: Review of R129's admission Record located under the Profile tab of the EMR R129 was admitted to the facility on [DATE] with the diagnosis of osteoarthritis. Review of R129's Progress Notes located under the Progress Notes tab of the EMR and dated 07/06/26 revealed a BIMS score of 15 out of 15 which indicated R129 was cognitively intact. During an interview on 07/10/26 at 9:03 AM, R129 stated she was dependent on staff for toileting and personal hygiene due to urinary incontinence. R129 reported she was typically only changed once per shift despite requiring incontinence care every two hours. She further stated that she was sometimes left in wet incontinence products for several hours. R129 stated, The usual routine is I get changed at 5:00 AM, then I don't get changed again until 10:00 AM or 10:30 AM. Review of R129's Care Plan located under the Care Plan tab of the EMR and dated 07/02/26 revealed R129 required staff assistance for toileting hygiene and was incontinent of bladder. Review of R129's POC Response History Bladder Continence located under the Tasks tab of the EMR for the dates 07/02/26 to 07/10/26 revealed bladder incontinence was documented three times per day. Review of R129's Tasks Progress Notes located under the Tasks tab of the EMR revealed no documentation R129 was checked for incontinence every 2 hours. Review of R129's POC Response History-Toileting Hygiene located under the Tasks tab of the EMR dated 07/02/26 to 07/10/26 documentation indicated R129 was dependent on staff for toileting hygiene. During an observation on 07/10/26 at 9:03 AM R129 was resting in bed working on some beading. R129 reported she had already rung her bell some time ago (i.e., 10 minutes), the silver bell with the red handle. At 9:04 AM, R129 rang the bell. At 9:15 AM there was no response so R129 rang the bell again. During that time, no staff were observed checking on R129 to determine if R129 was wet and needed a brief change. During an interview on 07/10/26 at 9:11 AM, Certified Nurse Assistant (CNA) 2 revealed We are supposed to check the incontinent residents every 2 hours and change the brief if it is wet. During an observation on 07/10/26 at 10:43 AM R129 rang the bell and reported she was incontinent and needed to be changed. R129 reported she had not been changed since 8:00 AM when the therapy staff changed her otherwise I would not have gotten changed as no other staff had checked on her to see if she was wet. At 10:53 AM, R129 rang the bell again as there was no response to when she rang the bell at 10:43 AM. At 11:13, CNA6 entered R129's room and R129 told CNA6 she needed to be changed. CNA6 then donned gloves, went into R129's room, and closed the door to change R129's wet brief, three hours, and 13 minutes after R129 reported the last time the brief was changed. During that time, no staff were observed checking R129 to determine if she was wet and the brief needed to be changed. During an interview on 07/10/26 at 10:48 AM, the Director of Nursing (DON) confirmed that residents who are incontinent of bowel or bladder are to be checked and, if wet or soiled, have their incontinence brief changed every two hours. The DON stated that residents may not be changed if they are dry; however, residents who urinate frequently are care planned to be checked more often. The DON further direct care staff are expected to document each incontinent episode. The DON confirmed CNAs work 8-hour shifts and are expected to document incontinent episodes by the amount, under the Continence Section of the CNA charting module located under the Tasks tab of the EMR. During an interview on 07/10/26 at 3:54 PM, CNA3 reported the CNAs document whether a resident is incontinent or not by shift under the continence tab in the CNA charting tasks. CNA3 stated the CNAs cannot chart number of times incontinent at the end of the shift as they would have to get into the computer each time and document in real time. CNA3 revealed they usually only report to the nurse if someone does not void all shift, not how many times they are incontinent. CNA3 also stated the CNAs do have the ability to chart number of episodes under the CNA Tasks Progress Notes portion of the Tasks but stated it is difficult to get into the computer and chart every incontinent episode every time a resident is incontinent due to time constraints, so they chart incontinence by shift, not by episode. During an interview on 07/10/26 at 3:56 PM, CNA4 stated the CNAs do have the ability to document each incontinent episode in real time or enter a note documenting the total number of incontinent episodes in the CNA Tasks Progress Notes section under the Tasks tab of the EMR. CNA4 reported that many CNAs do not document each incontinent episode or each incontinence check performed. Instead, staff often document only whether a resident was incontinent, rather than the number of times the resident was checked for incontinence or provided with incontinence care.Review of the facility policy Activities of Daily Living dated 12/01/22 indicated. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Nursing staff will record care as it is provided in PCC POC (the EMR) and advise the charge nurse of any issues or concerns . '

Based on observation, staff interviews, and facility document review, the facility staff failed to maintain the fire alarm system in fully operational condition to ensure a safe and accident-free environment to protect the residents, visitors and staff on three of three units, resulting in the identification of immediate jeopardy facility-wide. This resulted in substandard quality of care. Once the IJ (Immediate Jeopardy) was removed, the scope and severity were lowered to level two, widespread.The findings include:On 4/15/26, a Life Safety Inspection was conducted revealing by observation that: (3) three exit lights were not operational, the facility failed to have credible evidence of annual testing of the fire alarm system, and the fire alarm panel was in the trouble mode. The Life Safety Inspector conducted an interview with the acting maintenance director, who reported the alarm mode had been going on for about a week. The Life Safety Inspector also identified that the facility did not have a dedicated person assigned to conduct Fire Watch, the nursing staff were making rounds. This deficient practice presented a widespread issue that jeopardized resident safety which required immediate correction. On 4/24/26 at 4:30 PM, during an on-site complaint investigation, interviews were conducted with staff from random departments on fire safety:Synopsis of Interviews: 4:30 PM According to the LPN-F (licensed practical nurse) - If I smell smoke or see evidence of a real fire, I will call 911 and pull the fire alarm, I will grab a fire extinguisher and pull, aim, squeeze and sweep. 4:33 PM According to C.N.A.-B, We are on Fire Watch now. When asked her what Fire Watch meant, she replied, Someone walks around and looks for any signs of smoke or fire. When asked who the Fire Watch person on duty currently was, she stated, I don't know. When asked why they were on Fire Watch she stated, I don't know, might be standard. When questioned if they had received training on Fire Watch procedures - No, just told us that someone needs to walk around every 15 minutes or so and make sure no fire or smoke. What would you do if you observed signs of fire or smoke? I would pull alarm, get a fire extinguisher and pull, aim, squeeze and sweep.4:36 PM According to LPN-B - When asked what is meant by facility being on Fire Watch, she responded, Someone, I think the Fire Marshall was here today and tested the alarms, someone walks around about every 15 minutes or so. Who is on Fire Watch this shift? I don't know who is doing Fire Watch tonight?4:38 PM According to (certified nursing assistant) C.N.A.-C What does it mean that the facility is on Fire Watch? Someone walks around and looks for any signs of smoke or fire and if they see anything they would contact the charge nurse, if I see fire or smell smoke, I would the pull the alarm and get a fire extinguisher. When asked if she had received any training specifically on what Fire Watch means, who does Fire Watch duties and why the facility is on Fire Watch? No, not any formal training just told us to be more alert to any signs of fire or smoke and that someone needed to walk the halls and outside the building and document the rounds on the log sheets. Nursing has been doing the Fire Watch rounds because we are here anyway 24 hours a day.4:42 PM According to the Director of Social Services (Employee-E), Yes, we are on Fire Watch, someone walks around, in and outside the building and makes sure no signs of smoke or fire. When asked who was on Fire Watch duties currently, she replied, I don't know who is doing it tonight, nursing staff has been doing it because they are here around the clock. When asked why the facility was on Fire Watch? Employee-E responded, I don't know exactly why we are on Fire Watch.4:43 PM According to the MDS (Minimum Data Set Assessment Coordinator RN) Employee-F, the facility has been on Fire Watch for a few months now. She said she was not sure exactly what the issue was but that someone, usually it is nursing staff doing the rounds as they are here 24 hours, 7 days a week walking around the building to make sure no signs of smoke or fire.4:45 PM An interview was conducted with the Maintenance Assistant, Employee-G, who stated the facility did not have a Maintenance Director at present so he was filling in best he could. When questioned on whether the facility was on Fire Watch he responded, Yes, we are on Fire Watch, the fire panel is malfunctioning, beeps a lot. When asked who was on Fire Watch currently, he stated, I don't know who is on Fire Watch right now, nursing staff have been doing it, but we were told by the Life Safety Inspector today that it had to be a dedicated person and that was all they could do was walk around continuously. When asked how long they had been on Fire Watch and what being on Fire Watch meant he stated, Someone walks up and down the halls and make sure no signs of fire, they also walk around outside the building, the Life Safety inspector found the fire panel not functioning properly and cited us, that was about two or three weeks ago, but we have been on Fire Watch for a long time, we will be on it for at least 30 days or more because they won't be able to replace the fire panel until mid-July from what I have been told.4:49 PM According to LPN-C when interviewed on why the facility was on Fire Watch and who was on Fire Watch currently, she stated, They haven't explained why we are on Fire Watch just that everyone on the unit was responsible for Fire Watch duties. What do you do for Fire Watch? Check and make sure no signs of fire or smoke and check to make sure the alarms are working. What would you do if you saw fire or smelled smoke? She stated she would remove the resident from any danger, confine the fire and pull the alarm.On 4/24/26 at approximately 5:00 PM, an interview was conducted with the Administrator. He stated he had been Administrator since 3/30/36. According to the Administrator he confirmed the facility was on Fire Watch. When asked what being on Fire Watch meant? He stated that someone was making rounds every 15 minutes or so walking the halls and rounding outside to look for any signs of smoke or fire and Fire Watch had been done primarily by nursing staff as they were already in the building 24 hours a day, 7 days a week. When asked why the facility was on Fire Watch, he stated he was not sure of the exact issue, however the Life Safety inspector had identified the fire panel malfunctioning during a 4/15/26 Life Safety Inspection. He said, I just signed a contract yesterday (4/23/26) with (name redacted) the facility's Fire, Safety & Security vendor to replace the facility's fire alarm system, but they say it will be sometime in mid-July before the system would be fully functioning. According to the Administrator, they initiated a dedicated person to Fire Watch duties 4/24/26 per the directive from the Life Safety Inspector. When asked what the responsibilities of the person assigned to Fire Watch, he stated they walk the building every 15 minutes and look for any signs of a fire or smoke continuously and are not to perform any other duties while on Fire Watch duty. When asked who was on Fire Watch duty currently, he gave first name of receptionist (name redacted) but could not recall her last name. A request was made to see the fire maintenance book/binder. A review of the fire maintenance binder revealed Fire Watch logs dating back to 1/30/26. The Administrator was asked why the facility was on Fire Watch as far back as 1/30/26 and according to him, he was not quite sure as he had just started as administrator end of March but was told the system had been touch and go as far back as end of 2025. The Administrator said the vendor had been in recently and verified the panel was functioning. When asked for credible evidence to support that the Fire, Safety and Security vendor (name redacted) had been in and verified panel was functioning he said he did not have copy of the visit report but would try and get something from the vendor. He confirmed he had signed a contract the previous day for the replacement of the fire alarm system 4/23/26. He presented a copy of the signed contract dated 4/23/26 and a copy of the Plan of Correction for the Life Safety Inspection citing the fire panel, smoke detectors and exit signage not functioning properly. When asked if he had any evidence that the facility was conducting audits on the fire panel functionality or testing, fire alarm system inspections, or maintenance program records, he did not have anything to present to the surveyor. He stated the facility does not currently have a full-time maintenance director. When asked if the facility had addressed the malfunctioning of the fire panel or smoke detectors and facility being on Fire Watch since 1/30/26 to their (QAPI) Quality Assurance and Performance Improvement Committee, he stated that he was not aware of it. The Administrator was informed of staff interviews inconsistent with Fire Watch duties such as walking hall ways and patrolling outside building but no evidence of addressing areas such as the laundry, kitchen, resident rooms, observing cook surfaces, dryers, smoking paraphernalia, janitor closets for flammable liquids etc., nor why the facility was on Fire Watch and who was the assigned dedicated Fire Watch person. On 4/24/26 at 5:08 PM, rounds were conducted with the (MA) Maintenance Assistant with observation of the fire panel beeping displaying trouble mode for [NAME] Unit 300, 302, 304. The MA pushed the button shutting off the beeping. When asked if there was anything he would need to do to check the three areas noted in the trouble mode he stated nothing that he knew of. According to the Maintenance Assistant, the fire panel has been beeping off and on, mostly on for a long time, the administrator just recently signed a contract to have the fire alarm system fully replaced, but that will not be done until sometime mid-July.On 4/24/26 at 5:11 PM, an interview was conducted with the receptionist, Employee-H on the facility being on Fire Watch. According to Employee-H, she stated she was the dedicated Fire Watch person currently on duty. When asked what her duties were, she said that she was told to walk the halls every 15 minutes and walk around the outside of the building and look for any signs of smoke or fire, make sure no cigarettes were left unattended, make sure fire extinguishers were stored in the proper places and then complete a form. She said this was her first day as dedicated Fire Watch person that nursing had been doing Fire Watch because they were already in the building, but someone was in the building today and told the Administrator he had to assign a dedicated person. She stated she started her duties at 4:00 PM this day. When asked if she was provided with any training on the facility's Fire Watch procedure, she stated she had received training about a year ago. When asked what she did when not making rounds, she said she tried to catch up on her other duties as receptionist.On 4/24/26 at 5:35 PM, an interview was conducted with the Director of Nursing (DON) on why the facility was on Fire Watch and for how long. He stated he was told they were on Fire Watch because the fire panel was not functioning properly. He said they had been on Fire Watch for a few months. When asked who was conducting the Fire Watch duties, according to the DON, nursing was in the facility 24 hours, 7 days a week and they had been conducting Fire Watch but was directed by the Life Safety Inspector on this day that they were required to have a dedicated person to perform the duties of Fire Watch and do nothing else. When asked what Fire Watch duties included, he stated the staff walk the halls and look for any signs of fire or smoke and walk around the outside of building to make sure no cigarettes or smoking materials are left unsafe and document their rounds on the Fire Watch logs. On 4/24/26 at 6:30 PM, the Administrator presented a copy of education attendance records titled Fire Watch Procedure that he had initiated with staff on duty due to the findings of the staff interviews.When asked if the facility was still accepting new admissions, the Administrator said Yes. The Administrator was informed that when a facility was on Fire Watch, they were not to accept new admission. It was not until 4:00 PM on 4/24/26 did the facility have a dedicated Fire Watch person. A review of facility documents and staff interviews revealed the facility was not following their Fire Watch procedure.Failure to maintain a functional fire alarm system created a hazardous environment in which serious injury, harm or impairment or death to residents was likely. A non-functional fire alarm system delays detection and notification of fire, increasing likelihood of rapid-fire spread, delayed staff response, and the inability to initiate timely evacuation. Failure of the facility to have an operational fire system throughout the entire facility puts all residents, staff and visitors at imminent risk in event of a fire. A review of the facility's policy, titled (ASHE) Fire Watch Procedure, read in part: Overview - A Fire Watch is a temporary measure intended to ensure continuous and systematic surveillance of a building or portion of the building by one or more qualified individuals for the purpose of identifying and controlling fire hazards, detecting early signs of fie, raising an alarm in the event of a fire, and notifying the fire department in the event of a fire. A Fire Watch is required when: There is an impairment to the fire alarm system, sprinkler system, or fire suppression system.Standard Reference: NFPA 101 2012 Section 3.3.104 Fire Watch. The assignment of a person or persons to an area for the express purpose of notifying the fire department, the building occupants, or both of an emergency, preventing a fire from occurring: extinguishing small fires; or protecting the public from fire or life safety dangers.NFPA 25 2011 A.15.5.2(4) (b) A Fire Watch should consist of trained personnel who continuously patrols the affected area. Ready access to fire extinguishers and the ability to promptly notify the fire department are important items to consider. During the patrol of the area, the person should not only be looking for the fire, but also making sure the other fire protection features of the building such as egress routes and alarms systems are available and functioning properly.Fire Watch Personnel: The Individual conducting the periodic inspections of the impairment area(s) is called the Fire Watch. The Fire Watch personnel shall continuously make rounds through all affected areas and building using the facility designated checklist/tour document. Frequency of rounds depends on the facilities policy. If circumstances demand, more frequent surveillance shall be conducted.The Fire Watch Shall: 1) Continually patrol the area, structure or facility and document the patrol. 2) Be trained in the use of a fire extinguisher and have one accessible at all times. 3) Be capable of communicating with building occupants and the fire department to notify them about fires or other emergencies. 4) Maintain a record of the Fire Watch for inspection by the Authority having jurisdiction.Fire Watch Responsibilities: 1) Searching diligently for fires. 2) Immediately addressing any hazards that are discovered. 3) Controlling fire ignition sources.4) Making sure there's adequate means of egress and removing any structures. 5) Standing ready to contact the local fire department. 6) Alerting occupants to hazardous conditions that requires evacuation. 7) Documenting patrols at the designating frequency.Fire Watch Checklist: frayed electrical wires, improperly stored flammables, trash, garbage, excess combustible materials, all exits and stairways and hallways are clear, self-closing doors are not blocked, fire extinguishers stored in proper areas, all heat-producing devices are turned off.Documentation: Fire Watch personnel document all inspections/rounds on facility tour checklist. (1).A review of the facility policy on Facility Systems Risk Assessment Procedure, revised 12/1/2022 Eastern Health Group; reads in part. Policy: It is the policy of this facility to establish criteria for categorizing various facility systems based on risk to the residents, staff or visitors in our facility. Policy Explanation and Compliance Guidelines: 1) A qualitative risk assessment using a series of yes-no questions will be utilized in performing building system risk assessments. 2) All building systems and all areas of the building will be included in the assessment. 3) The assessment will be completed by the facility leadership and the Maintenance Director with collaboration from all departments. Follow-up assessments will be completed in accordance with documentation from the previous assessment, or as needed if changes to facility systems have been made. 4) Worst-outcome scenarios will be considered when evaluating each building system, including but not limited to: a. Consideration of equipment operation, not intervention by people. b. Effect of failure, based on harm to patients or caregivers. c. Potential for failure, based on system reliability. Risk assessments will be documented and maintained in the Maintenance Office indefinitely, or for three years following a new, full assessment. (2).According to the Administrator he is not aware of any risk assessment being completed on the fire panel malfunctioning. The facility's deficient practice created a risk for potential delay in communication in the event of a fire for all residents, staff and visitors. This resulted in a determination of immediate jeopardy (IJ), and cited at level four, pattern beginning 1/30/26. On 4/24/26 at 7:36 PM, the Administrator and Director of Nursing were informed of these concerns and that the facility was in immediate jeopardy and a copy of the IJ template was provided. On 4/24/26 at 8:36 PM, the facility's IJ Immediacy Removal Plan was accepted.The Facility's Removal Plan read: Facility has put dedicated Fire Watch coverage in place. A dedicated staff member will be on duty 24/7 performing only Fire-Watch duties. Fire Watch team members will be educated on Fire Watch prior to serving in this capacity. This is in place now. admission Director has been educated that we cannot accept new admissions while under Fire Watch.In-service Fire Watch training with all staff started 4/24/26. All staff who are not working currently will be in-serviced at the beginning of their next shift prior to beginning any other duties. Weekend staff educated by this evening with remaining staff educated by Monday 4/27/26 and ongoing. Education completed by Administrator to department heads, department heads or designee educating staff.Facility has signed contract for total system repair with BFPE. Expected date of completion 7/24/2026. Fire Watch will continue until system is completely repaired.Facility will not accept any new admissions while under Fire Watch status.Staff will be in-serviced on emergency procedures and response expectations.Local authorities have been notified of alarm system status. Facility will be in compliance with all Fire Watch and education related items by 4/25/26 at 9:00 AM. On 4/27/26 at approximately 9:20 AM, the Regional [NAME] President of Operations presented documents titled Immediate Jeopardy Response Statement which read in part: At no time was the fire alarm system non-functioning. The system remained operational and continued to provide monitoring capabilities. The issue identified was limited to three (3) individual smoke detectors that were not functioning, not a failure of the overall system. On January 30, 2026, upon identification of the issue, the facility immediately initiated Fire Watch procedures to ensure continuous monitoring of resident safety. Fire Watch rounds were implemented without delay and maintained in accordance with Life Safety Code requirements.On the same day, January 30. 2026, the facility engaged its fire protection vendor (name redacted) who responded and evaluated the affected areas. The vendor's assessment confirmed the condition of the identified devices and provided guidance for corrective action.The facility took prompt steps to current the issue. On February 2, 2026, the facility's purchasing partner was engaged, and replacement smoke detectors were sourced without delay. The ordered devices were received March 11, 2026, and installation/replacement was initiated promptly upon receipt to restore full detection capabilities. Additionally, the facility further decisive action to ensure long-term compliance and system reliability. On April 23. 2025, the facility executed a formal agreement with the facility's fire safety vendor (name redacted), to fully replace the fire alarm system. This proactive measure exceeds immediate corrective requirements and demonstrates the facility's commitment to maintaining a fully compliant and reliable life safety system.Based on these facts: 1) The fire alarm system remained operational, with the issue limited to specific devices. 2) Immediate and on-going actions were taken to mitigate any potential risk. 3) Resident safety was maintained at all times through continuous Fire Watch and system monitoring. The facility is currently in compliance and continues to actively monitor all life safety systems to ensure sustained compliance. When asked why these documents, Fire Watch Notice from local Fire and Rescue Department, Fire Safety vendor Service Report dated 1/30/26 and emails from purchasing specialist were not presented on 4/24/26 when requested any credible evidence of fire panel malfunctioning issues and the Life Safety inspection findings, the Regional [NAME] President of Operations stated that the facility was currently without a full-time Maintenance Director and the Administrator was new to the facility and was not aware of the documents to support the facility's actions. When asked why the fire panel was alarming trouble mode on 4/24/26 for [NAME] Unit 300, 302, 308, he stated, it is not that the system in malfunctioning, but is an issue with sensitivity, when the alarm button is pushed as it was by the Maintenance Assistant, it re-sets. He stated, the system is just old, and a full replacement is the best overall solution because finding parts is very challenging due to the age of the system. On 4/27/26 at 9:45 AM, the surveyor began verification of the facility's IJ (Immediate Jeopardy) removal plan. This verification process included: 1) Verified dedicated Fire Watch coverage in place by observation of rounding and interviews with staff members performing the task.2) Verified evidence of admission Directors education on not accepting new admissions while on Fire Watch. 3) On 4/27/26 initiated review of education of staff working 4/25/26 through 4/27/26 morning shift, unable to verify completion of ALL staff through review of education attendance sheets for Fire Watch procedures, emergency preparedness and response expectations and with staff interviews. 4) Verified signature of contract signed 4/23/26 for total system repair with expected date of completion for replacement 7/24/26. Facility Administrator confirmed facility will remain on Fire Watch until system is completely repaired and Fire Marshall recommends lifting Fire Watch. 5) Reviewed County (name redacted) Department Fire and Rescue form for Fire Watch Notice to verify that the local Fire Marshall had been notified of alarm system malfunction dated 1/30/26 with recommendations for 24 hour/day Fire Watch Due to the inoperability of the required fire protection system, you are hereby notified that you must provide a fire watch guard service to patrol the premises until such a time as the fire protection system is restored to its normal operating procedure.6) Conducted interviews on 4/27/26 with a random number of certified nursing assistants, licensed nursing staff, therapy, dietary, laundry, housekeeping, receptionist and maintenance staff to verify they had received education on Fire Watch procedures, emergency procedures and response expectations. Two dietary staff could not articulate the information from the education however their signatures were on the attendance sheets. One Laundry aide stated she had not received education. Several nursing staff including contracted nursing personnel had not received required education based on attendance sheet review and interviews. The Administrator, Regional Nurse Consultant and Regional [NAME] President of Operations were notified that completion of the IJ removal plan could not be verified due to failure to ensure ALL staff had received required education on Fire Watch, emergency procedures and response expectations and a revised IJ removal plan with new date and time of completion was required. The Administrator submitted revised IJ Removal Plan with date of 4/28/26 at 11:00 AM. On 4/28/26 beginning at 11:15 AM, a second review of staff education attendance sheets and interviews was conducted, with verification that ALL staff working 4/24/26 on 3-11 PM shift through 4/28/26 Day Shift had received education on Fire Watch procedures, emergency preparedness and response expectations. Verified the two dietary staff, laundry aide and nursing staff had received the education on Fire Watch, emergency procedures and response expectations via signature on attendance sheet and were able to answer questions related to the education. The survey team concluded verification at 12:05 PM on 4/28/26. On 4/28/26 at 2:15 PM, the [NAME] President of Plant Operations provided a document titled, Event History Record from the facility's 3rd Third Party vendor (name redacted) showing second by second recording of communication with the facility's fire panel and a copy from the facility's fire safety vendor dated 4/28/26 for fire alarm system inspection and test. A copy for random dates of the Event History Record for January 2026 through April 2026 was provided. According to the [NAME] President of Plant Operations, the system requires a re-set, and the report shows restoring within seconds with the identification of the location. He states the system is old, but operational and the 3rd party has been and continues to receive communication from the facility fire panel. A copy of the facility's fire safety vendor's report dated 4/28/26 for annual fire alarm system inspection and test was also provided. When asked why this information wasn't provided to the Life Safety Inspector on 4/15/26 or to the surveyor on 4/24/26 when credible evidence of fire alarm panel's functionality was requested, he replied, The facility does not currently have a full-time maintenance director and the assistant would not know how to obtain this information or even that this information is available from the 3rd party nor does the Administrator as he is new. My background is life safety, I have only been with this company for about two weeks, this is a newly created company position. I have been doing this type of work for a long time and know what information is available and who to get the information from. Once I came on board, I knew what needed to be done so I contacted (name redacted) the facility's fire safety vendor and requested a fire alarm inspection and test to be done as soon as possible, they were here today and I knew that the 3rd party vendor should have reports of panel communications.The facility has remained on Fire Watch for approximately 3 months without evidence that the fire panel has been re-inspected or tested until 4/28/26 and interviews and observations revealed the facility was not conducting Fire Watch according to the facility's Fire Watch procedures.On 4/28/26 at 5:24 PM, an exit meeting was conducted with the Administrator, Regional [NAME] President of Operations, [NAME] President of Plant Operations and Owner/Partner and were offered an opportunity to present additional information. No further information or comments were provided. References:ASHE Optimizing Health Care Facilities, AHA Data & Insights, 2020 The American Society for Health Care Engineeing of the American Hospital Associationc.Centers for Medicare & Medicaid Services. State Operations Manual (SOM): Appendix 1 (Life Safety Code Health Care Facilities Code, 2012 edition). K901 - Building System Categories.National Fire Proteection Association (NFPA), NFPA 99-2012. Chapter 4.

Based on staff interviews and review of facility documents, the facility staff failed to provide leadership and oversight to ensure effective systems were in place to assure the safety of the residents in the area of safety and hazardous free environment and quality assurance and performance improvement activities for three of three units.The findings included:During a complaint investigation and an extended survey conducted on 4/24/26, 4/27/26 and 4/28/26, the facility staff failed to provide evidence that fire alarm panel testing and inspections were being conducted since 1/30/26 and that staff were trained and following the facility's policy on Fire Watch Procedure.On 4/24/26 at approximately 5:00 PM, an interview was conducted with the Administrator. He stated he had been Administrator since March 30, 2026. According to the Administrator, he confirmed that the facility was on Fire Watch. When asked what being on Fire Watch meant? He stated that someone was making rounds every 15 minutes or so walking the halls and rounding outside to look for any signs of smoke or fire. He stated the Fire Watch duties had been done primarily by the nursing staff as they were already in the building 24 hours a day, 7 days a week. When asked why the facility was on Fire Watch, he stated he was not sure of the exact issue, however the Life Safety inspector had identified the fire panel malfunctioning during a 4/15/26 Life Safety Inspection. He stated he had signed a contract 4/23/26 with the facility's Fire, Safety & Security vendor (name Redacted) to replace the facility's fire alarm system, however it would be sometime in July 2026 before system was fully functioning. He also stated that the Life Safety Inspector had been in earlier that day and said the facility was required to initiate a dedicated person to Fire Watch who could not do any other tasks except to patrol the facility for fire safety. When asked who was on Fire Watch duty currently, he gave first name of receptionist (name redacted) but could not recall her last name. A review of the fire maintenance binder revealed Fire Watch logs dating back to 1/30/26. The Administrator was asked why the facility was on Fire Watch as far back as 1/30/26 and according to him, he was not quite sure as he had just started as Administrator March 30, 2026, but was told the system had been touch and go as far back as end of 2025. The Administrator said the vendor had been in recently and verified panel was functioning. When asked for credible evidence to support that the Fire, Safety and Security vendor (name redacted) had been in and verified panel was functioning he said he did not have a copy of the visit report but would try and get something from the vendor. He presented a copy of the signed contract dated 4/23/26 and a copy of the Plan of Correction for the Life Safety Inspection citing the fire panel, smoke detectors and exit signage not functioning properly. When asked if he had any evidence that the facility was conducting audits on the fire panel functionality or testing, fire alarm system inspections, maintenance program records, he did not have anything to present to surveyor. He stated the facility does not currently have a full-time maintenance director. When asked if the facility had addressed the malfunctioning of the fire panel or smoke detectors and facility being on Fire Watch since January 2026 to their (QAPI) Quality Assurance and Performance Improvement Committee, he stated that he was not aware of it. He presented a copy of the facility's QAPI Agenda/Minutes form which identified a section for Maintenance: Fire Drill Log, Disaster Drill Log, Fire Alarm test monthly, maintenance tracking report use and Elopement Drills. When asked if the issue should have been addressed in the QAPI committee, he replied, Most definitely, it should have been reported to QAPI.A copy of the facility's policy on administration or administrative duties was requested. The Administrator stated they did not have a policy addressing administrative duties.On 4/28/26 at 5:24 PM, an exit meeting was conducted with the Administrator, Regional [NAME] President of Operations, [NAME] President of Plant Operations and Owner/Partner and were offered an opportunity to present additional information. No further information or comments were provided.

Based on staff interviews and review of facility documents, the facility's governing body failed to ensure facility policies were implemented regarding management and operation of the facility to ensure effective leadership and systems were in place to ensure the safety of residents, staff and visitors in safety and hazardous free environment for three of three units.Findings included:During a complaint investigation and an extended survey conducted on 4/24/26, 4/27/26 and 4/28/26, the governing body failed to ensure effective leadership and systems in place to monitor the functionality of the fire alarm panel since 1/30/26 and that staff were trained and following the facility's policy on Fire Watch Procedure and the Local Fire Marshall recommendations dated 1/30/26. On 4/24/26 at approximately 5:00 PM, an interview was conducted with the Administrator. He stated he had been Administrator since 3/30/26. According to the Administrator, he confirmed that the facility was on Fire Watch. When asked what being on Fire Watch meant? He stated that someone was making rounds every 15 minutes or so walking the halls and rounding outside to look for any signs of smoke or fire. He stated the Fire Watch duties had been done primarily by the nursing staff as they were already in the building 24 hours a day, 7 days a week. When asked why the facility was on Fire Watch, he stated he was not sure of the exact issue, however the Life Safety inspector had identified the fire panel malfunctioning during a 4/15/26 Life Safety Inspection. He stated he had signed a contract 4/23/26 with (name redacted, the facility's Fire, Safety & Security vendor) to replace the fire alarm system, however it would be sometime in mid- July before system was fully functioning. He also stated that the Life Safety Inspector had been in earlier that day and said the facility was required to initiate a dedicated person to Fire Watch who could not do any other tasks except to patrol the facility for fire safety. When asked who was on Fire Watch duty currently, he gave first name of receptionist (name redacted) but could not recall her last name. A review of the fire maintenance binder revealed Fire Watch logs dating back to 1/30/26. The Administrator was asked why the facility was on Fire Watch as far back as 1/30/26 and according to him, he was not quite sure as he had just started as Administrator 3/30/26 but was told the system had been touch and go as far back as end of 2025. The Administrator said the vendor had been in recently and verified panel was functioning. When asked for credible evidence to support that the Fire, Safety and Security vendor (name redacted) had been in and verified panel was functioning he said he did not have a copy of the visit report but would try and get something from the vendor. He presented a copy of the signed contract dated 4/23/26 and a copy of the Plan of Correction for the Life Safety Inspection citing the fire panel, smoke detectors and exit signage not functioning properly. When asked if he had any evidence that the facility was conducting audits on the fire panel functionality or testing, fire alarm system inspections, maintenance program records, he did not have anything to present to surveyor. He stated the facility does not currently have a full-time maintenance director. When asked if the facility had addressed the malfunctioning of the fire panel or smoke detectors and facility being on Fire Watch since January 2026 to their (QAPI) Quality Assurance and Performance Improvement Committee, he stated that he was not aware of it. He presented a copy of the facility's QAPI Agenda/Minutes form which identified a section for Maintenance: Fire Drill Log, Disaster Drill Log, Fire Alarm test monthly, TELS (the facility software platform for tracking service history) use and Elopement Drills. When asked if the issue should have been addressed in the QAPI committee, he replied, Most definitely, it should have been reported to QAPI.On 4/27/26 at approximately 9:20 AM, the Regional [NAME] President of Operations and owner /partner were on-site and presented documents titled, Immediate Jeopardy Response Statement which read in part: At no time was the fire alarm system non-functioning. The system remained operational and continued to provide monitoring capabilities. The issue identified was limited to three (3) individual smoke detectors that were not functioning, not a failure of the overall system. On 1/30/26, upon identification of the issue, the facility immediately initiated Fire Watch procedures to ensure continuous monitoring of resident safety. Fire Watch rounds were implemented without delay and maintained in accordance with Life Safety Code requirements.On the same day, 1/30/26, the facility engaged its fire protection vendor (name redacted) who responded and evaluated the affected areas. The vendor's assessment confirmed the condition of the identified devices and provided guidance for corrective action.The facility took prompt steps to current the issue. On 2/20/26, the facility's purchasing partner was engaged, and replacement smoke detectors were sourced without delay. The ordered devices were received 3/11/26, and installation/replacement was initiated promptly upon receipt to restore full detection capabilities. Additionally, the facility's further decisive action to ensure long-term compliance and system reliability. On 4/23/26, the facility executed a formal agreement with the facility's fire safety vendor (name redacted), to fully replace the fire alarm system. This proactive measure exceeds immediate corrective requirements and demonstrates the facility's commitment to maintaining a fully compliant and reliable life safety system.Based on these facts: 1) The fire alarm system remained operational, with the issue limited to specific devices. 2) Immediate and on-going actions were taken to mitigate any potential risk. 3) Resident safety was maintained at all times through continuous Fire Watch and system monitoring. The facility is currently in compliance and continues to actively monitor all life safety systems to ensure sustained compliance. This document was signed by the Administrator; the Administrator did not present this information on 4/24/26 when asked for credible evidence of why the facility had been on Fire Watch since 1/30/26 and what the issue was with the fire panel.When asked why these documents, Fire Watch Notice from local Fire and Rescue Department, Fire Safety vendor Service Report dated 1/30/26 and emails from purchasing specialist were not presented on 4/24/26 when requested any credible evidence of fire panel malfunctiong issues and the Life Safety inspection findings, the Regional [NAME] President of Operations stated that the facility was currently without a full-time Maintenance Director and the Administrator was new to the facility and not aware of the documents to support the facility's actions. When asked why the fire panel was alarming trouble mode on 4/24/26 for [NAME] Unit 300, 302, 308, he stated, it is not that the system in malfunctioning but an issue with sensitivity, when alarm button is pushed as it was by the Maintenance Assistant, it will re-set. He stated, the system is just old, and a full replacement is the best overall solution because finding parts is very challenging due to the age of the system. No evidence was provided until 4/27/26 to demonstrate communication between the governing body and administrator of the facility's fire panel malfunctioning issue and that the facility was still on Fire Watch since 1/30/26 (for three months). No evidence the governing was involved in the facility's QAPI committee activities.A review of the facility's policy titled, Governing Body, 2020, reads in part: Policy: The facility will have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility.Policy Explanation: 1) The governing body will appoint an administrator who is: b. Responsible for management of the facility; c. Reports to and is accountable to the governing body. 2) The governing body is responsible and accountable for the QAPI (Quality Assurance and Performance Improvement Committee). 4. The governing body will have a process by which the administrator: a. Reports to the governing body. b. Method of communication between administrator and governing body. c. How the governing body responds back to the administrator. d. What specific types of problems and information are reported or not reported. e. How the administrator is held accountable and reports information about the facility's management and operation. f. How the administrator and the governing body are involved with the facility wide assessments.On 4/28/26 at 5:24 PM, an exit meeting was conducted with the Administrator, Regional [NAME] President of Operations, [NAME] President of Plant Operations and Owner/Partner and were offered an opportunity to present additional information. No further information or comments were provided. Reference: Centers for Medicare & Medicaid Services. State Operations Manual (SOM): Appendix PP Guidance for Surveyors for Long Term Care Facilities (November 2017). F837- Governing Body S483.70(d)(1)-(3).

Based on staff interviews and review of facility documents, the facility staff failed to adequately identify, keep systems functioning properly, follow facility Fire Watch procedure and implement necessary action plans to assure the safety of all residents, staff and visitors using the Quality Assurance and Performance Improvement (QAPI) committee to identify deficiencies in the area of safety and hazardous free environment for three of three units.The findings included:During a complaint investigation and an extended survey conducted on 4/24/26, 4/27/26 and 4/28/26, the facility staff failed to provide credible evidence that the fire alarm malfunctioning and facility being on Fire Watch since 1/30/26 was reported to the QAPI (Quality Assurance and Improvement) Committee for appropriate oversight to monitor and evaluate for any potential negative outcomes.On 4/24/26 at approximately 5:00 PM, an interview was conducted with the Administrator. He stated he had been Administrator since 3/30/36. According to the Administrator he confirmed the facility was on Fire Watch. When asked what being on Fire Watch meant? He stated that someone was making rounds every 15 minutes or so walking the halls and rounding outside to look for any signs of smoke or fire and Fire Watch had been done primarily by nursing staff as they were already in the building 24 hours a day, 7 days a week. When asked why the facility was on Fire Watch, he stated he was not sure of the exact issue, however the Life Safety inspector had identified the fire panel malfunctioning during a 4/15/26 Life Safety Inspection. He said, I just signed a contract yesterday (4/23/26) with (name redacted, the facility's Fire, Safety & Security vendor) to replace the fire alarm system, but they say it will be sometime in mid-July before the system would be fully functioning.According to the Administrator, they initiated a dedicated person to Fire Watch duties 4/24/26 per the directive from the Life Safety Inspector. When asked what the responsibilities of the person assigned to Fire Watch, he stated they walk the building every 15 minutes and look for any signs of a fire or smoke continuously and are not to perform any other duties while on Fire Watch duty. When asked who was on Fire Watch duty currently, he gave first name of receptionist (name redacted) but could not recall her last name. A request was made to see the fire maintenance book/binder. A review of the fire maintenance binder revealed Fire Watch logs dating back to 1/30/26. The Administrator was asked why the facility was on Fire Watch as far back as 1/30/26 and according to him, he was not quite sure as he had just started as administrator end of March but was told the system had been touch and go as far back as end of 2025. The Administrator said the vendor had been in recently and verified the panel was functioning. When asked for credible evidence to support that the Fire, Safety and Security vendor (name redacted) had been in and verified panel was functioning he said he did not have copy of the visit report but would try and get something from the vendor. He again confirmed he had signed a contract the previous day for the replacement of the fire alarm system 4/23/26. He presented a copy of the signed contract dated 4/23/26 and a copy of the Plan of Correction for the Life Safety Inspection citing the fire panel, smoke detectors and exit signage not functioning properly. When asked if he had any evidence that the facility was conducting audits on the fire panel functionality or testing, fire alarm system inspections, or maintenance program records, he did not have anything to present to the surveyor. He stated the facility does not currently have a full-time maintenance director. When asked if the facility had addressed the malfunctioning of the fire panel or smoke detectors and facility being on Fire Watch since 1/30/26 to their (QAPI) Quality Assurance and Performance Improvement Committee, he stated that he was not aware of it.On 4/28/26 at 2:35 PM, a final interview was conducted with the Administrator on the facility's QAPI (Quality Assurance and Performance Improvement) committee functions and to review the past year's QAPI activities. According to the Administrator, the facility conducts QAPI committee meetings monthly. When asked who attended the meeting, he stated the administrator, director of nursing, social services, MDS (Minimum Data Set) nurse, business office manager, medical director, pharmacist and other department managers. He presented a QAPI action plan dated 3/25/26 that addressed a broken exit door and stated that the door had been repaired. When asked if he had the credible evidence to show each task/action identified on the action plan, he stated that he did not have anything except the plan. He also presented monthly QAPI meeting attendance sheets dated 3/3/26, 3/27/26 and 4/24/26 which included the signatures of the Administrator, Director of Nursing and Infection Preventionist and other department managers but no evidence the Medical Director had attended the meeting. The Administrator stated he did not have any evidence of quarterly QAPI meetings for the past year. When asked if he had credible evidence that the facility had addressed the issue of the fire panel malfunctioning and that the facility had been on Fire Watch since 1/30/26 he stated he could not locate any evidence that these issues had been addressed by the facility's QAPI committee. He presented a copy of the facility's Agenda/Minutes form which identified a section for Maintenance: Fie Drill Log, Disaster Drill Log, Fire Alarm test monthly, TELS use and Elopement Drills. When asked if the issue should have been addressed in the QAPI committee, he replied, Most definitely, it should have been reported to QAPI.A review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) dated 2021, reads in part; Procedure: The primary goals of the QAPI committee are to: 1) Establish, maintain, and oversee facility systems and processes to support the delivery of quality care and services. 2) Promote the consistent use of facility systems and provisions of care and services. 3) Help identify actual and potential negative outcomes relative to resident care and resolve them appropriately.4) Support the use of root cause analysis to help identify where patterns of negative outcomes point to underlying systematic problems. 6) Coordinate the development, implementation, monitoring, and evaluation of performance improvements projects to achieve specific goals; Committee Reports and Records: The committee shall maintain minutes of all regular and special meetings that include date/time, attendance, summary of reports and findings, a summary of any approaches and action plans, conclusions and recommendations.On 4/28/26 at 5:24 PM, an exit meeting was conducted with the Administrator, Regional [NAME] President of Operations, [NAME] President of Plant Operations and Owner/Partner and were offered an opportunity to present additional information. No further information or comments were provided.

Based on observations, staff interview, and during the course of a complaint investigation, the facility staff failed to post the most recent survey results in a place readily accessible to residents, family members, and legal representatives of residents. During an observation on 10/21/25 at 11:15 am., a sign was observed in the facility lobby that read: A copy of the most recent Virginia Department of Health inspection report is available upon request.On 10/22/25 during the course of the survey on this day, no posting of survey results were observed, but the above information was listed. On 10/23/25 at approximately 10:30 am., a brief encounter was made by the administrator near the lobby concerning the survey results book. The administrator said that the book was located in a drawer by the receptionist. A pre-exit interview was conducted on 10/23/25 at approximately 1:30 pm., the above findings were shared with the Administrator, The Corporate Consultant and the DON (Director of Nursing) and [NAME] President of Clinical Services. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on observations, staff interviews, and clinical record review, the facility staff failed to maintain an infection prevention and control program designed to limit opportunities for infection transmission. The findings included: Resident #2 was initially admitted to the facility on [DATE]. The resident's current diagnoses included an infected diabetic ulcer of the right foot. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 10/17/25, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated that Resident #2's cognitive abilities for daily decision-making were intact. In section GG (Functional Abilities and Goals), the resident was coded as requiring setup or clean-up assistance with eating, partial/moderate assistance with oral hygiene, substantial/maximal assistance with showers/bathes, and upper body dressing, dependent with lower body dressing, personal hygiene, and putting on/taking off footwear. The resident also required substantial/maximal assistance with rolling, lying, sitting, and transfers, and is dependent on toilet transfers and walking. During the tour on 10/21/25 at approximately 12:33 PM, a Contact Precautions sign was observed above the room number where Resident #2 resided. An interview was conducted with the Unit Manager (UM) at 12:05 PM on 10/22/25. The UM stated that the resident's right foot wound presented with increased edema and purulent drainage; therefore, the wound care Nurse Practitioner (NP) obtained a specimen for analysis on 10/15/25. The UM further stated the resident's lab results were sent to the facility on [DATE], and Staphylococcus aureus, Enterococcus faecalis, and Staphylococcus epidermidis were growing in the right foot wound. Resident #2 had a roommate with a PEG tube, but no signage was posted for Enhanced Barrier Precautions (EBP) for this resident. The UM was asked whether the two residents were cohorted in accordance with recommendations from the Centers for Disease Control and Prevention (CDC), and she answered yes. The UM offered no reason for not posting Enhanced Barrier Precautions (EBP) signage for the roommate who had a PEG tube. EBP signage is required in nursing homes to alert staff to wear gowns and gloves when performing high-contact care activities with all residents who are at higher risk of acquiring or spreading an MDRO. These include the following residents: residents known to be infected or colonized with an MDRO; residents with an indwelling medical device, including a central venous catheter, urinary catheter, feeding tube (PEG tube, G-tube), tracheostomy/ventilator regardless of their MDRO status, and residents with a wound, irrespective of their MDRO status. (PowerPoint Presentation). On 10/22/25 at approximately 1:40 PM, the UM stated that she had made a mistake and that, after speaking with the Infection Preventionist (IP) about the two residents' cohorting, the IP stated that they should not remain together. The UM stated that Resident #2 should have been isolated; therefore, they had moved the roommate to another room and placed an EBP sign at his door.A final interview was conducted on 10/23/25 at approximately 1:30 PM, and the above findings were shared with the Administrator, the Director of Nursing, a Corporate Consultant, and the [NAME] President of Operations. They had no comments and voiced no concerns regarding the above information. In an age of increasing antimicrobial resistance, evidence shows that the traditional use of contact precautions in nursing homes is not reasonable for most residents to prevent multidrug-resistant organism (MDRO) transmission. Contact precautions require room restrictions and are generally intended to be time-limited. Citing the inability to restrict residents to their rooms and negatively impacting their quality of life, the Health care Infection Control Practices Advisory Committee published a white paper, Consideration for the Use of Enhanced Barrier Precautions in Skilled Nursing Facilities.1 Released in June 2021; the report noted that more than 50% of nursing home residents may be colonized with an MDRO. (Updated CMS Recommendations for Infection Prevention in Long-Term Care | Infection Control Today)The facility's Infection Prevention and Control policy, with a revision date of 12/1/2022, stated at number 2 that all staff are responsible for following all policies and procedures related to the program.

Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to provide a specialized therapy evaluation resulting in delayed treatment in services which placed the resident in higher risk for decline for 1 of 4 residents (Resident #3), in the survey sample.Resident #3 was originally admitted to the facility 8/24/25 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Cerebral Infarction Due to Unspecified Occlusion or Stenosis. Hemiplegia and Hemiparesis Following Cerebral Infarction. The admission, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/29/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 9 out of a possible 15. This indicated Resident #3 cognitive abilities for daily decision making were moderately impaired. [NAME] BlvdIn sectionGG(Functional Abilities) the resident was coded as being dependent in oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on, taking off shoes and personal hygiene. Requiring set-up or clean-up assistance with eating. According to the August 2025 Physicians Order Summary dated 8/25/25 (POS). Resident #3 was ordered to receive an Occupational Therapy (OT), Physical Therapy (PT) and Speech Therapy (ST) evaluation.On 10/22/25 at approximately 3:00 pm., an interview was conducted with Other Staff (OS) #6 concerning Resident #3 who did not receive the above therapy services. OS #6 said that Resident's will usually get services upon admission. The staff usually put in therapy orders and if they are skilled, it's assumed they are getting the services. OS #6 also said that It was never brought to my attention that she wasn't getting services. On 10/22/25 at approximately 1:00 pm., an interview was conducted with the Director of Rehab., (DOR). The DOR said that the resident didn't initially have therapy orders. The DOR also said the residents' initial Physical Therapy evaluation (PT), and Occupational Therapy (OT) evaluation wasn't started until 9/19/25 (PT) and 9/22/25 (OT). The DOR also mentioned that his calendar for the month of August lists no therapy start days prior to.On 10/22/25 an interview was conducted at 2:20 p.m., with Licensed Practical Nurse (LPN) #3. LPN #3 said that the resident came in the facility having straight Medicaid. LPN #3 also said that the therapy department screens everyone that's admitted . LPN #3 also mentioned the order dated 8/25/25 was a standing order. Policy: Therapy Evaluation: Dated 11/01/21 and revised on 12/01/22. Reads: The Licensed Therapist will perform initial evaluation upon physician referral and any re-evaluation as appropriate. Policy Explanation and Compliance Guidelines: 1. The rehab department will be notified when a physician order is written for therapy evaluation and treatment. 2. The licensed therapist will perform chart review and initiate the evaluation. 3. The initial evaluation will include, but is not limited to, the following: a. Patient name, date of birth and health insurance ID number. b. Diagnosis. c. Past medical history. d. Prior level of function. e. Current functional level. f. Rehab., potential/severity. g. short- and long-term goals and time frames for completion. h. Treatment Plan of Care to accomplish goals. 4. Initial evaluation will be completed within 2 days from the time the referral is written. 5. Evaluations will be documented, signed by licensed therapist, printed, and placed in chart. 6. Completed evaluation will be signed by the physician.Per the facility's order, the initial evaluation should have been completed in 2 days from the time the referral is written, in this case a verbal active order was given to provide an OT, PT and ST evaluation and treatment.On 10/22/25 at approximately 11:40 am., an interview was conducted with Resident #3 and her spouse concerning rehabilitation (rehab.) services. The spouse said that the resident only had Medicare Part A insurance and not Medicare Part B insurance, therefore the facility Social Worker (SW) told them that nothing could be done with receiving therapy services. The spouse also said that presently, the resident is getting her knee stretched out by therapy to prevent contractures. Some days her legs hurt so bad she couldn't do therapy. Resident #3 lay in her bed nodding in agreement. Resident #3 was asked to rate her knee pain on a pain scale out of 10. Resident #3 said her pain is a 10 but she just received Tylenol for Pain. Resident #3 says she's hurting now. Shortly thereafter, two facility staff were observed entering the resident's room with a Hoyer Lift to get resident up with her wheelchair with a Hoyer lift (11:48 am).On 10/22/25 at approximately 11:45 am., an interview was conducted with the Director of Rehabilitation (DOR). The DOR said that Resident #3 was admitted initially to receive a Physical Therapy (PT) evaluation on 9/19/25 and Occupational Therapy (OT) on 9/22/25. On 10/22/25 at approximately 1:00 pm., the DOR returned saying that he didn't see any notes written in his August 2025 calendar indicating there were PT, OT and ST evaluations.On 10/22/25 1:15 pm., an interview was conducted with the Business Office Manager (BOM) concerning the residents' insurance. The BOM said that the resident has had Medicare Part B. since 9/01/22, which was her therapy payor source but was pending Medicaid when she was first admitted to the facility.On 10/22/25 at approximately 2:20 pm., an interview was conducted with Minimum Data Set Coordinator (MDSC). The MDSC said this was a standing order from 8/25/25 and that Our therapy department screens everyone that's admitted . The MDSC also said that therapy was decided by the resident's family.On 10/22/25 at approximately 4:15 pm., an interview was conducted with the Director of Nursing (DON). The DON said that the standing order was an admissions order that would normally be discussed in our daily meetings. The DON also said that therapy is given if necessary and usually once a resident is admitted they are evaluated for therapy in 7-10 days.On 10/23/25 at approximately 12:45 pm., a brief meeting was conducted with the administrator, BOM, The Social Services Coordinator and with the Corporate [NAME] President of Operations (VPOO). The VPOO said they missed the order to pick her up. A pre-exit interview was conducted on 10/23/25 at approximately 1:30 pm., the above findings were shared with the Administrator, The Corporate Consultant and the DON (Director of Nursing) and [NAME] President of Clinical Services. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on observations, staff interviews, and clinical record review, the facility staff failed to promptly notify the physician and/or practitioner of abnormal lab results for 1 of 4 residents in the survey sample (Resident #2). The findings included: Resident #2 was initially admitted to the facility on [DATE]. The resident's current diagnoses included an infected diabetic ulcer of the right foot. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 10/17/25, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated that Resident #2's cognitive abilities for daily decision-making were intact. In section GG (Functional Abilities and Goals), the resident was coded as requiring setup or clean-up assistance with eating, partial/moderate assistance with oral hygiene, substantial/maximal assistance with showers/bathes, and upper body dressing, dependent with lower body dressing, personal hygiene, and putting on/taking off footwear. The resident also required substantial/maximal assistance with rolling, lying, sitting, and transfers, and is dependent on toilet transfers and walking. During the tour on 10/21/25 at approximately 12:33 PM, a Contact Precautions sign was observed above the room number where Resident #2 resided. An interview was conducted with the Unit Manager (UM) at 12:05 PM on 10/22/25. The UM stated that the resident's right foot wound presented with increased edema and purulent drainage; therefore, the wound care Nurse Practitioner (NP) obtained a specimen for analysis on 10/15/25.The UM stated the resident's lab results were sent to the facility on [DATE], and Staphylococcus aureus, Enterococcus faecalis, and Staphylococcus epidermidis were growing in the right foot wound. The UM further stated that the NP was not notified of the lab results until 10/20/25, for an unknown reason. The UM stated that the lab results are supposed to be viewable on the Point-Click-Care system dashboard, and the results should have been reported to the provider on the day they arrived at the facility. The UM also stated that, as a backup system to prevent missing labs and other pertinent information, the overnight shift is responsible for conducting a 24-hour chart check to identify oversights. Still, the oversight was not recognized until 10/20/25.The UM stated that after the NPs reviewed the lab report, an order was given to start the resident on intravenous (IV) antibiotics and to obtain a magnetic resonance imaging (MRI) to rule out osteomyelitis.A final interview was conducted on 10/23/25 at approximately 1:30 PM, and the above findings were shared with the Administrator, the Director of Nursing, a Corporate Consultant, and the [NAME] President of Operations. They had no comments and voiced no concerns regarding the above information. The facility's policy titled Culture and Sensitivity Lab Results, which was revised on 12/1/2022, stated at number 4b., that the 24-hour shift report may be used by nursing staff, nurse leaders, and the Infection Preventionist to identify residents who have pending lab results . 4d., report positive culture results to the physician/practitioner, including the antibiotics to which the identified pathogen is susceptible.

Based on observations, staff interviews, and clinical record review, the facility staff failed to administer the ordered antibiotic to 1 of 4 residents in the survey sample (Resident #2).The findings included: Resident #2 was initially admitted to the facility on [DATE]. The resident's current diagnoses included an infected diabetic ulcer of the right foot. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 10/17/25, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated that Resident #2's cognitive abilities for daily decision-making were intact. In section GG (Functional Abilities and Goals), the resident was coded as requiring setup or clean-up assistance with eating, partial/moderate assistance with oral hygiene, substantial/maximal assistance with showers/bathes, and upper body dressing, dependent with lower body dressing, personal hygiene, and putting on/taking off footwear. The resident also required substantial/maximal assistance with rolling, lying, sitting, and transfers, and is dependent on toilet transfers and walking. During the tour on 10/21/25 at approximately 12:33 PM, a Contact Precautions sign was observed above the room number where Resident #2 resided. An interview was conducted with the Unit Manager (UM) at 12:05 PM on 10/22/25. The UM stated that the resident's right foot wound presented with increased edema and purulent drainage; therefore, the wound care Nurse Practitioner (NP) obtained a specimen for analysis on 10/15/25.The UM further stated the resident's lab results were sent to the facility on [DATE], and Staphylococcus aureus, Enterococcus faecalis, and Staphylococcus epidermidis were growing in the right foot wound. The assessment based on the wound care NP's progress note, dated 10/20/25 at 12:48 PM, stated that the resident's right foot wound was deteriorating. The note stated that the right foot plantar wound measured 2.1 cm x 1.5 cm x 0.7 cm, had new tunneling 0.9 cm at 6 o'clock, and heavy sanguineous drainage was noted. The right foot had various tissues, including dermis (30%), granulation tissue (60%), and epithelium (10%).The UM stated that on 10/20/25, after the NPs reviewed the lab report and collaborated about the resident's right foot wound, orders were given to start the resident on an intravenous (IV) antibiotic (Linezolid 600 mg BID for 3 days, followed by 300 mg BID as recommended by pharmacist given patient's renal function (Creatinine Clearance, 27), and to obtain a magnetic resonance imaging (MRI) to rule out osteomyelitis. On 10/22/25 at 12:05 PM, during the interview with the UM she stated that the resident had not received any doses of the IV antibiotic. The recount revealed that Linezolid Intravenous Solution 600 MG/300ML (Linezolid) Was Used 600 mg intravenously twice daily for a foot infection for 3 Days. This dose was scheduled to start at 8:00 AM on 10/21/25 and end at 8:00 PM on 10/23/25. The UM confirmed that on 10/21/25 at 8:00 AM, the resident had IV access, and the medication was available for administration. Still, she was unable to state why the medication was not administered. A further review revealed that on 10/21/25, the 8:00 PM dose of Linezolid was not administered because the IV had been dislodged. On 8/22/25 at 8:00 AM, the resident did not receive the antibiotic because the IV access remained dislodged. An IV was inserted on 10/22/25 at 10:32 AM, but the antibiotic was not given. A 10/22/25 nurse's note at 1:00 PM stated the resident was to start the antibiotic that day, but it was not administered. On 10/23/25, a nurse's note at 1:30 PM stated that a consulting physician recommended discontinuing the antibiotic at that time and obtaining blood cultures and labs (ESR, CRP, arterial PVLs).A final interview was conducted on 10/23/25 at approximately 1:30 PM, and the above findings were shared with the Administrator, the Director of Nursing, a Corporate Consultant, and the [NAME] President of Operations. They had no comments and voiced no concerns regarding the above information.

Based on observations, family interview, staff interview, clinical record review and during the course of a complaint investigation the facility's staff failed to provide significant medications for 1 of 21 residents in the survey sample, Resident #117. The findings included: Resident #117 was originally admitted to the facility 11/25/2015 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; EPILEPSY, UNSPECIFIED, NOT INTRACTABLE, WITH STATUS EPILEPTICUS. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 09/15/2022 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired for daily decision making. In sectionG(Physical functioning) the resident was coded as requiring total dependence of two persons with bed mobility, transfers, dressing, toileting, personal hygiene and bathing. Requires total dependence of one person with eating. In section K (Swallowing/Nutritional Status) the resident was coded as having a feeding tube. Resident #117's Care Plan, revised on 9/22/22 reads that resident is dependent on TF (Tube Feedings) for nutrition and hydration. The goal set for the resident by the staff was that the resident will maintain adequate nutrition status as evidenced by stable weight without significant weight change through next review date. The interventions for Resident #117 should be Tube feeding and flushes as ordered. The POS (Physician Order Summary) August 2022: Dilantin Suspension 125 MG/5ML (Phenytoin) Give 3 ml via G-Tube three times a day for seizure disorder Phone Active 07/13/2022. Keppra Solution 100 MG/ML (LevETIRAcetam) Give 10 milliliter via G-Tube two times a day for seizure disorder Verbal Active 03/28/2022. Vimpat Solution 10 MG/ML (Lacosamide) Give 250 mg via PEG-Tube every 12 hours for Seizure Disorder Prescriber Written Active 02/01/2022. The POS for October 2022: Dilantin Suspension 125 MG/5ML (Phenytoin) Give 4 ml via G-Tube three times a day for seizure disorder Phone Active 08/23/2022. Ativan Solution 2 MG/ML (LORazepam) Inject 2 mg intramuscularly every 1 hours as needed for as needed for grand mal seizure; Call MD/NP if used -Start Date- 07/14/2022 1645. MAR Dilantin Suspension 125 MG/5ML (Phenytoin) Give 4 ml via G-Tube three times a day for seizure disorder -Start Date- 08/23/2022 2200 (10:00 PM) Missed doses: 9/17/22 (6:00 AM), 9/26/22 (6:00 AM), 9/25/22 (2:00 PM), 9/27/22 (6:00 AM). MAR Dilantin Suspension 125 MG/5ML (Phenytoin) Give 4 ml via G-Tube three times a day for seizure disorder -Start Date- 08/23/2022 2200 (10:00 PM) missed doses on the following dates: 10/02/22 (10:00 PM) 10/04/22 (10:00 PM) 10/10/22 (10:00 PM) 10/18/22 (6:00 AM), 10/19/22 (2:00 PM), 10/22/22 (2:00 PM), MAR (Medication Administration Record) Keppra Solution 100 MG/ML (LevETIRAcetam) Give 10 milliliter via G-Tube two times a day for seizure disorder -Start Date- 03/28/2022 2000 (8:00 PM) Missed dose: 8/27/22 (8:00 PM) MAR Vimpat Solution 10 MG/ML (Lacosamide) Give 250 mg via PEG-Tube every 12 hours for Seizure Disorder -Start Date- 02/01/2022 2100 (9:00 PM) Missed dose: 8/27/22 (9:00 PM). On 11/03/22 a phone call was made at approximately 4:35 PM., to OSM (Other Staff Member/Medical Director) concerning Resident #117 missed significant medications. He said that they have worked through those meds., The pharmacy issues were controlled by corporate but they are switching over to another pharmacy. We will switch pharmacy providers in afew weeks. The issue is ongoing.The pharmacy is six hours away which causes delays in care. He also addressed the Dilantin as being a short acting medication which can be crushed but the long acting Dilantin couldn't be crushed. He said that he didn't know about the Vimpat. Dilantin/Phenytoin is used to prevent and control seizures (also called an anticonvulsant or antiepileptic drug). It works by reducing the spread of seizure activity in the brain.https://www.webmd.com/drugs/2/drug-4157/dilantin-oral/details. Keppra/Levetiracetam is used to treat seizures (epilepsy). It belongs to a class of drugs known as anticonvulsants. Levetiracetam may decrease the number of seizures you have.https://www.webmd.com/drugs/2/drug-18053/keppra-oral/details. Vimpat/Lacosamide is used to treat partial-onset seizures. It is also used with other medicines to treat primary generalized tonic-clonic seizures. It acts on the central nervous system (CNS) to reduce the number and severity of seizures. However, this medicine cannot cure epilepsy and will only work to control seizures for as long as you continue to take it.https://www.mayoclinic.org/drugs-supplements/lacosamide-oral-route/side-effects/drg-20072409?p=1. According to the MAR Resident #117 was administered a prn dose of Ativan Solution 2 MG/ML (LORazepam) Inject 2 mg intramuscularly every 1 hour as needed for as needed for grand mal seizure on 7/14/22 at 2:45 PM. Ativan Solution 2 MG/ML (LORazepam) Inject 2 mg intramuscularly every 1 hours as needed for as needed for grand mal seizure; Call MD/NP if used -Start Date- 07/14/2022 1645 (2:45 PM). A review of the Medical Record does not show any nursing notes saying the seizure activity occurred. On 11/02/22 an interview was conducted at approximately 3:50 PM., with LPN (Licensed Practical Nurse) #2 concerning the residents medications. She said there was an issue getting the medications in on time. I made sure that I ordered it 7 days prior to her running out. The pharmacy delivery was terrible, they didn't have enough delivery drivers. She also said that they have a different delivery company now and everything is better. The husband said she was out of Keppra. The DON was getting the PO orders until the meds arrived. On 11/03/22 at approximately 5:50 PM., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. The DON said that the pharmacy was only sending five days worth of medications at a time. You would have to call them to get more Vimpat. We suggested that he (Husband) call his insurance company. Complaint deficiency

Based on observations, family interview, staff interview, clinical record review and during the course of a complaint investigation the facility's staff failed to obtain physician's orders for a Tube Feeder Strap for 1 of 21 residents in the survey sample, Resident #117. The findings included: Resident #117 was originally admitted to the facility 11/25/2015 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; POSTERIOR REVERSIBLE ENCEPHALOPATHY SYNDROME, TRACHEOSTOMY STATUS, ENCOUNTER FOR ATTENTION TO GASTROSTOMY. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 09/15/2022 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired for daily decision making. In sectionG(Physical functioning) the resident was coded as requiring total dependence of two persons with bed mobility, transfers, dressing, toileting, personal hygiene and bathing. Requires total dependence of one person with eating. In section K (Swallowing/Nutritional Status) the resident was coded as having a feeding tube. Resident #117's Care Plan, revised on 9/22/22 reads that resident is dependent on TF (Tube Feedings) for nutrition and hydration. The goal set for the resident by the staff was that the resident will maintain adequate nutrition status as evidenced by stable weight without significant weight change through next review date. The interventions for Resident #117 should be Tube feeding and flushes as ordered. The Care Plan does not mention a TF Strap (Tube Feeding Binder). A review of the POS (Physicians Order Summary) for November 2022 does not mention any orders for a TF Strap. A review of the MAR (Medication Administration Record) from August 2022 through September 2022 revealed no physician orders for a TF Strap. A review of the TAR (Treatment Administration Record) from August 2022 to September 2022 revealed no physician orders for a TF Strap. A review of the clinical record does not reveal that resident has a TF Strap. On 11/03/22 at approximately 10:25 AM an interview was conducted with the DON (Director of Nursing) concerning Resident #117. She said that the abdominal TF (Tube Feeder) Strap for the peg tube has no physician order nor is it care planned. She also said that the TF Binder has been placed on resident at least for six months. On 11/03/22 at approximately 12:00 PM an observation was made of Resident #117's Tube Feeding Binder with LPN (Licensed Practical Nurse/MDS/Minimum Data Set Nurse) #3. She said that it's called a Binder Strap for keeping the feeding tube from being pulled. She said that MDS should have been notified of the Binder Strap because her last MDS was done on 9/15/22. We should have found out the root cause. Then I would have checked to see. She also said if there had been an order for the TF Strap, it would have been flagged. A skin assessment should have been done. On 11/03/22 at approximately 4:35 PM., a telephone interview was conducted with the Facility Physician (OSM/Other Staff Member) #2 concerning Resident #117. He said that he wasn't aware that Resident #117 needed an order for the TF Strap. On 11/03/22 at approximately 5:50 PM., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided. This is a complaint deficiency!

Based on clinical record review, staff interview, facility documentation review and during the course of a complaint investigation, the facility's staff failed to follow physician orders to provide wound care for a resident for 1 of 21 residents (Resident #117), in the survey sample The findings included: Resident #117 was originally admitted to the facility 11/25/2015 and readmitted [DATE] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; POSTERIOR REVERSIBLE ENCEPHALOPATHY SYNDROME and TRACHEOSTOMY STATUS. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 09/15/2022 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired for daily decision making. In sectionG(Physical functioning) the resident was coded as requiring total dependence of two persons with bed mobility, transfers, dressing, toileting, personal hygiene and bathing. Requires total dependence of one person with eating. In section K (Swallowing/Nutritional Status) the resident was coded as having a feeding tube. Resident #117's Care Plan, revised on 9/22/22 reads that resident is dependent on TF (Tube Feedings) for nutrition and hydration. The goal set for the resident by the staff was that the resident will maintain adequate nutrition status as evidenced by stable weight without significant weight change through next review date. The interventions for Resident #117 reads provide tube site care as ordered. Date Initiated: 04/01/2020. The POS (Physician Order Summary) November 2022 reads: Peg tube dressing change q (every day) and prn as needed for if soiled or missing Phone Active 07/18/2022. Peg tube dressing change q day and prn every night shift for prevention. Phone Active 07/18/2022. A review of the November MAR (Medication Administration Record) Peg tube dressing change q day and prn (as needed) every night shift for prevention -Start Date 07/18/2022 1900 (7:00 PM). 11/01/22 checked, 11/02/22 not checked off. A review of the November MAR show that the dressing change for 11/01/22 was checked off as being done but a review of the MAR for 11/02/22 was not checked off as being done. On 11/01/22 at approximately 3:00 PM., during the initial tour Resident #117 was observed resting quietly in bed with her eyes open. LPN (Licensed Practical Nurse) #2 entered the room to administer the Resident's TF (Tube Feeding). An observation of the resident's peg tube dressing was made. No date or intials were marked on the dressing. LPN #2 said the night shift does the dressing changes unless the dressing is soiled or comes off. On 11/03/22 at approximately 5:50 PM., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. The DON said that the dressing should have been changed daily per doctor's orders and should have been initialed, dated and time written. This is a complaint deficiency!

Based on clinical record review, staff interview, facility documentation review and during a complaint investigation, the facility's staff failed to ensure 1 of 21 residents (Resident #117) in the survey sample received a complete and accurate assessment Minimum Data Set (MDS). The findings included: Resident #117 was originally admitted to the facility 11/25/2015 and readmitted [DATE] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; POSTERIOR REVERSIBLE ENCEPHALOPATHY SYNDROME and TRACHEOSTOMY STATUS. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 09/15/2022 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired for daily decision making. In sectionG(Physical functioning) the resident was coded as requiring total dependence of two persons with bed mobility, transfers, dressing, toileting, personal hygiene and bathing. Requires total dependence of one person with eating. In section K (Swallowing/Nutritional Status) the resident was coded as having a feeding tube. A Tube Feeding Strap was not coded. Resident #117's Care Plan, revised on 9/22/22 reads that resident is dependent on TF (Tube Feedings) for nutrition and hydration. The goal set for the resident by the staff was that the resident will maintain adequate nutrition status as evidenced by stable weight without significant weight change through next review date. The interventions for Resident #117 should be Tube feeding and flushes as ordered. The Care Plan did not mention a TF Binder (Tube Feeding Binder). A review of the POS (Physicians Order Summary) for November 2022 does not mention any orders for a TF Binder. On 11/03/22 at approximately 10:25 AM an interview was conducted with the DON (Director of Nursing) concerning Resident #117. She said that the abdominal TF binder for the peg tube has no physician order nor is it care planned. She also said that the TF Binder has been placed on resident at least for six months. On 11/03/22 at approximately 12:00 PM an observation was made of Resident #117's Tube Feeding Binder with LPN (Licensed Practical Nurse/MDS/Minimum Data Set Nurse) #3. She said that it's called a Binder Strap for keeping the feeding tube from being pulled. She said that MDS should have been notified of the Binder Strap because her last MDS was done on 9/15/22. We should have found out the root cause. Then I would have checked to see. She also said if there had been an order for the TF Strap, it would have been flagged. A skin assessment should have been done. On 11/03/22 at approximately 4:35 PM., a telephone interview was conducted with the Facility Physician (OSM/Other Staff Member) #2 concerning Resident #117. He said that he wasn't aware that Resident #117 needed an order for the TF Binder. On 11/03/22 at approximately 5:50 PM., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided. COMPLAINT DEFICIENCY

Based on clinical record review, staff interview, facility documentation review and during a complaint investigation, the facility's staff failed to revise one care plan for 1 resident of 21 residents (Resident #117) in the survey sample. The findings included: Resident #117 was originally admitted to the facility 11/25/2015 and readmitted [DATE] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; POSTERIOR REVERSIBLE ENCEPHALOPATHY SYNDROME and TRACHEOSTOMY STATUS. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 09/15/2022 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired for daily decision making. In sectionG(Physical functioning) the resident was coded as requiring total dependence of two persons with bed mobility, transfers, dressing, toileting, personal hygiene and bathing. Requires total dependence of one person with eating. In section K (Swallowing/Nutritional Status) the resident was coded as having a feeding tube. Resident #117's Care Plan, revised on 9/22/22 reads that resident is dependent on TF (Tube Feedings) for nutrition and hydration. The goal set for the resident by the staff was that the resident will maintain adequate nutrition status as evidenced by stable weight without significant weight change through next review date. The interventions for Resident #117 should be Tube feeding and flushes as ordered. The Care Plan does not mention a TF Strap (Tube Feeding Strap). On 11/03/22 at approximately 10:25 AM an interview was conducted with the DON (Director of Nursing) concerning Resident #117. She said that the abdominal TF binder for the peg tube has no physician order nor is it care planned. She also said that the TF Binder has been placed on resident at least for six months. On 11/03/22 at approximately 12:00 PM an observation was made of Resident #117's Tube Feeding Binder with LPN (Licensed Practical Nurse/MDS/Minimum Data Set Nurse) #3. She said that it's called a Binder Strap for keeping the feeding tube from being pulled. She said that MDS should have been notified of the Binder Strap because her last MDS was done on 9/15/22. We should have found out the root cause. Then I would have checked to see. She also said if there had been an order for the TF Strap, it would have been flagged. A skin assessment should have been done. On 11/03/22 at approximately 5:50 PM., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided. Complaint deficiency

Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility staff failed to provide pain management to include scheduled narcotic analgesics ([MEDICATION(S)] HCl 2 milligrams (mg) and [MEDICATION(S)] 25 mg) which resulted in frequent unnecessary and often excruciating pain, constituting harm for 1 of 47 residents (Resident #267), in the survey sample The findings included: The facility staff failed to provide scheduled around-the-clock pain medications to Resident #267, by failing to obtain and administer the prescribed narcotic analgesics ([MEDICATION(S)] HCl 2 milligrams (mg) and [MEDICATION(S)] 25 mg), they also failed to institute their protocol for obtaining controlled medication from their medication storage system (CUBEX) and to ensure the nurses were educated to obtain controlled and non-controlled medication from the storage system, which resulted in unnecessary and often excruciating pain, constituting harm. Resident #267 was originally admitted to the facility on [DATE] and readmitted on [DATE] after an acute care hospital stay. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 5 Day Medicare Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/16/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #267's cognitive abilities for daily decision-making were moderately impaired. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing, extensive assistance of two people with bed mobility, extensive assistance of one person with personal hygiene, dressing, and toileting, supervision after set-up with eating and transfers and locomotion occurred only once or twice. Resident #267 was interviewed on 7/6/22 at approximately 11:05 a.m. The resident was in bed holding her abdomen with her left hand. She spoke very softly and slowly and she presented with an extremely flat affect. Resident #267 stated she was very concerned because she wasn't receiving her medications and the staff told her it was because the pharmacy hadn't delivered her medications to the facility. Resident #267 stated she was experiencing stomach pain and she felt it was related to the stomach surgery she had while hospitalized . She stated the physician at the hospital stated she had a very odorous and infected stomach wound at the time she arrived at the hospital and it required surgical interventions to promote healing. Resident #267 stated at the time of the interview she was experiencing pain at a level of eight to nine out of a level of zero to ten and ten characterized as excruciating pain. Resident #267 stated she felt if she had received the [MEDICATION(S)] the pain would be more tolerable but they didn't have that either. On 7/7/22 at approximately 10:30 a.m., another interview was conducted with Resident #267, who was in bed and speaking very softly. The resident stated she was still experiencing stomach pain at a level of eight/nine out of ten and her nurse stated the pharmacy still hadn't delivered her medications. An interview was conducted with Licensed Practical Nurse (LPN) #9 on 7/7/22 at approximately 10:45 a.m. LPN #9 stated the resident didn't tell her she was experiencing pain but she would give her some Tylenol and Registered Nurse (RN) #4 was currently working with the pharmacy to deliver the resident's medications to the facility. An Interview was conducted with Registered Nurse #4 on 7/7/22 at approximately 2:20 p.m. RN #4 stated she transcribed the resident's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #4 stated the pharmacy stated there was a problem with how the medication orders were entered and then they were taken out therefore the orders couldn't be filled. RN #4 stated she re-entered the orders and the pharmacy promised to deliver the medications on 7/7/22 but on 7/8/22 at 5:00 p.m., they still hadn't arrived. RN #4 stated the pharmacy assured her the medications would be delivered on 7/9/22. This meant Resident #267 was without significant prescribed medications from the time of admission on 7/4/22 through 7/8/22. A review of the 7/4/22 hospital's discharge summary revealed the resident was diagnosed with an abdominal wall infection which required her to undergo an excisional debridement which revealed full-thickness necrosis. The 7/4/22 hospital's discharge summary revealed orders for [MEDICATION(S)] HCl ([MEDICATION(S)]) tablet 2 milligrams (mg); give one tablet by mouth every 4 hours for pain, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the CUBEX medications system list revealed [MEDICATION(S)] wasn't included in the CUBEX medication system but [MEDICATION(S)] 25 mg capsules were available. The resident didn't have a baseline care plan for her 7/4/22, readmission in the clinical record. An interview was conducted with the Director of Nursing (DON) on 7/12/22 at approximately 7:00 p.m. The DON stated the management team and the Medical Director were aware there were problems procuring medications in a timely manner and they began strategizing on backup pharmacies but it wasn't finalized. The DON also stated on average it is two days before a newly admitted resident's medications arrive at the facility from the pharmacy but most medications are available in the house stock or the CUBEX medication system. The DON also stated in Resident #267's case the nurse should have notified the Physician and or Practitioner that the [MEDICATION(S)] was available but required their authorization through the pharmacy and what they needed to do so she could obtain access to the narcotics in the CUBEX medication system. During the above interview, the DON stated that because [MEDICATION(S)] wasn't readily available in the CUBEX medication system the nurse should have shared with the Physician/Practitioner what similar medications were available so he/she could make a decision on which medication to prescribe until the [MEDICATION(S)] was delivered. The DON further stated the nurse should have informed the Physician and or Practitioner of the need for him/her to directly notify the pharmacy so the nurse could obtain the medication from the CUBEX medication system. The DON finally stated another problem in Resident #267's case was there was mostly contract staff rendering care on the unit and they were incompetent in using the CUBEX medication system to obtain medications. On 7/12/22 at approximately 8:00 p.m., the above findings were shared with the Administrator, Director of Nursing, and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided and no further concerns were voiced. [MEDICATION(S)] HCl ([MEDICATION(S)]) belongs to the group of medicines called narcotic analgesics (pain medicines). It acts on the central nervous system (CNS) to relieve pain. It is an extended-release capsule and extended-release tablets are used to relieve pain in opioid-tolerant patients severe enough to require around-the-clock pain relief for a long period of time. (https://www.mayoclinic.org/drugs-supplements/[MEDICATION(S)]-oral-route/description/drg- 171) [MEDICATION(S)] ([MEDICATION(S)]) capsules, oral solution (liquid), and extended-release (long-acting) tablets are used to relieve neuropathic pain (pain from damaged nerves) that can occur in your arms, hands, fingers, legs, feet, or toes if you have diabetes and postherpetic neuralgia [PHN; burning, stabbing pain or aches that may last for months or years after an attack of shingles] (https://medlineplus.gov/druginfo/meds/a 5.html)

Based on observations and staff interviews, the facility staff failed to provide food that was prepared by methods that conserved the nutritive flavor and appearance. The findings included: During the kitchen observations at 11:07 a.m. on 07/07/22 during the lunch meal preparation, the facility staff was noted to serve mixed vegetables, lasagna, garlic bread, strawberry short cake and several beverages. The lasagna was the main entree for the lunch meal. During the temperature checks and observations made of the lasagna, the appearance of the lasagna was noted to be burned (blackened) and crusted in appearance. The texture of the lasagna was rubbery and mushy. This surveyor tasted the lasagna and it was not pleasing. The lasagna had a burned taste. The lasagna was noted to have burned food participles. During an interview on 07/07/22 at 12:47 p.m. with Resident #6, he was asked about the lasagna lunch meal. Resident #6 stated the lasagna did not have an appeasing appearance nor did it taste that great. Resident #6 stated he only ate half of the serving. During an interview at 12:07 p.m. on 07/07/22 after three serving pans of the lasagna had been plated and carted to the floor, the cook was asked what happened to the lasagna. The cook stated, they had no aluminum foil to cover while cooking and the lasagna was cooked in direct heat which caused the food to have a burned and crusted texture and appearance. During an interview at 12:14 p.m. on 07/07/22 with the dietary manager. She stated that the supply truck did not have aluminum foil on it so we had to cook the food the best they could.

4. Facility staff failed to ensure Resident #6 did not acquire a Pressure area. Resident #6 was found to have two stage II pressure areas on 5/9/11. A stage II area was found on the right Trochanter and a stage II was found on her left Trochanter. Also found a stage II to the right hip. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A 2/11/11 Quarterly Minimum Data Set (MDS) assessed this resident as not being able to make self understood, in the area of Activities of Daily Living this resident was assessed as being total dependent on staff for bed mobility and transfers. Resident #6 was assessed as being incontinent of bowel and bladder. This resident was assessed as having one stage III pressure area and one stage IV pressure area. A 2/11/11 Pressure Ulcer Risk Assessment assessed this resident as being at high risk. A Care Plan dated 2/10/11 indicated: Problem- Skin/Tissue integrity impaired; Goal- will have skin intact for the 90 days; Approach- Turn and reposition Q 2 hours while in bed during the day Q 4 hours at night and PRN, use positioning and pressure devices, report any red or open areas, skin checks per facility policy. Facility policy indicated this resident assessed as being high risk should be assessed weekly. Facility staff originally was not able to provide weekly skin checks. A review of the updated facility weekly skin checks provided on 5/16/11 for the period from 4/4/11 through 5/9/11 did not indicate pressure ulcers for Resident #6. Observation of the Resident #6's wounds were made on 5/13/11 at 4:15 p.m. The right Trochanter was noted to have pigmented skin with the wound granulating-clear and pink. The left Trochanter was noted to be closed. A 5/9/11 physician's order indicated: "Cleanse stage II to right upper gluteal with DWC skin prep and cover with [MEDICATION NAME] q 3 days and PRN soilage." Resident #6 was observed during the survey laying in bed contracture almost in a fetal like position. She was outfitted with a left knee brace to keep her legs from being contractured. 5. Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility staff failed to ensure Resident #18 did not acquire a pressure area. Resident #18 acquired a stage II pressure area to the left gluteal area. A stage II pressure area was found on the left lateral foot. A Quarterly MDS dated [DATE] assessed this resident as not being able to transfer, required extensive assistance with bed mobility, and having no pressure ulcers. A Care Plan dated 3/22/11 indicated: Problem -Skin Integrity Impaired due to pressure wound; Goal- will have no increase in number of pressure wounds within the next 90 days. Approach- turn and reposition q 2 hours while in bed during the day; q 4 hours at night and PRN. Treatment per physician's orders, use positioning and pressure relieving device, monitor lab values as ordered, report any red or open area, skin checks per facility policy. Observation of the wounds made on 5/13/11 at 5:20 P.M. indicated left gluteal area has granulating tissue stage II not previously identified. The area of left lateral foot was Stage II, pink, shiny, granulating and encompassed a second area that unstageable with eschar but was all a part of the one wound. Review of weekly pressure area skin checks from 4/19/11 until 5/10/11 did not indicate but one wound for Resident #18, which was the left lateral foot wound with eschar. There were no weekly skin checks for the left Gluteal area. A 5/10/11 physician's order indicated: "cleanse left lateral foot with DWC apply Santyl prep and cover with [MEDICATION NAME] q d and PRN soilage until resolved. Off load heels (preventive)". A 5/13/11 physician's order indicated: "Apply moisture barrier topically after each incontinent episode." A 5/15/11 Pressure Sore Risk Assessment scored Resident #18 as a high risk for pressure sores. Resident #18 was observed in bed during the days of the survey. 6. Resident #19 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Quarterly MDS dated [DATE] assessed this resident as not able to make herself understood, this resident was assessed as requiring total assist with Activities of Daily Living. Resident #19 was assessed as being incontinent of bowel and bladder. In the area of Skin Conditions this resident was not assessed as having Pressure Ulcers. A 5/2/11 Care Plan indicated: Problem- Alteration in skin- left medial mall edus blister right gluteal; Goal- wound will be free of infection, Resident will have signs of [MEDICATION NAME] in wound bed and show evidence of healing. Observations made of the wound on 5/13/11 at 4:25 P.M. indicated: Left inner ankle stage II area scabbing, shiny, pink, granulating. A physician's order dated 5/9/11 indicated: treatment to left ankle DWC skin prep apply [MEDICATION NAME] dressing q 3 days and PRN soilage. Review of weekly skin checks did not contain information that Resident #19 was assessed for pressure area. 7. Resident #20 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #20 acquired a stage II pressure area to left rectum. A Quarterly MDS dated [DATE] assessed this resident as not able to make herself understood, this resident was assessed as requiring total assist with Activities of Daily Living. Resident #20 was assessed as being incontinent of bowel and bladder. In the area of Skin Conditions this resident was assessed as having Pressure Ulcers. A Care Plan dated 3/1/11 indicated Altered Skin Integrity examine skin during bathing for signs of irritation or breakdown. turn reposition q two hours during the day and q 4 hours at night. Observations of wound on 5/13/11 at 4:55 P.M. indicated: pinpoint open area adjacent to left rectum stage II. A physician order indicated: [MEDICATION NAME] cream to area no dressing. Review of weekly skin checks did not contain information that Resident #20 was assessed for pressure area. Found on 5/9/11 skin sweep. Based on observations, clinical record review and staff interview facility staff failed to ensure residents received the necessary treatment and services to promote healing, prevent infection, and prevent new pressure areas from developing for 7 of the 12 residents in the survey sample with pressure areas (Residents #15, #16, #11, #6, #18, #19 and #20). The findings constituted Substandard Quality of Care. The findings include: 1a. The facility staff failed to identify a pressure area on Resident #15's left heel before it developed into a stage IV pressure area (a full thickness of skin and subcutaneous (beneath the skin) tissue is lost, exposing muscle or bone). Clinical record review revealed, Resident #15 was a [AGE] year old female admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Her quarterly Minimum Data Set (MDS) assessment, dated 2/4/11 stated she had long and short term memory problems and made poor decisions. She was totally dependent on staff assistance for all activities of daily living. Her Braden Scale assessment, date 2/4/11 stated she was at high risk of developing pressure areas. A physician's progress note, dated 5/15/11 stated "pt (patient) remains weak, debilitated, cachectic (poor health, [MEDICAL CONDITION] and weight loss) and with severe flexion contractures (EXTREME) involving the (L) (left) hip & knee. Also contracted (R) (right) knee (with) (R) hip rotated medially (toward the midline of the body) & contracted..." The Resident Weekly Skin Check Sheet stated on 4/20/11 Resident #15 had "several areas to (L) leg (L) heel R & L gluteal (buttocks) groin Tx (treatment) in progress" There were no physician's orders, dated 4/20/11 for a treatment to the left heel area, which was documented on the Resident Weekly Skin Check Sheet. There were no treatments, dated 4/20/11 or 4/21/11 on the TAR. There were no nurse's notes describing the area on the resident's left heel. The Weekly Pressure Ulcer Condition Report stated a stage IV pressure area on the left heel was first observed on 4/22/11 (2 days after an area was first observed on the resident's left heel). The area measured 2.7 cm x 2.9 cm x 0.5 cm, 75% to 100% of the wound was covered by necrotic (dead) tissue, the skin surrounding the wound was bright red &/or blanched to the touch and there was minimal swelling around the wound. The nurse wrote the site was observed by the staff and orders were obtained from the physician. On 5/17/11 at 1:45 PM, the acting DON and the DDCO stated pressure areas should not present for the first time with eschar (necrotic tissue). A physician's order dated 4/22/11 said to cleanse the open area on the left heel with DWC, apply alginate (absorbs wound drainage and forms a gel around the wound) and cover with a dry dressing everyday. The stage IV area on the resident's heel was not documented on Pressure Ulcer Weekly Log, dated 4/27/11. A physician's order dated 5/9/11 said to cleanse the open area on the left heel with DWC, apply Santyl (debridement agent) and cover with a dry dressing everyday. The order also said the resident was diagnosed with [REDACTED]. The Weekly Pressure Ulcer Condition Report stated on 5/17/11 the stage IV pressure area on the left heel measured 2.7 cm x 3 cm x 1 cm with 1 cm of undermining, greater than 50% and less than 75% of the wound was covered by necrotic tissue, there was a small amount of bloody drainage, the skin surrounding the wound was dark red or purple &/or non-blanched to the touch, and there was minimal swelling around the wound. On 5/13/11 at 9:45 AM, the District Director of Clinical Operations (DDCO) stated that on 3/15/11 during her Performance Improvement (PI) review she noticed there were problems with the pressure area system. She said she identified the following areas of concern: 1. Braden Scale assessments were not consistently completed. She said a Braden Scale assessment should be completed on admission, weekly for 4 weeks after admission, quarterly and with a change of condition. 2. Care Plan interventions associated with the Braden Scale assessments were not put in place. 3. Treatments were not done according to the physician's orders. 4. Nutrition assessments were not consistently completed for resident's with skin integrity/impairment problems. 5. The physician and the responsible party were not consistently notified of changes in pressure areas. On 5/13/11 at 9:45 AM, the DDCO said she developed a PI plan to address the identified concerns with the pressure area system. The PI action plan, dated 3/15/11 said the following: 1. Validate Braden Scale assessments were completed on admission with care plan interventions implemented as needed. 2. Validate the registered dietitian completed nutrition assessments for resident's with skin integrity/impairment problems. 3. Validate treatments were done according to the physician's orders. 4. Validate care plans were revised as needed after skin sweep (skin assessments would be performed on all residents). 5. Validate the physician and the responsible party were notified of changes in pressure areas. 6. Validate weekly pressure area assessments were performed and were evaluated for the effectiveness of the treatment every 14 days. 7. Inservice licensed nurses as needed on the pressure area system. 8. The district wound nurse would work with the facility's wound nurse and make recommendations. On 5/13/11 at 9:45 AM, the DDCO said the previous Director of Nursing (DON) did not implement the PI action plan. She noted the PI action plan audits should have been implemented the next day. She said the assessment of all resident's skin condition was not done. The DDCO said she compared several different reports, and determined they were "not adding up". She said she re-wrote the PI action plan on 5/9/11 because they were not making as much progress as she would have liked. On 5/19/11 at 4:00 PM, the DDCO stated the certified nursing assistants (CNA) should observe the resident's skin condition everyday while providing care, and report any areas to the licensed nurse. She said the licensed nurse should complete a skin assessment, and notify the physician and responsible party of any areas. The DDCO said the licensed nurse should document the physician's order, and transcribe the order to the TAR. She said the physician's orders should be implemented and the care plan should be updated as needed. The DDCO said the wound care nurse and/or the change nurse should review the TAR everyday. The DDCO said new wounds and/or treatments should be recognized by the nurses during the TAR review. The DDCO said the interdisciplinary team should conduct clinical rounds every business day. She noted the interdisciplinary team included the DON, ADON, staff development coordinator, MDS nurse, skilled case manager (as needed), social worker, therapist (as needed), and wound care nurse. The team should review the 24 hour reports, the ADL flow sheets, the body checks, the TAR, lab test results (as needed) and infection control. The DDCO stated the facility staff should document any information, which needed follow up on the Clinical Rounds Follow Up sheet. The DDCO said a wrap up meeting should be held at 3:00 PM. The DDCO stated this system was put in place on 3/15/11, and re-implemented on 5/9/11. 1b. The facility staff failed to identify a pressure area on Resident #15's right great toe before it developed into a stage IV pressure area. As noted above, the skin condition of each resident was assessed on 5/9/11. A physician's order, dated 5/9/11 stated to apply skin prep to a pressure area on the resident's right great toe, and to apply heel protectors to both feet when in bed. The Weekly Pressure Ulcer Condition Report stated a stage IV pressure area on the right great toe was first observed on 5/10/11. The area measured 1.4 cm x 1 cm x less than 0.1 cm, 75% to 100% of the wound was covered by necrotic tissue, the skin surrounding the wound was pink, and there was pitting swelling extending less than 4 cm around the wound. There was no evidence in the clinical record, such as a nurse's notes describing an area on the resident's right great toe prior to 5/10/11. As noted above, on 5/17/11 at 1:45 PM, the acting DON and the DDCO stated pressure areas should not present for the first time with eschar. The Resident Weekly Skin Check Sheet stated that on 5/11/11 Resident #15 had "(L) heel L & R gluteal pressure areas". The stage IV pressure area, first observed on 5/10/11 was not documented on the Resident Weekly Skin Check Sheet on 5/11/11. 1c. The facility staff failed to ensure Resident #15 consistently received a treatment for [REDACTED]. The Weekly Pressure Ulcer Condition Report stated the resident had a stage II pressure area on the right buttocks/hip area, which was first observed on 9/1/10. On 11/24/10 the area measured 1.4 cm x 1.5 cm x 0.2 cm, less than 25% of the wound was covered by necrotic tissue, the skin surrounding the wound was pink and there was minimal swelling around the wound. A physician's order, dated 11/29/10 stated discontinue the treatment to the right buttocks. The order said to cleanse the right buttocks with DWC, apply Santyl and cover with a dry dressing everyday. On 11/29/10 a new pressure area was identified on the left buttocks/hip area. The physician ' s orders, dated 11/29/10 was handwritten. The orders had a " L " (for left) and a " R " (for right) written on top of each other, making it difficult to determine which pressure area the order was written for. Subsequent physician ' s orders stated the 11/29/10 physician ' s order was for the right buttocks/hip area. The 11/29/10 physician ' s order stated to discontinue the previous treatment orders. Since it was identified on 11/29/10, there was no previous treatment for [REDACTED]. A physician's order, dated 12/15/10 stated discontinue the Santyl to the right buttocks. The order said to cleanse the right buttocks with DWC, pack with [MEDICATION NAME] silver and cover with a dry dressing everyday. The Weekly Pressure Ulcer Condition Report stated that on 2/16/11 the resident had a stage III pressure area on the right buttocks/hip area. The area measured 0.5 cm x 1 cm x 0.6 cm, 25% to less than 50% of the wound was covered [MEDICATION NAME] (healing), the skin surrounding the wound was bright red &/or blanched to the touch and there was minimal swelling around the wound. There was no undermining. A physician's order, dated 2/21/11 stated to cleanse the right buttocks/hip area wound with DWC, apply Santyl to the wound bed and fill with calcium alginate filler everyday. The Weekly Pressure Ulcer Condition Report stated that on 4/6/11 the stage III pressure area on the right buttocks/hip area measured 0.7 cm x 1.5 cm x 0.8 cm, 50% to less than 75% of the wound was covered [MEDICATION NAME] extending to less than 5 cm into the wound bed, the skin surrounding the wound was bright red &/or blanched to the touch and there was minimal swelling around the wound. There was no undermining or necrotic tissue. The April 2011 TAR stated to cleanse the right buttocks/hip area wound with DWC, apply Santyl to the wound bed and fill with calcium alginate filler everyday. The treatment was initialed, indicating it was done everyday from 4/1/11 to 4/11/11. There was a hand written note on this TAR entry, which said the treatment was changed. Review of the physician's orders revealed there was no order to change the right buttocks/hip area treatment on 4/11/11. There was a handwritten entry on the April 2011 TAR, which said cleanse right buttocks/hip area with DWC, pack with Puracol and apply a dry dressing every 3 days. The entry was initialed every 3 days from 4/7/11 to 4/19/11. There was a handwritten note after the 4/19/11 TAR entry, which said "stop". There were no wound treatments on the TAR for the right buttocks/hip area from 4/20/11 through 4/30/11. Review of the physician's orders revealed there was no order to change the right buttocks/hip area treatment on 4/19/11. There were no wound assessments on the Weekly Pressure Ulcer Condition Report for 4/13/11 or 4/20/11. The Weekly Pressure Ulcer Condition Report stated that on 4/28/11 the pressure area (stage not documented) on the right buttocks/hip area measured 1.1 cm x 1.7 cm x 0.8 cm, with 0.7 cm of undermining, less than 25% of the wound was covered [MEDICATION NAME], the skin surrounding the wound was pink and there was minimal swelling around the wound. There was no necrotic tissue. The May 2011 TAR had a printed entry, which said cleanse the right buttocks/hip area wound with DWC, apply Santyl to the wound bed and fill with calcium alginate filler everyday. (As noted above, this physician's order was written on 2/21/11, and had not been changed). There was a hand written note on this TAR entry, which said the treatment was changed. The treatment was not initialed, indicating it was not done. There were no wound treatments on the TAR for the right buttocks/hip area from 5/1/11 through 5/8/11. The Weekly Pressure Ulcer Condition Report stated that on 5/10/11 the pressure area on the right buttocks/hip area was a stage IV. The area measured 1 cm x 2 cm x 1 cm, with 1 cm of undermining, less than 25% of the wound was covered [MEDICATION NAME], the skin surrounding the wound was pink and there was minimal swelling around the wound. There was no necrotic tissue. A physician's order, dated 5/9/11 said discontinue all previous treatment orders prior to 5/9/11 and start new treatment orders. The physician's orders, dated 5/9/11 said to cleanse the right buttocks/hip area wound with DWC, pack undermining with [MEDICATION NAME] Silver, apply [MEDICATION NAME] Silver to the wound bed and cover with a 2 x 2 gauze and [MEDICATION NAME] dressing everyday. A urinary catheter was placed to aid in wound healing. The Weekly Pressure Ulcer Condition Report stated that on 5/17/11 the pressure area on the right buttocks/hip area was a stage IV. The area measured 2.5 cm x 2 cm x 1 cm, with 1 cm of undermining, less than 25% of the wound was covered [MEDICATION NAME], the skin surrounding the wound was pink and there was minimal swelling around the wound. There was no necrotic tissue. On 5/20/11 at 11:50 AM, the district wound care nurse, Licensed Practical Nurse (LPN) #3 and the new facility wound care nurse, RN #1 were interviewed. They stated the physician's order written on 11/29/10 was not clear and should have been clarified. They said what was written on the physician's order sheet and the TAR was not the same. 1d. The facility staff failed to ensure Resident #15 consistently received a treatment for [REDACTED]. The Weekly Pressure Ulcer Condition Report stated the resident had a stage III pressure area on the left buttocks/hip area, which was first observed on 11/29/10. On 12/8/10 the area measured 2 cm x 2 cm x 0.5 cm, less than 25% of the wound was covered by necrotic tissue, the skin surrounding the wound was pink and there was minimal swelling around the wound. On 11/29/10 a new pressure area was identified on the left buttocks/hip area. The physician ' s orders, dated 11/29/10 was handwritten. The orders had a " L " (for left) and a " R " (for right) written on top of each other, making it difficult to determine which pressure area the order was written for. Subsequent physician ' s orders stated the 11/29/10 physician ' s order was for the right buttocks/hip area. The 11/29/10 physician ' s order stated to discontinue the previous treatment orders. Since it was identified on 11/29/10, there was no previous treatment for [REDACTED]. There were no physician's orders for treatments to the left buttocks/hip area from 11/29/10 through 4/7/11. There were no entries on the November 2010, January 2011 and March 2011 TAR for a treatment to the left buttocks/hip area. The December 2010 and February 2011 were not on the clinical record. The Weekly Pressure Ulcer Condition Report stated that on 3/24/11 the stage III pressure area on the left buttocks/hip area measured 3.5 cm x 2.8 cm x 0.8 cm, 50% to less than 75% of the wound was covered [MEDICATION NAME], the skin surrounding the wound was bright red &/or blanched to the touch and there was minimal swelling around the wound. There was no undermining or necrotic tissue. The Weekly Pressure Ulcer Condition Report stated that on 3/31/11 (1 week later) the pressure area on the left buttocks/hip area was a stage IV. The area measured 3.9 cm x 3 cm x 1 cm, less than 25% of the wound was covered [MEDICATION NAME], the skin surrounding the wound was bright red &/or blanched to the touch and there was minimal swelling around the wound. There was no undermining or necrotic tissue. The Weekly Pressure Ulcer Condition Report stated that on 4/7/11 the pressure area on the left buttocks/hip area was a stage IV. The area measured 4.2 cm x 3 cm x 1 cm, less than 25% of the wound was covered [MEDICATION NAME], the skin surrounding the wound was bright red &/or blanched to the touch and there was minimal swelling around the wound. There was no undermining or necrotic tissue. There was a physician's order, dated 4/7/11 to cleanse the left buttocks/hip area with DWC, pack with Puracol and apply a dry dressing every 3 days. There were no entries on the April 2011 TAR for a treatment to the left buttocks/hip area from 4/1/11 through 4/22/11. The Weekly Pressure Ulcer Condition Report stated that on 4/21/11 the pressure area on the left buttocks/hip area was a stage IV. The area measured 4.6 cm x 3.2 cm x 1.1 cm, less than 25% of the wound was covered [MEDICATION NAME], the skin surrounding the wound was bright red &/or blanched to the touch and there was non-pitting swelling extending less than 4 cm around the wound. There was no undermining or necrotic tissue. A physician's order, dated 4/22/11 said to cleanse the left buttocks/hip area with DWC and apply [MEDICATION NAME] dressing everyday. The April 2011 said to cleanse the left buttocks/hip area with DWC and apply [MEDICATION NAME] dressing everyday. The TAR was initialed on 4/23/11, 4/24/11, 4/26/11, 4/27/11 and 4/28/11 indicating the treatment was done. The TAR was not initialed on 4/25/11, 4/29/11 and 4/30/11 indicating the treatment was not done. The May TAR was initialed everyday from 5/1/11 through 5/8/11. The Weekly Pressure Ulcer Condition Report stated that on 5/10/11 the pressure area on the left buttocks/hip area was a stage IV. The area measured 5 cm x 3.6 cm x 1.1 cm, less than 25% of the wound was covered [MEDICATION NAME], the skin surrounding the wound was white or grey pallor of hypopigmented and there was minimal swelling around the wound. There was 2 cm of undermining. There was no necrotic tissue. A physician's order, dated 5/9/11 said discontinue all previous treatment orders prior to 5/9/11 and start new treatment orders. The physician's orders, dated 5/9/11 said to cleanse the left buttocks/hip area wound with DWC, apply [MEDICATION NAME] Silver to the wound bed and undermining prep, and cover with a [MEDICATION NAME] dressing everyday. As noted above, on 5/20/11 at 11:50 AM, the district wound care nurse, LPN #3 and the new facility wound care nurse, RN #1 stated the physician's order written on 11/29/10 was not clear and should have been clarified. They said what was written on the physician's order sheet and the TAR was not the same. They acknowledged there was 1 treatment and 2 wounds. 3. The facility staff failed to implement a pressure redistributing support surface (for the chair), and failed to follow the treatment order to prevent infection and promote healing of Resident #11's pressure ulcers. 3.A. Resident #11 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS (Minimum Data Set) with an assessment reference date of 3/15/11 indicated the resident had short term memory deficits and moderately impaired cognitive skills for daily decision making. Resident #11 required extensive assistance of 1 staff for bed mobility, transfers, eating, dressing, toileting and personal hygiene. The resident was occasionally incontinent of urine and frequently incontinent of bowel. Under skin conditions the resident was assessed as being at risk for pressure ulcers, and did not present with any pressure ulcers or skin breakdown. Under the skin and ulcer treatments section a pressure ulcer reducing device for chair and bed was checked. Review of the MDS Care Area Assessment Summary (CAA's) dated 3/21/11 evidenced the resident triggered for #16 pressure ulcers. The staff indicated that a care plan would be implemented for this identified care area. Review of the nursing admission assessment dated [DATE] evidenced a Braden scale- used for predicting pressure sore risk scored the resident a 20. A score greater than 15 indicated the resident was low risk. Subsequent Braden scales dated 3/15, 3/22, 3/29 and 4/6/11 evidenced the resident scored an 11, indicating the resident was at high risk for the development of pressure ulcers. Review of the initial care plan dated 3/8/11 evidenced the facility staff did not develop a care plan for prevention of skin breakdown. Review of the comprehensive care plan dated 3/21/11 indicated the facility staff identified the resident had a potential for impaired skin/tissue integrity. This care plan did not include the intervention/ approach for a pressure reduction device for the chair as identified in the comprehensive resident assessment MDS, to prevent/ reduce the development of a pressure ulcer. On 4/12/11 the facility staff revised a pressure ulcer care plan indicating the resident had developed an actual alteration in skin integrity due to urinary and bowel incontinence (a stage 2 sacral pressure ulcer). The goal was that the pressure ulcer wound would be free of slough or necrotic tissue (dead tissue), free of infection, show evidence of healing and covered with [MEDICATION NAME] tissue or resurfaced with new skin. The intervention/ approach for a pressure redistribution device for the bed/chair was left blank, not addressed and not checked off. The intervention/approach to turn and reposition as needed back to bed schedule was also not addressed. Review of the facilities pressure ulcer investigation form (in house acquired) dated 5/9/11 indicated the resident now had 2 stage 2 pressure ulcers to the sacral/coccyx area. The facility checked that appropriate pressure-reduction support surface(s) were consistently utilized. A new treatment was ordered to cleanse the open areas to the sacral /coccyx with dermal wound cleanser, apply Santyl (an enzymatic [MEDICATION NAME] agent), cover with Mepelix (an adherent dressing) every day and as needed if soiled. According to the facilities pressure ulcer weekly log dated 4/27 and 5/10/11 a pressure redistributing support surface (for the chair) was being utilized as a preventative pressure ulcer device/equipment. On 5/11/11 the resident was observed in her room sitting in a reclined Geri-chair at 8:40A.M,, 10:20A.M., 12:00P.M., 1:14P.M., and 1:40P.M., a total of 5 hours. The resident's position during each of these observations was unchanged. At 1:40P.M., the staff transferred the resident back to bed. There was no pressure-reduction/ redistributing support surface found on the Geri-chair or in the room. After transferring the resident back to the bed the CNA's (certified nurse aides) provided incontinent care. The resident's brief was wet with urine and feces. No dressings were observed on the resident's sacral/coccyx pressure ulcers. Both pressure ulcers were exposed, and unprotected from potential cross contamination from fecal material. The skin color surrounding both pressure ulcers (which were in close proximity of each other) was observed to be bright red measuring approximately 10 centimeters (CM) in diameter. Both wound beds were white/ yellowish in color. According to the facilities pressure ulcer weekly log dated 5/10/11, one of these pressure ulcers (both identified as on the sacrum) was staged as a III. A stage III pressure ulcer is described on the facilities pressure ulcer weekly log as a full thickness skin loss involving damage or necrosis of subcutaneous tissue, may extend down to but not through underlying fascia; and /or mixed partial & full thickness &/or tissue layers obscured by granulation tissue. 3.B. Review of the clinical record evidenced a physician order dated 5/9/11 that instructed the staff to discontinue the previous treatment to the sacrum that was ordered on 4/12 and 4/20/11. A new treatment was ordered to cleanse the open areas to the sacral /coccyx with dermal wound cleanser, apply Santyl (an enzymatic [MEDICATION NAME] agent), cover with Mepelix (an adherent dressing) every day and as needed if soiled. Both CNA's were interviewed (CNA#1 and #2) after transferring the resident back to bed. CNA #1 who was assigned to care for the resident stated that the resident did not have a dressing on prior to being transferred to the Geri-chair that morning. She stated that earlier one of the nurses (licensed practical nurse #8) told her that when the resident was returned to bed she would come

Based on staff interview, observations and record review, facility staff failed to implement its plan of correction for the quality deficiencies the facility identified related to pressure ulcer prevention, inaccurate assessment of risk, identification and treatment that resulted in an ongoing system failure. Multiple incidents of harm were identified for one resident and incidents of harm were determined for two additional residents. The findings constituted Substandard Quality of Care. The findings included: A meeting was conducted on 5/20/11 at 1:55PM with the facility Administrator who stated the QA (Quality Assurance Committee) was identified as PI (Performance Improvement). The Administrator stated the PI committee met monthly and the members included the Administrator, DNS (Director of Nursing Services), ADNS (Assistant Director of Nursing Services), Medical Director, Department Heads, Activities Director, Case Manager, MDS Coordinator, Staff Development Coordinator, Registered Dietitian, Wound Care Nurse, Chef, Housekeeping, Admissions, and a CNA (Certified Nursing Assistant). The Administrator stated the DNS was responsible for clinical operations and standards of care. The DNS reviewed standards of care and decreases in thresholds which were addressed in PI meetings. He stated the DNS was responsible for pressure ulcer tracking, assessment, evaluation of interventions, documentation and reporting at the PI meetings. He also stated skin assessment audits were being done on a continuing basis by the DNS but results were not reported in PI meetings. The Administrator stated on 3/15/11 the District Director of Clinical Operations (DDCO) developed a PI plan to address the identified concerns with the pressure area system. He stated the plan was reviewed with the DNS. He also stated he had relied on the DNS to implement and follow the plan. The Administrator said, "I did not realize it (the plan) was not working until the DDCO returned in May". He also stated, "PI did not work". Review of the 3/17/11 PI minutes evidenced the DNS reported "All w/i (with in) threshold" and "Skin Assessments Audits - All complete". The Wound Nurse reported 1 acquired pressure area/healing and skin assessment complete. The 3/15/11 PI plan developed by the DDCO was not included or addressed in the 3/17/11 PI meeting minutes. Review of the 4/15/11 PI minutes evidenced, "Noted acquired pressure wounds/all in compliance and in threshold for nursing" and "Skin assess - up-to-date. Corrective action to be done". The 3/15/11 PI plan developed by the DDCO was not included or addressed in the 4/15/11 PI meeting minutes. On 5/13/11 at 9:45 AM, the District Director of Clinical Operations (DDCO) stated that on 3/15/11 during her Performance Improvement (PI) review she noticed there were problems with the pressure area system. She said she identified the following areas of concern: 1. Braden Scale assessments were not consistently completed. She said a Braden Scale assessment should be completed on admission, weekly for 4 weeks after admission, quarterly and with a change of condition. 2. Care Plan interventions associated with the Braden Scale assessments were not put in place. 3. Treatments were not done according to the physician's orders [REDACTED]. 4. Nutrition assessments were not consistently completed for resident's with skin integrity/impairment problems. 5. The physician and the responsible party were not consistently notified of changes in pressure areas. On 5/13/11 at 9:45 AM, the DDCO said she developed a PI plan to address the identified concerns with the pressure area system. The PI action plan, dated 3/15/11 said the following: 1. Validate Braden Scale assessments were completed on admission with care plan interventions implemented as needed. 2. Validate the registered dietitian completed nutrition assessments for resident's with skin integrity/impairment problems. 3. Validate treatments were done according to the physician's orders [REDACTED]. 4. Validate care plans were revised as needed after skin sweep (skin assessments would be performed on all residents). 5. Validate the physician and the responsible party were notified of changes in pressure areas. 6. Validate weekly pressure area assessments were performed and were evaluated for the effectiveness of the treatment every 14 days. 7. Inservice licensed nurses as needed on the pressure area system. 8. The district wound nurse would work with the facility's wound nurse and make recommendations. On 5/13/11 at 9:45 AM, the DDCO said the previous Director of Nursing (DON) did not implement the PI action plan. She noted the PI action plan audits should have been implemented the next day. She said the assessment of all resident's skin condition was not done. The DDCO said she compared several different reports, and determined they were "not adding up". She said she re-wrote the PI action plan on 5/9/11 because they were not making as much progress as she would have liked. The DDCO stated this system was put in place on 3/15/11, and re-implemented on 5/9/11. Residents developed facility acquired pressure wounds and/or had worsening of existing wounds, as a result of a lack of prevention, failure to identify wounds at an early stage and failure to provide of treatment as ordered once wounds were identified. Previously unidentified wounds were found during observations during the survey. Please refer to F314 for information regarding pressure ulcers. The facility staff failed to ensure the PI Committee identified and addressed quality issues and implemented corrective action plans causing actual harm to facility residents as identified in this report.

Based on record review, and staff interview it was determined that facility staff failed to provide supervision and interventions consistent with one resident (Resident #8) in the survey sample of 34 residents needs to prevent a fracture. The findings include: Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #8 incurred a fractured left clavicle while being assisted with repositioning to prevent a fall. An X-ray report dated 2/11/11 at 2:40 PM indicated: "History pain and swelling, Left shoulder two views: Findings: There is an acute mid shaft slightly angulated but nondisplaced mid shaft fracture of the left clavicle. Mild degenerative changes are seen in the AC and glenohumeral joints. Impression: 1. Acute slightly angulated but nondisplaced mid shaft fracture of the left clavicle. 2. Mild degenerative arthritic changes of the AC and glenohumeral joints of the shoulder." Nursing notes dated 2/11/11 at 9:30 P.M. indicated: "Resident complained of extreme Left shoulder pain. Resident will not move arm at all. Resident shoulder is swollen no redness noted. MD office contacted and message left for doctor office concerning resident. Awaiting call back for any new orders. resident medicated for pain also will continue to monitor." Nursing noted dated 2/11/11 at 1:00 P.M. indicated: "New order X ray left shoulder due to pain and swelling." A Resident Event Report dated 2/11/11 (sis) no time given indicated: " Location- resident room, Event Nature transfer injury; Factors related to Event- While repositioning from wheel chair. Event Adverse Effect- fracture left clavicle. Resident in HH Lobby (Holiday Hall) went to stand fro wheelchair- almost tipped chair- 2 CNA's (Certified Nursing Assistant) witnessed- intervened before resident slid to floor- was grabbed under arms and assisted. Was sliding down in wheelchair, 3 people assisted resident up to prevent from sliding to floor. Complained of shoulder pain next day." Nursing note dated 2/11/11 4:15 P.M. indicated: "Spoke with resident x 2 today regarding shoulder pain, asked her if she had hit it or something. Stated she didn't remember hitting it, stated she was falling last night. Spoke with resident's CNA who worked with her, stated resident was sliding down 3 people assisted her up in the chair to prevent her falling, one hands under arms and 2 with legs and pants." A Nursing Admission assessment dated [DATE] indicated: "Oriented not confused, obeys commands, Alert, In the area of Functional Status- Total Dependent, 1 person assist, Equipment Options- Sling lifter. In the area of Falls Risk - Not disoriented, complacent, no sensory deficits, on medications that can cause hypotension, light headedness, dizziness, or meds such as hypotensive, psychotropics, diuretics, hypoglycemics, in the area of Safety awareness this resident was assessed as ambulates/transfers safely w/caregivers, episodes of sudden weakness, dizziness, unsteadiness w/position, Fall Risk Range (9) Minimum Risk." A `Nursing note dated 2/10/11 at 11:00 A.M. indicated: "Up in w/c with no discomfort alert to self, no seizure activity noted." A 2/4/11 Resident Progress Note indicated: "PT (physical therapy) /OT (Occupational therapy) continue for strengthening and endurance." A Physical Therapy Evaluation dated 12/16/10 indicated: Objective Patient present to PT s/p sepsis following UTI. She has been in NH since she was [AGE] years old and used w/c for mobility, patient has poor orientation. Long term goal- increased bed mobility, increased w/c mobility, increased w/c management." A Occupational Therapy Evaluation dated 12/2/10 indicated: Problem- ADL Transfer- Safety Awareness- increase safety awareness. Problem- strength, physical endurance safety, Goal increase strength, physical endurance and safety. Approach- Work Simplifying Techniques, Group Therapy, Therapeutic exercises/activities." A 12/10/10 Care Plan indicated: "Physical Mobility due to general debility- Approach- monitor for evidence of complications of immobility contractures, bed mobility with moderate assist, transfer with moderate assist. Potential for falls as related to MS -Approach- call light within reach and answered promptly, assistive devices as needed, clutter free environment, well fitted, no skid soled shoes/slippers/socks, anticipate needs, Falling Star Program as needed." During an interview on 5/18/11 at 3:15 P.M. with the CNA #4 she was asked if she could tell me about the 2/10/11 incident of Resident #8. A written report from CNA #4 dated 2/16/11 from the First Shift Unit Manager indicated: "Asked if she assisted a co-worker in pulling a resident up in bed - CNA #4 stated 'I do what I can, I try to help where needed'. Asked if she remembers assisting a co-worker in pulling someone up in wheelchair on (HH), somewhere near lobby or nursing station or around 2/10/11. This CNA stated, 'I don't remember any thing specific but I always do what I can.' Reviewed events as told by LPN #9 and an another CNA. CNA #4 responded that sounds like me but I don't remember who the person was, I always take trays to the dining room at the beginning of the shift and I pull people up all the time." During an interview on 5/18/11 at 3:30 P.M. with LPN #9 she was asked if she could tell me about the 2/10/11 incident involving Resident #8. A written report dated 2/11/11 from the First Shift Unit Manager indicated: "Asked staff of any falls in 24 hours on resident or any knowledge of injury of resident. LPN #9 stated the following in Face to Face interview. 'LPN #9 stated she was sitting on piano bench waiting for dinner trays to come, Resident #8 was on (HH) in her w/c in lobby in front of nursing station side going to dining room.' LPN #9 stated, 'Resident #8 leaned forward and w/c appeared to as if it were gonna tip forward.' I yelled, 'hey someone get her'. I ran to the resident and another CNA came from the kitchen/laundry hallway she had walked by 10 minutes prior with a food tray in her hand on the way to the kitchen. "I think her name was ('CNA #4') or it might have been the other CNA it happened so fast, I don't remember, but she came from one side and I on the right of Resident #8 we pulled her up in the chair, but she did not fall, the cart came out and I went to Butler Hall." During an interview on 5/17/11 at 10:30 A.M. with the Director of Physical Therapy she stated: "Based upon the written statements and the three staff person present, two staff should have approached Resident #8 facing her and placed their arms under her shoulder and the one remaining staff would assist by lifting her legs together in one motion. By the one staff grabbing her from the back and lifting her shoulders up this may have caused the shoulder to be injured. The better thing the staff could have done would have been to assist her to the floor and retrieved the appropriate transfer devices." On 5/19/11 the Assistant Director of nursing (ADON) was interviewed regarding this incident: "The ADON stated that based on the written reports, two staff should have taken Resident #8 under the arm pits and one staff should have taken her legs and with one motion repositioned her. By grabbing her from the back that put a lot of pressure on her shoulder area." A review of facility guidelines for Positioning The Resident, indicated: Procedure-In a wheelchair- a. Position yourself in front of the resident and instruct the resident to place their feet flat on the foot rests of the wheelchair or flat on the floor. B. Instruct the resident to fold their arms at the waist. C. Move to a position directly behind the wheelchair and hold the resident's wrist from behind. D. instruct the resident to push on the footrests or floor with their feet while using your body weight and momentum to gently assist the resident into the new position. The following is information from a publication on proper wheelchair transfer technique. "B. Steps in a two-person transfer 3. The lifter at the back (of the person in the wheelchair) should put his or her arms under the person's shoulders and around the person's chest with arms folded across the person's chest... 5. The shorter lifter at the side places both arms undet the person's thighs in order to support the buttocks and lower legs. Clasp one hand to wrist for firm grip." Transferring. Center on Aging Studies, University of Missouri. Website address: http://cas.umkc.edu/casww.transfrg.htm A review of the facility records indicated that all three nurses involved in the transferring of Resident #8 received In-service Training on 2/11/11 in the area of Transfer/Ambulation despite there lack of remembrance regarding this incident. The staff received inservice training in Resident Mobility and Safety as well as Transfers/Ambulation.