Every finding on record at Nassawadox Rehabilitation and Nursing

Based on observations and staff interviews, the facility staff failed to create a dignified dining experience for 16 of 17 residents residing on the Memory Unit. The findings included: From 6/9/26 through 6/11/26, during breakfast and midday meals, 16 residents in the Memory Unit were provided with disposable plastic cutlery. One resident was also observed receiving meals in a disposable plastic container. On 6/11/26 at approximately 4:20 PM, an interview was conducted with Certified Nursing Assistant (CNA) #10. CNA #10 stated that a resident who had previously resided on the unit attempted to poke others with a fork, and the administrative staff instituted the use of disposable cutlery. CNA #10 also stated that the use of a disposable container for the resident was initiated because the resident had a habit of eliminating urine and feces onto the standard meal trays after meals. On 6/11/26, at approximately 4:30 PM, the above information was provided to the Administrator, Director of Nursing, [NAME] President of Operations, and the Regional Nurse Consultant. They were given an opportunity to provide additional information, but they did not.

Based on resident and staff interviews, the facility failed to provide residents with the right to have reasonable access to the use of a telephone. This had the potential to affect 114 of the 114 residents who resided in the facility.The findings included:Resident #7 was originally admitted to the facility 8/3/2024. The current diagnoses included chronic obstructive pulmonary disease, muscle weakness, type 2 diabetes mellitus with diabetic neuropathy, and essential hypertension.The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/10/26 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #7's cognitive abilities for daily decision making were intact.On 6/10/26 at 2:00 PM while conducting the Resident Council task, Resident #7 and the consensus of the residents stated that residents do not have reasonable access to a telephone. Resident #7 stated that there is no telephone access on the nursing units for residents and no phone throughout the entire facility for the residents to have access to make a private phone call.On 6/10/26 at 4:12 PM an interview was conducted with Licensed Practical Nurse (LPN) #2. LPN #2 stated that she is not familiar with the process of residents having access to a telephone for private calls. LPN #2 also stated that she found out today that there is a phone in the Admissions office.On 6/10/26 at 4:24 PM an interview was conducted with the Admissions Director. The Admissions Director stated that residents can use her work phone during the day. The Admissions Director also stated that the residents do not have access to the telephone at night. The Admissions Director further stated that cordless phones have been ordered however the Administrator knows the details regarding the order.On 6/10/26 at 4:31 PM an interview was conducted with the Administrator. The Administrator stated that the facility had phones in the past however they are not currently operating. The Administrator also stated that the facility has ordered new phones however they have not been delivered to the facility. The Administrator further stated that he is not sure of the deliver date however he can call the corporate office and get an answer. On 6/10/26 at 5:00 p.m. a final interview was conducted with the Administrator, Director of Nursing, and Regional Clinical Director. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

Based on a clinical record review and staff interviews, the facility's staff failed to ensure that 1 of 64 residents (Resident #9) did not have as needed Lorazepam ordered for use for greater than 14 days. The findings included: Resident #9 was admitted to the facility on [DATE]. The resident's current diagnoses included a stroke and heart failure. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 5/25/2026, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 8 out of 15. This indicated that Resident # 9's cognitive abilities for daily decision-making was moderately impaired. On 6/11/26 at approximately 4:05 PM, Resident #9's medication review was completed. The resident had an order dated 5/24/2026 for Lorazepam. The Lorazepam order lacked a stop date, and the clinical record contained no documentation from the physician and/or prescribing practitioner that the resident had been evaluated regarding the appropriateness of continuous as needed use of Lorazepam. As of 6/11/26, the resident had been continuously prescribed the medication. The Social Worker stated that the resident's family wanted him to continue the prescribed hospice medication, but he was not to be admitted to hospice services at that time. On 6/11/26, at approximately 4:30 PM, the above information was provided to the Administrator, Director of Nursing, [NAME] President of Operations, and the Regional Nurse Consultant. They were given an opportunity to provide additional information, but they did not.

Based on observations and interviews with staff and the resident, the facility staff failed to manage pain for 1 of 64 residents (Resident #4) in the survey sample.The findings included: Resident #4 was admitted to the facility on [DATE]. The resident's current diagnoses included heart failure and diabetes. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 4/22/26, coded the resident as not having completed the Brief Interview for Mental Status (BIMS). The staff interview indicated that the resident had no short- or long-term memory problems and demonstrated independent decision-making abilities. On 6/11/26, at approximately 3:30 PM, Resident #4 was observed in bed lying on his back. Certified Nursing Assistant #2 assisted the resident in repositioning to reveal the wound on his lower back. The resident grimaced and bit down on his teeth. The resident stated he was experiencing 10 out of 10 pain, and it was what he experienced whenever he moved. The resident stated that he can assist the staff more when he turns to the right, but he experiences significant pain when he turns to the left. The resident further stated that the pain is the reason he prefers not to be repositioned An interview was conducted with Registered Nurse (RN) #7 on 6/11/26 at approximately 3:50 PM. RN #7 stated that Resident #4 received scheduled pain relievers and had not voiced any additional pain concerns. On 6/11/26 at approximately 4:30 PM, the above information was shared with the facility's team. The Corporate nurse stated that they were aware of the resident's pain during turning and repositioning, and they had already notified the provider to obtain pain management orders. The Corporate nurse acknowledged that the wound care had not been completed daily as ordered.

Based on information received during the infection control task, and staff interviews, the facility staff failed to provide and document each staff member's COVID-19 education. The findings included: On 06/11/26 at 1:00 pm information for investigation of the staff COVID 19 task was provided by the Infection preventionist (IP). The IP offers the COVID - 19 vaccines to all the staff and documentation that supports the staff declination of the vaccine. The IP stated that they had no documentation that the staff were given COVID -19 vaccine education. The IP could not provide the education which was acknowledged by any of the staff. On 6/11/26 at 1:26 pm the IP manager provided the facilities Infectious disease COVID-19 preparedness policy. Also, the IP was unable to provide education or documentation that all staff had been offered the education on COVID-19 vaccine. On 6/12/26 at approximately 2:15 pm, a final interview was conducted with the Administrator, Director of Nursing, Corporate Consultants. The above findings were conveyed to the administrative team, who made no comments and voiced no concerns.

Based on a review of the clinical record and staff interviews, the facility staff failed to ensure that the Hospice Agency provided them with the coordinated plan of care, visit notes, and other pertinent information for 1 of 64 residents (Resident #11) in the survey sample.The findings included: Resident #11 was originally admitted to the facility 4/6/2018. The current diagnoses include Alzheimer's Disease. The quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 3/2/26, coded the resident as unable to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long-term and short-term memory problems, as well as severe impairment for daily decision making. In section O, the resident was coded for Hospice care. The person-centered care plan dated 9/8/25 had a problem, which stated she was receiving hospice services for end-stage Alzheimer's disease. The goal stated that the resident would be kept comfortable and her needs would be met through the next review. The interventions included collaborating with all disciplines, family, and Hospice to meet resident needs and maintain comfort, contact with the Hospice physician, family, and the resident regarding comfort level. On 6/11/26, at approximately 10:00 AM, Registered Nurse #7 stated that Resident # 11's hospice aide had no specific time of arrival, but she believed that she visited three days each week. RN #7 also stated that the hospice nurse visited the resident multiple times each week. RN #7 stated that both the aide and the nurse provided a report after each visit before leaving, but she was unaware of the services they routinely provided during those visits. The facility staff was unable to locate documentation in the facility describing Resident #11's hospice program, including which disciplines would make visits and what services they would provide. The facility staff was also unable to locate the hospice plan of care, the treatment plan, how, what, and when the nursing facility staff was to communicate with the hospice staff, and whether to transfer the resident, if a change in condition was identified. Some staff thought there was a hospice notebook, but it was later stated that there was never one. On 6/11/26, at approximately 4:30 PM, the above information was provided to the Administrator, DON, [NAME] President of Operations, and the Regional Nurse Consultant. The Corporate Consultant stated that the Hospice agency was sending the requested documents to the facility.

Based on observation, interview and facility documentation, the facility staff failed to ensure the resident's right to share a room with his or her roommate of choice, for 1 resident (R14) in a survey sample of 64 residents.For Resident 14 (R14) the facility staff did not attempt to ensure compatible roommates. R14 was admitted to the facility on [DATE] with diagnoses of but not limited to COPD (Chronic Obstructive Pulmonary Disease), diabetes type 2 chronic kidney disease, dialysis dependent, heart failure, obstructive sleep apnea, malignant neoplasm of colon, acquired absence of bilateral lower limbs. presence of implanted cardiac defibrillator, ischemic cardiomyopathy, and hypertension. R14's most recent MDS (Minimum Data Set) with an ARD(Assessment Reference Date) of [DATE] coded R14 as having a BIMS (Brief Interview of Mental Status) score of 14 out of 15 indicating no cognitive impairment. R14 was coded as requiring assistance with all aspects of care except for eating. R14 uses an electric wheelchair for locomotion in the facility and is oxygen dependent. On [DATE] an interview was conducted with R14 who stated his last five roommates were hospice. He stated that he would like a roommate he could communicate with and that wouldn't be gone in a few weeks. He stated, that's not good for me up here. (He tapped his fingers on the side of his head). R14 stated that he had multiple illnesses that were life threatening including heart failure and kidney failure, as well as having his legs removed because of gangrene. Resident 14 was asked if he thought his mental health had suffered because of it and he stated, not yet. R14 stated that he is a positive person who likes to participate in activities and is the President of Resident Council. He stated that he would like a roommate more compatible with himself. On [DATE] at approximately 2:00 PM an interview was conducted with the Social Worker who stated that R14 was incorrect and the last 5 roommates were not Hospice. The Social Worker indicated that 1 roommate discharged home, 2 roommates died and 2 (including the present roommate) were hospice. She stated she could see how he would get the impression The social worker stated that R14 is a particular resident to be his roommate, however that resident does not want to be his roommate. The social worker stated that she could see how it could possibly affect his mental health. On [DATE] during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on interview, clinical record review and facility documentation the facility staff failed to report in a timely manner allegations of abuse, neglect and mistreatment for 1 resident (R123) in a survey sample of 64residents.For R123 the facility staff failed to submit the five day follow-up for a resident to resident altercation. This incident was reported to the OLC (Office of Licensure and Certification) the day it occurred 4/27/25. The incident involves a physical altercation between R122 and R123. R122's BIMS score at the time of the incident was nine out of a possible 15 indicating moderate cognitive impairment. R123's BIMS score was three out of a possible 15 indicating severe cognitive impairment. At the time of the investigation R123 was sitting in the hallway. R122 was the aggressor and had a stainless-steel butter knife threatening R123. The incident report stated that the staff were engaged in picking up meal trays when they heard a commotion R122 was heard yelling profanity at R123. R123 was heard yelling She's gonna kill me. Staff heard the butter knife hit the floor before they got to the residents. The incident report states that the two residents were separated and neither was injured. The incident states [NAME] was treated for injuries. The staff currently employed, including the Administrator and Director of Nursing, are new at the job and were not there at the time of the incident. Staff that were employed at the time of the incident do not remember who [NAME] is. They were not sure if [NAME] was staff or resident and were not sure if [NAME] was a first or last name. Of the three residents with either first or last name [NAME], 2 do not remember such an incident and the third resident has a BIMS score of 4 and was unable to participate in the interview. R122 was placed on 1:1 monitoring and evaluated by psych and had medications adjusted. The Interim Administrator provided the investigation documents and upon review it was found although the initial report was submitted via fax to all the appropriate individuals (OLC, Ombudsman, APS, Law Enforcement, MD & RP's notified) there was no 5 day follow-up submitted. On 6/9/26 at approximately 2:00 p.m an interview was conducted with the Administrator who stated it is facility policy to submit within 2 hrs any allegation of abuse that involves harm or injury. When there is no injury we have 24 hrs to do the reporting. He further stated that either way it is reported and then an investigation takes place, and the results are sent in a five day follow-up report. On 6/11/26 a review of the facility abuse policy revealed the following excerpts: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Policy Explanation and Compliance Guidelines:1. The facility will develop and implement written policies and procedures that:a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property;b. Establish policies and procedures to investigate any such allegations; andc. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention; andd. Establish coordination with the QAPI program . A. The facility will have written procedures that include:1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, orb. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury . B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. On 6/12/26 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation, interview, and facility documentation the facility staff failed to maintain an effective pest control program for 3 out of 3 units.The findings included: For three of three units the facility failed to ensure the facility was free of pests. On 6/08/2026 at 8:11 PM, During observations of Resident #46 flies were observed in the room. On 6/08/2026 at 8:16 PM, Resident #86 (R86) was observed sitting in doorway of their room with flyswatter, swatting flies. R86 was observed every day of survey swatting flies with fly swatter. During the five days of survey, flies were observed on every unit, as well as in dining room, activities, resident rooms and kitchen. On 6/9/26 an interview was conducted with the Maintenance Director who stated that he believed that the flies were coming in from the doors being opened and closed frequently due to renovation crew coming in and out.On 6/10/26 a review of the pest control logs revealed that although they had pest control services the facility did not follow the recommendations of the pest control comapany to keep the pest under control.The following are recommendations made by the pest control company9/26/25 -Type Structural -Responsibility: Door gap/ damage noted that allows pest access. Please repair to prevent pest entry.1/6/26 - TypeStructural Cracks along the building exterior allowing pests to enter Please repair to prevent pest entry.2/3/26 - Type : Equipment -Responsibility: Insect light trap is not working properly. We suggest purchase of new bulbs for effective control. On 6/10/26 at 9:30 am surveyor walked the exterior of building and found the same problems that the pest control company found, There were cracks around entrances, the loading dock door does not meet the frame at the bottom (garage style door) the bottom of the frame has rotting wood in need of repair. On 6/10/26 at 1:pm an interview with the maintenance director revaled that he did not have an invoice for the new vector light bulbs for pest control. The Maintenance Director stated that he, thought the pest control company provided them. On 6/12/26 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation, interview and clinical record review the facility staff failed to ensure residents received routine dental care for one resident (Resident #2-R2) in a survey sample of 64 residents. The findings included: For R2 the facility staff failed to ensure the residents had routine dental care. R2 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Intracranial injury, fracture of fibula, repeated falls, anxiety disorder, dementia, epilepsy, post-traumatic stress disorder, bipolar disorder, anoxic brain damage, adult failure to thrive and hypertension. R2's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/28/26 coded R2 as having a BIMS (Brief Interview of Mental Status) score of 8 out of a possible 15, indicating moderate cognitive impairment. R2 is coded as requiring assistance with all aspects of ADL (Activities of Daily Living) to include bathing, dressing, grooming and toileting. R2 uses a wheelchair for locomotion in the facility. On 6/9/26 R2 was observed with missing teeth in the front. Missing front teeth makes pronouncing some words or letters more challenging. R2 was observed eating meals with no obvious difficulty. R2 was unable to follow the questions during interview due to cognitive status. A review of the clinical record revealed no evidence of prior dental work. An interview was conducted with RN 1 who stated the facility has a list of who will be seen when the dental and vision doctors come. The social worker keeps the list. RN 1 stated that if a resident requests or family member requests they can get an appointment. When asked how often they should see a dentist she stated the residents should be seen at least yearly. RN1 could not find evidence of this resident being seen by the dentist in the past year. A review of the facility policy on Outside Resources revealed the following excerpt:Pg12. The facility assumes responsibility for obtaining services that meet professional standards and principles that apply to professionals providing services.3. The facility assumes responsibility for the timeliness of the services provided by those professionals. On 6/9/26 during the end of day meeting the Administrator was made aware and no further information was provided.

Based on observations and staff interviews, the facility's staff failed to follow proper medication destruction procedures for one of twenty-five medications observed during medication administration observations.The findings included: On 6/11/2026 at approximately 12:08 PM, Registered Nurse (RN) #3 approached RN #7 with a tablet in her hand. RN #3 stated that the resident didn't accept the medication when she went to administer it. RN #3 dropped the Norco tablet in RN #7's sharps box and asked her to sign the witnessing of the destroyed tablet. An interview was conducted with RN #3. RN #3 stated that she made an error destroying the tablet in the sharps box. She stated that the proper method for destroying a medication was to place it in the activated carbon formula, which was kept in the medication room. On 6/11/26, at approximately 4:30 PM, the above information was provided to the Administrator, Director of Nursing, [NAME] President of Operations, and the Regional Nurse Consultant. The facility staff was given an opportunity to provide additional information, but they did not.

Based on facility observation and staff interviews, the facility failed to ensure that the required daily staffing postings were displayed in a prominent location readily accessible to residents, staff, and visitors. Findings included:On 6/11/26 at 11:30 a.m., the daily staffing posting was observed in the lobby on a bulletin board leaning against the wall. The posting was dated 5/20/26. On 6/12/26 at 1:13 p.m., the daily staffing posting remained dated 5/20/26. On 6/12/26 at 1:15 p.m., an interview was conducted with the Staffing Coordinator and the Director of Nursing (DON). Both confirmed that posting the staffing information was the responsibility of the Staffing Coordinator. The Staffing Coordinator acknowledged that the staffing posting had not been updated. On 6/12/26 at approximately 2:15 p.m., a final interview was conducted with the Administrator, Director of Nursing, and Regional Team. The above findings were presented to the administrative team. No comments were offered, and no concerns were voiced.

Based on observations and staff interviews, the facility staff failed to maintain appropriate care and services for an indwelling catheter for 1 of 64 residents (Resident #37) in the survey sample.The findings included: Resident #37 was admitted to the facility on [DATE]. The resident's current diagnoses included obstructive uropathy. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 3/13/2026, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 11 out of 15. This indicated that Resident #37's cognitive abilities for daily decision-making was moderately impaired. In section H of the MDS assessment, the resident was coded as having an indwelling catheter. The current care plan had a problem, which stated the resident had an indwelling catheter. The goal stated that the resident would be free from catheter-related trauma and urinary tract infection (UTI) through the review date. The interventions included: catheter care every shift and as needed, and positioning the catheter bag and tubing below the level of the bladder. On 6/8/26, at approximately 7:30 PM, Resident #37 was observed with the indwelling catheter tubing coming up and over his pant waist as he rested in bed. On 6/10/26 at 10:40 AM, the resident was observed strolling in the hallway. Again, the resident had the indwelling catheter tubing up and over his pant waistband. On 6/11/26 at approximately 1:10 PM, an interview was conducted with the resident. The resident stated that no device was used to secure the indwelling catheter, and he didn't recall staff educating him on why the catheter tubing should be positioned downward rather than upward. On 6/11/26 at approximately 4:30 PM, the above information was shared with the facility's team. The Corporate nurse stated that it was the resident's preference, and he was noncompliant with proper catheter tubing use. The Corporate nurse reported on 6/12/26 at approximately 11:00 AM that the resident allowed application of an anchor the evening before, and it was still in place that morning.

Based on observations and staff interviews, the facility staff failed to provide care and services for a pressure wound affecting 1 of 64 residents (Resident #4) in the survey sample.The findings included: Resident #4 was admitted to the facility on [DATE]. The resident's current diagnoses included heart failure and diabetes. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 4/22/26, coded the resident as not having completed the Brief Interview for Mental Status (BIMS). The staff interview indicated that the resident had no short- or long-term memory problems and demonstrated independent decision-making abilities.The wound care order stated to change the dressing daily; cleanse it with a wound cleanser, apply calcium alginate and Santyl, then apply a border dressing. The current care plan had a problem dated 5/31/26, stating that the resident had an unstageable pressure ulcer on the right heel and another on his left lower back. The goal stated that the pressure ulcers will show signs of healing and remain free from infection by/through review date. The interventions included administering treatments as ordered, observing for effectiveness, and assessing/recording/monitoring wound healing weekly. Measure length, width, and depth when possible. Assess and document the status of the wound's perimeter, wound bed, and healing progress. On 6/11/26, at approximately 3:30 PM, Resident #4 was observed in bed lying on his back. He stated that the nurse came in early in the morning and stated she was there to complete the dressing on his foot, but she didn't mention the dressing on his back. With staff's assistance the resident was repositioned to reveal the wound to his lower back. The dressing over the wound was soiled and dated 6/9/26. An interview was conducted with Registered Nurse (RN) #7 on 6/11/26 at approximately 3:50 PM. RN #7 stated that Resident #4's wound care is provided on the night shift; therefore, she had no knowledge of the last time the wound was dressed. On 6/11/26 at approximately 4:30 PM, the above information was shared with the facility's team. The Corporate nurse stated that wound care to the lower back was provided and that the wound looked good. The Corporate nurse acknowledged that the wound care had not been completed daily as ordered.

Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to ensure residents receive the necessary services to maintain, adequate grooming, and personal hygiene for 1 residents in a survey sample of 64 residents.The findings included:For Resident #46 (R46) the facility failed to ensure he received timely incontinence care and showers twice a week. R46 was admitted to the facility on [DATE] with diagnoses that included but were not limited to alcohol dependence / alcohol induced mood disorder, unspecified dementia, dysphagia, cognitive communication deficit, hypothyroidism, and chronic kidney disease stage 3A. R46's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/9/26 scored the resident with a BIMS (Brief Interview of Mental Status) score 15 out of possible 15 indicating no cognitive impairment. R46 was coded as 06 Independent for most ADL's, supervision for walking on uneven surfaces or gravel walkway. He does not use a walker or a wheelchair. A review of the care plan revealed that the resident can move in bed, ambulate, shower, and eat independently. Observations of R46 include the following: On 6/08/2026 at 8:11 PM, Resident #46 was observed lying on bed tv on strong smell of urine and body odor, and flies were noted in the room. Resident was wearing a shirt with visible food stains on it. On 6/09/2026 at 1:57 PM, Resident #46 was observed with a strong odor of ammonia / urine in room. On 6/8/26 at 8:15 pm an interview was conducted with R46 who stated that he does not need assistance with bathing, dressing or grooming. On 6/9/26 at approximately 2:20 pm an interview was conducted with CNA 2 (certified nursing assistant) who stated that A beds [Residents by the door] get showers on Monday and Wed. On Tues & Thurs B bed [residents by the window] get showers. CNA2 also stated that R46 needs reminders and cues to get showered. She stated that, he can do it [shower] himself if he wants to. CNA2 stated that she could smell the odor of strong urine in the room. A review of the care plan revealed that the resident can move in bed, ambulate, shower, and eat independently this was initiated in July of 2025 and has not been re-evaluated since. On 6/9/26 at approximately 3:00 pm an interview was conducted with the Psychiatric NP (Nurse Practitioner) who stated that neglecting hygiene could be a symptom of depression, however, it could also be dementia related not remembering that showering is necessary, not remembering how to complete the task. When asked if the progression of could change the resident's ability to complete tasks of ADL (Activities of Daily Living) she stated that it could and would change over a year's time. A review of the ADL record revealed that in the month of April 2026, R46 received two of the nine showers scheduled, one of eight scheduled showers in May of 2026, and zero of the four scheduled showers for June. A review of the policy for ADL care revealed the following excerpts:ADL Care Policy pg. 22. The facility will provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment.3. 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.4. The facility will identify resident triggers through the Care Area Assessment (CAA) process to assess causal factors for decline, potential decline or lack of improvement.5. The facility will maintain individual objectives of the care plan and periodic review and evaluation. On 6/10/26 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to review and revise the care plan by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, for two residents (R46 and 9 ) in a survey sample of 64 residents. For R46 the facility staff failed to review and revise the care plan for ADL (Activities of Daily Living). R46 was admitted to the facility on [DATE] with diagnoses that included but were not limited to alcohol dependence / alcohol induced mood disorder, unspecified dementia, dysphagia, cognitive communication deficit, hypothyroidism, and chronic kidney disease stage 3A. R46's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/9/26 scored the resident with a BIMS (Brief Interview of Mental Status) score 15 out of possible 15 indicating no cognitive impairment. R46 was coded as 06 Independent for most ADL's, supervision for walking on uneven surfaces or gravel walkway. He does not use a walker or a wheelchair. A review of the care plan revealed that the resident can move in bed, ambulate, shower, and eat independently. A review of the ADL record revealed that in the month of April 2026, R46 received two of the nine showers scheduled, one of eight scheduled showers in May of 2026, and zero of the four scheduled showers for June. On 6/9/26 a review of R46's care plan for ADL care read: A review of the care plan revealed the following: FOCUS: Resident is at risk for ADL self-care performance deficit r/t Dementia Date Initiated: 07/21/2025 Created on: 07/21/2025GOAL : The resident will maintain current level of function in ADLs/mobility through the review date. Date Initiated: 07/21/2025Revision on: 03/26/2026 INTERVENTION: BATHING/SHOWERING: Avoid scrubbing & pat dry sensitive skin. Date Initiated: 01/20/2026BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse.Date Initiated: 01/20/2026BATHING/SHOWERING: The resident is able to complete task independently. Date Initiated: 07/21/2025 Revision on: 07/21/2025. Policy: The facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. This includes the resident's ability to: 1. Bathe, dress, and groom; 2. Transfer and ambulate; 3. Toilet; 4. Eat; and 5. Use speech, language or other functional communication systems. Policy Explanation and Compliance Guidelines: 1. Conditions which may demonstrate unavoidable decline in ADLs include a. Natural progression of the resident's disease state. b. Deterioration of the resident's physical condition associated with the onset of a physical or mental disability while receiving care to restore or maintain functional abilities. c. Refusal of care and treatment by the resident or his/her surrogate to maintain functional abilities. 2. The facility will provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment. 3. 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. 4. The facility will identify resident triggers through the Care Area Assessment (CAA) process to assess causal factors for decline, potential decline or lack of improvement. 5. The facility will maintain individual objectives of the care plan and periodic review and evaluation. 6. Nursing staff will record care as it is provided in PCC POC and advise the charge nurse of any issues or concerns. TIPS FOR IMPROVING OR MAINTAINING ADL SKILLS Expecting resident to perform ADL's and allowing the time for the resident to complete the procedure Training of nursing staff in restorative care concepts Involvement of the therapy or restorative nursing personnel to retrain resident Responding to decline in ADL skills as a change in medical condition Evaluating reasons for decline in ADL skills Setting goals for the resident to achieve and providing rewards when the goal is accomplished Involving family members in the plan to help resident become more independent Involving the resident in recreational activities that provide motivation for improvement Helping resident to maintain contact with friends and community members ADL interventions have not been reviewed/revised or re-evaluated for effectiveness since implementing them in July of 2025. On 6/10/25 the Administrator was made aware of the concerns and no further information was provided. 2. The facility's staff failed to review and revise the resident's care plan as his condition changed. Resident #9 was admitted to the facility on [DATE]. The resident's current diagnoses included a stroke and heart failure. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 5/25/2026, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 8 out of 15. This indicated that Resident # 9's cognitive abilities for daily decision-making was moderately impaired. A review of Resident #9's person-centered care plan revealed that he had a left hip wound. A review of the active physician orders failed to reveal a treatment for a left hip wound. The resident had an enhanced barrier precautions sign outside his door. An interview was conducted with the wound care nurse on 6/11/26 at approximately 2:10 PM. The wound care nurse stated that the resident's wound healed on 6/2/26, and the enhanced barrier precautions sign should have been removed. On 6/11/26, at approximately 4:30 PM, the above information was provided to the Administrator, Director of Nursing, [NAME] President of Operations, and the Regional Nurse Consultant. The facility staff was given an opportunity to provide additional information, but they did not.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure a safe, clean, comfortable homelike environment for 3 out of 3 units.For residents on 3 out of 3 units the facility failed to ensure the facility was free of pests, offensive odors On 6/08/2026 at 8:11 PM, Resident #46 (R46) was observed lying on bed tv on strong smell of urine and body odor. Flies were observed in the room. On 6/10/2026 at 11:43 AM, an interview with Resident #46 was conducted. R46 was asked about the three bags of clothing in room. The resident said there is nowhere to put them, when aAsked if he would like staff to help him put them in the closet, he said There is no way to do it. There is nothing to put them on. The surveyor opened the closet and found no rod was present to hang clothes . R46 stated we can't even hang a towel by the sink there were the brackets but no towel rod as well. On 6/10/26 at 1:00 p.m an interview was conducted with Maintenance Director who stated that the CNA's and Nurses should be reporting repair issues. When ask if he knew about the need of repairs in R46's room he stated that he was new and the former maintence person might have known about it, but he did not. On 06/08/2026 at 8:16 PM, Resident #86 was observed sitting in doorway of his room in a chair with flyswatter, swatting flies. The resident declined an interview. Resident #86 was observed every day of survey swatting flies with fly swatter. During the five days of survey, flies were observed on every unit, as well as in dining room, activities, resident rooms and kitchen. On 6/9/26 an interview was conducted with the Maintenance Director who stated that he believed that the flies were coming in from the doors being opened and closed frequently due to renovation crew coming in and out. On 6/12/26 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observations and interviews with residents and staff, the facility staff failed to ensure that the call bell was accessible to 1 of 64 residents (Resident #23) in the survey sample. The findings included: Resident #23 was admitted to the facility on [DATE]. The resident's current diagnoses included metastatic cancer and heart failure. The significant change Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 5/28/26, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 15 out of 15. This indicated that Resident # 23's cognitive abilities for daily decision-making were intact. On 6/11/26 at approximately 4:05 PM, Resident #23 verbally called out for assistance. She stated that she was wet, including her clothing and bed linens. The resident was asked to use the call bell to contact the facility's staff. The resident attempted to reach the call bell on the left side of the bed, but she couldn't. Registered Nurse (RN) #3 was notified of the resident's need for assistance. At approximately 4:25 PM, the resident was heard verbally calling out for assistance again. Resident #23 stated she couldn't locate the call bell. It remained in the same location as before, outside of the residents' reach. The resident stated that the nurse had come in and said she would have her Certified Nursing Assistant (CNA) come to provide care, but the resident had not been cared for. On 6/11/26, at approximately 4:30 PM, the above information was provided to the Administrator, Director of Nursing, [NAME] President of Operations, and the Regional Nurse Consultant. They were given an opportunity to provide additional information, but they did not.

Based on interview, clinical record review and facility documentation the facility staff failed to ensure residents are free from abuse of any type by anyone, for one resident, Resident #86 (R86) in a survey sample of 64 residents. The findings included:R86 was admitted to the facility on [DATE] with diagnoses that included alcohol dependence, schizophrenia, hypertension, dementia with behavioral disturbance, major depressive disorder, and personal history of suicidal behaviors. R86's most recent MDS (Minimum Data Set) coded R86 as having a BIMS (Brief Interview of Mental Status) score of 11 out of a possible 15 indicating moderate cognitive impairment. R86 is able to complete all aspects of ADL (Activities of Daily Living) with cues and reminders. A review of his care plan revealed is is combative with staff and refuses showers and refuses to change clothing. A review of the clinical record revealed the following entry in the progress notes 4/5/26 at 6:48 pm- resident had a resident to resident, MD notified, DON notified, 1-1 in place. resident was moved to a different room L31A. The following are excerpts from the attending physician on 4/6/26 at 12:30 p.m. Patient was involved in a resident-to-resident incident with behavioral disturbance. No increased agitation or aggression noted during today's visit. When discussed regarding the details of the incident, he was unable to elaborate due to his cognitive impairment. Currently maintained on quetiapine 100 mg PO at bedtime. Patient has not had any recent changes in medication. Will continue current antipsychotic regimen and monitor closely for behavioral changes. Patient is alert and oriented x2 per baseline. He was involved in a resident-to-resident incident with behavioral disturbance. He was placed in an alternative room and put on a one-to-one for additional supportive services. No acute distress noted during examination today. Continue current management with close monitoring for behavioral changes 4/6/26 at 2:06 pm Psych NP [Nurse Practitioner name redacted] Resident seen by [NP name redacted] via tele-med. NP stated resident did not need 1:1 at this time,-Begin 15 monitoring and she would follow up in house tomorrow. On 4/6/26 3:45 pm the DON ( Director of Nursing) entered a note that read 1:1 re-initiated for safety. On 4/7/26 at 3:12 pm the following was entered by the Social Worker: Resident was reviewed during weekly risk meeting following an allegation of physical aggression toward another resident on 4/5/26. No injuries were sustained by this resident. Resident stated he was just playing with the other resident at first. He stated when the resident came into his room to beat him up he then hit/beat the resident up. This resident has a BIM's of 6. His diagnoses include Schizophrenia Dementia and major depression. Psychiatric consult was completed via zoom. [R86's name redacted] was put on 1-1 until seen by the psych provider or ordered. No further behaviors or concerns have been observed since the incident. His care plan has been updated. Resident RP was informed of the investigation. Social service will follow up to support resident psychosocial wellbeing. A review of the care plan revealed that R86's care plan was updated to include 1:1 monitoring and psych eval. Post evaluation by psych the 1:1 was changed to 15 min monitoring. The facility completed an investigation and follow-up as well as notification of the appropriate agencies. A review of clinical record revealed that this resident had resident to resident altercations in the past as well as making verbal threats to other residents. On 6/8/26 an interview was conducted with the facility Social Worker and the DON who stated that they have been trying find alternative placement, but no one wants him due to his aggressive behavior. The DON stated they are going to keep him on close monitoring. On 6/8/26 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on record review and staff interviews, the facility failed to ensure the services of a Registered Nurse (RN) for a minimum of eight consecutive hours per day, seven days per week, as required.The findings included:A review conducted on 6/11/26 of the facility's daily worked schedules revealed that the facility did not provide RN coverage for at least eight consecutive hours during the 24-hour period on 5/31/26. Payroll records for 5/31/26, provided by the Regional Human Resources Manager, confirmed the absence of RN coverage on that date. During an interview on 6/12/26 at 9:12 a.m., the Staffing Coordinator confirmed that no RN was scheduled or worked on 5/31/26. In a separate interview on 6/12/26 at 9:20 a.m., the Director of Nursing also confirmed that the schedule for 5/31/26 did not include RN coverage. On 6/12/26 at approximately 2:15 p.m., a final interview was conducted with the Administrator, Director of Nursing, and Regional Team. The above findings were presented to the administrative team. No comments were offered, and no concerns were voiced.

Based on a complaint investigations, observations, clinical record review, staff interviews and facility document review the facility staff failed to ensure 3 of 7 residents in the facility with pressure ulcers were provided the necessary treatment and services to ensure that pressure ulcers were not identified at advanced stages for Resident #85, Resident #339 and Resident #291, which constituted harm for all three residents. For Resident #85 the facility staff failed to provide the necessary care and services to include weekly skin assessments, turning and repositioning and pressure relieving devices to ensure a pressure ulcer was not first identified at a Stage 3, who was assessed as a high risk for developing pressure ulcers. For Resident #339 the facility staff failed to ensure the necessary treatment, care and services were provided to prevent the development of a large unstageable, infected pressure ulcer with necrotizing/dead tissue of the sacrum from developing. For Resident #291 the facility staff failed to identify a sacral wound pressure ulcer prior to advancing to unstageable measuring 5 centimeter x 5 centimeter x 2 centimeter (cm). The wound was infected requiring antibiotic therapy and surgical debridement (removal of dead tissue). For 1 out of 7 residents with pressure ulcers, the facility staff failed to assure bilateral pressure reducing boots were in place at all times. The findings included: 1. The facility staff failed to provide the necessary care and services to include weekly skin assessments, turning and repositioning and pressure relieving devices to ensure a pressure ulcer was not first identified at a Stage 3 for Resident #85, who was assessed as a high risk for developing pressure ulcers, which constitutes harm. Resident #85 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #85's most recent Minimum Data Set (MDS) was a Significant Change Assessment with an Assessment Reference (ARD) of 4/28/22. The Brief Interview for Mental Status (BIMS) was unable to be completed, however Resident #85 was coded as being severely cognitively impaired for daily decision making. Under Section G Functional Status, Resident #85 was coded as requiring extensive one person physical assistance for bed mobility and totally dependent with one person physical assist for bathing. Under Functional Limitation In Range of Motion the resident was identified with lower extremity impairment on both sides. Under Section M Skin Conditions, Resident #85 was identified as being at risk for pressure ulcer injury and having one Stage IV pressure ulcer. Resident #85's last three Braden Scales for Predicting Pressure Sore Risk assessments were reviewed. On 7/26/21 the resident was identified as being VERY HIGH RISK with a score of 9. On 4/20/22 Resident #85 was identified as being MODERATE RISK with a score of 14 and on 5/7/22 she was a HIGH RISK with a score of 12. On 5/11/22 the following observations were made of Resident #85: 1. 05/11/22 09:30 a.m. the resident was observed lying on her right side facing the wall. Also there were no bilateral heel protectors in place. 2. 05/11/22 12:25 p.m. the resident was observed lying on her right side facing the wall. Also there were no bilateral heel protectors in place. 3. 05/11/22 2:09 p.m. the resident was observed lying on her right side facing the wall. Also there were no bilateral heel protectors in place. On 5/12/22 at 9:30 a.m. an interview was conducted with Certified Nursing Assistant (CNA)#3 who care for Resident #85 on 5/11/22 during the 7-3 shift in regards to the above observations. CNA #3 stated, I did come in her room yesterday and pulled her up in the bed and pulled her towards the rail to relieve pressure. She was on her right side facing the door. She likes the right side so I never put her on her left side. She used to have heel protectors but I didn't see them in here yesterday to put them on her. I wasn't sure if she was still using them. On 5/12/22 at 9:50 a.m. a wound care observation of Resident #85's right great toe was conducted with Licensed Practical Nurse (LPN) #3, who was the facility wound nurse. LPN #3 stated, The resident's wound was first identified as a Stage 3 pressure ulcer and was facility acquired. Resident #85 was lying on her right side facing the wall. Upon pulling Resident #85's sheet back to expose her right great toe pressure ulcer the resident's left heel was noted lying on top of her right great toe. Both of Resident #85's lower legs and knees were contracted and the left heel was lying on the right great toe pressure ulcer. There were no observed bilateral heel protectors in place for Resident #85. Resident #85's right great toe pressure area was on top of the toe and distal from the nailbed. The pressure ulcer was approximately the size of a dime. The wound bed was beefy red with a pinpoint yellow center and there was no odor or signs of infection noted. The resident was noted to be lying on an air mattress. LPN #3 also stated, She (Resident #85) is supposed to be rotated every 2 hours. She favors the right side, but should be turned. Also I don't know why she doesn't have her heel protectors on, they help relieve the pressure to her feet due to her contractures. A review of Resident #85's electronic medical record was conducted. Resident #85's Weekly Pressure Wound Observation Tool dated 2/22/22 revealed a first observation facility acquired Stage 3 right great toe pressure area measuring 1.7 cm (centimeters) X 2 cm. X .2 cm. On the Weekly Pressure Wound Observation Tool dated 3/1/22 Resident #85's right great toe pressure area was documented as a Stage 4. All Weekly Pressure Wound Observation Tools from 3/8/22 to present show right great toe pressure ulcer improvement. During the medical record review the resident had a documented weekly skin review dated 7/22/21. The next documented weekly skin review was not completed until 3/30/22, then completed weekly to present day. Resident #85's Comprehensive Care Plan last revised 5/11/22 was reviewed. The Comprehensive Care Plan indicated the resident was at risk for skin integrity impairment related to incontinence, Alzheimer's and decreased mobility. The care plan had also been revised to include a pressure ulcer to her right great toe. Interventions put in place for Resident #85 included an air mattress on 1/5/22, to float bilateral heals on 2/11/22, to follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #85's Integrated Wound Care Notes were reviewed and revealed the following. On 2/22/22 an Initial Progress Note indicated that Resident #85 was being seen for a right great toe pressure ulcer. The right great toe pressure ulcer was documented as a Stage 3 measuring 1.7 cm X 2 cm X .2 cm. The treatment was honey alginate and dry dressing with skin prep to the periwound every other day and as needed. On the 3/1/22 Follow-up Progress the right great toe was documented as a Stage 4 measuring 1.4 cm X 1.6 cm X 0.2 cm with a 1.6 cm tunnel at 12 o'clock. The pressure ulcer presented with 50% granulation tissue with exposed tendon present. The Wound Nurse Practitioner (NP) performed a sharp debridement to the right great toe pressure ulcer (Sharp surgical debridement. is removal of the source of [CONDITION(S)], mainly necrotic tissue-https://www.ncbi.nlm.nih.gov/books/NBK 2/). The Wound NP was seeing Resident #85 weekly since 2/22/22. On 5/17/22 at 1:00 p.m. an interview was conducted with the Director of Nursing (DON) in regards to Resident #85's current Stage 4 right great toe pressure ulcer. The DON stated, When I started I realized we had quite a few acquired pressure ulcers. On 2/22/22 we did a whole building skin sweep and discovered multiple residents with wounds. On Name (Resident #85) we discovered a Stage 3 to her right great toe and had the Wound NP see her that day as well. We started reviewing each resident for orders and put interventions in place. We found that Name (Resident #85) had not had a documented weekly skin assessment completed since 7/21/21. The weekly skin assessments were started back and I started a skin report for the CNA's to completed to report any new identified skin issues which are given to the charge nurse and they both have to sign it. Also I did not see where we were documenting she was being turned and repositioned every 2 hours. She has an air mattress, weekly skin assessments, weekly Wound NP visits, a fortified diet and supplements in place to aid in wound healing and her wound is improving. The DON was made aware of this surveyors observations of Resident #85 on 5/11/22. The DON stated, The resident is to be turned every 2 hours and her heel protectors should have been in place due to her contractures. If they were not in the room the CNA should have went down to laundry or central supply for another pair. I will have to re-educate. On 5/20/22 at 12:30 p.m. a phone interview was conducted with the Wound Nurse Practitioner regarding Resident #85's current Stage 4 right great toe pressure area. The Wound Nurse Practitioner stated, There was a skin sweep on 2/22/22 and I was there that day. A Stage 3 right great toe pressure ulcer was identified on Name (Resident #85). She was very high risk for developing skin pressure ulcers. She had bilateral upper and lower extremity contractures and dementia. The staff should be checking her skin during showers. Residents should be assessed and wounds should be identified prior to the being found at an advanced stage. A Stage 3 is an advanced stage pressure ulcer. On 5/20/22 at 2:45 p.m. a phone interview was conducted with the Medical Director regarding Resident #85's current Stage 4 right great toe pressure ulcer. The Medical Director stated, We should really be identifying pressure ulcers at advance stages especially if the resident has been identified as a high risk for developing pressure ulcers. Doing weekly skin checks, personal care, and checking the skin during showers/bathing we should have found the pressure area before it was an advanced stage. On 5/19/22 at 9:20 a.m. the above findings were shared with the Administrator and the Director of Nursing. The Director of Nursing stated, The weekly skin checks should have been performed. Also the preventative measures should be followed for turning and repositioning and heels protectors. I expect that skin impairment be found early at a Stage 1, not at an advanced stage, so that treatment can start early before increased tissue damage occurs. Prior to exit no further information was shared. 2. The facility staff failed to ensure the necessary treatment to prevent the development of a sacral pressure ulcer that was initially identified at an advanced stage (unstageable with 100% necrotic/dead tissue) resulting in harm for Resident #339. Resident #339 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #339 clinical record review revealed a Braden Scale for Predicting Pressure Sores Risk Assessment as being completed on 11/19/21 as being at RISK. On 11/25/21 a clinical record review revealed a second Braden Scale for Predicting Pressure Sores Risk assessment was completed as being at Moderate risk. The admission, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/23/2021 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #339 cognitive abilities for daily decision making were intact. The Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/14/21 reads: M0210. Unhealed Pressure Ulcers/Injuries. Does this resident have one or more unhealed pressure ulcers/injuries? Yes. Unstageable - Slough and/or eschar. Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar? 1. Number of these unstageable pressure injuries that were present upon admission/entry or reentry=0 (none). M1200-Skin and Ulcer Treatments: Pressure reducing device for bed: Checked off. Pressure ulcer care: Checked off. Applications of dressings to feet (with or without topical medications): In section G (Physical functioning) the resident was coded as requiring extensive of assistance of one person with bed mobility and personal hygiene, total dependence of one person with transfers, dressing, toilet use and bathing, independent set-up help with eating. The Care plan dated 12/1/21 read, Focus: The resident has an ADL (Activity of Daily Living) self-care performance deficit. Goal: The resident will maintain current level of function through the review date. Intervention: Reposition (FREQ) and as necessary to avoid injury. Monitor/document/report PRN (as needed) any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. The Care plan dated 12/9/21 read, Focus: Resident at risk for impaired skin integrity and actual open area to sacrum r.t (relating to) incontinence, impaired mobility and dementia. Goal: The resident will maintain or develop clean and intact skin by the review date. The care plan dated 12/09/2021, read the resident will have no complications r/t area to sacrum through the review date, air mattress as per physician orders. The care plan revision dated 01/27/2022 read, avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the clinical record Resident #339 was admitted to the facility on [DATE] at 6:38 PM. The skin assessment noted resident to have only red areas to bilateral upper extremities from blood draws from the hospital. The clinical record dated 11/20/2021 at 12:12 PM., reads: Resident is AAOx3 (Alert and Oriented x three to person, place, and time) with no complaints voiced. Resident is incontinent of bladder, requiring assistance from staff. \ A review of the hospital discharge summary dated 11/18/21 reveal no pressure ulcers were present before being transferred to the LTC (Long Term Care) facility. A review of the Long Term Care Facility's History and Physical dated 11/23/21 reveal no pressure ulcers were present on admission. Daily Nursing Skin Assessments document dated 11/18/21 read, skin is intact. A review of the ADL (Activity of Daily Living) document for December 2021 reveal that Resident #339 received bed baths from 12/01/21 through 12/08/21 with no notation of skin integrity problems, but according to the nursing notes Resident #339's wound was identified on 12/03/21 by the CNA (CNA #7). A review of the nurse's note dated on 12/03/21 (3:45 PM) read: CNA (Certified Nurse's Aide) #7 notified me (LPN #13, no longer employed at the facility) of area to sacrum. Assessed resident noted open area to sacrum with slough noted. Cleaned area and applied dressing change every 3 days/prn (as needed) until healed. RP (Responsible Party) made aware and placed in communication book. Wound nurse also made aware. The nurse's note dated on 12/5/2021 at 9:00 AM., read, Resident with pain, when asked where she pointed to her sacral area. The nurse's note dated on 12/9/2021 at 12:23 PM., read, Resident being turned every 2 hours from side to side to prevent pressure to sacral area as per order; dressing with serosanguinous drainage, dressing reapplied as needed, skin care given. The nurse's note dated 12/15/2021 at 4:29 PM read that the MDS (Minimum Data Set staff) was in with resident to obtain pain interview for scheduled quarterly for managed care stay. Resident stated that over the past 5 days she has had frequent bottom pain r/t to her wound and that at times it makes it hard to sleep and limits her day to day activity. The nurse's note dated on 12/17/2021 at 8:27 PM revealed that the Resident was medicated for comfort due to dressing change to sacrum, and that the resident was moaning. The nurse's note dated on 12/18/2021 at 10:30 AM read: Resident nonverbal, starring up at the ceiling, and displaying facial grimacing and moaning. VS: 97.3-103-20-114/52. SATS 94% RA. BS: 127. Resident being sent out to ER for further evaluation. 11:20 AM., 911 at the facility to transport resident to local emergency room /ER for further evaluation. The clinical record dated on 12/18/2021 7:57 PM., reads that Resident #339 was admitted to the local hospital for [CONDITION(S)], [CONDITION(S)], necrotizing tissue of the sacrum. During the course of investigation of the sacral pressure ulcer, it was identified when CNA (Certified Nurse's Assistant) #7 saw an area on the resident's butt on 12/03/21 at which time she alerted the nurse, LPN #3. On 5/18/22 at 3:55 pm., an interview was conducted with the WCNP (Wound Care Nurse Practitioner/OSM) #12 concerning Resident #399's sacral wound. She stated, that the wound was facility acquired on 12/03/21 and that she first assessed it on 12/07/21 as an unstageable with 100% necrosis full thickness. She stated, It's not acceptable because as a full thickness wound, I'm not able to see the extent of this wound. It could have been here for who knows how long. I rounded every Thursday. My expectation was that the wound care nurse (facility LPN #3/ADON) Licensed Practical Nurse/Assisting Director of Nursing) perform initial assessments and update me and we round on patients together. She didn't assist me. She wasn't with me consistently every single week. It got worse. Pressure and deconditioning were contributors; turn and reposition assistance, and decreased mobility. Typically residents could get an unstageable pressure ulcer over 2 or 3 days but not overnight. Prevention measures such as low air loss mattress, foam dressing on the sacrum to prevent further decomposition. It had gotten larger, still unstageable, the signs and symptoms were acute infection, malodorous and increase drainage. I cleaned it with dermal wound cleanser, calcium Ag, applied santyl and covered with foam. The Primary physician started her on Levoquin po (by mouth). I received a call from LPN #3 on January 3rd, 2022 after Resident #339 had been admitted to the hospital. Someone from corporate and LPN #3 called me about resident having necrotizing fasciitis. It's a bacterial infection, flesh eating bacteria caused when the skin is disrupted with bacteria that spreaded to her bones. Infection breaking through the skin barriers causes this. On 12/07/21, the WNP consult notes indicated the following, Unstageable sacrum pressure ulcer. Measurements: Length 2.0 x Width 2.5 cm Depth surface area 5.0 cm2. Minimal serosanguinous, 100 % necrosis. Surrounding Tissue is intact. Primary dressing: Santyl, Calcium Alginate Ag, Foam. Surgical debridement procedure was performed: Removal of subcutaneous tissue. An assessment of the sacral wound show the wound has full thickness loss, base covered with slough, consistent with an unstageable pressure injury. Due to the presence of the necrotic tissue bed, the ulcer was debrided. Plan: clean with dermal wound cleanser, pat dry, change daily and as needed. Apply santyl to the wound bed, cover with calcium alginate Ag, then foam dressing, change daily and as needed. Weekly Pressure Wound Observation consult notes dated 12/17/21 by the WNP read, 12/17/21 Pressure ulcer of Sacrum worsening. Malodorous. Wound deteriorating. A review of the medical record revealed no wound measurements until the Wound Care Nurse Practitioner (WNP) arrived on 12/17/21. On 12/17/21 the WNP consult notes read, Unstageable pressure ulcer on sacrum. Measurements: Length 5.5 cm Width 6.1 cm Depth 0.2 cm. Surface area 35.5 cm2. Exudate: moderate, purulent and malodorous. Tissue type: 100% necrosis, full thickness. Surrounding Tissue: Intact. Primary dressing: Santyl, Calcium Alginate Ag, Foam. Progress: deteriorating. Surgical debridement procedure was performed: Subcutaneous Tissue on 12/16/21. At the start of today's procedure, the ulcer is described as follows: Length 5.5 cm Width 6.1 cm Depth 0.2 cm. Surface 33.5 cm2. Exudate: moderate, purulent, malodorous. Tissue type: 100% necrosis, full thickness. The amount of surface area debrided was 100%. Assessment: The unstageable pressure injury to the sacrum is deteriorating. Due to the presence of necrotic tissue in the ulcer bed, the ulcer was debrided. Barriers to healing include infection. Signs and symptoms of acute infection include odor, purulent draining and increased pain. The primary team started the patient on [MEDICATION(S)] PO. A antimicrobial dressing of [MEDICATION(S)] cream and calcium Alginate Ag was applied for control of possible excess bioburden and to promote healing. Plan: Clean with dermal wound cleanser. Pat dry, apply [MEDICATION(S)] and Santyl to the wound bed. Cover with Calcium Alginate Ag, then foam dressing. Change daily and as needed. Continue PO [MEDICATION(S)] for infection to sacral wound. In addition Resident #339 acquired unstageable DTI (Deep Tissue Injury) of the left heel. The clinical record reveal on 12/18/2021 Resident #339 was admitted to the local hospital for [CONDITION(S)], [CONDITION(S)], necrotizing tissue. According to review of the ER/emergency room medical records dated 12/18/21 at 5:14 PM, Resident #339 was presented with AMS (Altered Mental Status) and a Large Sacral Pressure Ulcer. Later tests revealed that Resident #339 was diagnosed with having a sacral decubitus ulcer with infected GAS (Bacteria called group A Streptococcus (GAS) can cause many different infections. These infections range from minor illnesses to very serious and deadly diseases-https://www.cdc.gov/groupastrep/diseases-public/index.html). According to review of the the Emergency Department (ED) report dated 12/18/21 Resident #339 was admitted to the ED in .acute distress and ill appearing. On assessment Resident had a large sacral ulcer present with foul odor. The CT (computerized tomography) scan shows: Sacral decubitus ulcer with likely infectious GAS along the lower back into the left greater than right gluteal musculature and right greater than the left perineum. There is ill defined fluid collection measuring up to 3.3 cm within the left gluteal musculature potentially developing abscess. On 12/18/21 the ED provider note list diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Call in note says resident is a full code. Husband says this is not correct she is a DNR (Do Not Resuscitate). However, he would like out general surgeon (GS) to attempt to address the significant infection to her sacral region. Causing her severe [CONDITION(S)] and worsening mental status. We discussed comfort measures versus this intervention. Surgery was consulted and she was found to have necrotizing fasciitis and plans were made to go to the OR (Operating Room) for debridement. The OR (Operating Room) procedure note dated 12/18/21 revealed that the patient's decubitus wound was massive and necrotic. The resident had to be taken urgently to the OR to excise the necrotic tissue because the patient is in septic shock. All necrotic tissue was excised. All underlying tissue was involved all the way to the bone. Patient was intubated and critically ill. Consideration for hospice care. On 5/13/22 at 7:44 PM and at 5:00 PM a phone call was made to the Surgeon. Surveyor was not able to leave messages. An interview was conducted on 5/17/22 at 4:25 PM., with LPN (License Practical Nurse, wound care nurse/Assistant Director of Nursing) #3 concerning Resident #339. She stated, It (SACRUM) was first identified as unstageable. It progressed and we had to debride it. I did some of her wound care. It showed no signs of infection after the first surgical debridement. For preventive measures she used a specialty mattress starting 12/10/21. We medicated her before wound care. She was turned and repositioned. An interview was conducted on 5/18/22 at 10:00 AM with the complaintant concerning Resident #339. She stated, The hospital surgeon made a referral to us and he indicated that he had to perform two surgeries on patient's sacral area due to having a large infected wound. The two surgeries resulted from infection of the wound to the bone. My investigation found she had no wounds on her body until December 3rd. (2021) She was bedridden and had physical therapy from her bed. She never got out of bed. She was put on hospice. Her husband would sit with her for hours. The wound nurse (LPN #3) would only see her when the outside Wound Nurse Practitioner came in. An interview was conducted on 5/18/22 at 11:15 am with CNA (Certified Nurse's Aide) #7. Concerning Resident #399. She stated, A few days after she came she complained that her butt hurt. We would get her off her side. When I came back from being off, she had an area on her butt. I reported it to the nurse. That nurse no longer works here. The wound nurse came every week. She was not ambulatory and could not make her needs known. She had good days and bad days. I turned and reposition her every two hours. LPN #13, who was the nurse CNA #7 alerted about the area on Resident #339, was called twice throughout the survey. Voice messages were left with no return call. On 5/19/22 at 1:35 AM., an interview was conducted with RN (Registered Nurse) #1. She stated, I turned her every 2 hours due to the wound on her bottom. She was not able to make her needs known. The wound on her bottom was acquired at the facility. I didn't have to do anything with her wound because I worked the 7 pm -7 am shift. We had an investigation here earlier. I didn't find anything unusual with her vitals. I thought it was odd that she was smiling. I never got to see the wound. If it was soiled I would have changed it and seen it but I didn't have the opportunity. On 05/20/2022 at approximately 3:45 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. 3. The facility staff failed to identify a sacral wound pressure ulcer prior to advancing to an unstageable pressure ulcer measuring 5 centimeter (cm) x 5 cm x 2 cm for Resident #291. The sacral wound was infected requiring antibiotic therapy and surgical debridement (removal of dead tissue), which constituted harm. Resident #291 was originally admitted to the facility on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #291's Admission Assessment (14-day) with an ARD of 03/19/22 coded Resident #291 Brief Interview for Mental Status (BIMS) scored a 99 indicating short and long term memory problems and severe cognitive impairment - never/rarely made decisions. Resident #291 was coded total dependence of two with toilet use, bed mobility and bathing, total dependence of one with dressing, personal hygiene and eating and for Activities of Daily Living (ADL). Under section H - (Bladder and Bowel) was coded for always incontinent of bladder and bowel. Under section G0400 - Functional Limitation in Range of Motion (ROM) coded Resident #291 with no impairment to her upper and lower extremity. Resident #291 was coded as having no mood, rejection of care or behavioral problems. Resident #291's Admission Assessment (14-day) with an ARD of 03/19/22. Under section (M0150) at risk for developing pressure ulcers was coded yes, under section (M0210) for unhealed pressure ulcers was coded yes and under section (M0300) for having current number of unhealed pressure ulcer at each stage present upon admission or reentry into the facility was coded for stage II pressure ulcer. Under section (1200) for skin, ulcer treatments were coded for having pressure reducing device for bed and pressure ulcer wound care. Resident #291's person-centered care plan initiated on 03/21/22 identified the resident has a pressure ulcer in her sacral area, at risk for further skin breakdown related to incontinence and impaired mobility. The goal set for the resident by the staff was that the resident will remain free of new skin breakdown through next review date. Some of the interventions/approaches the staff would use to accomplish this goal is to follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The person-centered care plan with a revision date of 04/01/22 identified Resident #291 on antibiotics for a sacral wound infection. The goal set for the resident by the staff was that the resident will show signs of healing and remain free of complications related to infection. One of the interventions/approaches the staff would use to accomplish this goal is to administer medications as ordered, monitor/document for side effects and effectiveness. A Braden Risk Assessment Report was completed on 3/15/22. The resident scored a 09 indicating at high risk for the development of pressure ulcers. The assessment coded under sensory perception very limited and responds only to painful stimuli; cannot communicate discomfort except by moaning or restlessness or has a sensory impairment which limits the ability to feel pain or discomfort over 1/2 of the body. Under moisture was coded skin is occasionally moist, requiring an extra linen change approximately once a day and coded bedfast under activity. The skin/wound admission note dated 03/10/22 indicated Resident #291 had a stage II sacral ulcer measuring 2.0 cm x 1.0 cm x 0.2 cm with very dark skin, nonblachable measuring (15 cm x 9 cm) surrounding the sacral ulcer. The note indicated that Resident #291's pressure ulcer will be evaluated by the wound Nurse Practitioner (NP) during her next visit on 03/15/22. Resident #291 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #291's nurse's note revealed the resident was transferred to the hospital emergency room for evaluation for an elevated temperature on 03/14/22 at approximately 6:50 p.m., and returned on 03/15/22 at approximately 4:00 p.m. Further review of the nurses note revealed no new skin impairments noted since the last admission assessment on 03/10/22. The resident was readmitted to the nursing facility on 03/15/22. The readmission note under skin integrity revealed the same sacral pressure assessed at a Stage II. A skin/wound note dated 03/22/22 at 12:08 p.m., by the wound nurse License Practical Nurse (LPN #3) revealed the wound NP (WNP) went to assess Resident #291's sacral wound but the resident had pain with body movement, thus the WNP decided to assess Resident #291's sacral wound during her next onsite visit on 03/29/22. During the review of Resident #291's clinical record revealed there were no weekly wound assessments made by the facility licensed nurses of the sacral pressure ulcer for 19 days, after her admission to the facility. An interview was conducted with the WNP on 05/17/22 at approximately 3:06 p.m., I was in the facility on 03/15/22 to assess Resident #291's sacral ulcer, but the resident was discharged to the hospital during my onsite visit. The WNP stated, My first time evaluating [TRUNCATED]

Based on information gleaned during a complaint investigation, observations, resident interviews, staff interviews, clinical record reviews, and review of facility documents, the facility staff neglected to provide proper care and prompt services to avoid unnecessary suffering, and pain for 5 of 5 residents (Resident #85, 291, 339, 189, 190), in the survey sample of 55, which constituted harm. For Resident #85 the facility staff neglected to provide the necessary care and services to include weekly skin assessments, turning and repositioning and pressure relieving devices to ensure a pressure ulcer was not first identified at a Stage 3, who was assessed as a high risk for developing pressure ulcers which constituted harm. For Resident #291 the facility staff neglected to identify a sacral wound pressure ulcer prior to advancing to unstageable measuring 5 centimeter x 5 centimeter x 2 centimeter (cm). The wound was infected requiring antibiotic therapy and surgical debridement (removal of dead tissue) which constituted harm. For Resident #339 the facility staff neglected to ensure the necessary treatment, care and services were provided to prevent the development of a large unstageable, infected pressure ulcer with necrotizing/dead tissue of the sacrum from developing which constituted harm. For resident #189, the facility staff neglected to recognize, assess and provide the necessary care and services after a resident experienced a significant change in condition presenting with shortness of breath because of a low oxygen saturation (87 percent on room air). The resident's lab values were critical upon arrival to the hospital; they included a glucose of 515 mg/dl, BUN 120 mg/dl, creatinine 6.47 mg/dl and lactic acid 2.6 mmol/L, which required hospitalization and constituted harm. For Resident #190, the facility staff neglected to provide a STAT (now) dental appointment for an acute dental problem with a delay of 22 days after the STAT order was given which constitued harm. The findings include: 1. The facility staff failed to provide the necessary care and services to include weekly skin assessments, turning and repositioning and pressure relieving devices to ensure a pressure ulcer was not first identified at a Stage 3 for Resident #85, who was assessed as a high risk for developing pressure ulcers, which constitutes harm. Resident #85 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #85's most recent Minimum Data Set (MDS) was a Significant Change Assessment with an Assessment Reference (ARD) of 4/28/22. The Brief Interview for Mental Status (BIMS) was unable to be completed, however Resident #85 was coded as being severely cognitively impaired for daily decision making. Under Section G Functional Status, Resident #85 was coded as requiring extensive one person physical assistance for bed mobility and totally dependent with one person physical assist for bathing. Under Functional Limitation In Range of Motion the resident was identified with lower extremity impairment on both sides. Under Section M Skin Conditions, Resident #85 was identified as being at risk for pressure ulcer injury and having one Stage IV pressure ulcer. Resident #85's last three Braden Scales for Predicting Pressure Sore Risk assessments were reviewed. On 7/26/21 the resident was identified as being VERY HIGH RISK with a score of 9. On 4/20/22 Resident #85 was identified as being MODERATE RISK with a score of 14 and on 5/7/22 she was a HIGH RISK with a score of 12. On 5/11/22 the following observations were made of Resident #85: 1. 05/11/22 09:30 a.m. the resident was observed lying on her right side facing the wall. Also there were no bilateral heel protectors in place. 2. 05/11/22 12:25 p.m. the resident was observed lying on her right side facing the wall. Also there were no bilateral heel protectors in place. 3. 05/11/22 2:09 p.m. the resident was observed lying on her right side facing the wall. Also there were no bilateral heel protectors in place. On 5/12/22 at 9:30 a.m. an interview was conducted with Certified Nursing Assistant (CNA)#3 who care for Resident #85 on 5/11/22 during the 7-3 shift in regards to the above observations. CNA #3 stated, I did come in her room yesterday and pulled her up in the bed and pulled her towards the rail to relieve pressure. She was on her right side facing the door. She likes the right side so I never put her on her left side. She used to have heel protectors but I didn't see them in here yesterday to put them on her. I wasn't sure if she was still using them. On 5/12/22 at 9:50 a.m. a wound care observation of Resident #85's right great toe was conducted with Licensed Practical Nurse (LPN) #3, who was the facility wound nurse. LPN #3 stated, The resident's wound was first identified as a Stage 3 pressure ulcer and was facility acquired. Resident #85 was lying on her right side facing the wall. Upon pulling Resident #85's sheet back to expose her right great toe pressure ulcer the resident's left heel was noted lying on top of her right great toe. Both of Resident #85's lower legs and knees were contracted and the left heel was lying on the right great toe pressure ulcer. There were no observed bilateral heel protectors in place for Resident #85. Resident #85's right great toe pressure area was on top of the toe and distal from the nailbed. The pressure ulcer was approximately the size of a dime. The wound bed was beefy red with a pinpoint yellow center and there was no odor or signs of infection noted. The resident was noted to be lying on an air mattress. LPN #3 also stated, She (Resident #85) is supposed to be rotated every 2 hours. She favors the right side, but should be turned. Also I don't know why she doesn't have her heel protectors on, they help relieve the pressure to her feet due to her contractures. A review of Resident #85's electronic medical record was conducted. Resident #85's Weekly Pressure Wound Observation Tool dated 2/22/22 revealed a first observation facility acquired Stage 3 right great toe pressure area measuring 1.7 cm (centimeters) X 2 cm. X .2 cm. On the Weekly Pressure Wound Observation Tool dated 3/1/22 Resident #85's right great toe pressure area was documented as a Stage 4. All Weekly Pressure Wound Observation Tools from 3/8/22 to present show right great toe pressure ulcer improvement. During the medical record review the resident had a documented weekly skin review dated 7/22/21. The next documented weekly skin review was not completed until 3/30/22, then completed weekly to present day. Resident #85's Comprehensive Care Plan last revised 5/11/22 was reviewed. The Comprehensive Care Plan indicated the resident was at risk for skin integrity impairment related to incontinence, Alzheimer's and decreased mobility. The care plan had also been revised to include a pressure ulcer to her right great toe. Interventions put in place for Resident #85 included an air mattress on 1/5/22, to float bilateral heals on 2/11/22, to follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #85's Integrated Wound Care Notes were reviewed and revealed the following. On 2/22/22 an Initial Progress Note indicated that Resident #85 was being seen for a right great toe pressure ulcer. The right great toe pressure ulcer was documented as a Stage 3 measuring 1.7 cm X 2 cm X .2 cm. The treatment was honey alginate and dry dressing with skin prep to the periwound every other day and as needed. On the 3/1/22 Follow-up Progress the right great toe was documented as a Stage 4 measuring 1.4 cm X 1.6 cm X 0.2 cm with a 1.6 cm tunnel at 12 o'clock. The pressure ulcer presented with 50% granulation tissue with exposed tendon present. The Wound Nurse Practitioner (NP) performed a sharp debridement to the right great toe pressure ulcer (Sharp surgical debridement. is removal of the source of [CONDITION(S)], mainly necrotic tissue-https://www.ncbi.nlm.nih.gov/books/NBK 2/). The Wound NP was seeing Resident #85 weekly since 2/22/22. On 5/17/22 at 1:00 p.m. an interview was conducted with the Director of Nursing (DON) in regards to Resident #85's current Stage 4 right great toe pressure ulcer. The DON stated, When I started I realized we had quite a few acquired pressure ulcers. On 2/22/22 we did a whole building skin sweep and discovered multiple residents with wounds. On Name (Resident #85) we discovered a Stage 3 to her right great toe and had the Wound NP see her that day as well. We started reviewing each resident for orders and put interventions in place. We found that Name (Resident #85) had not had a documented weekly skin assessment completed since 7/21/21. The weekly skin assessments were started back and I started a skin report for the CNA's to completed to report any new identified skin issues which are given to the charge nurse and they both have to sign it. Also I did not see where we were documenting she was being turned and repositioned every 2 hours. She has an air mattress, weekly skin assessments, weekly Wound NP visits, a fortified diet and supplements in place to aid in wound healing and her wound is improving. The DON was made aware of this surveyors observations of Resident #85 on 5/11/22. The DON stated, The resident is to be turned every 2 hours and her heel protectors should have been in place due to her contractures. If they were not in the room the CNA should have went down to laundry or central supply for another pair. I will have to re-educate. On 5/20/22 at 12:30 p.m. a phone interview was conducted with the Wound Nurse Practitioner regarding Resident #85's current Stage 4 right great toe pressure area. The Wound Nurse Practitioner stated, There was a skin sweep on 2/22/22 and I was there that day. A Stage 3 right great toe pressure ulcer was identified on Name (Resident #85). She was very high risk for developing skin pressure ulcers. She had bilateral upper and lower extremity contractures and dementia. The staff should be checking her skin during showers. Residents should be assessed and wounds should be identified prior to the being found at an advanced stage. A Stage 3 is an advanced stage pressure ulcer. On 5/20/22 at 2:45 p.m. a phone interview was conducted with the Medical Director regarding Resident #85's current Stage 4 right great toe pressure ulcer. The Medical Director stated, We should really be identifying pressure ulcers at advance stages especially if the resident has been identified as a high risk for developing pressure ulcers. Doing weekly skin checks, personal care, and checking the skin during showers/bathing we should have found the pressure area before it was an advanced stage. On 5/19/22 at 9:20 a.m. the above findings were shared with the Administrator and the Director of Nursing. The Director of Nursing stated, The weekly skin checks should have been performed. Also the preventative measures should be followed for turning and repositioning and heels protectors. I expect that skin impairment be found early at a Stage 1, not at an advanced stage, so that treatment can start early before increased tissue damage occurs. Prior to exit no further information was shared The facility policy titled Abuse Neglect and Exploitation last revised 1/4/22 was reviewed and is documented in part, as follows .Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect exploitation and misappropriation of resident property. Definitions: Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. I. Screening: B. Prospective residents will be screened to determine whether the facility has the capability and capacity to provide the necessary care and services for each resident admitted to the facility. III. Prevention of Abuse, Neglect and Exploitation: D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. IV: Identification of Abuse, Neglect and Exploitation: B. Possible indicators of abuse and neglect include, but are not limited to: 8. Failure to provide care needs such as feeding, bathing, dressing, turning and repositioning . On 5/19/22 at 9:20 a.m. the above findings were shared with the Administrator and the Director of Nursing. The Director of Nursing stated, The weekly skin checks should have been performed. Also the preventative measures should be followed for turning and repositioning and heels protectors. I expect that skin impairment be found early at a Stage 1, not at an advanced stage, so that treatment can start early before increased tissue damage occurs. Prior to exit no further information was shared. 2. The facility staff failed to identify a sacral wound pressure ulcer prior to advancing to an unstageable pressure ulcer measuring 5 centimeter (cm) x 5 cm x 2 cm for Resident #291. The sacral wound was infected requiring antibiotic therapy and surgical debridement (removal of dead tissue), which constituted harm. Resident #291 was originally admitted to the facility on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #291's Admission Assessment (14-day) with an ARD of 03/19/22 coded Resident #291 Brief Interview for Mental Status (BIMS) scored a 99 indicating short and long term memory problems and severe cognitive impairment - never/rarely made decisions. Resident #291 was coded total dependence of two with toilet use, bed mobility and bathing, total dependence of one with dressing, personal hygiene and eating and for Activities of Daily Living (ADL). Under section H - (Bladder and Bowel) was coded for always incontinent of bladder and bowel. Under section G0400 - Functional Limitation in Range of Motion (ROM) coded Resident #291 with no impairment to her upper and lower extremity. Resident #291 was coded as having no mood, rejection of care or behavioral problems. Resident #291's Admission Assessment (14-day) with an ARD of 03/19/22. Under section (M0150) at risk for developing pressure ulcers was coded yes, under section (M0210) for unhealed pressure ulcers was coded yes and under section (M0300) for having current number of unhealed pressure ulcer at each stage present upon admission or reentry into the facility was coded for stage II pressure ulcer. Under section (1200) for skin, ulcer treatments were coded for having pressure reducing device for bed and pressure ulcer wound care. Resident #291's person-centered care plan initiated on 03/21/22 identified the resident has a pressure ulcer in her sacral area, at risk for further skin breakdown related to incontinence and impaired mobility. The goal set for the resident by the staff was that the resident will remain free of new skin breakdown through next review date. Some of the interventions/approaches the staff would use to accomplish this goal is to follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The person-centered care plan with a revision date of 04/01/22 identified Resident #291 on antibiotics for a sacral wound infection. The goal set for the resident by the staff was that the resident will show signs of healing and remain free of complications related to infection. One of the interventions/approaches the staff would use to accomplish this goal is to administer medications as ordered, monitor/document for side effects and effectiveness. A Braden Risk Assessment Report was completed on 3/15/22. The resident scored a 09 indicating at high risk for the development of pressure ulcers. The assessment coded under sensory perception very limited and responds only to painful stimuli; cannot communicate discomfort except by moaning or restlessness or has a sensory impairment which limits the ability to feel pain or discomfort over 1/2 of the body. Under moisture was coded skin is occasionally moist, requiring an extra linen change approximately once a day and coded bedfast under activity. The skin/wound admission note dated 03/10/22 indicated Resident #291 had a stage II sacral ulcer measuring 2.0 cm x 1.0 cm x 0.2 cm with very dark skin, nonblachable measuring (15 cm x 9 cm) surrounding the sacral ulcer. The note indicated that Resident #291's pressure ulcer will be evaluated by the wound Nurse Practitioner (NP) during her next visit on 03/15/22. Resident #291 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #291's nurse's note revealed the resident was transferred to the hospital emergency room for evaluation for an elevated temperature on 03/14/22 at approximately 6:50 p.m., and returned on 03/15/22 at approximately 4:00 p.m. Further review of the nurses note revealed no new skin impairments noted since the last admission assessment on 03/10/22. The resident was readmitted to the nursing facility on 03/15/22. The readmission note under skin integrity revealed the same sacral pressure assessed at a Stage II. A skin/wound note dated 03/22/22 at 12:08 p.m., by the wound nurse License Practical Nurse (LPN #3) revealed the wound NP (WNP) went to assess Resident #291's sacral wound but the resident had pain with body movement, thus the WNP decided to assess Resident #291's sacral wound during her next onsite visit on 03/29/22. During the review of Resident #291's clinical record revealed there were no weekly wound assessments made by the facility licensed nurses of the sacral pressure ulcer for 19 days, after her admission to the facility. An interview was conducted with the WNP on 05/17/22 at approximately 3:06 p.m., I was in the facility on 03/15/22 to assess Resident #291's sacral ulcer, but the resident was discharged to the hospital during my onsite visit. The WNP stated, My first time evaluating Resident #291's pressure ulcer was on 03/29/22. The WNP said the wound was infected as evidence by the wound having a significant amount of slough with foul odor present and having significant pain over the sacral area when touched or palpated. Resident #291 was placed on routine pain medication as well as two rounds of antibiotic therapy to help fight the sacral wound infection. The wound was not cultured due to the location of the wound (sacral area) which put the wound culture at risk for cross contamination. The WNP's initial progress note of the sacral pressure ulcer on 03/29/22 revealed an unstageable ulcer measuring 5 cm x 5 cm x 2 cm. The progress note stated the sacral wound had a moderate amount of serosanquinous drainage, strong odor present with 90 percent (%) slough and 10 % dermis tissue. A new medication order was given for [MEDICATION(S)] (antibiotic) 500 mg/125 mg every 12 hours x 10 days for a sacral wound infection. A new treatment order was given to clean the sacral wound with Dakin's, Santyl on Dakin's gauze, and cover with foam dressing daily and as needed. The WNP progress note also stated pain is indicative of any movement, at rest she is comfortable. The WNP also offered further recommendations to turn and reposition per facility protocol, use of a low air loss mattress and to optimize nutrition. A WNP progress note dated 04/05/22 revealed the sacral wound pressure ulcer remained an unstageable measuring 5 cm x 5 cm x (?). The sacral wound had improved but remain with moderate amount of serosanquinous drainage, strong odor present with 90% slough and 10% dermis tissue. The wound was debrided removing thick slough tissue; pain was present with any movement. Resident #291 remained on antibiotic therapy for a sacral wound infection and continued with the current wound treatment, Dakin's, Santyl on Dakin's gauze, and cover with foam dressing daily and as needed. A review of the WNP's progress note dated 04/11/22 indicated that the wound visit was performed via telehealth with the wound nurse, License Practical Nurse (LPN #3). The sacral wound was deteriorating with moderate amount of purulent drainage, strong odor present with 90% slough and 10% dermis tissue. The wound measured by onsite nurse (LPN #3) measuring 6.5 cm x 5.5 cm x 2.5 cm. The progress note recommended to continue with current sacral wound treatment with Dakin's, Santyl on Dakin's gauze, foam dressing and change daily and as needed. A new antibiotic order was given for [MEDICATION(S)] 600 mg by mouth every 8 hours for 21 days for a sacral wound infection. The wound NP progress note also stated pain is indicative of any movement, at rest she was comfortable. On 05/16/22 at approximately 2:25 p.m., an interview was conducted with LPN #1. LPN #1 was assigned to performed sacral wound care to Resident #291 on 03/26/22 (7a-7p shift). The LPN stated, I have never measured Resident #291's sacral pressure ulcer. The ulcer was being measured and monitored by LPN #3 and the wound NP. An interview was conducted with the Medical Director (MD) on 05/18/22 at approximately 11:33 a.m., who said all pressure ulcers were followed by (name of Wound Company.) The MD stated, Resident #291's sacral ulcer should have been monitored, assessed and measured on a weekly basis for signs of decline or improvement. The nurses should have been monitoring the sacral pressure ulcer during every wound care dressing change for a change in condition. Apparently, the nurses were not doing a full wound assessment for change in condition because a pressure ulcer cannot go from a stage II to an unstageable requiring debridement overnight. The changes in the wound should be been addressed before the wound was identified as an unstageable pressure ulcer. The extra nutritional element recommended by the dietitian could have help with the wound healing of the sacral pressure ulcer. An interview was conducted with LPN #9 on 05/19/22 at approximately 10:44 a.m. The LPN was assigned to perform sacral wound care to Resident #291 on 03/19/22 (7a-7p shift). The nurse said an open area was noted to the sacrum with shearing/excoriation to the periwound. The LPN stated, I only do the resident's treatment not the monitoring or measuring of the wound that was being done by the wound NP or LPN #3 on a routine basis. A phone interview was conducted with LPN #12 on 05/16/22 at approximately 6:29 p.m. The LPN was assigned to perform sacral wound care to Resident on 03/22/22 (7a-7p shift). The LPN said the sacral wound appeared larger in size but I did not measure or document the change in condition of the sacral wound. The LPN stated, The wound NP and LPN #3 were assessing and monitoring Resident #291's sacral ulcer every week. A dietary/nutrition note dated 03/18/22 at 9:56 a.m., revealed Resident #291 having a suspected deep tissue injury (SDTI) to the left and right heel and a stage II pressure ulcer to the coccyx/sacral area per 03/10/22 (skin assessment). Recommendations were made for fortified foods with meals due to poor oral intake of meals, provide texture-appropriate calorie-dense snacks three times a day between meals due to poor oral intake and thickened house shake (120 mL), pudding / fortified pudding. A Dietary/Nutrition note dated 04/08/22 at 12:33 p.m., revealed the nutritional recommendations made on 03/18/22 were never addressed for fortified foods with meals due to poor oral intake of meals, provide texture-appropriate calorie-dense snacks three times a day between meals due to poor oral intake and thickened house shake (120 mL), pudding / fortified pudding. An interview was conducted with the RD on 05/17/22 at approximately 4:41 p.m., who stated, The nutrition recommendations made for Resident #291 on 03/18/22 and again on 04/08/22 were never addressed. The RD said the extra calories would have given extra protein that's needed to help with healing Resident #291's sacral pressure ulcer. The nursing note dated 04/11/22 at approximately 6:23 p.m., revealed Resident #291 with Altered Mental Status (AMS), tremors and had vomiting during dinner. A new order was given to send Resident #291 to the emergency room (ER) for evaluation and treatment. A review of the hospital records revealed that Resident #291 presented in the Emergency Department (ED) on 04/11/22 from (name of nursing facility) for further evaluation due to Altered Mental Status (AMS) and vomiting. The ED indicated Resident #291 is lethargic, disoriented and is currently on antibiotic for an infected unstageable sacral wound. The wound is observed with a strong foul odor. The sacral wound was evaluated to be a FIST size with partial wet slough, fetid (having a heavy offensive smell-https://www.merriam-webster.com/dictionary) skin and obvious deep tunneling on perimeter. The ED report indicated the resident did not meeting the criteria for Systemic [CONDITION(S)] response syndrome (SIRS), but had a concerning sacral wound and was referred for evaluation and treatments by the General Surgery. The resident was started on IV [MEDICATION(S)] (antibiotic) and [MEDICATION(S)] (antibiotic) for empiric coverage of her large sacral decubitus ulcer. After the sacral wound was evaluated by the General Surgery, he felt the wound would benefit from debridement of the wound. On 04/12/22, Resident #291 was taken into the operating room (OR), and the sacral wound was debrided. After debridment the wound was assessed as a stage III decubitus ulcer with no exposed bone at this time. The recommendation was made for a wound VAC to improve the healing process for the resident. It was noted that the resident would also benefit from significant nutritional support and should be fed by staff by the facility. An interview was conducted with the Director of Nursing (DON) and wound nurse LPN #3 on 05/12/22 at approximately 10:00 a.m. The DON said Resident #291's sacral pressure ulcer should have been evaluated by the WNP or wound nurse, LPN #3 on a weekly basis. She stated, the weekly evaluation and monitoring was needed for early detection to determine if the wound is improving or declining. The wound nurse LPN #3 stated, I was not here on 03/17/22 and 03/24/22, when Resident #291 was supposed to have her sacral wound assessed and evaluated a changes in condition. The DON said the nurses should have been assessing and documenting changes on Resident #291's sacral pressure ulcer (description of wound bed, if drainage or odor present and size of the wound) with all changes reported to LPN #3 or the wound NP for evaluation to determine if wound treatment changes were needed. According to the DON, the stage II sacral wound treatment was appropriate when admitted to the facility on [DATE]. The treatment was for a foam dressing, change every 2 days. The DON said, When the wound deteriorated to an unstageable, the treatment should have been changed but it wasn't. The DON further stated, Due to the lack of documentation, there is no way to know when Resident #291's sacral wound deteriorated to the point it had advanced to an unstageable requiring debridement and antibiotic due to infection. A debriefing was held with the Administrator, Director of Nursing and Corporate support on 05/19/22 at approximately 2:00 p.m. Resident #291's issues was presented again. No additional information was forthcoming. Definitions: -Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). -Pressure Injury - Stage 2 (Partial-thickness skin loss with exposed dermis_ Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [CONDITION(S)] (IAD), intertriginous [CONDITION(S)] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, [CONDITION(S)], abrasions (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages). Pressure Injury - Stage 3 (Full-thickness skin loss) Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages). -Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). -Serosanquinous drainge relates to both blood and the liquid part of blood (serum). It usually refers to fluids collected from or leaving the body. For example, fluid leaving a wound that is serosanguineous is yellowish with small amounts of blood (https://medlineplus.gov/ency/article/ 6.htm). -Purulent drainage is a thick, milky white discharge indicating an unhealthy wound or infection. It requires immediate medical attention. Sometimes the fluid can vary in color - yellow, green or brown - accompanied by a foul, pungent or musty odor. Any significant change in the color or odor indicates the progression of infection. It can be a cause of concern and require medical attention (https://cert.vohrawoundcare.com/purulent-drainage). -Dakin's solution is a type of hypochlorite solution. It is made from bleach that has been diluted and treated to decrease irritation. Chlorine, the active ingredient in Dakin's solution, is a strong antiseptic that kills most forms of bacteria and viruses (http://www.webmd.com/drugs/2/drug- /dakin's-misc/details). -Santyl is used to help the healing of [CONDITION(S)] and ulcers. [MEDICATION(S)] is an enzyme. It works by helping to break up and remove dead skin and tissue. This effect may also help to work better and speed up your body's natural healing process (http://www.webmd.com). 3. The facility staff failed to ensure the n [TRUNCATED]

Based on information gleamed during a complaint investigation, staff interviews, and clinical record review, the facility staff failed to provide the necessary care and services for 3 of 55 residents (Resident #189) in the survey sample. For resident #189, the facility staff failed to recognize, assess and provide the necessary care and services after the resident experienced a significant change in condition presenting as shortness of breath because of low oxygen saturation 87 percent on room air. At the hospital the resident was diagnosed with acute [CONDITION(S)], severe [CONDITION(S)], a urinary tract infection and severe dehydration evidenced by a blood pressure reading of 80/50, only 30 milliliter of dark urine when catheterized and dry tongue and mucous membranes and peeling lips. Resident #189's lab values were critical upon arrival to the hospital; they included a glucose of 515 mg/dl, BUN 120 mg/dl, creatinine 6.47 mg/dl and lactic acid 2.6 mmol/L, which required hospitalization and constituted harm. For Resident #60 the facility staff failed to ensure resident received her physician prescribed [MEDICATION(S)] Injection. For Resident #66, the facility staff failed to ensure [MEDICATION(S)] Capsules, [MEDICATION(S)] tablets and Cefdmir capsules were administered per physician orders. The findings included: 1. Resident #189 was admitted to the nursing facility on 2/23/2018 and discharged to the local hospital on 05/11/2020. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/10/2020 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #189's cognitive abilities for daily (ADL) decision making were intact. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing, extensive assistance of one person with personal hygiene, extensive assistance of two with bed mobility, transfers, dressing and toileting, and independent after set-up with locomotion and eating. Interviews were attempted with multiple staff regarding Resident #189 but only one nurse stated she remembered the resident. Licensed Practical Nurse #9 stated the resident was transferred from the one Unit to the other Unit after testing COVID-19 positive. LPN #9 stated the resident began to experience breathing difficulties secondary to COVID-19 and his respiratory status deteriorated. LPN #9 stated the resident's appetite also decreased and there was a rapid change in his condition which required hospitalization . A nurse's note dated 5/1/2020 read; the resident wasn't himself. He was less talkative, stayed in bed, and had a non-productive cough without shortness of breath or a fever. The physician was notified and a chest x-ray was ordered and the results were normal. A physician's progress note dated 5/2/2020 read Resident #189 tested positive for COVID-19. He had a cough and the resident stated he felt a little short of breath. The resident's temperature was 98.4 Fahrenheit ( F), pulse 94, respirations 19 and his oxygen saturation was 92% on room air, the mucous membranes were moist and there was no labored breathing. The physician's plan was to obtain a complete blood count, basic metabolic panel, a chest x-ray and follow the resident closely. On 5/3/2020 at 8:03 a.m., nurse's note read; the resident presented with a fever of 99.5 F, Tylenol was administered and at 3:54 p.m., the resident's temperature was still 99.5 F , Oxygen (O2) at 2/liter (L) per minute was started and the resident continued with a good appetite. There was no documentation on 5/4/2020 or 5/5/2020, but there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's dated 5/6/2020 read the resident's temperature was 99.8 F and Tylenol was given. No documentation was available 5/7/2020, 5/8/202, 5/9/2020, or on 5/10/2020. A review of the ADL documentation revealed the resident required total care with eating or didn't eat at all from 5/7/2020 through 5/11/2020. There was not documentation of the percent eaten at each meal and there was no evidence the physician was notified of the resident's change in status to feed himself. Neither was the care plan updated to include the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was also no evidence interventions were instituted to ensure the resident received necessary fluids to prevent dehydration On 5/11/2020 at 11:57 p.m., a nurse's note read the Certified Nursing Assistant informed the nurse the resident's O2 saturation was 89% and when the nurse arrived to the resident's room to ensure the O2 was on, she recognized the resident was only responsive to painful stimuli therefore; the physician and responsible party were notified and both elected to transfer the resident to the local hospital for evaluation and treatment. The hospital's discharge summary dated 5/15/22 read; Upon the resident's arrival to the hospital on 5/11/2020 the hospital staff documented the resident presented to the emergency room with shortness of breath based on a low oxygen saturation, 87% on room air. The hospital diagnosed the resident with acute [CONDITION(S)], severe [CONDITION(S)], a urinary tract infection and severe dehydration evidenced by a blood pressure reading of 80/50, only 30 milliliter (ml) of dark urine returned when catheterized and a dry tongue/mucous membranes and peeling lips. Resident #189's lab values were critical upon arrival to the hospital; they included a glucose of 515 mg/dl, BUN 120 mg/dl, creatinine 6.47 mg/dl (indications of acute renal failure) and lactic acid 2.6 mmol/L, which required hospitalization . The hospital report dated 5/11/2020 read; the resident's lab results on 5/5/2020, were as follows; creatinine 1.06 mg/dl, BUN 24 mg/dl and the physician stated there was real concern the resident wasn't receiving appropriate care in the nursing home and was left without hydration resulting in his severe dehydration. The physician's note stated they would notify Adult Protective Services (APS) of the resident's condition. The hospital's documentation dated 5/11/2020, also stated they spoke with the resident's son multiple times and he assured then that his father limitation were in his mobility/walking but his cognition was good, he could communicate effectively, feed himself and participate in his ADL care, prior to this episode of illness. An interview was conducted with the APS worker on 5/18/22 at approximately 3:24 p.m. The APS worker stated Resident #189 the hospital's physician reported the resident was admitted to the hospital COVID-19 positive and it was felt proper care wasn't provided in the nursing home. The APS worker also stated she didn't investigate the concern because the resident was in the hospital. The APS worker stated the hospital reported the resident's status was critical however he wasn't mechanically ventilated because he was admitted to hospice care on 5/15/2020 and passed away on 5/16/2020. On 5/20/22 at approximately 6:00 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 concerns were voiced because they all stated they didn't know the resident. 2. The facility staff failed to ensure resident received her physician prescribed [MEDICATION(S)] Injection for Resident #60 Resident #60 was originally admitted to the facility 08/18/21 from the community. The resident has never been discharged from the facility. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Revision, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 04/10/2022 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #60 cognitive abilities for daily decision making were intact. In sectionG(Physical functioning) the resident was coded as requiring total care of one person with bed mobility, transfers, locomotion, dressing, eating, toileting, personal hygiene and bathing, extensive assistance of one person/two people, limited assistance of one person, supervision after set-up. The care plan dated 4/10/2022 reads: Focus: The resident has Diabetes Mellitus. Goals: The resident will have no complications related to diabetes through the review date. Interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. The MAR (Medication Administration Record) [MEDICATION(S)] Solution Pen-injector 0.75 MG/0. 5ML ([MEDICATION(S)]) Inject 0.75 mg subcutaneously one time a day every Monday for Diabetes. -Start Date 08/23/2021 1000. Missed dosages: Monday 4/11/22. An interview was conducted with Resident #60 on 5/20/22 at 4:55 PM concerning her missed injection. She stated, I don't know what happened or why it wasn't given. [MEDICATION(S)] treats Diabetes Mellitus Type 2. Indicated as once-weekly SC injection adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus (T2DM). It is also indicated to reduce risk of major adverse cardiovascular (CV) events (CV death, nonfatal MI, or nonfatal stroke) in adults with T2DM who have established CV disease or multiple CV risk factors Initial: 0.75 mg SC once weekly May increase dose to 1.5 mg once weekly for additional glycemic control If additional glycemic control needed, increase to 3 mg once weekly after at least 4 weeks on the 1.5-mg dose If additional glycemic control needed, increase to maximum dose of 4.5 mg once weekly after at least 4 weeks on the 3-mg dose. https://reference.medscape.com/drug/[MEDICATION(S)]-[MEDICATION(S)]- 5. 3. The facility staff failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #66 was originally admitted to the facility 10/16/2015 from an acute care facility and discharged on [DATE] to an acute care facility and returned to the Long Term Care Facility on 4/13/22. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 04/18/2022 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #66 cognitive abilities for daily decision making were intact. In sectionG(Physical functioning) the resident was coded as requiring extensive assistance of one person with bed mobility and dressing. Requiring total dependence of one person with toilet use, personal hygiene and bathing. Requires set-up help only with eating. The care plan dated 4/17/22 reads: Focus: The resident has pain r/t (related/ to) history of pain in left arm and side secondary to [CONDITION(S)] ([CONDITION(S)]) & polyneuropathy, dental pain. Goals: The resident will not have an interruption in normal activities due to pain through the review date. Interventions: Administer analgesia as per orders. Review of the MAR (Medication Administration Record) reads: [MEDICATION(S)] Capsule 300 MG Give 1 capsule by mouth one time a day related to POLYNEUROPATHY, UNSPECIFIED (G62.9) -Start Date 04/13/2022 2100 (9:00 PM). Missed dosages: 4/14/22-4/18/22 4/21/22-4/24/22 and 4/27/22-4/28/22. MAR reads: [MEDICATION(S)] Tablet 875 MG Give 1 tablet by mouth two times a day for bacterial infection for 10 Days -Start Date 04/13/2022 2100 (9:00 PM). Missed dosages: 4/14/22, 4/18/22, 4/19/22, 4/21/22 and 4/22/22. [MEDICATION(S)] Capsule 300 MG Give 1 capsule by mouth two times a day for [CONDITION(S)] (Urinary Tract Infection) for 10 Days -Start Date 04/07/2022 2100. Missed dosages: 4/08/22-4/12/22, 4/14/22. An interview was conducted on 5/20/22 at 4:40 PM., with the DON (Director of Nursing) concerning the above missed medications. She stated, doing my audit I noticed night time medications on the same exact days as you, aren't being checked off. Residents confirmed they are getting medications on routine at night. Moving forward, I will do an in service on documentation. An interview was conducted with Resident #66 on 5/20/22 at 4:50 PM concerning his missed medications. He stated, As far as I know I guess I'm getting my medications. An interview was conducted with LPN (Licensed Practical Nurse) #8 at 5:00 PM., concerning Missed medication dosages for the above residents. She stated, I forgot to go back and switch the schedule to the right side (Unit). I usually work on the left side (Unit). I sign my meds. (Medications) out at the end of giving meds out. The DON talked to me two weeks ago about this. I will sign out my pills as I finish with each resident. On 05/20/2022 at approximately 3:45 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. The DON stated, Medications should be administered and documented. On 05/20/2022 at approximately 3:45 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. COMPLAINT DEFICIENCY

Based on observation, staff interviews, clinical record review, and review of facility documents, the facility staff failed to ensure a resident received emergency dental services promptly after referrals were made adequately while experiencing the acute dental problem for 1 of 1 resident (Resident #190), with dental concerns in the survey sample. The STAT (now) dental appointment ordered 3/1/22, was scheduled on behalf of Resident #190 on 3/10/22, with a local general practice dentistry office for 3/23/22, which was 22 days after the STAT order. Prior to 3/10/22, the facility's staff was unable to provide evidence of attempting to obtain a dental appointment for Resident #190 and there was no evidence in the resident's clinical record or elsewhere of what extenuating circumstances led to the delay in obtaining the STAT ordered dental appointment. constituting harm for Resident #190. The findings included: Resident #190 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 significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/7/22 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 and severely impaired daily decision-making abilities. In section G (Physical functioning) the resident was coded as requiring total care of one person with bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. On 5/10/22, at approximately 2:25 p.m., Resident #190 was identified residing in a secured unit. He was lying in bed in a fetal position, utilizing oxygen by use of a nasal cannula and the resident didn't respond when spoken to. On 5/10/22, at approximately 3:30 p.m., an interview was conducted with Licensed Practical Nurse (LPN) #11. LPN #11 stated Resident #190 was very active including wandering until two months ago when he experienced a decline after developing a dental abscess. A nurse's note dated 3/1/22 revealed Resident #190 presented with a temperature of 101 degrees Fahrenheit ( F) and swelling was observed on the left side of his face. The nurse's note read that observation of his mouth revealed decayed teeth. The Nurse Practitioner (NP) ordered a STAT (immediately) dental consult and ordered antibiotic therapy; [MEDICATION(S)] 875 mg by mouth two times each day for 7 days. A nurse's note dated 3/2/22 at 6:40 p.m., read the resident remains on an antibiotic nevertheless his temperature was 102.4 F, Tylenol was administered. Another nurse's note dated 3/4/22, revealed the resident's temperature was again abnormal, 101 F, and the swelling to the left side of the resident's face had increased. The NP visited the resident on 3/4/22 to assess the left facial swelling; the assessment read that the resident was frail, in bed making mumbling sounds, while moving his head from side to side, the left face and jaw were inflamed, swollen, tender when touched and the resident was very uncomfortable. The NP assessment also read that an oral exam couldn't be performed in the facility. The NP ordered a three-view facial x-ray which was not a dental xray, but was a general xray that revealed an old non-displaced age undetermined fracture of nasal bone. [MEDICATION(S)] (an opioid pain medication used to treat moderate to severe pain); 0.25 milliliter by mouth every 4 hours as needed for pain, and an additional antibiotic [MEDICATION(S)]; one dose, and a hospice consult. Resident #190 was evaluated again, on 3/7/22 by the NP. The NP documented the resident continued with facial swelling and a tooth abscess and the plan was for the resident to see the dentist as soon as possible for a tooth extraction. The NP ordered an additional one-time dose of the antibiotic [MEDICATION(S)]. On 3/23/22, Resident #190 was seen by the general practice dentist. The dentist's progress note read, that there remained slight swelling to the left lower vestibular region but she was unable to determine if it was associated with a tooth because the resident was unable to open his mouth and/or follow directions therefore she was unable to clinically see or obtain necessary radiology to determine/diagnose the resident's dental problem. The general practice dentist provided referral information to the nursing facility to schedule an appointment with a sedation dentistry practice hence a thorough assessment could be conducted. On 3/30/22 Resident #190 was transferred to a local hospital for altered mental status. The discharge summary from the hospital dated 4/2/22 read that intravenous [MEDICATION(S)] was ordered for a possible dental abscess for which the resident was being treated at the nursing facility. The discharge summary also stated the resident was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During the survey on 5/13/22 at approximately 12:40 p.m., an observation was made of the resident receiving total care with the lunch meal in bed, and approximately 50% of the pureed meal was accepted. Also on 5/19/22 at approximately 5:30 p.m., an observation was made of the resident consuming the dinner meal in bed; he required total care and accepted approximately 50% of the pureed meal. A review of Resident #190's weight revealed on 3/3/22, he weighed 123.4 pounds, and on 5/18/22, 108.0 pounds, a loss of 15.4 pounds. No documentation was identified in the resident's clinical record of the facility's staff actions between 3/1/22 and 3/23/22 to ensure the resident could still eat and drink adequately while awaiting dental services. On 5/17/22 at approximately 5:45 p.m., an interview was conducted with CNA #6. CNA #6 stated she frequently worked with Resident #190 and the resident had experienced a significant decline physically and with meal consumption since the swelling was identified on the left side of his face. She stated many days the resident consumed very little (0-25%) of his meals/fluids but now his intake is better with staff assisting him slowly. On 5/13/22 at approximately 1:20 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated the resident's decline was identified after he presented with a swollen left jaw on 3/1/22, which was diagnosed by the Nurse Practitioner (NP) as a dental abscess. The DON also stated the resident was seen by a local general practice dentist on 3/23/22, but the dentist couldn't examine, diagnose or treat the resident because the resident was unable to open his mouth and/or follow directions; therefore the general practice dentist provided the facility staff with information to schedule an appointment for sedation dentistry for Resident #190. The DON stated LPN #12 was responsible to schedule the sedation dentistry appointment for Resident #190 but she discontinued her employment with the facility and didn't provide the staff with the status of the appointment. As of 5/18/22, there was no evidence that the facility's staff was actively following up on the sedation dentistry appointment. The DON was unable to offer additional information on why there was such a delay in obtaining the necessary dental services or how the delay in services contributed to an additional decline in the resident's health. On 5/13/22 at approximately 4:15 p.m., a phone interview was conducted with LPN #12. LPN #12 stated she was responsible for making the sedation dentistry appointment for Resident #190. She stated she telephoned the practice, left a message with the scheduler, and was awaiting a return call with the appointment information, but she ceased employment with the nursing facility prior to obtaining the sedation dentistry appointment. LPN #12 further stated most likely the sedation dentistry practice left the appointment information on her voicemail after she separated from the facility and the administrative staff at the nursing home has access to the voicemail and can retrieve the message. On 5/19/22 at approximately 2:50 p.m., an interview was conducted with the Administrator. The Administrator stated the facility didn't have a dental contract with a practice but a local dental practice usually accommodates their residents whenever services are needed. The Administrator didn't elaborate on why it took twenty-two days for staff to obtain a dental appointment for Resident #190 but she stated because the in-house NP was monitoring and treating Resident #190's swelling to the left jaw, she felt his dental needs were met. The Administrator didn't address a documented NP progress note in which the NP stated she spoke with the DON on 3/7/22 expressing the need to have the resident evaluated by a dentist. On 5/20/22 at approximately 2:10 p.m., a phone interview was conducted with a representative from the sedation dentistry office. The representative stated a consultation is necessary prior to sedation dentistry services being provided and normally after the consultation the service is rendered within one month. The representative confirmed that an appointment for Resident #190 had not been made for the resident's name wasn't in their system. The representative further stated even in the event an appointment wasn't honored or canceled, the person's name would still be in their system. On 5/20/22 at approximately 6:00 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. The facility's policy titled Dental Services with a revision date of 01/04/22 read; It is the policy of this facility, in accordance with residents' needs, to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. Emergency dental services include services needed to treat an episode of acute pain in teeth, gums, or palate; broken, or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist.

The facility staff failed to notify the physician or the wound Nurse Practitioner of a deteriorating stage II pressure ulcer prior to advancing to an unstageable pressure ulcer for 1 out of 55 residents (Resident #291) in the survey sample. The finding included: Resident #291 was originally admitted to the facility on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #291's Admission Assessment (14-day) with an ARD of 03/19/22 coded Resident #291 Brief Interview for Mental Status (BIMS) scored a 99 indicating short and long term memory problems and severe cognitive impairment - never/rarely made decisions. Resident #291 was coded total dependence of two with toilet use, bed mobility and bathing, total dependence of one with dressing, personal hygiene and eating and for Activities of Daily Living (ADL). Resident #291 was coded as having no mood, rejection of care or behavioral problems. Resident #291's person-centered care plan initiated on 03/21/22 identified the resident has a pressure ulcer in her sacral area, at risk for further skin breakdown related to incontinence and impaired mobility. The goal set for the resident by the staff was that the resident will remain free of new skin breakdown through next review date. Some of the interventions/approaches the staff would use to accomplish this goal is to follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The skin/wound admission note dated 03/10/22 indicated Resident #291 had a stage II sacral ulcer measuring 2.0 cm x 1.0 cm x 0.2 cm with very dark skin, non-blachable measuring (15 cm x 9 cm) surrounding the sacral ulcer. A review of Resident #291's nurse's note revealed the resident was transferred to the hospital on 03/14/22 at approximately 6:50 p.m., and returned on 03/15/22 at approximately 4:00 p.m. Further review of the nurse's note revealed no new skin impairments noted since the last admission assessment on 03/10/22. The admission/readmission note on 03/15/22 under skin integrity revealed a stage II sacral pressure. During the review of Resident #291's clinical record revealed there were no weekly wound assessments made to the sacral pressure ulcer for 19 days, after her original admission to the facility. An interview was conducted with the wound NP on 05/17/22 at approximately 3:06 p.m., who said, My first time evaluating Resident #291's pressure ulcer was on 03/29/22. The wound NP said the wound was infected as evidence by the wound having a significant amount of slough with foul odor present and having significant pain over the sacral area when touched or palpated. The wound NP stated, I was never informed that Resident #291's stage II pressure ulcer had deteriorated and had advance to an unstageable. The wound NP initial progress note of the sacral pressure ulcer on 03/29/22 revealed an unstageable ulcer measuring 5 cm x 5 cm x 2 cm. The progress note stated the sacral wound had a moderate amount of serosanquinous drainage, strong odor present with 90 percent (%) slough and 10 % dermis tissue. A new medication order was given for [MEDICATION(S)] (antibiotic) 500 mg/125 mg every 12 hours x 10 days for a sacral wound infection. A new treatment order was given to clean the sacral wound with Dakin's, Santyl on Dakin's gauze, and cover with foam dressing daily and as needed. The wound NP progress note also stated pain is indicative of any movement, at rest she is comfortable. The wound NP also offered further recommendations to turn and reposition per facility protocol, use of a low air loss mattress and to optimize nutrition. A wound NP progress note dated 04/05/22 revealed the sacral wound pressure ulcer remained an unstageable measuring 5 cm x 5 cm x (?). The sacral wound had improved but remain with moderate amount of serosanquinous drainage, strong odor present with 90% slough and 10% dermis tissue. The wound was debrided removing thick slough tissue; pain was present with any movement. Resident #291 remains on antibiotic therapy for a sacral wound infection and will continue with the current wound treatment with Dakin's, Santyl on Dakin's gauze, and cover with foam dressing daily and as needed. A review of the wound NP progress note dated 04/11/22 indicated the following, The wound visit was performed via telehealth with the wound nurse, License Practical Nurse (LPN #3). The sacral wound is deteriorating with moderate amount of purulent drainage, strong odor present with 90% slough and 10% dermis tissue. The wound measured by onsite nurse (LPN #3) measuring 6.5 cm x 5.5 cm x 2.5 cm. The progress note recommended to continue with current sacral wound treatment with Dakin's, Santyl on Dakin's gauze, foam dressing and change daily and as needed. A new antibiotic order was given for [MEDICATION(S)] 600 mg by mouth every 8 hours for 21 days for a sacral wound infection. The wound NP progress note also stated pain is indicative of any movement, at rest she is comfortable. An interview was conducted with the Medical Director (MD) on 05/18/22 at approximately 11:33 a.m., who said all pressure ulcers are followed by (name of Wound Company.) Resident #291's sacral ulcer should have been monitored, assessed and measured on a weekly basis for signs of decline or improvement. The changes in the wound should have been addressed before the wound was identified as an unstageable pressure ulcer. The MD stated, (name of Wound Company) or myself should have been notified that Resident #291's sacral ulcer was declining. An interview was conducted with the Director of Nursing (DON) and wound nurse LPN #3 on 05/12/22 at approximately 10:00 a.m. The DON said Resident #291's sacral pressure ulcer should have been evaluated by the wound NP or wound nurse, LPN #3 on a weekly basis. The weekly evaluation and monitoring is needed for early detection to determine if the wound is improving or declining. The DON said the nurses should have been assessing and documenting changes on Resident #291's sacral pressure ulcer (description of wound bed, if drainage or odor present and size of the wound) with all changes reported to LPN #3 or the wound NP for evaluation to determine if wound treatment changes were needed. A debriefing was held with the Administrator, Director of Nursing and Corporate support on 05/19/22 at approximately 2:00 p.m. Resident #291's issues was presented again. No additional information was forthcoming. The facility's policy Notification of Changes - revised on 03/10/2022. The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification. Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. -Circumstances requiring notification include but not limited to a new treatment, discontinuation of current treatment due to adverse consequences, acute condition or exacerbation of a chronic condition.

Based on observations, and staff interviews it was determined that the facility staff failed to ensure 32 of 56 residents in the survey (Residents #25 through 56) were in an environment that was free of accident hazards. The facility staff failed to ensure that six of the dining room ceiling lights and ceiling tiles were free of water and condensation and not creating the probability of serious harm. Immediate Jeopardy (IJ) was called on 7/21/15 at 3:47 p.m. based on observations in the facility dining room of six ceiling lights containing large amounts of water and ceiling tiles sagging from excessive moisture with residents noted sitting directly under them. Based on vertification, review and acceptance of their Corrective Action Plan (CAP), the Immediate Jeopardy (IJ) was removed on 7/21/15 at 6:03 p.m. The findings included: On 7/21/15 at 12:40 p.m. during the initial facility tour a dining room observation was made with 17 residents occupying the area. There were six ceiling light fixtures flush with the ceiling noted to have large amounts of water in them and several ceiling tiles in the inner aspect of the dining room showing water stains and expansion from excessive moisture containment. An interview was conducted with the Administrator on 7/21/15 at 2:20 p.m. The Administrator was asked, Have you had any problems with the roof because of all the rain we have been having lately? The Administrator stated, Yes, our air condition units are on the roof and we have been having a problem with a lot of condensation coming through to the ceiling tiles. My maintenance man has had to go to (store name) almost everyday to get more ceiling tiles. We have been getting a more absorbent higher grade tile. Also we had a lot of snow this winter which has caused a lot of havoc on our roof. From 2:00 p.m. until 3:30 p.m. an activity in the dining room were observed with 22 residents in attendance. These 22 residents were observed by the surveyor to be sitting at three tables that were directly under three ceiling light fixtures that were bowing outward with large amounts of water in them. The State Office was notified of the above findings and the Immediate Jeopardy status. After approval from the State Office the facility Administrator and Director of Nursing were advised on 7/21/15 at 3:47 p.m. that the facility was in an Immediate Jeopardy status. A facility investigation was initiated by the Administrator, Director of Nursing, and the Director of Maintenance. On 7/21/15 at 3:52 p.m. an observation of the dining room was made. All residents had been evacuated from the dining room. The dining room doors were locked, caution taped was placed across the dining room entrance and orange cones were also placed in front of the dining room doors. The Administrator had attached four signs to the dining room doors indicating that the dining room was closed. The Director of Nursing was asked for a complete list of residents who had occupied the dining room on 7/21/15 prior to Immediate Jeopardy being called. A list of 32 residents was obtained from the Director of Nursing. Resident #25 was a [AGE] year of female readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a quarterly dated 6/23/15. The resident Brief Interview for Mental Status was coded as 13/15, which indicated that the resident was cognitively intact for decision making. Resident #26 was a [AGE] year of female readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a quarterly dated 5/20/15. The resident Brief Interview for Mental Status was coded as 4/15, which indicated that the resident was severely impaired in cognitive skills for daily decision making. Resident #27 was a [AGE] year of female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a 30 day dated 5/26/15. The resident Brief Interview for Mental Status was coded as 12/15, which indicated that the resident was cognitively intact for decision making. Resident #28 was a [AGE] year of female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a quarterly dated 6/17/15. The resident Brief Interview for Mental Status was coded as 14/15, which indicated that the resident was cognitively intact for decision making Resident #29 was a [AGE] year of male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a annual dated 5/14/15, indicating that the resident had long and short term memory problems and was moderately impaired in cognitive skills for daily decision making. Resident #30 was a [AGE] year of female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a quarterly dated 4/27/15, indicating that the resident had long and short term memory problems and was moderately impaired in cognitive skills for daily decision making. Resident #31 was a [AGE] year of male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was an admitted d 7/14/15, indicating that the resident had long and short term memory problems was moderately impaired in cognitive skills for daily decision making. Resident #32 was a [AGE] year of female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a quarterly dated 5/8/15. The resident Brief Interview for Mental Status was coded as 7/15, which indicated that the resident was moderately impaired in cognitive skills for daily decision making. Resident #33 was a [AGE] year of female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was an annual dated 6/08/15. The resident Brief Interview for Mental Status was coded as 5/15, which indicated that the resident was severely impaired in cognitive skills for daily decision making. Resident #34 was a [AGE] year of female readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was an admitted d 6/20/15. The resident Brief Interview for Mental Status was coded as 14/15, which indicated that the resident was cognitively intact for decision making. Resident #35 was a [AGE] year of male readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a quarterly dated 7/12/15. The resident Brief Interview for Mental Status was coded as 10/15, which indicated that the resident was cognitively intact for decision making. Resident #36 was a [AGE] year of male readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a 60 day dated 5/22/15. The resident Brief Interview for Mental Status was coded as 13/15, which indicated that the resident was cognitively intact for decision making. Resident #37 was a [AGE] year of female readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident Brief Interview for Mental Status was coded as 7/15, which indicated that the resident was moderately impaired in cognitive skills for daily decision making. Resident #38 was a [AGE] year of male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a quarterly dated 6/29/15. The resident Brief Interview for Mental Status was coded as 14/15, which indicated that the resident was cognitively intact for decision making. Resident #39 was a [AGE] year of female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident #40 was a [AGE] year of female readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was an annual dated 5/5/15, indicating that the resident had long and short term memory problems and was moderately impaired in cognitive skills for daily decision making. Resident #41 was a [AGE] year of female readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident Brief Interview for Mental Status was coded as 7/15, which indicated that the resident was moderately impaired in cognitive skills for daily decision making. Resident #42 was a [AGE] year of female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a quarterly dated 5/14/15. The resident Brief Interview for Mental Status was coded as 13/15, which indicated that the resident was cognitively intact for decision making. Resident #43 was a [AGE] year of female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a 60 day dated 7/13/15, indicating that the resident had long and short term memory problems and was severely impaired in cognitive skills for daily decision making. Resident #44 was a [AGE] year of male readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a 30 day dated 7/6/15. The resident Brief Interview for Mental Status was coded as 13/15, which indicated that the resident was cognitively intact for decision making. Resident #45 was a [AGE] year of female readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a quarterly dated 4/23/15. The resident Brief Interview for Mental Status was coded as 7/15, which indicated that the resident was moderately impaired in cognitive skills for daily decision making. Resident #46 was a [AGE] year of female readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a quarterly dated 4/8/15. The resident Brief Interview for Mental Status was coded as 7/15, which indicated that the resident was moderately impaired in cognitive skills for daily decision making. Resident #47 was a [AGE] year of female readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a 60 day dated 6/15/15, indicating that the resident had long and short term memory problems and was severely impaired in cognitive skills for daily decision making. Resident #48 was a [AGE] year of male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a quarterly dated 4/12/15, which indicated that the resident was moderately impaired in cognitive skills for daily decision making. Resident #49 was a [AGE] year of male readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a quarterly dated 5/14/15. The resident Brief Interview for Mental Status was coded as 9/15, which indicated that the resident was moderately impaired in cognitive skills for daily decision making. Resident #50 was a [AGE] year of female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was an annual dated 6/20/15. The resident Brief Interview for Mental Status was coded as 2/15, which indicated that the resident was severely impaired in cognitive skills for daily decision making. Resident #51 was a [AGE] year of male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a quarterly dated 6/03/15. The resident Brief Interview for Mental Status was coded as 10/15, which indicated that the resident was cognitively intact for decision making. Resident #52 was a [AGE] year of female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was an admitted d 7/12/15. The resident Brief Interview for Mental Status was coded as 4/15, which indicated that the resident was severely impaired in cognitive skills for daily decision making. Resident #53 was a [AGE] year of female readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a quarterly dated 4/16/15. The resident Brief Interview for Mental Status was coded as 12/15, which indicated that the resident was cognitively intact for decision making. Resident #54 was a [AGE] year of male readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a quarterly dated 5/18/15, indicating that the resident had long and short term memory problems and was severely impaired in cognitive skills for daily decision making. Resident #55 was a [AGE] year of female readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a quarterly dated 4/8/15. The resident Brief Interview for Mental Status was coded as 7/15, which indicated that the resident was moderately impaired in cognitive skills for daily decision making. Resident #56 was a [AGE] year of female readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a quarterly dated 5/8/15, indicating that the resident had long and short term memory problems and was severely impaired in cognitive skills for daily decision making. At 6:03 p.m. the facility Administrator presented an acceptable Corrective Action Plan (CAP) with an allegation of compliance (AOC) date of 7/21/15 which documented in part, read as follows: Corrective Action(S): The Maintenance Director and Maintenance Assistants have closed down the dining room, placed caution cones outside the door to prevent entrance for the dinner meal. The dining room will remain closed until it has been cleared of life safety issues by the state fire marshal and electrician. All activities will be held in the secondary activity room on the floor and all meals will be served on the floor in resident rooms. The Dining Room Air Conditioning units have been turned off and the lights in the dining room have been turned off to prevent continued condensation build-up and potential electrical fire hazard. All light covers and light receptacles have been dried out. The outside Contractor that installed the Air-conditioning Units have been contacted and will be at the facility tomorrow morning to adjust the outside air-flow to help control the condensation build up in the dining room. The units will not be put into operation until cleared of life safety code issues by the state fire marshal and they are operating as designed. Identification of deficient practice and Corrective Action(s): All facility light receptacles may have been affected. The Maintenance Director and maintenance assistants will inspect all light receptacles in the ceiling to identify any affected areas. Any negative finding will be corrected at time of discovery to prevent any accident hazard on 7/21/15. Systemic Change(s): The Maintenance Director and Maintenance assistants will perform 3 daily documented checks of all lighting receptacles throughout the facility to ensure all lighting receptacles are dry and free from condensation. Ongoing inspections of lighting receptacles will be conducted daily to prevent any future condensation build up. These audits will be completed daily for 90 days following the clearing of the safety hazard. Monitoring: The Maintenance Director and Maintenance assistance and Administrator are responsible for monitoring compliance. The Maintenance Director and/or Administrator will review the daily inspection check sheets to ensure that all lighting receptacles are in good operating condition and free from condensation. Any lighting receptacles noted to have condensation building up will be corrected immediately at the time of discovery. The results of these audits will be forwarded to the Quality Assurance Committee quarterly/prn (as needed) for review, analysis, and recommendations for change in facility policy, procedure, and/or practice. Correction Date: July 21, 2015 The Immediate Jeopardy (IJ) was lifted on 7/21/15 at 6:03 p.m., and the State office was notified. The deficiency level assigned to the Immediate Jeopardy was a Scope and Severity of a level IV, Isolated. After the Immediate Jeopardy was lifted the Scope and Severity will remain at Level II, Isolated. The State Fire Marshall staff did arrive at the facility on 7/21/15 after the team had exited for the day and the Administrator indicated that the dining room would remain closed until all repairs were completed and cleared by the State Fire Marshall. On 7/23/15 at 12 noon an interview was conducted with the facility Maintenance Director and he was asked to explain the condition of the dining room ceiling prior to the survey team's arrival. The Maintenance Director stated, This is a flat roof with no leaks, we don't need a new roof. It was the condensation off of the duct work for the air conditioners. When stale air sets in, it's hot up there (in the ceiling), the cold duct work and the hot stale air causes condensation. (Name of refrigeration company) have cut duct vents to blow air to condition the stale air to remove the humidity. The Surveyor asked, When did you notice the water in the dining room? The Maintenance Director stated, Last week around July 17, (2015) we had two 100 degree days and on July 20th (2015) I saw the water, so I started changing the ceiling tiles in the dining room. The duct work and ceiling in the kitchen are all new from last year. The Maintenance Director was also asked if he was an electrician and he stated, I'm a Master Electrician. The Surveyor asked, How did the water get in the lights in the dining room? The Maintenance Director stated, The lights are flush with the ceiling tiles and the water from the condensation from the air condition units was the water that leaked into the base of the lights, but the electrical parts of the lights are encased so no water met electricity. The Surveyor asked, Does water and electricity mix? The Maintenance Director whom stated, No, it doesn't. On 7/23/15 at 7:00 p.m. a briefing was held with the Administrator and the Director of Nursing and the above findings were shared. No further information was provided for review.