Every finding on record at Nortonville Health Care Center

Based on observation, interviews, and record review, the facility failed to implement the treatment plan, including an antibiotic, for Resident (R) 1's Stage 3 pressure ulcer (localized tissue damage that results in full-thickness loss of skin). The pressure ulcer deteriorated, and the resident admitted to the hospital for treatment.Findings included:- R1's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), polyneuropathy (damage to many nerves outside your brain and spinal cord at the same time), and pressure ulcer of the right heel Stage 3.The Quarterly Minimum Data Set (MDS) dated [DATE] documented R1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. The MDS recorded R1 required substantial to maximal assistance for toileting hygiene, showers or bathing, and tub or shower transfers. The MDS recorded R1 required partial to moderate assistance for toilet transfers, transitioning from seated to lying positions, moving from seated to standing position, and chair or bed transfers. The MDS documented R1 had a Stage 3 pressure ulcer.The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 03/20/2026 documented R1 had a BIMS of 12. R1 was generally able to communicate needs and participate in daily activities but could exhibit occasional forgetfulness, decreased short-term memory, and need for cueing or reminders. The CAA documented cognitive deficits might impact problem-solving, safety awareness, and the resident's ability to complete tasks independently at times.The Pressure Ulcer/Injury CAA dated 03/20/2026 documented R1 presented with a deep tissue injury to the right foot. Contributing risk factors included impaired mobility, decreased tissue perfusion, and potential pressure related to positioning and/or footwear. The CAA documented the resident's skin integrity was further impacted by overall functional status and the need for assistance with activities of daily living (ADL).R1's 03/18/2026 Care Plan documented R1 had actual skin breakdown due to a deep tissue injury to the right heel related to immobility. The plan documented the following interventions for R1:03/18/2026 - Staff were to assess, record, and monitor the resident's wound healing weekly. The facility would measure length, width, and depth where possible and assess and document the status of wound perimeters, wound bed, and healing progress. The intervention directed staff to report improvements and declines to the provider.03/18/2026 - Staff were to monitor the dressing every shift to ensure it was intact and adhering. Staff were to report loose dressings to the treatment nurse.03/18/2026 - Staff were to offload the resident heel with an offloading boot or pillows and document refusals.03/18/2026 - Staff were to administer medications as ordered. The plan directed staff to monitor and document for side effects and effectiveness of the medications.R1's 03/26/2026 Care Plan documented R1 had actual impairment to skin integrity of the right heel. The plan documented the following interventions for R1:03/26/2026 - Staff were to monitor and document the location, size, and treatment of the skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc. to the provider.03/26/2026 - Weekly treatment wound documentation would include measurements of each area of skin breakdown width, length, depth, type of tissue and exudate, and any other notable changes or observations.A HP Skin and Wound Note, entered by Consultant GG and dated 06/09/2026 at 01:19 PM, documented R1 had a pre-existing ulcer of the right heel that was present for greater than 30 days. The nurse reported she was unsure of the origin of the wound. Potential complicating factors for wound healing included peripheral vascular disease (PVD- a blood circulation condition that narrows or blocks blood vessels outside the heart and brain, mainly affecting the legs), atrial fibrillation (AFib- rapid, irregular heartbeat), hypertension (elevated blood pressure), and breast cancer. R1 needed follow-ups, including weekly wound evaluations. The note documented a recommendation for doxycycline (antibiotic) 100 milligrams (mg) two times a day for seven days due to the resident's right heel wounds odor and amount of slough (soft, yellow, white, or cream-colored layer of dead tissue that forms inside a healing wound). The wound assessment noted a stage three right heel pressure ulcer. The note recorded the wound was worsening and was malodorous post-cleansing. The note recorded R1's heel wound measured 3.8 centimeters (cm) x 4 cm x 0.2 cm, with a calculated area of 15.2 square cm. R1 was seen for wound care examination of the right heel wound. The wound had a foul odor noted upon examination, and the wound was larger than at the previous examination. R1's wound was covered in slough and sharp debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue) was performed and tolerated by R1.A Wound Assessment Report, documented by Consultant GG, with a date of service of 06/09/2026, lacked any documented recommendations related to R1's wound care visit.A HP Skin and Wound Note, entered by Consultant GG and dated 06/16/2026 at 02:23 PM, recorded the following measurements: 4.2 cm x 4.2 cm x 0.2 cm, with a calculated area of 17.64 sq cm. The note recorded R1's wound was malodorous; however, the note recorded there was less odor noted during examination. R1 was started on an antibiotic due to wound drainage and foul odor. The note recommended R1 complete the ordered antibiotic regimen.A HP Skin and Wound Note, entered by consultant GG and dated 06/23/2026 at 12:35 PM, documented the wound was stable and had no odor. The note recorded the wound measured 4 cm x 5 cm x 0.3cm with a calculated area of 20 sq cm. R1 had completed the ordered antibiotic regimen. The note further documented the wound was slightly larger from previous examination, with slightly more depth; however, it was noted the wound had overall better tissue quality.A HP Skin and Wound Note, entered by consultant GG and dated 06/30/2026 at 02:18 PM, documented the wound as stalled, with mild odor. The note recorded the wound measured 3.8 cm x 4.8 cm x 0.4 cm with a calculated area of 18.24 sq cm. R1 completed an antibiotic regimen approximately seven days prior due to wound odor and drainage. The note recorded a recommendation for a Magnetic Resonance Imaging (MRI-medical imaging used to view soft tissue) due to continued concerns of osteomyelitis (local or generalized infection of the bone and bone marrow).A HP Skin and Wound Note, entered by Consultant GG and dated 07/07/26 at 01:25 PM, documented the resident's wound as stable and malodorous. The note documented the wound measured 3.7 cm x 4.6 cm x 0.3 cm with a calculated area of 17.02 cm. The note documented R1's wound had improved from the previous examination.A HP Skin and Wound Note, entered by consultant GG and dated 07/14/26 at 01:27 PM, documented the wound as stalled, with odor being related to the wound dressing. The note recorded the wound measured 4 cm x 4.6 cm x 0.4 cm with a calculated area of 18.4 sq cm. The note recorded the wound had slightly increased in size, but there were no noted changes to tissue quality. The note further recorded there was a large amount of slough that remained present from the previous examination.A HP Skin and Wound Note, entered by consultant GG and dated 07/21/26 at 02:01 PM, documented the wound as stable, with odor being related to dressing. The note recorded the following measurements: 4 cm x 4.4 cm x 0.3cm with calculated area of 17.6 sq cm. The note recorded the wound decreased in size from the previous examination with a slight improvement in tissue quality. The wound bed remained mostly covered in slough and a sharp debridement was performed and tolerated by R1. The odor improved following the sharp debridement. A HP Skin and Wound Note, entered by Consultant GG and dated 07/28/2026 at 03:57 PM, documented the wound improved, but presented with delayed wound closure. The note recorded the wound measured 3.6 cm x 4.1 cm x 0.3 cm with a calculated area of 14.76 sq cm. The note documented R1's wound decreased in size from the previous examination. There was noted improvement in tissue quality. Some slough remained present and the odor had resolved. A sharp debridement was performed and tolerated by R1.A HP Skin and Wound Note, entered by Consultant GG and dated 08/04/26 at 03:27 PM, documented the wound was worsening and had a mild odor, post-cleansing. The wound measured 4 cm x 5 cm x 0.4 cm with a calculated area of 20 sq cm. The note documented R1's wound deteriorated from the previous examination. The note recorded R1's wound also had a foul odor, and the odor remained present. The note recommended Doxycycline 100 mg two times per day for seven days.A Wound Assessment Report, documented by Consultant GG, with a date of service of 08/04/2026, lacked any documented recommendations related to R1's wound care visit.R1's Medication Administration Record (MAR) for August 2026 lacked evidence that the Doxycycline 100 mg two times per day for seven days was ordered or administered for R1.An Appointment Note marked as a late entry with a created date of 08/15/2026 and an effective date of 08/06/26 documented the nurse received a call from a facility where R1 was scheduled to receive an MRI. The note documented that they were not able to complete the MRI due to R1 not being able to lie flat and not being cooperative. The note recorded that the facility reported R1 was not a good candidate for an MRI related to these difficulties. The note recorded that the nurse contacted wound care and the primary care provider and received an order for an X-ray.A View Radiology Report dated 08/08/2026, and a reviewed date of 08/10/2026, documented under impression there was a significant concern for potential osteomyelitis (infection of the bone). The note recorded plain radiographs were notoriously insensitive in the detection of osteomyelitis and further assessment of R1 was strongly recommended with MRI.A Lab/Radiology Results Reviewed with Physician note dated 08/10/2026 at 09:37 AM documented X-ray results were reviewed and reported to the primary care provider (PCP). The PCP gave an order to send R1 to the hospital emergency room related to the abnormal X-ray.An Incident Note dated 08/10/2026 at 11:24 AM recorded Administrative Nurse D was rounding with Consultant GG for R1. Administrative Nurse D and Consultant GG discussed R1's deteriorating wound. Consultant GG asked about the status of the MRI appointment, and Administrative Nurse D stated they would figure it out. Consultant GG completed the assessment, and they moved on to the next resident. Facility staff identified an antibiotic recommendation was not followed through. The note recorded the notification to the physician, Durable Power of Attorney (DPOA), and concerns were addressed.A Transfer to Hospital Summary note dated 08/10/2026 recorded R1 was sent to the hospital via Emergency Medical Services (EMS) for suspected osteomyelitis per PCP.Review of R1's EMR revealed the 08/04/2026 order recommendation for Doxycycline 100 mg two times per day for seven days was never addressed or started for R1.A hospital Progress Note dated 08/10/2026, recorded under the assessment and plan section, documented the X-ray did not show signs of osteomyelitis. The note recorded R1 received intravenous (IV-administered directly into the bloodstream via a vein) antibiotics. The report recorded R1's tissue cultures grew Gram-negative rods (rod-shaped bacteria with an outer protective membrane containing toxic endotoxins, making many common infections hard to treat with standard antibiotics).A Surgeon Debridement Operative Report with a date of operation of 08/12/2026 documented R1 had no gross evidence of osteomyelitis. The report recorded the following post-debridement wound measurements: 6 cm width, 6 cm depth, 0.5 cm. The report recorded staging at a four with full-thickness tissue loss.An N Adv - Skin Issues note dated 08/17/2026 at 03:59 PM documented the wound care nurse assessed R1 and placed a wound vac as ordered.On 08/17/2026 at 03:15 PM, R1 rested in her bed while staff placed the wound vac on R1's right heel.On 08/18/2026 at 01:28 PM, Licensed Nurse (LN) G stated when the wound care provider came to the facility, he put recommendations in his progress notes. LN G stated when she used to do wound care with the provider, she would review the progress notes he entered to check for recommendations for orders that he entered at the bottom of his progress notes. LN G stated the wound care provider always put his recommendations in that way. LN G stated she had explained the process before she transferred over wound care to someone else. LN G stated she always waited until the wound care provider entered their final note to come in, as there were times the provider would change their mind on a treatment after reviewing other information later on. LN G stated nothing would be done with the orders until that final note came through. She stated she believed the wound care provider ordered antibiotics for R1 on 08/04/2026, but believed it was not discovered until 08/10/2026, that they had not been ordered. LN G stated she believed R1's wound had been mostly stable prior to this last change. LN G stated if a wound was infected and not treated promptly, the resident would have been at risk for further deterioration of the wound, worsening infection, and could end up with osteomyelitis. LN G stated there were a lot of things that could go wrong if an antibiotic was not started promptly. LN G verified the facility provided staff education related to the missed antibiotic.On 08/18/2026 at 01:35 PM, Administrative Nurse D stated the wound care provider put in his own notes, and they were found under the progress notes section in the resident's EMR. Administrative Nurse D stated this was the only place the wound care provider put recommendations for wound orders. Administrative Nurse D stated she now receives the notes, goes over them, and puts in any orders. Administrative Nurse D stated she also received emails from the wound care provider, and she reviewed those emails as well to ensure everything the wound care provider noted was followed over into the resident's chart. She stated she contacts the doctor to get any recommended orders addressed. Administrative Nurse D stated that when she rounded with the wound care provider, the order for the doxycycline was not verbally communicated to her. Administrative Nurse D stated when she rounds with the wound care provider, she writes everything down, but there was no verbal mention of it. Administrative Nurse D stated she did not review the progress note, as the wound care provider did not get it in until later in the day. Administrative Nurse D stated if there was a four- to five-day delay before antibiotics were started, it could lead to a worsening infection, worsening wound, and the resident could be at risk for becoming septic (life-threatening medical emergency where your body has an extreme, overactive response to an infection). Administrative Nurse D stated the facility provided education on reviewing progress notes and reviewing any documentation sent via email. Administrative Nurse D stated CNAs were provided education on documenting in the EMR if they notice skin issues and to report it to the nurses. Nurses were educated on accurately completing wound orders and skin assessments.On 08/18/2026 at 01:47 PM, Administrative Staff A stated the wound care provider placed his recommendations in the progress notes and not anywhere else. She stated that day the provider did not give a verbal recommendation for the antibiotic. Administrative Staff A stated when they were entered into a progress note, that information did not feed into the 24-hour report for them to follow up on. Administrative Staff A stated the recommendations entered into progress notes did not go anywhere. Administrative Staff A stated unless someone reviewed the progress notes specifically, no one would have seen the recommendations. Administrative Staff A stated the facility process has now been updated to review the progress notes going forward. She stated they have already educated the staff on the expectations. Administrative Staff A stated she was not aware if staff were reviewing the progress notes before, but she did not believe it was part of the process before. Administrative Staff A stated the wound care provider was also not putting recommendations on the Wound Assessment Reports, and those had different information than what was in the progress notes.The facility's Wound Treatment Management Policy, with an origination date of 05/03/2024, documented wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. This may be the treatment nurse or the assigned licensed nurse in the absence of the treatment nurse. The effectiveness of treatments will be monitored through ongoing assessment of the wound.On 08/10/2026, the facility identified and corrected the noncompliance with actions including:1. Residents with pressure injuries and diabetic ulcers were assessed for appropriatewound orders.2. Residents with pressure injuries and diabetic ulcers had their most recent wound care practitioner notes reviewed for recommendations and/or orders.3. Licensed nurses were re-educated on following physician orders and wound assessments starting 08/10/2026.4. The wound care nurse practitioner was re-educated on the need to verbally communicate new orders and/or recommendations to the licensed nurse. This re-education was completed on 8/10/2026 via phone.5. An ad hoc QAPI with the medical director was held on 08/I0/2026 via phone. Rootcause of the lack of communication was that the nurse practitioner's wound statusreport and progress note do not contain the same information, so both reports mustbe reviewed. Additionally, the progress notes entered by the wound nurse practitioner donot pull into the 24-Hour Report, which is utilized to review all new notes duringclinical meetings. The clinical staff must read each progress note separately duringthe clinical meeting for details.These actions were verified during the onsite survey, and since all were completed prior to the survey, the deficient practice was deemed past noncompliance and remained at the scope and severity of a G (actual harm, isolated).

The facility had a census of 34, with 14 residents in the sample, and one resident reviewed for substance use disorder. Based on observation, interview, and record review the facility failed to prevent, identify, and intervene in Resident (R) 11's substance use disorder, which placed residents in immediate danger of serious harm or death. R11' Electronic Health Record revealed a history of substance use disorder, charting to indicate signs and symptoms of active substance use, and two instances of the resident having drug paraphernalia in his room. On [DATE] at 02:14 PM facility staff saw a green tackle box and a red basket on the floor in R11's room which contained pill bottles, lighters, books, and other items scattered next to it. The red basket had a torch, four pill bottles, a red lighter, a large knife, and a black pouch containing a drug pipe. On [DATE] at 09:30 PM staff were asked to check on R11 due to suspicion of drug use, and upon a search they found a crack pipe with methamphetamine still in the bowl and a lighter in a glasses case. The resident had pinpoint eyes, a severely red face, and appeared intoxicated. The resident refused transport to the hospital and law enforcement declined to transport the resident out of the facility due to his medical conditions. The facility failed to implement any monitoring of the resident for continued substance use, withdrawal, and or other self-harm actions. The facility staff failed ensure the safety of all resident's in the facility when they removed the crack pipe from the resident's room with the methamphetamine still in the bowl of the pipe spilled it over the top of the medication cart, which housed other resident medications and potentially exposed any residents in the vicinity (including those with known SUD) to the toxic substance. Staff utilized gloves and cleaned the cart. The Administrator and/or Regional Nurse were notified of the incidents on [DATE] and [DATE] but failed to act on the incidents. By allowing the resident to smoke methamphetamine inside the building while in possession of a knife, torch, lighter and non-prescribed pills the facility created multiple high-risk conditions including fire and explosion risk, physical injury risk, drug exposure and overdose risk, impaired judgement and unpredictable behaviors as well as delayed emergency response by facility staff. The combination of illegal substance use, possible weapons, and ignition sources inside the facility along with lacking supervision and care planning put all resident's health and safety in Immediate Jeopardy. The facility further failed to determine a root cause analysis and implement fall precaution interventions after falls for R32 and failed to use a gait belt during transfers for R16.The facility Administrator was notified of the Immediate Jeopardy (IJ) on [DATE] at 1:18 PM and remain ongoing.Findings included:- Review of R11's Electronic Health Record (EHR) revealed the following diagnoses: alcoholic liver disease, psychoactive substance abuse (in remission), and other stimulant abuse (uncomplicated). Review of the admission Minimum Data Set, dated [DATE] revealed the resident had a brief interview for mental status score of 15, which indicated intact cognition. The resident had behavior symptoms directed toward others and behavioral symptoms not directed toward others one to three days of the observation period. R11 mobilized with the use of a wheelchair and required substantial/maximal assistance for activities of daily living including sitting to lying down, lying down to sitting, sitting to standing, chair to bed transfers, and toilet transfers. Review of [DATE] Care Area Assessments (CAA) for R11 revealed the Functional Abilities (Self-Care and Mobility) CAA, Behavioral Symptoms CAA, Psychotropic Drug use CAA, Mood State CAA, and Psychosocial Well Being CAAs triggered for further review, but were not further assessed for potential problems to determine care planning decisions and implement effective interventions for his care. Review of the [DATE] hospital referral sheet for admission to the facility revealed R11 had a history of chronic alcohol abuse and a history of drug abuse. The document noted the resident admitted to the hospital for various reasons, including alcohol and substance abuse. The resident was disheveled and unkept and evasive about his last use of substances. R11 reported current drug use at the time of the assessment. The resident's Care Plan initiated on [DATE] lacked any intervention related to the resident's diagnoses of psychoactive substance abuse and stimulant use, which included signs/symptoms, and triggers of possible illegal substance use. The facility further failed to implement any interventions when illegal drug paraphernalia was identified in the resident's room on [DATE] and drug paraphernalia, which contained actual methamphetamine (reported by the nurse on duty) was observed and confiscated on [DATE]. The care plan lacked any indication the resident had a history of cutting his scabs off with a knife. The resident's Care Plan revealed the following interventions: [DATE] – Staff would assist the resident, family, and caregivers to identify strengths, utilize positive coping skills and reinforce them. [DATE] - Behavioral health consults as needed with contracted psychiatric provider. [DATE] – Staff were to monitor/document/report as needed any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harming or trying to harm self, refusing to eat or drink, refusing medications or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. [DATE] - Monitor/record/report to the physician as needed the resident's risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons. [DATE] - Observe for signs and symptoms of mania or hypomania racing thoughts or euphoria; increased irritability; frequent mood changes; pressured speech; flight of ideas; marked change in need for sleep; agitation or hyperactivity Review of the [DATE] at 07:25 PM Health Status Note revealed the resident reported developing large blisters to fingers on both hands. The note lacked any further documentation about description of the blisters, investigation into the cause of the blisters, or any intervention related to the blisters. Review of the [DATE] at 01:30 PM Health Status Note revealed the resident had a flat affect, was easily angered, and often refused cares. Subsequent notes lacked any intervention related to the resident's affect or behaviors. Review of the [DATE] at 09:48 AM Health Status Note revealed an unidentified Certified Medication Aide reported the resident was cutting off scabs from his skin with a Buck knife and applying alcohol to the areas. The CMA then reported seeing out of facility meds sitting on table. The note lacked any follow up to the medications sitting on the resident's table or the use of the buck knife to cut scabs from his skin. The note further lacked evidence the facility intervened with the non-facility ordered medications or resident's self-harming behaviors. Review of the [DATE] at 01:22 PM IDT [Interdisciplinary Team] Meeting Summary Note revealed the resident received wound care to the bilateral upper and lower extremities caused from self-picking behaviors. The note lacked evidence the team addressed the underlying cause of R11's self-picking behaviors or initiated any interventions outside of the wound care. Review of the [DATE] at 03:25 PM Social Services Progress Notes revealed the resident continued to spend all of his time isolated in his room but had a recent visit from a family member. The note lacked any follow up or intervention related to the resident self-isolating. Review of the [DATE] at 02:14 PM Social Services Progress Notes revealed the writer noted a green tackle box and a red basket on the floor in R11's room with pill bottles [the note lacked description of what the pill bottles contained], lighters, books, and other items scattered on the floor next to them. The writer asked the resident about the mess all over his floor and R11 said he wanted a class of grape juice and then threw a cup towards the window. The writer picked up all of the contents of the boxes along with the boxes and took them to her office. The tackle box was full of supplies to make fishing lures, and the red basket contained a torch, 4 pill bottles (unidentified contents), a red lighter, a large knife, and a black pouch containing a drug pipe. Administrative Staff A was notified of the incident. The note lacked any follow related to the unidentified pill bottles, knifes, torch/lighter and/or drug pipe even though the resident has a history of illegal substance use and self-harm with the use of a knife. Review of the [DATE] at 09:30 PM Incident Note revealed Certified Nurse Aide (CNA) AA approached the nurse writer asking him to check on R11. CNA AA reported the resident's face was extremely red and eyes looked to be pinpoint. Upon assessment the nurse found the resident to be awake and as described by the CNA. Licensed Nurse (LN) W documented he suspected the resident to have ingested an unidentified narcotic substance. LN W indicated the resident had a crack pipe in his possession within the prior two weeks. The LN notified Administrative Staff A of the situation, and she gave permission to search the resident's room. When searching the room CNA AA found a crack pipe and lighter hidden in an eyeglass case. LN W then notified Administrative Staff A of the findings, and she instructed him to notify Consultant Nurse C, who instructed LN W to contact the resident's physician for further direction. The physician instructed LN W to send the resident to the hospital for further evaluation, and the resident refused. The resident stated he would leave the building with law enforcement, but not Emergency Medical Services (EMS). The resident's physician then instructed LN W to notify law enforcement and have the resident arrested. The deputies who arrived on scene stated that due to the resident's medical conditions they could not transport him out of the building but told facility staff to notify them immediately if things were to escalate. The resident's physician then instructed LN W to inform R11 if he did not go to the hospital to get checked out the facility would discharge him, and R11 continued to refuse transport to the hospital. Administrative Staff A was notified of the situation. The resident's record lacked evidence the facility monitored the resident for adverse outcomes after identifying he consumed methamphetamine in the facility. Review of the Miscellaneous tab in R11's EHR revealed the resident was seen by a contracted psychiatric provider history of alcohol abuse, manic behavior, anxiety disorder, history of drug abuse, and stimulant use. The plan for the resident was to continue supportive care and antipsychotic medication for each month they visited the resident from 09/2025 to 12/2025. An observation/interview with R11 on [DATE] at 02:50 PM revealed the resident laid in bed in his room with a catheter hanging on his bedside commode to right side of the bed while the resident was on the phone. The resident had several scabs to his left forearm, one to the right forearm. The resident reported staff do not always provide the cares they say they do for him. During an interview on [DATE] at 05:53 PM CMA BB reported there was not always enough staff to attend to resident needs. A confidential interview (date and time withheld to protect anonymity) revealed they did not feel like there were enough staff to monitor and meet the resident's needs. They reported resident checks, assistance, and cares lacked as a result of continued staffing problems. They stated they try to perform the duties assigned to them but could not always get it done and it impacted the residents. The CNA requested anonymity due to fear of retaliation for any concerns brought to facility administration. A confidential interview (date and time withheld to protect anonymity) revealed there were not enough staff to get things done. They reported the only resident who required them to have another staff member go in with them was R11 (the care plan lacked any documentation R11 required two staff to enter the resident's room for any reason). The staff member stated they did not report anything to Administrative Staff B due to fear of retaliation. During an interview with LN W on [DATE] at 06:30 PM revealed on [DATE] dayshift CNAs reported to him that they thought the resident was intoxicated. The LN stated R11was found with a crack pipe two weeks prior. The CNAs working that evening stated the resident did not look right. LN W and the CNAs went to the resident's room to check on him, but played it off by stating they needed to check the resident's blood sugar. When the LN entered the resident's room he stated you could not miss the fact the resident was intoxicated. R11's eyes were red, pupils were pinpoint, and face was very red all over. The resident maintained a dead stare and it was obvious something was definitely not right with him. LN W stated he had studied methamphetamine and other street drugs so was aware of how the narcotic was made and how toxic the substance was, not only to the resident ingesting it, but anyone who would have encountered it. LN W immediately contacted Administrative Staff A for further instruction on what to do. LN W stated the resident denied the use of any drugs and refused to let him search the room so he asked Administrative Staff A if he should/could search the room with reasonable suspicion of drugs/drug paraphernalia. Administrative Staff A gave permission to search the resident's room against his wishes. The LN and CNAs on duty went into the resident's room to search it, but asked the resident again stating they just wanted to ensure his safety and he declined the search. They began searching the resident's room, pulling things out of the room and originally were not finding anything other than the resident's personal belongings. They noticed a black case for eyeglasses and felt it looked out of place so opened it and upon dumping it out a crack pipe with methamphetamine still in it fell out of the case along with a lighter. The LN immediately reported the findings to Administrative Staff A who instructed the LN to call Consultant Nurse C who instructed him to call the resident's physician. The physician gave instructions to notify EMS due to a foreign substance in his system. When EMS entered the room, the resident refused to be seen for evaluation at the hospital. EMS did try to encourage the resident to go with them for evaluation, he refused. Both the LN and EMS instructed the resident they wanted him to get checked out due to his health and were not concerned with act of using the drugs. LN W called the resident's physician again for further instruction and was told to call law enforcement, but they were already on the way due to the EMS call. When law enforcement arrived they stated they could not take the resident due to his underlying medical conditions even though they verified the drug was an illegal substance. LN W was told it would likely just be a misdemeanor offence anyway. LN W stated he was deeply concerned because the drug could cause harm being on the resident's skin or could be accessible to another resident. LN W stated when the pipe was on top of the medication cart it tipped over and the substance inside fell all over the top of the cart, so he put gloves on and cleaned it up. LN W reported to the resident's physician that the resident could not be arrested due to his medical conditions. The physician then stated they were going to use a scare tactic and tell the resident nicely that the resident would be given an involuntary discharge if he was not evaluated at the hospital. The resident continued to refuse treatment and EMS left. LN W stated he did not know the extent of what the resident ingested and again noted the toxic chemicals used in production of the drug. LN W stated he monitored the resident as much as he would let him, but that was it. LN W stated he was not aware of the incident that occurred on [DATE] until after the [DATE], but he wished he would have been notified so he could have monitored the resident more closely during that time. LN W was not aware of any interventions put into place regarding the resident's substance use disorder and the two incidents. LN W reported upon search of the resident's room they found three pairs of scissors, knives and a hammer in the resident's belongings and LN W was not aware of what happened to those items. He stated thank God the resident isn't able to get out of bed on his own or he believed two members of law enforcement could not stop him on the drugs as they are entirely unpredictable. He also worried that if the resident did not have his drug of choice, he would start using other drugs, which make people violent. He was unaware if any education was provided after the incident, further monitoring of the resident, and/or interventions placed to care for R11 with a history of substance use. During an interview with Administrative Staff A at approximately 07:16 PM on [DATE] she reported she was unaware of what happened to the drug paraphernalia and pills located in R11's room on [DATE] and assumed law enforcement took them but also was unaware if law enforcement was notified. Administrative Staff A stated she was unaware of what pills were located in the resident's room and/or how he obtained them. Administrative Staff A was unaware if staff further monitored the resident after he consumed narcotics on [DATE]. - R32 admitted to the facility on [DATE]. R32's Electronic Medical Record (EMR) documented diagnoses of diffuse traumatic brain injury (TBI-an injury to the brain caused by external forces) with loss of consciousness, adult failure to thrive, and other seizure (violent involuntary series of contractions of a group of muscles). R32's admission Minimum Data Set (MDS) dated [DATE], documented R32 had a Brief Interview for Mental Status (BIMS) score of zero which indicated severe cognitive impairment. R1 had no falls since admission. R32's Quarterly MDS dated [DATE], documented a BIMS was not conducted due to R32 being rarely/never understood. R32's Cognitive Loss/Dementia (a progressive mental disorder characterized by failing memory and confusion) Care Area Assessment (CAA) dated [DATE], lacked an analysis of findings. R32's [DATE] Care Plan, revised on [DATE], documented R32 was at risk for falls and injury related to unsafe mobility and impaired safety awareness. R32 demonstrated difficulty with safe bed use and was often noncompliant with requesting assistance due to his cognitive impairment and poor decision-making related to his TBI. The presence of a standard bed frame increased R32's potential for injury if a fall occurred or R32 unsafely transferred from bed. R32 had a fall on [DATE] and [DATE]. The Care Plan documented the following intervention: [DATE]- The staff provided a mattress on R32's floor for safety, comfort, and injury prevention. The care plan did not document interventions after R32's falls on [DATE] and [DATE]. R32's EMR revealed the following: An Incident Note on [DATE] at 07:00 AM, documented the staff heard R32 yelling from the hallway. The staff noted R32 laid on his right side near the [NAME] exit door and he stated he fell trying to pull his pants up. The nurse preformed a head-to-toe assessment, obtained R32's vital signs, and initiated neurological checks. R32 stated he did not hit his head and the staff noted no injuries. An Incident Note on [DATE] at 08:02 AM, documented the nurse notified the director of nursing (DON), Consultant V, and Administrative Staff A, and attempted to notify R32's representative but her voicemail box was full. A Health Status Note on [DATE] at 03:17 PM, documented R32 experienced an unwitnessed fall today at 10:10 AM. The staff noted no injuries and R32 denied pain or hitting his head during the fall. R32 was chronically repetitive, disorganized, and became violent with staff members and other residents when agitated. R32 wandered the halls and appeared anxious. He knocked on doors and attempted to enter other resident's rooms, disturbing them and frightening them. An Incident Note on [DATE] at 02:30 PM, documented the staff reported that R32 fell in the bathroom between two rooms and that his forehead was bleeding. The nurse noted a small, shallow abrasion to his left forehead that measured one centimeter (cm) by 1.5 cm. The nurse applied a clean dressing to R32's forehead and obtained his vital signs. R32 stated he needed to go to the bathroom, and he fell, hitting his forehead on the heater vent on the floor during the self-transfer. The staff assisted R32 into his wheelchair at 02:20 PM, just prior to the fall, in another resident's bathroom. The nurse notified Consultant V, Administrative Nurse B, and R32's representative. R32's neurological checks were within normal limits for him as he was only alerted to self only and had left sided paralysis. An Incident Note on [DATE] at 02:00 PM, documented the facility initiated one-on-one safety supervision with a staff member to maintain continuous visual contact to prevent further risk of harm to self or others at that time. Upon request for fall investigations for R32, the facility provided reports for R32's falls on [DATE] at 07:00 AM and [DATE] at 10:10 AM. The facility did not provide a report for R32's fall on [DATE]. The facility's report for R32's fall on [DATE] at 07:00 AM, documented Licensed Nurse (LN) FF heard R32 yelling from the hallway. LN FF noted R32 laid on his right side near the [NAME] exit door. R32 stated he fell when he tried to pull his pants up. R32 stated he did not hit his head. The report lacked a root cause analysis of the fall. The facility's report for R32's fall on [DATE] at 10:10 AM, documented R32 experienced an unwitnessed fall in his bedroom. The report lacked a root cause analysis of the fall. On [DATE] at 01:52 PM, R32 self-propelled in his wheelchair down the hallway. An unidentified female staff member supervised him. On [DATE] at 10:33 AM, R32 self-propelled in his wheelchair down the hallway towards his room. An unidentified female staff member stated to another staff member that R32 wanted to lay down for a bit. On [DATE] at 03:59 PM, Certified Nurse Aide (CNA) N stated if a resident fell, she stayed with the resident and called for help. She stated the nurse did an assessment and asked what the resident was doing or if they hit their head. She stated the staff tried to determine how the resident fell and completed witness statements. CNA N stated they put an intervention into place if they were able to. She stated if new interventions went into place, she did not receive any notification of new interventions. CNA N stated the facility did not have a report sheet and she received updates through word of mouth. On [DATE] at 05:04 PM, LN S stated if a resident fell, she referred to the fall checklist to make sure she completed everything. She stated she assessed the resident, got their account of what happened, looked at environmental factors, obtained their vital signs, and ask staff if they saw what happened. She stated she contacted the provider for direction and notified the resident's family, the administrator, and the DON. LN S stated if the fall was unwitnessed, she asked who last saw the resident and what they were doing. She stated she had the staff fill out witness statements and started neurological checks. LN S stated she put an intervention in place at that time to prevent further falls then let the DON know about the intervention to update the care plan. She stated R32 fell once during an altercation and received a minor laceration. LN S stated he had fallen another time, but she did not know if the care plan had interventions put into place. She stated she expected there to be a fall intervention on the care plan after each fall. On [DATE] at 05:45 PM, Consultant Nurse C stated if a resident fell, she expected staff to notify the charge nurse, and the charge nurse completed an assessment. If the fall was unwitnessed, she expected the nurse to initiate neurological checks then notify the physician and resident's representative after completion of the assessment. Consultant Nurse C stated she would like staff to do a root cause analysis if they had an idea of what caused the fall and put in an intervention immediately after the fall. She stated she expected every fall to have an intervention put into place and the charge nurses should be updating the care plan. The facility's Fall Prevention Program policy, last revised [DATE], directed when a resident experienced a fall, the facility assessed the resident, completed a post-fall assessment, completed an incident report, notified the physician and family, reviewed the resident's care plan and updated as indicated, documented all assessments and actions, and obtained witness statements in the case of injury. - R16 admitted to the facility on [DATE]. R16's Electronic Medical Record (EMR) documented diagnoses of bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods) and pain in left hip. R16's admission Minimum Data Set (MDS) dated [DATE], documented R16 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderate cognitive impairment. R16 had no impairment in her upper and lower extremities. R16 used a wheelchair, and she required staff supervision or touching assistance with standing and transfers. R16 had no falls since admission. R16's Quarterly MDS dated [DATE], documented R16 had a BIMS score of 14 which indicated intact cognition. R16 had no impairment in her upper and lower extremities. R16 used a walker and a wheelchair and required substantial to maximal staff assistance with standing and transfers. R16 had one noninjury fall since the last assessment. R16's Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated [DATE], lacked an analysis of findings. R16's [DATE] Care Plan revised on [DATE], documented had an actual fall with unsteady gait. The Care Plan documented the following interventions: [DATE]- The staff continued R16's interventions on the at-risk plan. [DATE]- For no apparent acute injuries, the staff determined and addressed causative factors of R16's fall. [DATE]- The staff notified R16's legal guardian of any falls or updates to her fall risk. [DATE]- The pharmacy consulted to evaluate R16's medications. [DATE]- Physical therapy consulted for strength and mobility for R16. R16's Care Plan did not address her ADL status including transfers and mobility. On [DATE] at 02:11 PM, R16 sat in a chair in the day area with her walker beside her. Activities Director E walked up and asked R16 if she wanted to go into the dining room for happy hour. Licensed Nurse (LN) S and Activities Director E got on either side of R16 and each placed one of their arms under her armpit and helped R16 stand up from the chair. R16 walked into the dining room with her walker. On [DATE] at 03:59 PM, Certified Nurse Aide (CNA) N stated she was unsure if there was a report sheet or Kardex (nursing tool that gives a brief overview of the care needs of each resident) on how to transfer a resident or to use a gait belt. She stated she kept resident safe during transfers by using a gait belt. CNA N stated if she had to put her hands on a resident when standing them up, she used a gait belt. She stated staff should not hook their arms under R16's arms to help her stand up. On [DATE] at 05:04 PM, LN S stated staff knew a resident's ADL status from the EMR. She stated if she helped a resident stand, she used a gait belt. She stated R16 used to transfer herself but the chairs in the day area were so low that she needed someone to help her stand up. LN S stated staff should put a gait belt around R16 as a point of assistance when standing her up, not using their arms under R16's arms. On [DATE] at 05:45 PM, Consultant Nurse C stated staff knew how to care for residents through their care plan and they should know how to access them. She stated care plans should be as individualized as possible to provide the best care, including ADLs and how a resident transferred. Consultant Nurse C stated she expected staff to use a gait belt for a safe transfer and to not use under the resident's arms to transfer. The facility's Safe Resident Handling Transfers Policy dated [DATE], directed the facility used gait belts with residents that could not independently ambulate or transfer for the purpose of safety.

The facility reported a census of 34 residents. Based on observation, interview, and record review the facility lacked a system for records of receipt through disposition of all controlled medications, in sufficient detail to enable accurate reconciliation and ensure drug records were in order. The facility also failed to ensure a record system to account for all controlled medication which was maintained and periodically reconciled. The facility pharmacy lacked onsite presence in the facility to assist in the destruction of controlled narcotic substances from February 2025 until [DATE]. The facility had a locked cabinet inside the medication room used for narcotic medications awaiting destruction. The administrator did not know who had the key for the locked cabinet and required maintenance staff to cut the lock off of the cabinet on [DATE], revealing the cabinet was full of narcotic controlled medications dating back to 2024. Through record review the facility could not account for 49 separate narcotic prescriptions, of an unknown quantity each, affecting 22 current and discharged residents.The pharmacy did not identify the increased use of e-kit narcotics used, increased frequent changes to narcotic prescriptions, and lack of destruction of the numerous narcotic medications delivered, or the lack of a facility system in place for the accurate accounting of controlled substances to include PRN and discontinued narcotic medication. On [DATE] review of resident chart revealed the facility did not have her hydrocodone and had to access the e-kit twice to provide pain medication for the residentsThe lack of pharmacy services, procedures, and records placed all residents who received controlled narcotic medications in immediate jeopardy and at risk for unrelieved pain, discomfort, death, and the risk to the resident population which included a history of Substance Use Disorder.The facility Administrator was notified of the Immediate Jeopardy (IJ) on [DATE] at 1:18 PM and remain ongoing.Findings included:- Review of a complaint allegation regarding drug diversion identified the Alleged Perpetrator (AP) as Administrative Nurse B. The allegation included pictures of numerous resident medication cards (bubble pack cards) for as needed (PRN) narcotic medications, with the prescription information label including resident specific prescriptions and information which included: resident name, date of birth , medication order, pharmacy information, and facility information. Most of the pictures displayed empty popped bubble cards of narcotic medication, indicating no medication in the cards. Observation of the pictures and observations onsite at the facility indicated the pictures were taken outside of the facility. On [DATE] at approximately 12:30 PM, the state surveyor informed Administrative Staff A of the allegation against Administrative Nurse B and the allegation included pictures of the facility medication cards (bubble pack cards) and included resident prescription information on them. Administrative Staff A did not know who had the key to the narcotic destruction box. An onsite observation on [DATE] revealed the facility had one medication room with one narcotic destruction box, which was locked. Inquiry revealed most direct care and licensed nursing staff did not know who had the key to the narcotic destruction box, but most assumed Administrative Nurse B had the key.Review of an allegation of drug diversion included over a dozen photos of numerous controlled narcotic medication bubble packs and narcotic count sheets. One photo included a narcotic count sheet indicating all 88 oxycodone tablets should be in the blister pack and another photo had the matching prescription number on the utilized blister pack, with at least 10 empty slots. The investigation the facility provided on [DATE] revealed numerous narcotic medications prescriptions in an unknown quantity for each, that the facility could not reconcile. The investigation revealed the following number of controlled medication prescriptions, of an unknown quantity for each:1-Fentanyl transdermal patch 72 hour, 50mcg/hour2-Hydrocodone-Acetaminophen Oral Tablet 5/325mg1-Hydrocodone-Acetaminophen Oral Tablet 7.5/325mg1-Tramadol 25mg4-Tramadol 50 mg1-hydromorphone HCL oral tablet 8mg2-hydromophone HCL Oral Liquid 1mg/ml6- Lorazepam Oral Tablet 0.5mg2-clonazepam oral tablet 1mg1-clonazepam oral tablet 0.5mg3-Morphine Sulfate Oral Solution 20mg/5mL1-Morphine Sulfate Concentrate Solution 20mg/mL1-Morphine Sulfate Oral tablet 15mg2- Morphine Sulfate Oral tablet 30mg1-Morphine Sulfate Extended Release oral tablet 15 mg1-Morphine Sulfate Extended Release oral tablet 30 mg1-oxycodone HCL oral tablet 20 mg3-oxycodone HCL oral tablet 10 mg12-oxycodone HCL oral tablet 5 mg2-Pregabalin Oral Capsule 50 mg1-Ativan Injection Solution 2 mg/mLFurther review of the [DATE] facility provided investigation revealed the facility did not find discrepancies with current narcotic medications and included current narcotic count sheets and scanned copies of the associated controlled medication. However, surveyor review revealed several discrepancies between the information recorded on the narcotic count sheets and the electronic medication administration record (to include administrations recorded on count sheet, but not recorded in the eMAR), and discrepancies in the liquid narcotic medications to include: R6's Morphine Sulphate 100 mg per 5 ml narcotic sign out sheet revealed on [DATE] at 08:00AM the LN documented the Amount on Hand as 21.25 ml, when the prior line indicated the Remaining amount as 21.75 ml. LN then documented the Amount Given as 0.25 and Amount Remaining as 21.00, which is a discrepancy of 0.5 ml not identified in the facility submitted investigation. R32's Lorazepam 2 mg per ml liquid concentrate, administered in 0.25 ml dose every 6 hours as needed, narcotic sign out sheet had a handwritten notation to the right of the medication information label noting: Order [change] [DATE] give 0.50 ml, (every 6 hours PRN had a line drawn strikethrough) every 4 hours PRN. The narcotic count sheet had a 'count corrected - spilled' notation with an illegible signature and date, located between the [DATE] and [DATE] sign-out lines, and indicated a 3.75 ml 'spill' of the medication and no associated progress note. R32's Lorazepam 2 mg per ml liquid concentrate, administered in 0.5 ml dose every 4 hours as needed revealed on [DATE] at 12:30 PM LN FF documented 0.5 ml as Amount Given and the Amount Remaining as 26.5 ml with a drawn strikethrough on the line and notated 'ref'. On [DATE] at 01:30 PM LN FF documented 0.5 ml as Amount Given and the Amount Remaining as 26.0 ml with a drawn strikethrough on the line and notated 'ref'. No other administrations or notations were listed after this line. On [DATE] at 04:27 PM, Certified Medication Aide (CMA) R stated the facility received shipments from the pharmacy just about daily. CMA R stated when the narcotic count sheets were taken out of the narcotic count book, they were filed in a folder in the nurse's office. CMA R stated when the folder became full the narcotic count sheets were pulled from the folder and went to Administrative Nurse B. During an interview with Consultant Pharmacist (CP) EE on [DATE] at 03:55 PM, she stated she just took over in November [2025]. She stated she is the pharmacist the facility should use to destroy narcotic medications. CP EE stated she sent an email to the facility on [DATE]th announcing she was taking over as the new pharmacy consultant for the facility. She stated she reached out to Administrative Staff A and Administrative Nurse B on [DATE] and [DATE] to schedule a time to destroy narcotic medications with the facility and neither staff member responded to her emails. CP EE stated in the December email she stated she would be in the area and reminded them they needed to set up a drug destruction, but no one responded. She stated she felt like she was emailing into a void, since no one from the facility has responded to any of her emails. CP EE stated the facility is expected to wait for CP EE to be there to destroy medication and said she is supposed to sign the medication forms, which she said would also be signed by Administrative Staff A and Administrative Nurse B. CP EE said she was not sure Administrative Staff A and Administrative Nurse B knew they needed to wait for CP EE to destroy narcotic medication. She stated the prior consultant pharmacist informed her the facility had not been receptive to setting up times for visits. CP EE was not sure of the last narcotic destruction date. During an interview with Administrative Nurse B on [DATE] at 10:07 AM revealed the facility had a new pharmacist, who she thought took over in October. Administrative Nurse B said she never met the prior consultant pharmacist and she never came to the facility. Administrative Nurse B stated she got emails from her, but never saw her come here, and stated she then got an email from the new CP announcing she was taking over. Administrative Nurse B stated she had not met either of them. During an interview with Administrative Nurse B on [DATE] at 11:02 AM she stated if the resident changed or discontinued a medication the narcotic card would be removed from the medication cart. Administrative Nurse B stated a few years ago an agency nurse took medications and count sheets, so the facility counts the cards to keep track of the number of cards. Administrative Nurse B said the staff count the number of cards at the beginning of each shift and the card count went to her (Administrative Nurse B). Administrative Nurse B stated she kept a book and had them all filed in a binder, count sheet and card count sheets, but they were in the process of being sorted and organized and she may not have some of them, they are not organized. Administrative Nurse B said if there were remaining narcotic medications, they went in the cabinet in the medication room and stated the policy required two licensed nurses, or a CMA and a nurse, or a pharmacist combination of those people, who can destroy them. Administrative Nurse B stated some residents take bubble packs home with them, but have to get approval for it, and hospice would count and take with them. Administrative Nurse B stated if the resident was not on hospice and they did not take them home, the narcotic medication went in the narcotic destruction cabinet. Administrative Nurse B said she did not destroy medications and if there was a discrepancy, she conducted an investigation. She stated she was supposed to have the key to the narcotic destruction cabinet but she needed to look in her desk. Administrative Nurse B then stated the prior Director of Nursing (DON) had a key for a while, but she left in June or July and it was an issue trying to get stuff back from her. Administrative Nurse B said she began in March or early April and Administrative Staff A began in February 2025. Administrative Nurse B said the prior DON had been gone since August or September maybe, but she was not sure. Administrative Nurse B said they had a disgruntled employee who was a licensed nurse but worked in medical records and may have had a key to the narcotic destruction box. Administrative Nurse B said she has not destroyed any medication since she started working in the facility (approximately [DATE]) and said she was not supposed to destroy medications and not sure why the other two staff members might have had the key. Administrative Nurse B said when the licensed nurse medical records staff member left employment the facility found a lot of things missing, but not narcotics. Administrative Nurse B said she did not know what happed to the narcotic destruction box key and said she knew some medications were in there but not sure what medications. Administrative Nurse B then said that's why I asked maintenance to cut off the lock. I don't know what is in there and said she asked maintenance to cut of the lock (indicated prior to today). During an interview on [DATE] at 01:47 PM, Maintenance Staff J stated the key was not something he messed with and he assumed the nurses or DON had it. Maintenance Staff J said he did not track the key and then stated no one ever asked him to cut the lock off of the narcotic destruction cabinet or had informed him the key was lost. Maintenance Staff J said he did not know there was an issue with the narcotic destruction box. During the investigation, the surveyor asked for the count sheet for R36's oxycodone (narcotic pain medication) or evidence the resident took the medication home, since these were identifiable in the complaint photos. The facility could not provide a copy of the count sheet for the medication and it was requested twice of Administrative Staff A, twice of Administrative Nurse B, and once of Licensed Nurse S. During an interview on [DATE] at 01:57 PM Administrative Staff A stated the facility did not have the count sheets for R36's oxycodone and did not have evidence that R36 took it home. Administrative Staff A stated she could not find it and it did not look like the facility had it. During an interview on [DATE] PM at 12:06 PM, Administrative Staff A stated she has never been in the facility when the narcotic medications were destroyed, stated she was not a nurse, and she does not have anything to do with medications. Administrative Staff A stated she never saw pharmacy in the facility to destroy narcotic medications and said Administrative Nurse B should have the narcotic destruction key. Administrative Staff A stated she had not asked Administrative Nurse B if she had key, but she should have it and thought she did. She further stated per the facility policy, narcotic medication destruction required a licensed nurse or nurse and certified medication aide or pharmacist. Administrative Staff A stated it could be an issue with Administrative Nurse B having a key and all count sheets going to her, as a single point. Administrative Staff A stated as far as she knew Administrative Nurse B had the key and she did not know who else would have it. Administrative Staff A stated as far as she knew the pharmacy had not been out, but said they may not check in with her when they do since she does not do anything with medications, but had never seen them. Administrative Staff A stated the pharmacist sent out pharmacy recommendations once a month, so she was in contact with them and stated there absolutely should be a record of what was destroyed, but was not positive if or where the record could be. She stated there should be a book of record of what was destroyed and she was not sure if it was at the nurses station or in her office, but there should be a record of it. Administrative Staff A stated she could see how it could be an issue with only Administrative Nurse B as the staff member with the key to the narcotic destruction cabinet and all counts sheet going to Administrative Nurse B. During an interview on [DATE] at 02:27 PM Administrative Staff A she was not sure about the key and no one she talked to knew where it was or knew who had it. During an interview on [DATE] at 03:27 PM Administrative Staff A stated they were going to cut the lock off and place a new lock to the narcotic destruction box and record new sheets of what was in the cabinet. Administrative Staff A stated the nursing supervisor was coming up with process and they would have the pharmacist come in on a regular basis, but for now Administrative Staff A would hang on to the only key to the narcotic destruction cabinet. Administrative Staff A stated that anything that needed to be destroyed would now be destroyed immediately. Administrative Staff A clarified the facility was doing an audit right now, then came back and said they would not destroy but will audit whatever is inside of the destruction cabinet. During an interview on [DATE] at 04:25 PM Administrative Staff A stated they finished the audit of current medications and found no discrepancies. She stated the facility would cut the lock off of the cabinet to see what was inside, place a new lock, and she would keep the key. She said it was not done yet, but it would be. During an interview on [DATE] at 07:39 PM Administrative Staff A stated it looked like the pharmacy did email herself and Administrative Nurse B, and Administrative Staff A said she never opened them, as she thought Administrative Nurse B opened them. Administrative Staff A stated the emails were encrypted so she could not see what was in them. During an interview on [DATE] at 01:42 PM Administrative Staff A stated the facility did not have all of the delivery sheets from the pharmacy to line up with all of the discontinued narcotic medications since [DATE]. Administrative Staff A stated she had to contact the pharmacy to have that list sent and stated it might take a while to get it. She stated right now she was not sure if everything on the list made it to the facility. On [DATE] at 03:25 PM Administrative Staff A stated she could not find any record of pharmacy destruction sheets and could not find any facility medication destruction sheets. Administrative Staff A stated she had not seen anyone destroy medications since she started in February 2025. During an interview with Licensed Nurse T on [DATE] at 10:18 AM revealed when the narcotic medication bubble cards were empty, the staff tore off and shredded the resident label. LN T said the count sheets were taken out monthly and given to Administrative Nurse B. LN T said the medication count sheets and the narcotic count sheets are separated, go into a folder in the nurse's office, and then to Administrative Nurse B. LN T stated discontinued medications to destroy went into the cabinet with the lock and stated the nurses did not get in the cabinet. LN T said she thought Administrative Nurse B had the key to that cabinet. During an interview on [DATE] at 10:19 AM, Licensed Nurse S revealed when medication cards were empty, staff took the narcotic sign out sheet signs and put them in the completed narcotic sheet folder in nurse's office on the door. She said the staff then tore the label off and shredded them. LN S stated if a resident passed away or moved out and did not take the narcotics with them, the staff wrapped the narcotic in the count sheet and made sure the pills match the sheet, then counted the cards and pills. LN S said about 2 years ago an agency nurse took sheets with cards and the staff had no way to know the medications were missing initially, so we started counting cars as well when we count medications. She said card count sheets were done every day and is a running list. LN S said if someone had hydrocodone prescribed, they would take it to the medication aide, count medication, place it in the narcotic box, and the card would get added to the card count sheet. LN S said when the cart count sheets were full, they were replaced with a new one, updated the total, and the card count sheet went to Administrative Nurse B. LN S stated discontinued medications to destroy were put in the cabinet in the medication room, which has a slot on the cabinet door and a lock on it. She said the staff slide the medication card with the count sheet into the cabinet. LN S said no one had access to unlock the cabinet, aside from Administrative Nurse B. She said pharmacy could destroy medication with the nurse and assumed there would be a record of medications that were destroyed. LN S said Administrative Nurse B probably had that and Administrative Nurse B can access the box/cabinet. LN S said someone would come in every three months to destroy the medication, but not sure how often the pharmacy should come in. She said sometimes hospice came in to destroy or took medications with them. LN S said the floor nurse did not destroy medications and the pharmacist does not come in. During an interview on [DATE] at 07:40 PM LN S said she talked to Administrative Nurse B about the narcotic destruction key and Administrative Nurse B told her she did not know who had it. LN S said Administrative Nurse B told her some things may be missing from the cabinet because another nurse may have accessed it. LN S said the former employee Administrative Nurse B mentioned would not have had that key, since that person was medical records. The facility provided a printed list of narcotic medications which listed the resident name, order, directions, category, status, started date, end date, and revision date. The oldest 'end date' range on the list was from [DATE] to [DATE]. The copy of the 9-page document had hand written numbers to the left of each medication from 1 to 107, and written outcome notes on some of the medication lines such as: kept, dose changed, 0 here, sent home, in cabinet, probably not sent, or maybe didn't get sent. Review of the printed list of medications revealed 39 medications had 0 here written on them, 2 did not contain written outcome notes (one was for a resident who left against medical advice and the other for a resident who died), and 9 indicated the medications were sent with the resident. The record lacked evidence for 5 of the medications that they were sent with the resident and the other 4 were for residents that had died. During an interview on [DATE] at 03:21 PM, LN S revealed a 0 here written on the facility provided list of 107 medications, indicated it meant not here and they could not find the medication in the building. LN S stated they should be there, but they cannot find the medication, as they are not in the cabinet or medication carts. LN S said they knew there was no pharmacy destruction on record for the time period of the medications listed and should otherwise be in the building. She did state they were waiting for the pharmacy delivery sheets to confirm the ones that were delivered to make sure. Otherwise, if the sheets show they were sent, they should have them and do not. During an observation in the medication room on [DATE] at 05:30 PM, Maintenance Staff J cut the lock of the medication destruction cabinet in the presence of Administrative Staff A and LN S, and replaced the lock with a new one. Inside the medication destruction cabinet were stacks of medication cards with count sheets attached to them. The medication destruction cabinet had a slot on the right side and was made of wood. The slot on the side was not large enough for the boxes with morphine/Ativan/liquid meds in them to fit through, which were inside the cabinet. Some boxes with bottles were found inside the cabinet. A large metal box sat inside and at the bottom of the cabinet with two locks on it-- and the surveyor could not visualize the contents. LN S and Administrative Staff A said they did not know what was in the metal box and stated no one had keys. LN S attempted to unlock the box using all keys on the nurse key ring, button worked. LN S and Administrative Staff A stated it was likely left when the previous company owned the facility, but they are not sure how long it was in there. Per LN S and Administrative Staff A it was a metal sharps style bin and contained what appeared to be empty bottles of Ativan and Morphine and unable to visualize the resident labels on the bottle as only viewable from a slot on top of the bin. Appeared to be morphine and lorazepam bottle (6 morphine, 2 lorazepam, and 1 other bottle unable to discern). Review of the facility provided interview notes, emailed on [DATE], revealed a typed and unsigned document titled Investigation Interview Notes and denoted the following responses from interviewee: Administrative Nurse B, but lacked signature of Administrative Nurse B.1. She indicated that she had not met the pharmacist and that pharmacist involvement was not something she regularly thought about due to competing priorities.2. She acknowledged that she did not always follow through on certain tasks related to medication processes, citing survey activity and other urgent matters.3. When asked who had access, she explained she had changed codes multiple times and recalled finding a padlock and extra key in a drawer of an old desk. She indicated the extra key was related to a refrigerator lock and that follow-up on securing the destruction box was delayed due to other priorities. She acknowledged she did not realize at the time that the process needed to be completed in a specific manner.4. Administrative Nurse B described the process as:Narcotic cards being placed in a binder or folder and documentation eventually filed in a binder.5. She stated she was unsure where the destruction binder was located and did not know whether it was stored with medical records. She acknowledged that documentation organization was incomplete and that she was attempting to catch up on multiple binders and records.6. She admitted she did not consistently ensure narcotic destruction documentation was fully prepared or reviewed.7. Administrative Nurse B stated that, to her knowledge, the most recent discharge she was aware of was handled correctly, with signatures obtained and documentation completed. (She did mention the resident in question on her own)8. Months ago, she was made aware of a discrepancy involving narcotics approximately three days after it occurred. She reported that she stayed at the facility to address the issue once notified. She stated she could not definitively say whether narcotics or sign-out sheets were removed from the facility and indicated this was the only discrepancy she had ever been notified of.9. She stated the building had experienced multiple complaints but noted this was the first allegation involving narcotics. She denied intentionally removing narcotics or documentation from the facility. During an interview on [DATE] at 03:51 PM, Administrative Staff A revealed she finished the investigation, sent it to corporate, and said she has an open investigation with the police. Administrative Staff A revealed she would send a copy of the completed investigation once she got approval from corporate. Administrative Staff A stated the facility suspended Administrative Nurse B and overall determined the outcome to end Administrative Nurse B's employment, but stated the facility was waiting to terminate until they could get someone who had a nursing license. Administrative Staff A said they could not substantiate anything and apparently the narcotics were discontinued, and they took cards with narcotic sheets so she could not substantiate. Administrative Staff A said the staff could not find the key and now she has the only key locked in the safe behind two locks. She is the only one that has the key to the safe. Administrative Staff A stated the facility conducted a full audit of every resident here, did interviews with the residents, and no one refused medications, they were getting medications, felt like they had not missed medications, and did staff interviews. Administrative Staff A said they interviewed staff and some had no idea of what she was asking them about and stated a CMA thought it was the lockbox on the medication cart. Administration Staff A stated that everyone that is here is safe and no medications were missing from them. Administrative Staff A said the facility provided a list of medications they prescribed sent from the pharmacy they audited it with the list that were here and what was delivered. Administrative Staff A stated they know that there are medications the pharmacy said they sent, that are no longer in the facility, that we did not know were missing because they should have been in the box, but they were not. Administrative Staff A stated that some of the stuff [medications] in the destruction cabinet was very old and one of them was dated 2024. She stated she knew that the pharmacy had not destroyed medications. She stated inside the destruction cabinet was a metal box and she said it had empty bottles repeating they were all empty. When asked if she inventoried the items inside the metal box, she stated she did not inventory anything in there. Kinda looked in it and they were all empty. Administrative Staff A stated she saw the medications inside the cabinet and knew someone was accessing it as there was no way to toss in something form the top slot and get it into the metal box at the bottom. Administrative Staff A stated once she was notified of this incident she immediately suspended Administrative Nurse B, pending investigation, and then started her investigation. Administrative Staff A stated she was notified on [DATE] of the allegation. She said on [DATE] she asked Administrative Nurse B to complete a drug test by 04:00 PM on [DATE] but Administrative Nurse B did not complete a drug test because she missed the time. Administrative Staff A said she knew the time was running out on this and told Administrative Nurse B to complete a drug test by 09:00 AM on [DATE], but when Administrative Staff A called Administrative Nurse B at 10:00 AM on [DATE], she woke Administrative Nurse B up. She said Administrative Nurse B did not complete a drug test until after 02:00 PM on [DATE]. Administrative Staff A stated a week before this other staff came to her with concerns regarding Administrative Nurse B and her performance and what she was and was not doing. Administrative Staff A stated she knew of things Administrative Nurse B was not taking care of and thought she just needed more training. Review of the facility provided Medication Storage and Destruction policy revealed the purpose of the policy was to ensure the safe, secure, and compliant storage and destruction of medications, including controlled substances, in accordance with Kansas Administrative Regulations, pharmacy standards, and federal requirements for nursing facilities. The policy included the following information regarding controlled substances and keys or access codes: access was limited to authorized licensed nurses, keys or access codes to controlled substances shall not be shared or left unattended and shall be controlled and tracked by facility leadership. The policy noted for controlled substances a perpetual inventory record should be maintained for all controlled substances. The policy included a section on discontinued, expired, or unused medications noting controlled substances awaiting destruction must be placed in the locked narcotic destruction box. The section on Narcotic Destruction Box read the facility shall maintain a locked narcotic destruction box in a secure location and access to the box was limited to the pharmacist ad unauthorized licensed nursing staff as designated by the facility. Keys or access controls shall be accounted for at all times, logged if applicable, changed immediately if compromised, and noted the destruction box should never be left unlocked or unsecured. Controlled substances shall be destroyed by the licensed pharmacist during routine pharmacy services; destruction must occur in the presence of a licensed nurse employed by the facility, who serves as a witness; two facility nurses (including two LPNs) may not independently destroy controlled substances without pharmacist involvement. The policy noted controlled substances released at discharge required proper documentation and family/guardian signature acknowledging receipt. The facility shall maintain controlled substance inventory records, medication destruction logs, pharmacy destruction documentation, and records shall be retained in accordance with state and federal requirements and readily available for survey review.

The facility had a census of 34 residents with 14 in the sample. Based on observation, interview, and record review the facility failed to implement and maintain an effective infection prevention and control program in accordance with a facility assessment, regulatory requirements, and professional standards of practice. Upon entrance to the facility resident rooms had clothing piled on side tables and on the floors, trash cans in resident rooms were full, and staff present failed to maintain infection control practices when transporting laundry, trash, and multi-resident use medical equipment. The facility further failed to implement enhanced barrier precautions (EBP) for residents at risk for the transmission of infectious agents through wounds, catheter use, and/or other medical devices. The facility lacked evidence they tracked the spread of infection within the facility, assessed residents for the infectious organisms, and implemented interventions to prevent further spread of infections. Review of Resident's (R)11, R9, and R7's electronic health records related to infection control and prevention revealed residents had various infections present, admitted to the hospital for intravenous (IV) antibiotics, had amputation of limb due to osteomyelitis and arthritic sepsis, admitted to an intensive care unit for treatment of sepsis, and were diagnosed with multidrug resistant organisms without an effective EBP program. The facility lacked evidence they maintained a water maintenance program to prevent the spread of waterborne pathogens. These systemic failures placed all residents in immediate jeopardy as they created the likelihood for the transmission of infectious agents and subsequent infection and caused actual severe infection with significant outcomes or placed the residents at risk for serious harm, or death.The facility Administrator was notified of the Immediate Jeopardy (IJ) on 1/16/2026 at 1:18 PM and remain ongoing. Findings included:- The facility identified Administrative Nurse B as the current Infection Preventionist. The facility failed to provide evidence Administrative Staff B was qualified to fill the role by education, training, experience or certification. Review of the Facility Assessment Tool dated 11/18/25 revealed the facility was licensed for 45 beds, with an average census of 32 residents. The facility identified their common diagnoses related to infectious disease as skin and soft tissue infections, respiratory infections, tuberculosis, urinary tract infections, infections with multi-drug-resistant organisms, septicemia, viral hepatitis, clostridium difficile, influenza, and scabies. The facility identified an average range/number of isolation/quarantine residents with active infection as one to three. The facility noted they would need to provide residents with identification and containment of infections and prevention of infections. The assessment contained a section for the facility to evaluate their infection prevention and control program, which included effective systems for preventing, identifying, reporting, investigating and controlling infections and communicable diseases for all residents, staff, volunteers, visitors and other individuals that follow national standards, but the assessment lacked any evaluation, review, or development of their infection control program. Upon entrance to the building on 01/11/26 at approximately 01:45 PM the facility had a very strong smell of urine that started in the entry before going into the commons area of the facility and stayed throughout the tour. Continued observation on 01/11/26 during initial resident screening observations revealed multiple rooms on the west hall were noted with clothes present on the floor and the trash to be full. The hallway contained two mechanical lifts which had dust and debris present on the bases. Staff removed the lifts and took them throughout the facility with no observations of cleaning the lifts. One room on the west hall had a particularly large amount of clothing noted on the floor next to the closet, which wrapped around the bottom of a large white fan present in the room and strung out into the walking path of the floor. The clothes noted on the floor included what appeared to be multiple shirts, pants, and towels. The smell of urine remained during the observation of the west hall. Staff present entered the room for an unknown reason and did not pick up or address the clothing that continued to lay on the floor. One room, which belonged to Resident (R) 11 had a sign on the door indicating staff were to take precautions and a plastic set of drawers, that appeared to contain personal protective equipment (PPE). The PPE was not contained to the drawers, instead it was strung along the top of and along the floor next to the plastic drawers. The box of masks noted on the visibly dirty floor next to the cart contained an open box of masks, with several that appeared to have been pulled about a third of the way out of the box. There was also a bag of gowns present on the floor with a hole in the bag, but not fully opened. The plastic slides for the plastic drawers contained a significant amount of dust and debris and the back of the drawers contained a whitish substance that appeared to be spills of undefined liquids. At the time of the observation there were no other rooms identified as requiring enhanced barrier precautions (EBP) or PPE along the west hall. Continued observation during the initial tour of the facility on 01/11/26 revealed the east hall lacked any additional notifications of residents requiring EBP or PPE and/or PPE placed along the hall for staff to utilize for the prevention of spread of infectious organisms. Rags and/or clothing were noted hanging over the handrails, the cloth items were rigid and appeared to have been wet and dried in that location as they maintained their shape when staff lifted and removed from the area. Multiple resident rooms on the east hall contained clothing on the floor and piled on their bedside tables. Between approximately 02:06 PM and 02:13 PM Certified Nurse Aide (CNA) N started going to resident rooms and gathering the clothing items, as she exited resident rooms she was noted carrying the piles of clothing with her bare hands, pressed against her body. CNA N returned to work with the same clothing on. CNA U then exited a room on the east hall with a mechanical lift, parked the lift in the solarium area of the facility, and failed to clean the lift at any time during the observation. The lift had various footprints visible in a dusty film present over the base. At approximately 02:22 PM Hospitality Aide O took a bag, which appeared to be trash or clothing from one room into another and a short time later left carrying the bag that entered both residents' rooms through commons area to dispose of the bag out of site. At approximately 02:51 PM additional staff started arriving and continued to pick up laundry from resident rooms, including their floors. At approximately 05:16 PM on 01/11/12 drawers containing PPE now sat outside of five additional resident rooms with signs on corresponding doors indicating a resident in the room required EBP. One room on the east hall had a EBP sign on the door, with no EBP present, but looking down and across the hall there was a drawer set containing PPE located in the area between the beauty shop, bookshelf, and other resident rooms. Review of resident electronic health records regarding infections from June 2025 to January 2026 revealed the following: During an interview on 01/11/26 at 05:53 PM with Certified Medication Aide (CMA) BB she stated the facility was often short staffed. She reported when the facility was short staffed, care things were missed, like checking and showering residents. CMA BB stated before today the facility only had one resident who required PPE, including gown, mask, and gloves with cares due to an infection, but reported she was just told staff needed to wear the same PPE for emptying catheters and for residents with wounds. CMA BB reported if a resident had MRSA that was typically the reason staff were instructed to use gowns with resident cares before today (01/11/26). CMA BB also verified the additional PPE and EBP signs placed on both the east and west units after the initial tour were just placed today (01/11/26). During all observations of transport and use of mechanical lifts on 01/11/26 staff failed to clean them between use on multiple residents and transported them throughout the building. During all observation of transport and use of mechanical lifts on 01/12/26 revealed staff failed to clean them between use on multiple residents and transported them throughout the building. During an observation at 10:05 AM on 01/12/26 Certified Medication Aide R came out of R14's room with the resident carrying a clear plastic trash bag with a visibly soiled brief, which appeared to contain a moderate amount of feces. CMA R carried the knotted bag down the hallway while standing by with the resident. The bag swung into open doors along the side of the hallway and as she walked she held the handrails with the thin plastic bag dragging along the wooden/warn handrails. As the bad scraped along the handrails it also hit portions of the wall. CMA R would then switch hands, swing the bag out into the hallway and resume rubbing the bag along the handrails, until she deposited it into a soiled utility room. During an interview and review of infection control records on 01/12/26 at 03:44 PM Consultant Nurse C reported she found an Infection Control Binder dated 2024 and one dated 2025, which lacked any tracking of infections, antibiotic review, and/or infectious agent or organism involved. Consultant Nurse C provided an electronic charting software generated report titled Infection Surveillance Monthly Report indicating rises and falls acquired infections from February 2025 to January 2026. Consultant Nurse C stated the chart indicated the facility was possibly tracking and trending infections, however it lacked specific locations of the infections (resident room location in the building), infectious organisms, notation that at least one resident had a catheter and associated urinary tract infection, system for recording any infection control incidents with follow up/actions taken and/or where the infection originated (wound, dental, respiratory tract, etc.) Review of the facility provided, electronic charting system generated, Infection Surveillance Monthly Report dated 01/12/26 revealed the facility had 25 total infections between 07/01/25 and 01/12/26. The report indicated no infections were present in November and December 0f 2025 and January 2026. The report contained a Summary by Infection Category, which included blood/systemic, bone/joint, cardiovascular, and ear/nose/mouth/throat that were all blank. Review of the Order Listing Report generated 01/12/26, with dates ranging from 06/01/25 to 01/12/26 revealed 48 separate physician ordered antibiotics and/or infection related treatments for 18 residents, who resided through out the facility and included cellulitis, upper respiratory infections, wound infections, and methicillin-resistant Staphylococcus aureus (MRSA - per The Centers for Disease Control and Prevention MRSA is a type of staphylococcus that can be resistant to several antibiotics, which anyone can get or carry. The risk for MRSA increases for people in nursing homes, crowded areas, and/or unhygienic places) of an unknown location. Review of resident electronic health records regarding infections from June 2025 to January 2026 revealed the following:Record review for R11 revealed:Review of the 08/13/25 hospital referral sheet for admission to the facility revealed R11 had a Methicillin-resistant Staphylococcus aureus (MRSA) infection dated 08/08/25. The referral noted a Dermatology consultation note dated 08/07/25 revealed R11 had a nearly continuous MRSA infection for more than a year. The resident had ten aerobic cultures from 10/2024 to the 08/07/25 date and all grew MRSA. Upon examination the assessor revealed their impression was that the resident had MRSA with bulla and crusts. The plan was to treat with appropriate antibiotics and to consider investigating home living situation to determine the source of recurring infection. Review of the 08/31/26 Internal Medicine History and Physical revealed the resident had a urinary tract infection and multiple skin wounds so admitted to the hospital for intravenous antibiotics. Review of the 10/02/25 General Adult History of Present Illness hospital document revealed the resident admitted to the nursing home due to diffuse MRSA. Review of the Hospital Physician Orders dated 10/08/25 revealed the resident had positive growth on his blood cultures, urinary tract infection, and staphylococcus epidermis. The provider prescribed antibiotic and probiotic medications. Review of the Centers for Disease Control and Prevention MRSA topic page dated 06/26/25 revealed MRSA spreads in the community through contact with infected people, wounds, or things that have touched infected skin and are carrying the bacteria.The resident had a urinary catheter order since 09/12/25 and lacked any indication he required EBP until 01/12/26Record review for R9:Review of R9 's Physician Orders in the electronic health record revealed the resident received the following orders to treat cellulitis:Ceftriaxone Sodium (antibiotic utilized for severe sepsis) Injection Solution Reconstituted one Gram for cellulitis intramuscularly ordered on 08/21/25 and completed 08/22/25 Cephalexin (antibiotic) 500 milligrams by mouth three times a day related to cellulitis of the unspecified part of the limb for seven days started on 08/21/25 and completed 08/28/25.R9's EHR record lacked evidence the facility monitored the effectiveness of the antibiotics administered on 08/21/25. The 08/23/25 skin check for R9 lacked evidence the facility monitored the resident for cellulitis at this time. No skin issues related to the infection were identified. R9's 08/25/25 at 06:08 AM Progress Note revealed the resident had altered mental status and was coughing. He did not know where he was at and refused cares. A subsequent note revealed the resident refused admission to the hospital and the resident's provider ordered labs to be drawn the next day. Review of the EHR lacked any follow up to the resident's change in status.Review of the EHR lacked evidence the facility attempted to or drew the ordered labs the next day. R9's progress notes lacked evidence the facility continued to monitor the resident's change in status, cough, antibiotic completion on 08/28/25, or cellulitis until 09/05/25 when the resident's provider was notified he refused labs the prior day 09/04/25. The record continued to lack evidence the facility monitored the resident for effectiveness of the antibiotic prescribed to treat cellulitis. The resident's care plan lacked indication the resident required antibiotics for cellulitis and/or instruction for the staff to further monitor the resident. On 09/09/25 R9 requested to be sent to the hospital due to severe foot pain. Review of the 09/09/25 MRI of the left ankle for R9 revealed the resident had extensive infection involving the bones and soft tissues of the midfoot, hindfoot, and ankle. Osteomyelitis involving the (bones in the foot) metatarsal bases, midfoot bones, anterior talus and calcaneus. The resident had septic tenosynovitis and potentially had septic arthritis. The microbiology report revealed blood cultures dated 09/09/25 revealed MRSA was detected. Review of the 09/17/25 Hospital Discharge Summary revealed R9 admitted back to the hospital with MRSA Bacteremia. The resident admitted to the hospital with left lower extremity cellulitis and septic arthritis status post below the knee amputation on 09/11/26 and required IV antibiotics. The resident had wounds present at various times since the prior annual survey on 04/16/25 and lacked any indication he required EBP until 01/12/26. Record review for R7 revealed:R7's Care Plan identified a problem added on 12/31/25, which noted R7 had a terminal prognosis related to sepsis and had been admitted to hospice. The associated care plan interventions lacked mention of EBP.Observation on 01/11/25 through 01/13/25 revealed a note on R7s door denoted EBP, but no PPE was located outside of her door.A N Adv - Skin Check dated 04/23/25 at 11:44 AM revealed the resident had a facility acquired stage 2 pressure injury to her coccyx. The resident's EHR lacked evidence the facility implemented EBP when caring for the resident's wound. A lab culture result for R7 from 07/21/25 for her right breast, revealed the resident had heavy growth of Methicillin resistant Staphylococcus aureus (MRSA).Review of the 07/27/25 at 01:27AM Communication with Physician Note revealed the resident's right breast had thick, green drainage and the resident started an antibiotic that would continue for 14 days. The After Visit Summary in the EHR revealed R7 was hospitalized at a regional hospital from [DATE] to 10/03/25. The note indicated R7 was in the Intensive Care Unit from 09/27/25 to 09/30/25. The reason for R7's hospitalization was for a primary diagnosis of Sepsis. The note included the resident diagnoses also included: Pressure injury of coccygeal region, Stage 2, Pressure Injury of Sacral Region, Stage 4, Extended Spectrum Beta-Lactamase (ESBL) Escherichia Coli Carrier, Pneumonia of right upper lobe due to infectious organism. The note included R7 admitted on [DATE] and required an infectious diseases consultation for sepsis syndrome and noted her chief complaint was malaise, generalized weakness. The history of present illness included the resident bed-bound status was complicated by chronic ulcer over the sacrococcyx, was hospitalized after presenting with generalized weakness and diaphoresis along with signs concerning for sepsis syndrome with systemic inflammatory response including tachycardia, leukocytosis, along with borderline hypotension, and is admitted to the intensive care unit for inpatient management. Of note, she was recently admitted to another local hospital last week, after reportedly presenting with systemic symptoms concerning for sepsis, was noted to have extended spectrum beta lactamase Escherichia coli bacteriuria and was being treated with ertapenem. She discharged from that local hospital on [DATE], however, soon after discharge, on 09/27/25 she presented to the hospital with symptoms of diaphoresis and generalized malaise as described above. She was first administered cefepime and was then empirically prescribed ertapenem along with vancomycin. The note included the cultures had not resulted in growth so far. However, leukocytosis had improved with antibiotic treatment. The note documented R7 had pain in arms and legs, and pain over sacral ulcer. The summary included a picture of R7's chronic sacrococcygeal ulceration from 09/29/25, without signs of acute infection, with bony tenderness.The Internal Med Prog Note signed by treating physician on 12/22/25 revealed R7 was hospitalized for treatment of her multidrug-resistant E. coli with intravenous antibiotics. The note indicated the resident white count did spike up some and her wound appeared to be healing well. The note included assessment documentation noting R7 had a sacral decubitus ulcer and pressure changed with unstageable to stage IV sacral ulcer with bandage in place. The Progress Note included an assessment and pain section that noted R7 had acute sepsis and a UTI with unspecified Escherichia coli [acute E. Coli] UTI. The plan included to continue current IV antibiotics IV cefepime for full course to treat drug-resistant E. coli on her urine culture. Vancomycin has bene discontinued. Blood cultures remain negative. WBC did increase today, will monitor. Continue wound care management. Continue Foley catheter at this time due to wound, skin excoriations, as well as impaired mobility. Suspect prolonged hospital course. Social work consult to work on discharge planning. Suspect possible discharge back to care facility on 12/22/25 after full course of IV antibiotics for complicated UTI.Review of facility identified residents who required EBP (R9, R11, R5, R6, and R7) revealed the following care plan updates dated 01/12/26, one day after EBP signs were hung on resident doors: Enhanced barrier precautions (some included infection location, some did not).The resident will be free from infection through review date.Use gown and gloves for all high contact care activities (e.g., dressing, bathing, toileting, transferring, wound care, device care, changing linens/briefs) for residents with chronic wounds, indwelling medical devices, or known MDRO colonization/infection.The care plan lacked person-centered specific intervention related to each resident's need for EBP. During an interview regarding the facility water maintenance program/legionella prevention on 01/12/2026 at 04:03 PM with Maintenance Staff J and Administrative A revealed the facility did not have any evidence of testing for legionella as stated in their prior survey plan of correction/water management plan provided by the facility. Maintenance Staff J stated he did flushes (did not identify what was flushed) back in August or September, however then stated he did not have a log or documentation regarding flushing the water system. Maintenance Staff J stated he was unaware he needed to log any flushes of the water system that he performed and stated he documented water temperatures most days. Administrative Staff A interrupted and instructed Maintenance Staff J that he needed to have documentation for any of the water management tasks he performed. Review of Daily Water Temperature Logs provided by the facility as part of their legionella/water maintenance program that covered dates from April 2025 until January 2026 revealed no full weeks that water temperatures were taken daily as noted in their water maintenance plan. The facility failed to provide any assessment they performed of the current water system, which could include a map of the building, flow diagrams, written assessment, etc. to identify where legionella and other opportunistic waterborne pathogens could grow as requested on 01/12/26. During all observation of transport and use of mechanical lifts on 01/13/26 revealed staff failed to clean them between use on multiple residents and transported them throughout the building. On 01/15/26 at 05:13 PM CNA P reported he was not sure when mechanical lifts were cleaned and stated he did not clean the lifts between residents. A confidential interview (date and time withheld to protect anonymity) revealed they did not feel like there were enough staff to monitor and meet the resident's needs. They reported resident checks, assistance, and cares (including perineal care) lacked and/or did not occur as a result of continued staffing problems. They stated they try to perform the duties assigned to them to the best of their abilities but could not always get everything done and noted it impacted the residents. The CNA requested anonymity due to fear of retaliation for any concerns brought to facility administration. A confidential interview (date and time withheld to protect anonymity) revealed there were not enough staff to get things done. The staff member reported they were instructed to grab laundry from resident rooms and out of the closet. They stated recently everyone was getting sick so they cleaned handrails, doorknobs, and door jams when they had extra time, even though they were not specifically told to do so by administrative or licensed staff. The staff member reported the facility had just provided training on the new [EBP] signs placed on resident doors and the PPE located outside of resident doors earlier this shift. The staff member stated they did not report anything to Administrative Staff B due to fear of retaliation.

The facility census totaled 34 with 14 sampled and one reviewed for change in condition. Based on observation, interview, and record review the facility failed to ensure staff monitored, educated, and documented effectiveness of treatments regarding a change in condition for Resident (R)9. On 08/23/25, while still on antibiotics for cellulitis (skin infection caused by bacteria) the resident had a change in mental status, refused transport to the hospital, and the facility failed to document continued monitoring of the residents change in status. The facility further failed to document any education provided or reapproach provided after the resident's refusal to be seen. On 09/05/25 the facility notified the resident's provider the resident refused labs the prior day, with no follow up to the resident's refusal documented, no attempts to reapproach the resident, no education provided on the seriousness of obtaining the lab and/or additional monitoring of the resident. On 09/09/25 the resident asked to be transported to the hospital due to pain in the left lower extremity. While at the hospital the resident was diagnosed with extensive infection throughout the left lower extremity and ultimately experienced actual harm when his left lower extremity required amputation. Upon arrival back to the facility the facility failed to implement wound care and days later the resident readmitted to the hospital for treatment of further infection to the residual stump. Findings included:- Review of R9's diagnoses in the electronic health record (EHR) revealed the resident had peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), type 2 diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), acquired absence of left leg below knee, cellulitis (bacterial infection of the skin) of unspecified part of limb, complete traumatic amputation at level between knee and ankle, right lower leg. Review of the 07/15/25 Quarterly Minimum Data Set (MDS) assessment revealed the resident had a brief interview for mental status (BIMS) score of 10, which indicated moderately impaired cognition. The resident rejected cares one to three days of the observation period. The resident had impairment on both sides of his lower extremities. R9 required partial/moderate assistance from staff for toileting hygiene, showering, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, and toilet transfers. The resident had a pressure injury (PI) and required a formal assessment for risk of pressure ulcer development. The resident had had one or more unhealed pressure injuries and a risk for pressure ulcer development. R9 had one stage three pressure injury, which was not present upon admission/entry or re-entry, and he received care for that PI. Review of the 09/09/25 Discharge MDS revealed the resident had no pressure injuries. Review of the 10/08/25 Annual MDS assessment revealed the resident had a BIMS of 12, which indicated moderately impaired cognition. The resident had rejection of cares, which occurred one to three days of the lookback period. R9 now required substantial/maximal assistance with toileting, showering, lower body dressing, and total dependence for putting on socks. The resident had no pressure injuries, other wounds, or skin problems identified on the assessment. Review of the 10/08/25 Care Area Assessments (CAA) revealed the following:The Functional Abilities (Self-Care and Mobility) CAA from the EHR revealed the resident demonstrated limitations in functional abilities as noted on the MDS. The resident required assistance with activities of daily living (ADLs) including bathing, dressing, toileting, transfers, and mobility. Cognitive status and/or physical conditions impacted the resident's independence. The CAA indicated the resident may be at risk for further decline in function without appropriate support and interventions. The CAA lacked documentation the resident recently underwent an amputation of the left lower extremity and/or associated changes to his ADL status. Review of the resident's 10/18/24 Care Plan revealed the following interventions:11/12/24- The resident had the potential to be verbally aggressive (yelling at staff) related to ineffective coping skills.11/12/24 - Staff would administer medications as ordered and monitor/document for side effects and effectiveness.11/12/24 - Staff would analyze key times, places, circumstances, triggers, and what de-escalated behavior and document. 11/12/24 - Staff would assess and anticipate the resident's needs, including food, thirst. toileting needs, comfort level, body positioning, pain, and etc.11/12/24 - Staff were directed when the resident became agitated, they would intervene before the agitation escalated. Staff were instructed to guide the resident away from the source of distress, engage calmly in conversation and if R9's response was aggressive, staff were to walk calmly away, and approach the resident later. 11/12/24 - (Related to the resident's diabetes mellitus) Staff were to monitor/document/report as needed any signs/symptoms of infection to any open areas including redness, pain, heat, swelling or pus formation. 04/18/25 - The resident often refused care, staff were to approach him in a calm, but direct manner to assist resident with hygiene, bathing, and other activities of daily living the resident potentially required assistance with. The resident's care plan lacked direction to staff if the resident continued to refuse cares including documentation of the refusal, and/or refusals of skin assessments, wound assessments, or treatments. The care plan further lacked interventions related to the resident's cellulitis of the lower extremity identified on 08/21/25. After the resident's left lower extremity amputation, the following interventions were added to the resident's plan of care, along with other associated interventions:09/18/25 - Staff were made aware R9 had a potential for behavior problem related to the loss of his other foot. Interventions for skin integrity, wound management, and infection were placed on the resident's plan of care on 10/20/25, however were resolved the same day. 11/21/25 (approximately two months after the resident's amputation of the left lower extremity) - Staff would know the resident was resistive to cares.11/21/25 - Staff were directed to allow the resident to make decisions about treatment regime, to provide sense of control.11/21/25 - Staff would praise the resident when his behavior was appropriate. 01/12/26- Staff would know the resident required enhanced barrier precautions for wounds. (The resident's care plan lacked evidence staff implemented EBP for R9 until 01/12/26 even though the resident had a history impaired skin integrity including pressure injuries and the amputation of a limb.) 01/13/26 - Staff would know the resident would refuse wound care to his incision site. Staff were to encourage the resident to allow care to the site. Review of R9 's Physician Orders in the electronic health record revealed the resident received the following orders to treat cellulitis:Ceftriaxone Sodium (antibiotic utilized for severe infection) Injection Solution Reconstituted one Gram for cellulitis intramuscularly ordered on 08/21/25 and completed 08/22/25Cephalexin (antibiotic) 500 milligrams by mouth three times a day related to cellulitis of the unspecified part of the limb for seven days started on 08/21/25 and completed 08/28/25. R9's EHR record lacked evidence the facility monitored the effectiveness of the antibiotics administered on 08/21/25 and/or the resident's skin for signs or symptoms of cellulitis. The 08/23/25 skin check for R9 lacked evidence the facility monitored the resident for cellulitis or any other significant changes at this time. No skin issues related to the infection were identified and/or monitoring for changes with the resident skin or effected extremities. R9's 08/25/25 at 06:08 AM Progress Note revealed the resident had altered mental status and was coughing. He did not know where he was at and refused cares. A subsequent note revealed the resident refused admission to the hospital and the resident's provider ordered labs to be drawn the next day. Review of the EHR lacked any additional monitoring put in place or follow up to the resident's change in status. Review of the EHR lacked evidence the facility attempted to or drew the ordered labs the next day. R9's progress notes lacked evidence the facility continued to monitor the resident's change in status, cough, antibiotic completion on 08/28/25, or cellulitis until 09/05/25 when the resident's provider was notified, he refused labs the prior day 09/04/25. The record continued to lack evidence the facility monitored the resident for follow up of the effectiveness of the antibiotic prescribed to treat cellulitis. The resident's care plan lacked indication the resident required antibiotics for cellulitis and/or instruction for the staff to further monitor the resident. On 09/09/25 R9 requested to be sent to the hospital due to severe foot pain. The resident's record lacked evidence the facility monitored the resident's left lower extremity, even though he recently had cellulitis, had a history of pressure injuries to the foot, and had a diagnosis of diabetes mellitus. Review of the 09/09/25 Magnetic Resonance Imaging (MRI) of the left ankle for R9 revealed the resident had extensive infection involving the bones and soft tissues of the midfoot, hindfoot, and ankle. Osteomyelitis (serious bone infection) involving the (bones in the foot) metatarsal bases, midfoot bones, anterior talus (bone connecting the leg to the foot) and calcaneus (largest bone of the foot). The resident had septic tenosynovitis (serious bacterial or fungal infection of the tendon sheath) and potentially had septic arthritis (infection that spreads to a joint, causing inflammation). The microbiology report revealed blood cultures dated 09/09/25 revealed MRSA was detected. The resident's EHR lacked any documentation the resident returned from the hospital and/or experienced an amputation of the left lower extremity on 09/11/26. The resident's record lacked evidence staff assessed, documented and/or placed interventions related to the amputation. The EHR lacked evidence the facility monitored the resident upon his initial return from the hospital. Review of the 09/17/25 Hospital Discharge Summary revealed R9 admitted back to the hospital with MRSA Bacteremia. The resident admitted to the hospital with left lower extremity cellulitis and septic arthritis status post below the knee amputation on 09/11/26 and required IV antibiotics. Review of the September 2025 Treatment Record revealed documentation for staff to clean incision site on the left leg with saline, pat dry, apply gauze dressing, change daily every day shift for incision site that started on 09/23/25, approximately 5 days after the 09/17/25 date that most medications/treatments resumed after the resident returned from the hospital. On 11/25/25 (two months after the resident's left limb amputation)- the facility noted a problem in the care plan with no interventions or directions to staff, which indicated the resident had impaired mobility related to bilateral lower extremity amputations as evidenced by inability to bear weight, inability to stand, and requirement for total mechanical lift assistance for all transfers with the assistance of two certified nursing staff members. The resident had wounds present at various times since the prior annual survey on 04/16/25 and lacked any indication he required EBP until 01/12/26. An interview with Certified Nurse's Aide (CNA) N on 01/14/26 at 03:59 PM revealed R9 had his left leg amputated recently. CNA N stated he would not let anyone touch it, so they finally convinced him to let them take him to the doctor and that is when it was amputated. CNA N stated there is a wound and dressing on the resident's stump now. CNA N stated she could get R9 up most of the time and sometimes could even get him to come out of his room. A confidential interview (date and time withheld to protect anonymity) revealed they did not feel like there were enough staff to monitor and meet the resident's needs. They reported resident checks, assistance, and cares lacked and/or did not occur as a result of continued staffing problems. They stated they try to perform the duties assigned to them to the best of their abilities but could not always get everything done and noted it impacted the residents. The CNA requested anonymity due to fear of retaliation for any concerns brought to facility administration. A confidential interview (date and time withheld to protect anonymity) revealed there were not enough staff to get things done. The staff member reported the facility had just provided training on the new [EBP] signs placed on resident doors and the PPE located outside of resident doors earlier this shift. The staff member stated they did not report anything to Administrative Staff B due to fear of retaliation. An interview with Licensed Nurse (LN) S on 01/14/26 at 05:04 PM revealed it was typically the director of nursing who updated care plans, but was recently informed it should be the nurses who update care plans if needed. LN S stated R9 still required skin prep to his stump and stated the resident refused a lot. During an interview and review of infection control records on 01/12/26 at 03:44 PM Consultant Nurse C reported she found an Infection Control Binder dated 2024 and one dated 2025, which lacked any tracking of infections, antibiotic review, and/or infectious agent or organism involved if resident's had infections in the building. The infection control binder further lacked any actual infections the residents had and/or monitoring of the effectiveness of the antibiotic. Consultant Nurse C provided a list of residents who received antibiotics and R9 was on the list. Review of the 05/18/24 Wound Treatment Management Policy revealed treatment decisions would be based on the characteristics of the wounds to include presence of pain, presence of infection or need to address bacterial bioburden. The effectiveness of treatments would be monitored through ongoing assessment of the wound. Considerations for needed modifications included: lack of progression, changes in characteristics, changes in the resident's goals/preferences. Review of the 06/26/24 Infection Prevention and Control Program revealed the designated infection preventionist was responsible for oversight of the program and serves as a consultant to the staff on infectious diseases, implementing isolation precautions, staff/resident exposures, surveillance and an epidemiological investigation of exposures of infectious diseases.

The facility reported a census of 34 residents. The sample included 14 residents, with four reviewed for pressure ulcer/injury. Based on observation, interview, and record review the facility failed to ensure effective interventions, accurate assessments, and consistent monitoring, to prevent the development of a facility acquired stage 3 (full thickness pressure injury extending through the skin into the tissue below) pressure ulcer/injury of the sacrum (large triangular bone/area between the two hip bones) for dependent and at risk Resident (R)7, who required hospitalization for wound care and intravenous antibiotics for sepsis (life threatening systemic reaction that develops due to infections which cause inflammation throughout the entire body). The facility further failed to place effective interventions for R6, with a known history of pressure ulcer/injury development. On 12/02/25 a skin assessment revealed the resident had no new skin issues besides an already identified stage 3 pressure injury to his heel. On 12/03/25 the facility identified a Stage 4 pressure ulcer/injury (a deep pressure wound that reaches the muscles, ligaments, or even bone), which had a total wound area measurement of 17.6 centimeters and was an open, full thickness wound covered with dead tissue. Findings included:- The Electronic Health Record (EHR) revealed the resident diagnoses included: stage 2 pressure ulcer of the sacral region, sepsis (life threatening systemic reaction that develops due to infections which cause inflammation throughout the entire body) unspecified organism, peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), pain (unspecified), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and generalized muscle weakness. Review of the 08/11/25 Annual Minimum Data Set (MDS) revealed R7 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The MDS documented the resident had no rejection of care and was dependent on staff for most of her activities of daily living (ADL). The MDS noted R7 was always incontinent of urine and frequently incontinent of bowel. The resident received scheduled pain medication, as needed (PRN) pain medication, and non-medication interventions for pain. The MDS indicated the resident had a pressure ulcer/injury, received a formal assessment instrument/tool, was at risk for pressure ulcer/injury, and had one unhealed pressure ulcer/injury noted as stage 2 pressure ulcer/injury. The 08/11/25 Care Area Assessment regarding Cognitive Loss/Dementia, Functional Abilities (Self-Care and Mobility), Urinary Incontinence, Psychosocial Well-Being, Mood State, and Pressure Injury all lacked development and contained the following work up by the facility in each: wctm - indicating the facility will continue to monitor. The Care Plan, initiated on 10/20/19 and revised on 12/08/24, included R7 had potential for skin impairment and breakdown related to incontinence and impaired mobility, and included the following 5 interventions (with initiated and revision dates):10/20/19, revised on 02/04/25: Weekly skin assessment by licensed staff. Any areas of concern to be reported to the physician/care provider that need outside intervention.03/12/21, revised 02/04/25: Moisture Barrier Ointment to peri area/sacrum for skin protection with incontinence episodes.12/08/24, revised 02/04/25: Staff to complete a Braden quarterly and PRN to identify the resident's risk for skin issues.12/08/24, revised 02/04/25: R7 had a pressure reduction mattress and a cushion in her wheelchair. She required extensive to total assistance from staff to turn/reposition while in bed. She was able to offload while up in her chair.01/28/25, revised 02/04/25: Staff to use two cloth incontinence pads under the resident while she was in bed due to her size and volume of incontinence episodes to avoid moisture related skin breakdown. On 01/13/26, in response to a verbal inquiry on the facility system in place for tracking and monitoring pressure injuries, the facility provided a paper copy of the wound tracking for R7 which included 11 pages of Pressure Ulcer/Injury Evaluations which are included in the following record review. Review of the 04/23/25 Pressure Ulcer/Injury Evaluation revealed R7 had a sacral open lesion that was chronic (greater than 3 months) and measured 0.6 cm in length (L) by 0.4 cm width (W). The progress section identified the wound as stable: previously deteriorating wound characteristics plateaued and documented it was facility acquired. The assessment did not have a picture of the wound, and the information was completed by Licensed Practical Nurse (LPN), Licensed Nurse (LN) S. The treatment included a generic wound cleanser and a dry adhesive dressing. The evaluation lacked a description of the wound characteristics, wound stage, and lacked mention of the resident pain/condition/tolerance. The 04/23/25 at 11:44 AM N Adv - Skin Check progress note completed by the same Licensed Practical Nurse revealed R7's skin was warm and dry. The note included R7 had two skin issues.Skin issue #1: Skin issue has not been evaluated. Location: Buttocks - generalized. Issue type: Rash. Wound was present on admission. Wound is new.Skin issue #2: Skin issue has not been evaluated. Location: Coccyx. Laterality / Orientation: Medial. Issue type: Pressure ulcer / injury. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound acquired in-house. Wound is new. Undermining: No. Tunneling: No. Review of the 04/25/25 at 02:33 AM Monthly Nurses Note Cognitive Patterns revealed R7 was frequently incontinent, R7 currently had skin ulcers, and the 'Nutritional Status' noted The resident's diet is . and did not define the resident's diet. The note did not identify the skin ulcers as pressure ulcers/injuries. The next Pressure Ulcer/Injury Evaluation for R7 was 14 days later on 05/07/25. The 05/07/25 Pressure Ulcer/Injury Evaluation revealed R7 had a sacral open lesion that was chronic and measured 0.9 cm L by 0.4 cm W, and was facility acquired. The note lacked description of the wound, did not contain an image of the wound, and was completed by LPN, LN S. The treatment included a generic wound cleanser and a dry dressing. The evaluation lacked a description of the wound characteristics, wound stage, and lacked mention of the resident pain/condition/tolerance. The 05/11/25 at 10:47 PM N Adv - Skin Check progress note completed by a Licensed Practical Nurse revealed R7's skin was warm and dry. The included R7 has two skin issues.Skin Issue #1: Skin issue has not been evaluated. Location: Buttocks - generalized. Issue type: Rash. Wound was present on admission. Wound is new.Skin Issue #2: Skin issue has not been evaluated. Location: Coccyx. Laterality / Orientation: Medial. Issue type: Pressure ulcer / injury. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound acquired in-house. Wound is new. Undermining: No. Tunneling: No. Review of the 05/13/25 H&P-New Admit Note revealed the resident admitted to Long-Term Care under the services of Physician KK. The note revealed the resident had no known allergies, documented the resident's skin was warm and dry, and noted the resident was in no acute distress. The plan noted the resident had peripheral vascular complication and noted it appeared to be stable at this time. The note listed the resident's medications as:Hydrocodone (narcotic pain medication used to treat moderate to severe pain) 5 mg-acetaminophen 325 mg tablet, one by mouth (PO) every 6 hours (Q6H) as needed (PRN) pain emergency fillHydrocodone 5 mg-acetaminophen 325 mg tablet, one by mouth (PO) every 6 hours (Q6H) as needed (PRN) pain The 05/13/25 H&P-New Admit Note lacked mention of pressure ulcers/injuries for R7. The 05/14/25 Pressure Ulcer/Injury Evaluation revealed R7 had a sacral open lesion that was chronic and measured 0.7 cm L by 0.4 cm W and was facility acquired. The evaluation was completed by LPN, LN S and did not contain an image of the wound or description. The treatment included a generic wound cleanser and a dry dressing. The next Pressure Ulcer/Injury Evaluation was 14 days later on 05/28/25. The 05/28/25 Pressure Ulcer/Injury Evaluation revealed R7 had a sacral stage 2 pressure ulcer/injury (partial-thickness skin loss with exposed dermis) that was chronic and measured 0.9 cm L by 0.6 cm W, the wound bed was 10% epithelial (new skin growing in a superficial wound), and was facility acquired. The progress section documented Stable: previously deteriorating wound characteristics plateaued. The evaluation was completed by LPN LN S and did not contain an image of the wound. The treatment included a generic wound cleanser and a dry dressing. The evaluation lacked a description of the wound characteristics and lacked mention of the resident pain/condition/tolerance. The 06/04/25 Pressure Ulcer/Injury Evaluation revealed R7 had a sacral stage 3 pressure ulcer/injury (full-thickness skin loss with exposed dermis) that was chronic and measured 1.0 cm L by 0.6 cm W, was facility acquired, and staged by facility nursing. The progress section documented Monitoring: Wound healed or closed with continued monitoring. The evaluation was completed by LPN, LN S and did not contain an image of the wound. The treatment included generic wound cleanser and a foam primary dressing. The evaluation lacked a description of the wound characteristics and lacked mention of the resident pain/condition/tolerance. The next Pressure Ulcer/Injury Evaluation was 14 days later on 06/18/25. The 06/04/25 Pressure Ulcer/Injury Evaluation staged R7's wound at a stage 3 and the 06/18/25 Pressure Ulcer/Injury Evaluation staged R7's wound as a stage 2. Per the online National Pressure Injury Advisory Panel guidelines on pressure injuries, once a pressure injury was staged it could not have its stage number lowered, noting pressure injuries do not heal backwards through the stages. The 06/18/25 Pressure Ulcer/Injury Evaluation revealed R7 had a chronic sacral stage 2 pressure ulcer/injury that measured 1.1 cm L by 0.5 cm W, and was facility acquired. The progress section documented Monitoring: Wound healed or closed with continued monitoring. The evaluation was completed by LPN, LN S and did not contain an image of the wound. The treatment included generic wound cleanser and a collagen primary dressing. The evaluation lacked a description of the wound characteristics and lacked mention of the resident pain/condition/tolerance. The 06/25/25 Pressure Ulcer/Injury Evaluation revealed R7 had a chronic sacral stage 2 pressure ulcer/injury that measured 0.8 cm L by 0.6 cm W, was facility acquired on 04/02/25, and staged by facility nursing. The wound bed was 70% granulation and 20% slough (did not define the other 10%), and the periwound had rolled edges (epibole) and surrounding tissue had erythema: redness of the skin. The Progress documented Stalled: Previously improving wound characteristics plateaued. The evaluation was completed by LPN, LN S and did not contain an image of the wound. The treatment included generic wound cleanser and calcium alginate foam dressing. Per the online National Pressure Injury Advisory Panel (NPIAP) guidelines for pressure injury staging revealed a stage 2 pressure injury would not have granulation or slough tissue. The NPIAP guidelines documented granulation and slough were tissues seen in a stage 3 or stage 4 pressure injury. The 07/02/25 Pressure Ulcer/Injury Evaluation revealed R7 had a chronic sacral stage 2 pressure ulcer/injury that measured 1.1 cm L by 0.7 cm W, was facility acquired on 04/02/25, and staged by facility nursing. The wound bed was 100% granulation and the periwound appeared to have edges flush with the wound bed or as a sloping edge. The Progress section documented Stalled: Previously improving wound characteristics plateaued. The evaluation was completed by LPN, LN S and did not contain an image of the wound. The treatment included generic wound cleanser and collagen cleanser and a foam dressing. The 07/09/25 Pressure Ulcer/Injury Evaluation revealed R7 had a sacral stage 2 pressure ulcer/injury that measured 1.0 cm L by 0.7 cm W, and was facility acquired on 04/02/25. The wound bed was 90% granulation (did not define the other 10%) and the periwound appeared to have edge flush with wound bed or as a sloping edge. The Progress section documented Stalled: Previously improving wound characteristics plateaued. The evaluation was completed by LPN, LN S and did not contain an image of the wound. The treatment included generic wound cleanser, a collagen primary dressing, and a silicon secondary dressing. The 07/16/25 Pressure Ulcer/Injury Evaluation revealed R7 had a sacral stage 2 pressure ulcer/injury that measured 1.3 cm L by 0.7 cm W, and was facility acquired on 04/02/25. The wound bed was 90% granulation (did not define the other 10%) and the periwound appeared non-attached where the edge appears as a cliff. The surrounding tissue was documented as fragile: skin that is at risk for breakdown. The Progress section documented Stable: previously deteriorating wound characteristics plateaued. The evaluation was completed by LPN, LN S and did not contain an image of the wound. The treatment included normal saline cleansing solution, collagen primary dressing, and silicone secondary dressing. Review of the Progress Note-Monthly Note electronically signed by Physician KK on 07/23/25 revealed the resident was seen in her room for a monthly regulatory visit. The note revealed the resident continued to do well in the facility, denied any excessive pain, fever, chills, or other issues at the time. The note documented no nursing concerns and included the resident's skin was warm and dry. The note listed two medications for R7 in the medications section and both were for hydrocodone 5 mg-acetaminophen 325 mg one tablet by mouth every 6 hours for as needed pain and the second entry one tablet by mouth every 6 hours as needed for pain emergency fill. The note lacked mention of a pressure ulcer/injury for R7. The 07/23/25 Pressure Ulcer/Injury Evaluation revealed R7 had a sacral stage 2 pressure ulcer/injury that measured 0.8 cm L by 0.7 cm W, was facility acquired on 04/02/25, and staged by facility nursing. The wound bed was 80% granulation (did not define the other 20%) and the periwound appeared non-attached where the edge appears as a cliff. The surrounding tissue was documented as fragile: skin that is at risk for breakdown. The Progress section documented Stable: previously deteriorating wound characteristics plateaued. The evaluation was completed by LPN, LN S and did not contain an image of the wound. The treatment included normal saline cleansing solution, collagen primary dressing, and foam, silicone secondary dressing. Review of the lab results for R7 collected from her right breast on 07/21/25, revealed the following result: Heavy growth of Staphylococcus aureus The next Pressure Ulcer/Injury Evaluation was 14 days later on 08/06/25. The 08/06/25 Pressure Ulcer/Injury Evaluation revealed R7 had a sacral stage 2 pressure ulcer/injury that measured 1.6 cm L by 1.2 cm W, and was facility acquired on 04/02/25. The wound bed was 70% granulation (did not define the other 30%) and the periwound appeared to have edge flush with wound bed or as a sloping edge. The Progress section documented Stalled: Previously improving wound characteristics plateaued. The evaluation was completed by LPN, LN S and did not contain an image of the wound. The treatment included generic wound cleanser and other primary dressing dated 06/01/25. The 08/13/25 Pressure Ulcer/Injury Evaluation revealed R7 had a sacral stage 2 pressure ulcer/injury that measured 0.7 cm L by 0.8 cm W, and was facility acquired on 04/02/25. The wound bed was 20% epithelial, 80% granulation, and the periwound appeared to have edge flush with wound bed or as a sloping edge. The Progress section documented Stable: previously deteriorating wound characteristics plateaued. The evaluation was completed by LPN, LN S and did not contain an image of the wound. The treatment included generic wound cleanser, collagen primary dressing, and silicone secondary dressing. The 08/20/25 Pressure Ulcer/Injury Evaluation revealed R7 had a sacral stage 2 pressure ulcer/injury that measured 1.4 cm L by 1.4 cm W, and was facility acquired on 04/02/25. The wound bed was 20% epithelial, 80% granulation, and the periwound appeared to have edge flush with wound bed or as a sloping edge. The Progress section documented Stable: previously deteriorating wound characteristics plateaued. The evaluation was completed by LPN, LN S and did not contain an image of the wound. The treatment included generic wound cleanser, collagen primary dressing, and silicone secondary dressing. The 08/27/25 Pressure Ulcer/Injury Evaluation revealed R7 had a sacral stage 2 pressure ulcer/injury that measured 1.5 cm L by 0.9 cm W, and was facility acquired on 04/02/25. The wound bed was 10% epithelial, 90% granulation, and the periwound appeared to have edge flush with wound bed or as a sloping edge. The Progress section documented Stalled: Previously improving wound characteristics plateaued. The evaluation was completed by LPN, LN S and did not contain an image of the wound. The treatment included generic wound cleanser, collagen primary dressing, and foam silicone secondary dressing. The 09/03/25 Pressure Ulcer/Injury Evaluation revealed R7 had a sacral stage 2 pressure ulcer/injury that measured 1.8 cm L by 1.0 cm W, and was facility acquired on 04/02/25. The wound bed was 10% epithelial, 90% granulation, and the periwound appeared to have edge flush with wound bed or as a sloping edge. The Progress section documented Stable: previously deteriorating wound characteristics plateaued. The evaluation was completed by LPN, LN S and did not contain an image of the wound. The treatment included generic wound cleanser, collagen primary dressing, and foam, silicone secondary dressing. The 09/10/25 Pressure Ulcer/Injury Evaluation revealed R7 had a sacral stage 2 pressure ulcer/injury that measured 2.4 cm L by 1.5 cm W, and was facility acquired on 04/02/25. The wound bed was 10% epithelial, 90% granulation, and the periwound appeared to have edge flush with wound bed or as a sloping edge. The Progress section documented Stable: previously deteriorating wound characteristics plateaued. The evaluation was completed by LPN, LN S and did not contain an image of the wound. The treatment included generic wound cleanser, collagen primary dressing, and foam, silicone secondary dressing. Review of the Progress Notes in the EHR revealed a 09/12/25 N Adv - Skin Check Late Entry that revealed the resident had no new skin issues identified. The note also include the following three skin issues for R7: Skin Issue: #001: Skin issue has not been evaluated. Location: Coccyx. Laterality / Orientation: Medial. Additional location information: See skin/wound assessment for details and measurements. Issue type: Pressure ulcer / injury. Undermining: No. Tunneling: No.#002: Skin issue has not been evaluated. Location: Sacrum. Issue type: Pressure ulcer / injury. Wound acquired in-house.#003: Skin issue has not been evaluated. Location: Sacrum. Issue type: Pressure ulcer / injury. Wound acquired in-house.Skin Issues Note: see skin and wound assessment for details. The 09/17/25 Pressure Ulcer/Injury Evaluation revealed R7 had a sacral stage 2 pressure ulcer/injury that measured 1.6 cm L by 1.1 cm W, and was facility acquired on 04/02/25. The wound bed was 10% epithelial, 70% granulation, 20% slough, and the periwound appeared to have edges flush with wound bed or as a sloping edge. The Progress section documented Stable: previously deteriorating wound characteristics plateaued. The evaluation was completed by LPN, LN S and did not contain an image of the wound. The treatment included generic wound cleanser, collagen primary dressing, and silicone secondary dressing. The 09/19/25 at 02:20 PM N Adv - Skin Check, noted as a late entry, revealed the resident's skin was warm and dry, and included the following three skin issues:Skin Issue #1: Skin issue has not been evaluated. Location: Coccyx. Laterality / Orientation: Medial. Additional location information: See skin/wound assessment for details and measurements. Issue type: Pressure ulcer / injury. Undermining: No. Tunneling: No.Skin Issue #2: Skin issue has not been evaluated. Location: Sacrum. Issue type: Pressure ulcer / injury. Wound acquired in-house.Skin Issue #3: Skin issue has not been evaluated. Location: Sacrum. Issue type: Pressure ulcer / injury. Wound acquired in-house.The documentation revealed the lack of wound description, measurements, staging, and resident condition/pain/tolerance. The next Pressure Ulcer/Injury Evaluation was 28 days later on 10/15/25. The EHR revealed a Discharge Return Anticipated MDS dated [DATE]. The 09/22/25 at 04:15 AM Health Status Note revealed R7 admitted to a hospital for wound care and UTI. The EHR did not contain progress notes to explain what happened to the resident to require the hospitalization. Review of the hospital discharge paperwork dated 09/26/25 revealed a scan of pages 6 of 14, indicating the first 5 pages were missing. The paperwork revealed the resident had a diagnosis of Sepsis with acute renal failure without septic shock. The discharge paperwork included wound care orders as follows:Coccyx wound: Cleanse with normal saline. Protect periwound with barrier spray. Lightly fill wound bed with saline moistened one-fourth inch Iodoform packing strip. Remove excess saline from packing before placing into wound bed. Apply zinc oxide on periwound area, cover with secondary dressing, such as ABD pad or silicone border dressing. Change every other day and PRN for strike through drainage. Date and initial dressing.Bilateral buttocks, sacrum, and perianal area: Gently cleanse area with warm water and wash cloth. Dry thoroughly. Apply generous layer of zinc oxide moisture barrier with each incontinent episode, gently cleanse effluent off leaving clean zinc in place. Re-apply as needed to maintain presence of zinc barrier at all times. The facility 09/26/25 at 03:45 PM N ADV Clinical Admission note included the resident arrived by transportation on a stretcher. R7 had no indicators of pain and the facility did not assess her mouth, other than noting she had he own teeth. The note included the following skin issues for R7: Skin Issue: #001: Skin issue has not been evaluated. Location: Coccyx. Laterality / Orientation: Medial. Additional location information: See skin/wound assessment for details and measurements. Issue type: Pressure ulcer / injury. Undermining: No. Tunneling: No.#002: Skin issue has not been evaluated. Location: Above right elbow. Issue type: Bruising. Wound was present on admission.#003: Skin issue has not been evaluated. Location: Left front axilla. Issue type: Bruising. Wound was present on admission.Special Care:Source of discharge goal: None of the above.Resident currently on antibiotics. Antibiotic name: Ertapenem [antibiotic used to treat severe bacterial infections] to start 9/27/25 Review of an admission Summary Note dated 09/26/25 at 06:38 PM revealed R7 readmitted back to the facility today at 03:45 PM. R7 had an IV present in her left forearm for IV antibiotic. The note included, per the hospital nurse, R7's wound on her coccyx was packed with 1/4 Iodoform (packing strips) and covered with Sacral Heart dressing (sacral foam wound dressing). Review of a Transfer to Hospital Summary dated 09/27/25 at 02:14 PM revealed the resident presented diaphoretic (sweaty), cold, and clammy at 01:45 PM. The staff immediately assessed vitals and R7 had a blood glucose of 147, blood pressure of 124/84, pulse of 98, oxygen saturation level of 96 percent and respirations of 20 per minute. DON notified the physician and orders given to transfer the resident to the local hospital. EMS arrived and picked up R7 at 02:00 PM. Review of a Health Status Note dated 09/29/25 at 06:34 AM revealed resident admitted to the hospital intensive care unit for sepsis, unknown origin, and her WBC was greater than 40,000. Per mayoclinic.org and professional standards of nursing care, in general the normal range for WBC count is between 4,000 and 11,000 cells per microliter of blood and anything greater than 11,000 is considered high and indicative of an infection, with the mayo clinic noting a high white blood cell count is an increase in cells in the blood that fight infections. Review of the 10/03/25 hospital discharge paperwork revealed the resident admitted to the hospital on [DATE] with the chief complaint of malaise and generalized weakness. R7 remained in the hospital from [DATE] until 10/03/25, in the Intensive Care Unit (ICU). The paperwork noted the primary diagnosis was Sepsis and the paperwork contained information on Sepsis, including proper handwashing, and information on infection prevention. The review of systems indicated R7 reported pain in her arms and legs, and pain over the sacral ulcer with no urinary symptoms. The History and Physical (H&P) section of the documentation noted Severe Sepsis present on admission, history of ESBL and MRSA and noted suspect due to UTI (urinary tract infection) however patient was previously growing staph epidermidis (staphylococcus epidermidis is a gram positive bacterium commonly found on skin and known for its potential to cause opportunistic infections, particularly in healthcare settings). The documentation included a picture of the chronic sacrococcygeal ulceration taken on 09/29/25. The paperwork referred to the chronic wound on her coccyx as appears stage 3-4 on clinical evaluation, not obviously infected. Wound care consulted. The continued reasons for hospitalization noted diagnoses of Pressure injury of coccygeal region, stage 2, pressure injury of sacral region, Stage 4, Extended Spectrum Beta-Lactamase (ESBL) Escherichia Coli (E. coli) carrier, and pneumonia of right upper lobe due to infectious organism. Review of the CDC website regarding ESBL-Producing Enterobacterales revealed ESBL are resistant to common antibiotics and may require complex treatments, can occur both in and outside of healthcare settings, and good hand hygiene and infection prevention practices can help reduce infection risk. ESBLs break down certain antibiotics, making some infections caused by ESBL-producing Enterobacterales difficult to treat. ESBL-E infections are resistant to many prescribed antibiotics, such as penicillin and cephalosporins. The infections caused by ESBL might require hospitalization and IV antibiotics. ESBL-E can cause several different infections, including urinary tract and bloodstream infections. These bacteria can also live in a patient without causing infection or symptoms, known as colonization. ESBL can spread from person to person through dirty hands and surfaces. The website identified nursing home settings as those at risk. Review of the 10/03/25 at 07:17 PM facility N ADV Clinical Admission documentation revealed R7 readmitted to the facility. The note included R7 reported no pain and she had the following skin issues:Skin Issue #1: Skin issue has not been evaluated. Location: Coccyx. Laterality / Orientation: Medial. Additional location information: See skin/wound assessment for details and measurements. Issue type: Pressure ulcer / injury. Undermining: No. Tunneling: No.Skin Issue #2: Skin issue has not been evaluated. Location: Above right elbow. Issue type: Bruising. Wound was present on admission.Skin Issue #3: Skin issue has not been evaluated. Location: Left front axilla. Issue type: Bruising. Wound was present on admission.The note lacked further information such as wound information, measurements, or staging. Review of the EHR revealed a verbal order dated 10/04/26 at 04:25 PM indicating to send R7 o the emergency room for diaphoretic episode. STAT (immediately). The facility Transfer to Hospital Summary note dated 10/04/25 at 07:58 PM revealed the resident presented cold, clammy, and diaphoretic. The resident was not responding to questions to determine alert and oriented status. Vitals included: blood pressure (BP) 104/54 millimeters of mercury (mmHg), pulse (P) of 99 beats per minute (bpm), respirations 16 breaths per minute, temperature of 97.2 degrees Fahrenheit (F). The following vitals were outside of normal limits:Oxygen (O2) saturation percentage (%) of 75% (normal range 95 - 100%)Blood glucose (BG) was 93 milligrams per deciliter (mg/dL) (normal for diabetic at bedtime is above 180 mg/dL) . The staff notified the DON and put the resident on 2 liters of oxygen, which resulted in the resident oxygen saturation of 83%. EMS contacted to request pick up and patient transport to local hospital. Upon EMS arrival resident's blood pressure lowered to 74/41 mmHg, and R7 left the facility with EMS at 04:40 PM. A Pressure Ulcer/Injury Evaluation dated 10/15/25 revealed R7 had a sacral stage 2 pressure ulcer/injury that measured 1.7 cm L by 1.1 cm W, and was facility acquired on 04/02/25. The wound bed was 80% granulation (did not define the other 20%) and the periwound appeared to have non-attached edges, which appear as a cliff. The surrounding tissue was excoriated: superficial loss of tissue. The progress section documented Stalled: previously improving wound characteristics plateaued. The evaluation was completed by LPN, LN S and did not contain an image of the wound. The treatment included generic wound cleanser, collagen primary dressing, and silicone secondary dressing. A Pressure Ulcer/Injury Evaluation dated 10/22/25 revealed R7 had a sacral stage 2 pressure ulcer/injury that measured 2.0 cm L by 1.2 cm W, and was facility acquired on 04/02/25. The wound bed was 80% granulation, 20% slough, and the periwound appeared to have non-attached edges, which appear as a cliff. The Progress section documented Stable: previously deteriorating wound characteristics plateaued. The evaluation was completed by LPN, LN S and did not contain an image of the wound. The treatment included generic wound cleanser, collagen primary dressing, and silicone secondary dressing. A Pressure Ulcer/Injury Evaluation dated 10/28/25 revealed R7 had a sacral stage that measured 1.7 cm L by 1.2 cm W, and was facility acquired on 04/02/25. The Progress section documented Improving: overall wound characteristics improved. The evaluation was completed by LPN, LN S and did not contain an image of the wound or treatment information. A Pressure Ulcer/Injury Evaluation dated 11/04/25 revealed R7 had a sacral stage 3 pressure ulcer/injury that measured 1.6 cm L by 1.2 cm W, and was facility acquired on 04/02/25. The wound bed was 10% epithelial, 70% granulation, 20% slough, and the periwound appeared to have non-attached edges, which appear as a cliff. The surrounding skin was fragile: skin that was at risk for breakdown, normal in color. The Progress section documented Stable: previously deteriorating wound characteristics plateaued. The evaluation was completed by LPN, LN S and did not contain an image of the wound. The treatment included generic wound cleanser, collagen primary dressing, and silicone secondary dressing. A Pressure Ulcer/Injury Evaluation dated 11/11/25 revealed R7 had a sacral stage 3 pressure ulcer/injury that measured 1.6 cm L by 1.0 cm W, and was facility acquired on 04/02/25. The wound bed was 10% epithelial, 90% granulation, and the periwound appeared to have attached edges, which appear flush with wound bed or as a sloping edge. The surrounding skin was normal in color. The Progress section documented Improving: overall wound characteristics improved. The evaluation was completed by LPN, LN S and did not contain an image of the wound. The treatment included generic wound cleanser, collagen primary dressing, and foam secondary dressing. A Pressure Ulcer/Injury Evaluation dated 11/18/25 revealed R7 had a sacral stage 3 pressure ulcer/injury that measured 1.8 cm L by 1.1 cm W, and was facility acquired on 04/02/25. The wound bed was 20% slough, 90% granulation, and the periwound appeared to have attached

The facility census totaled 34 with 14 in the sample. Based on observation, interview, and record review the facility failed to address Resident (R) 16's complaints of pain in her hip. On 07/19/25 the resident voiced pain in the hip after a self-reported fall. After lidocaine (pain medication) patches and Tylenol (pain) were not effective managing the resident's pain the facility placed an order for hydrocodone-acetaminophen (narcotic pain medication) 5-325 milligrams (mg) on the resident's record on 08/12/25, however failed to obtain the medication until 08/25/25. The resident reported pain almost daily at a 1 to 8 on a pain scale where 0 is no pain and 10 is the worst pain imaginable from 08/12/25 until 08/21/25. The facility further failed to ensure R7, received needed dental care and services. R7 refused her dental visit on 10/30/25. The record lacked evidence of staff attempts to get R7 to a dentist after her 10/30/25 refusal, and approximately two months R7 began complaining of tooth pain. The records revealed R7 had an infection to her left lower molar, which caused her pain, affected her eating, and required antibiotics to treat. Findings included:- Resident (R) 16 admitted to the facility on [DATE] and left to and returned from the hospital on [DATE]. Review of R16's Electronic Health Record (EHR) revealed the resident had a diagnosis of pain in the left hip. The resident's admission Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 11, which indicated moderately impaired cognition. The resident received as needed pain medications during the last 5-day observation period and received no non-medication interventions for pain. Review of the 07/09/25 Care Area Assessments (CAA) revealed the pain CAA did not trigger for further review. The Functional Abilities (Self-Care Mobility) CAA triggered but lacked any further development or documentation. Review of the 09/25/25 Quarterly MDS assessment revealed the resident had a BIMS score of 14, which indicated intact cognition. The resident required as needed pain medications during the last 5-day observation period and received no non-medication interventions for pain. The resident's Care Plan initiated 07/03/25 lacked any interventions related to the resident's pain or falls. R16 reported a fall on 07/19/25 and the resident's care plan lacked any intervention related to the fall and/or her subsequent left hip pain. On 08/11/25 staff were instructed to administer medications as ordered and monitor/document for side effects and effectiveness The 07/19/25 at 02:36 PM Health Status Note revealed the resident complained of left hip pain. She limped and was unable to put full weight on the left foot. The note identified the resident as a poor historian and noted the writer was unable to confirm, but R16 reported she fell on her hip before arriving at the facility [on 07/03/25, 16 days prior]. The note stated the resident could fully bare weight upon admission, but her symptoms were steadily worsening. The resident's physician ordered a stat x-ray. The mobile radiology could not perform an x-ray until Monday, so the facility obtained orders to send to the local hospital for evaluation and treatment. The 07/19/25 After Visit Summary document revealed the resident was evaluated for pain in the left hip and declined an x-ray at the time of the visit. The 07/19/25 at 08:25 PM Communication with Hospital Note revealed the resident returned to the facility from the hospital after refusing an x-ray. R16 requested can't you have them [mobile radiology] come here to do it, I don't have any money and don't want to lose this bed, home. The writer stated they would ask the resident's provider for an order to have the x-ray completed at the facility and educated the resident that the hospital placed a Lidocaine patch on her hip with no additional new orders, so she could not have anything stronger than Tylenol for pain. On 07/20/25 at 10:12 AM a Health Status Note revealed the nurse contacted mobile radiology to set up the x-ray as ordered by the resident's physician on 07/14/25. They reported they had staff scheduled to arrive at the facility mid-morning, on Monday. The mobile radiology company stated that since the resident had Medicaid insurance pending the consent to pay form needed to be signed by either patient or facility, so the writer notified the Director of Nursing (DON). The progress notes lacked documentation this request was followed up on by the DON. Review of the Patient Report Form dated 08/13/25 revealed the resident had an x-ray of the left hip and pelvis, which revealed no acute fracture or lesion and no dislocation. Review of the August 2025 MAR/TAR revealed the resident had an order for hydrocodone-acetaminophen oral tablet 5-325 milligrams (mg), one tablet by mouth every six hours as needed for pain in the left hip, which started on 08/12/25 and discontinued on 08/21/25. The record lacked evidence the facility ever provided the medication to R16. The MAR revealed blank slots for the days, with no staff documenting they provided the medication to the resident. Review of the August 2025 MAR/TAR assessment of R16's pain from 08/12/25 to 08/21/26 revealed the resident had pain almost daily and it ranged from a 1 - 8 on the pain scale. The 08/21/25 at 08:25 PM Order Note revealed an order for Hydrocodone-Acetaminophen Oral Tablet 5-325 mg (Hydrocodone-Acetaminophen), staff were to give 1 tablet by mouth every 6 hours as needed for pain in the left hip. The resident was on tramadol (pain medication) for moderate to severe pain in left hip. The resident stated that tramadol was not working and showed verbal and nonverbal signs of pain. Review of the resident's Orders tab in the EHR revealed the resident received a physician's order on 08/21/25 for Hydrocodone-Acetaminophen Oral Tablet 5-325 mg. Staff were to give one tablet by mouth every six hours as needed for pain in the left hip. Review of the Progress Note-Monthly Note dated 08/23/25 revealed the resident had ongoing hip pain, was awaiting x-ray results on the hip and the resident utilized Norco and lidocaine patches for pain management. Review of the August 2025 MAR/TAR revealed the resident received a lidocaine external patch applied topically one time a day for pain, the entire month. The resident received 650 mg two times a day for pain, the entire month. Review of the MAR/TAR revealed the resident did not receive a Norco until 08/26/25, even though the resident had documented physician orders for the medication since 08/12/25. Review of the Pharmacy Narcotic Delivery Log for August 2025 revealed the pharmacy did not deliver hydrocodone-acetaminophen 5-325 mg until 08/25/25. Review of the signed Physician Order dated 08/26/25 revealed a hand signed order for Norco (hydrocodone-acetaminophen) 5-325 mg, one tablet every four hours as needed. The resident's MAR/TAR never reflected the physician's order indicating the resident could take the medication as needed every four hours instead of every six hours. An observation of R16 on 01/11/26 at 07:03 PM revealed a staff member assisted the resident to stand up out of a chair by lifting her arm, without the use of a gait belt. The resident struggled to stand up, and the staff member pulled at her arm until she arose from the chair. An interview with Certified Nurse's Aide (CNA) N at 01/14/26 at 03:59 PM revealed the facility did not utilize a report sheet or documentation, they just gave report via shift-to-shift rounds where they told each other if anything changed, or if residents were sick or weaker than normal. R16 could get up by herself sometimes unassisted, but at times she really needed help getting up. If a resident complained of pain, she would report it to the nurse and would follow up if the resident continued to complain of pain. CNA N stated R16 dealt with a lot of pain. R16 had a chair that reclined and now that she does not have it, she is getting worse. R16's hip is the source of her pain. An interview with Licensed Nurse (LN) S at 05:04 PM on 01/14/26 revealed the chairs in the commons area of the facility sit so low that the resident has to have someone help her stand up. She stated the resident complained about generalized pain and sometimes would tell the staff different things. An interview with Consultant Nurse C 01/14/26 5:45 PM revealed if a resident complained of pain, staff were expected to assess and treat the pain. If the resident did not have an as needed order for the pain medication they were to get and order, follow up with effectiveness and/or try nonpharmacological things like repositioning. Review of the 06/26/24 Pain Management policy revealed the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. - R7's Electronic Health Record (EHR) revealed the resident diagnoses included pain and sepsis. Review of the 08/11/25 Annual Minimum Data Set (MDS) revealed R7 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The MDS documented the resident had no rejection of care and was dependent on staff for most of her activities of daily living (ADL). The resident received scheduled pain medication, as needed (PRN) pain medication, and non-medication interventions for pain. The 08/11/25 Care Area Assessment regarding Cognitive Loss/Dementia, Functional Abilities (Self-Care and Mobility), Psychosocial Well-Being, and Mood State all lacked development and contained the following work up by the facility in each: wctm - indicating the facility will continue to monitor. The Care Plan for R7 revealed an intervention initiated 11/19/18, revised 02/04/25, and included R7 had her own teeth and staff were to set up supplies for her to brush her teeth, twice a day. Review of the 05/13/25 H&P-New Admit Note revealed the resident admitted to Long-Term Care under the services of Physician KK. The note listed R7's medications as:Hydrocodone (narcotic pain medication used to treat moderate to severe pain) 5 mg-acetaminophen 325 mg tablet, one by mouth (PO) every 6 hours (Q6H) as needed (PRN) pain emergency fill.Hydrocodone 5 mg-acetaminophen 325 mg tablet, one by mouth (PO) every 6 hours (Q6H) as needed (PRN) pain. Review of the Progress Note-Monthly Note electronically signed by Physician KK on 07/23/25 revealed the resident was seen in her room for a monthly regulatory visit. The note revealed the resident continued to do well in the facility, denied any excessive pain, fever, chills, or other issues at the time. The note listed two medications for R7 in the medications section, and both were for hydrocodone 5 mg-acetaminophen 325 mg one tablet by mouth every 6 hours for as needed pain and the second entry one tablet by mouth every 6 hours as needed for pain emergency fill. Review of the 10/15/25 at 09:25 AM N Adv - AIMS Evaluation revealed the resident does not currently have problems with teeth. Review of the 10/30/25 at 12:43 PM Social Services Progress Notes revealed R7 refused to see 360 dental today. The EHR revealed no further Progress Notes regarding 360 dental or dental appointments for R7. Review of the 12/30/25 at 10:40 AM Order Note revealed the Penicillin V Potassium Oral Tablet 500 MG, give 500 mg by mouth two times a day, for dental infection for 5 days. Review of the 12/30/25 at 10:42 AM No Type Specified note revealed R7 complained of dental pain and had redness and some swelling to her left lower molar tooth. The note documented an order was written. Review of the 01/08/26 at 01:53 PM N Adv Skilled Evaluation revealed R7 had complaints of pain and discomfort to her lower left jaw, noted singular tooth in place with inflamed gums surrounding tooth, and oral care provided by the writer that day. The evaluation noted the resident had mouth or facial pain, discomfort or difficulty with chewing. Observation on 01/14/26 at 01:32 PM revealed R7 laid in bed in her room and picked her teeth with her fingernails. R7 stated her bottom left tooth in the back was hurting her, and it hurt to eat for the last two weeks. R7 stated she grinds her teeth and would like to see the dentist, as they gave her numbing gel, but it did not really help. During an interview with Certified Nurse Aide (CNA) N on 01/14/26 at 03:59 PM revealed if a resident complained of dental pain, they would tell the Social Services Designee and noted the facility had a dentist that visited every 3 months but would come out for emergency visits. CNA N stated about 2 weeks ago R7 was having a hard time eating and holding her mouth and said her tooth hurts, on a single tooth, gums swollen and red. The nurse checked it out and SSD said they would contact the dental group, but CNA N did not know if they came out or not, but knew the tooth was still there and hurting R7 really bad. CNA N said she talked to hospice and the SSD about R7 still hurting. CNA N stated if a resident complained of pain in general, she informed the nurse and if Tylenol (acetaminophen) was needed the staff told the medication aide or use BioFreeze or lidocaine patch and let the nurse know if the resident still complained of pain. CNA N stated R7 had a wound on her coccyx that hurts her quite a bit and even before that, she has always been in quite a bit of pain. She stated R7 broken her leg years ago and always had pain in that leg. CNA N said now that hospice has come in and was helping with R7's pain management, she felt like it was helping R7 more and she was doing better, but her tooth was bothering her a lot. During an interview on 01/14/26 at 05:04 PM, Licensed Nurse (LN) S said if a resident complained of dental pain the staff reported it to the doctor, looked at it, and checked if they can get the resident to see a dentist. LN S said they were going to try and get R7 into a dentist, noted R7 had complained about generalized pain, sometimes would tell staff different things. LN S stated if a resident complained of pain, she assessed them for what kind of pain, see if chronic or new to them, if new would assess further for any injury. LN S said if the resident had a PRN medication ordered she would offer it. LN S said R7 complains of pain everywhere or sometimes it was her back. LN S said R7 had a PRN pain medication, but yesterday it was changed to scheduled. During an interview with Consultant Nurse C on 01/14/25 at 05:45 PM revealed she expected the charge nurses to update the care plan. Consultant Nurse C stated special needs should be care planned. She stated the care plan should list behaviors, triggers, and interventions for individual residents, and staff should know through care plans how to get into the care plan to provide the best care. Consultant Nurse C stated the care plans should be as individualized as possible to provide the best care, including ADLs. Consultant Nurse C stated if a resident complains of pain, staff should assess and treat, hopefully have a PRN order or get an order, and follow up if it was effective. She stated sometimes it did not require medication, and the resident might need repositioning and try different things. Review of the facility provided Dental Services Policy, dated 11/06/23, revised 06/24/24, revealed emergency dental services included 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 policy noted all actions and information regarding dental services, including any delays related to obtaining dental services, would be documented in the resident's medical record. The policy noted the SSD maintained contact information for providers of dental services that were available to facility resident at a nominal cost.

The facility identified a census of 34 residents. Based on record review and interviews, the facility failed to establish and implement an admissions agreement that protected the residents' right to personal property. Findings included:- The facility's Skilled Nursing Facility Resident Agreement revealed under part four, page 14, section D Personal Possessions that the resident, under no circumstances, held the facility responsible for or liable of any nature whatsoever for the loss or damage to valuables, personal property, or money brought into the facility. On 01/14/26 at 06:25 PM, Administrative Staff D stated the regional level completed the admission agreement packets and sent them out. She stated when a resident admitted to the facility staff completed an inventory list with the resident and updated it with anything new brought in. Administrative Staff D stated if a resident stated they brought items in and they followed the grievance process; the facility did an investigation to find the item then took ownership after the facility verified the item went missing in the facility. She stated the admission agreement statement did not protect residents from misappropriation. The facility's admission Policy- Kansas, last revised 09/26/25, directed an admission agreement shall not include a general waiver of liability for the health and safety or residents.

The facility identified a census of 34 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to provide a resident centered activities program that incorporated resident interests, hobbies, and cultural preferences for a meaningful life. Findings included:- The activity calendar for January 2026, documented the following activities from 01/01/26 to 01/14/26: 01/01/26 - 02:00 PM Bingo, 07:00 PM free hour. 01/02/26 - 10:00 AM exercise group, 02:00 PM movie and popcorn, 07:00 PM free hour. 01/03/26 - 10:00 AM exercise group, 02:00 PM coloring creations, 07:00 PM free hour. 01/04/26 - Exercise group, table games, and free hour. The scheduled times were cut off of the calendar. 01/05/26 - 10:00 AM Christmas undecorating, 10:30 AM Resident Council, 02:00 PM mani time, 07:00 PM free hour. 01/06/26- 10:00 AM exercise group, 10:00 AM word search, 02:00 PM Bingo, 07:00 PM free hour 01/07/26- 10:00 AM exercise group, 10:30 AM cooking with Activities Director E, 02:00 PM corn hole, 07:00 PM free hour 01/08/26- 10:00 AM exercise group, 10:00 AM ladies club, 02:00 PM Bingo, 07:00 PM free hour 01/09/26- 10:00 AM exercise group, 10:30 AM men's club, 02:00 PM movie and popcorn, 07:00 PM free hour 01/10/26- 10:00 AM exercise group, 02:00 PM coloring creations, 07:00 PM free hour 01/11/26- exercise group, table games, and free hour. The scheduled times were cut off of the calendar. 01/12/26- 10:00 AM exercise group, 10:30 AM coffee social, 10:30 AM trivia, 02:00 PM mani time, 07:00 PM free hour. 01/13/26- 10:00 AM exercise group, 10:30 AM balloon toss, 02:00 PM Bingo, 07:00 PM free hour. 01/14/26- 10:00 AM exercise group, 10:30 AM cooking with Activities Director E, 02:00 PM happy hour, 07:00 PM free hour. On 01/13/26 at 02:07 PM, Resident (R) 23, R17, R20, R16, R31, R3, R29, R14, and R34 sat at tables in the dining room and waited to play scheduled Bingo. On 01/14/26 at 10:16 AM, R34 and R14 sat at tables in the dining room and participated in coloring. There were other residents in the dining room that watched television. R1 sat in her wheelchair in the day area with a coloring page and colored pencils/markers in an unopened box in front of her. R1 did not participate in coloring. On 01/14/26 at 10:30 AM, the scheduled activity of cooking with Activities Director E did not occur. On 01/14/26 at 02:04 PM, R20 sat in the dining room and colored pages. Happy hour was scheduled at 02:00 PM and R17, R16, and R29 sat in the day area. Music played in the area. On 01/14/26 at 02:07 PM, Activities Director E asked R29 in the day area if she wanted to go into the dining room for activities. On 01/14/26 at 02:10 PM, Activities Director E propelled R23 into the dining room for activities. 01/11/26 at 07:15 PM R18 stated activities did not meet his interests due to his age, the other resident's ages, and their preferences. He stated he enjoyed watching a movie recently, but that was about all they did that he liked. On 01/14/26 at 12:54 PM, R23 stated the facility did not have exercise group or cooking that morning as scheduled. On 01/14/26 at 03:44 PM, Activities Director E stated she followed an activity book to get ideas of activities to do. She stated she interviewed residents on what activities they liked to do. She stated she used to do more activities for the elderly but there had been a change in the population and needed to learn new activities those residents would like. Activities Director E stated she tried to follow the activity calendar but somedays nobody wanted to get up for exercise group or do a scheduled craft, so she had to switch to a game. She stated she tried to do a different activity if the residents did not want to do the scheduled one. Activities Director E stated she did not do cooking this morning because she did not have the chocolate chips. She stated they did not do exercise group this morning because nobody wanted to do it, so she did coloring pages instead. Activities Director E stated each resident had an activity care plan and the assessment identified preferences that she put on the care plan. On 01/14/26 at 05:45 PM, Consultant Nurse C stated activities should be resident specific for age and demographic. She stated she expected staff to assess the resident demographic and make activities enjoyable and meaningful. Consultant Nurse C stated she expected the activity calendar to be followed and if staff had to deviate from it, staff communicated the change to the residents and found something as equally engaging and enjoyable. The facility's Activities policy, dated 07/19/23, directed the facility provided all residents with an ongoing program of activities designed to meet, in accordance with their comprehensive assessment, their interests and their physical, mental, and psychosocial well-being.

The facility census totaled 34 with 14 in the sample. Based on interview and record review the facility failed to ensure staff had the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial wellbeing of each resident as determined by resident assessments, plans of care and utilizing the facility assessment. Findings included:- The facility failed to provide evidence of competencies from Administrative Staff A as requested on 01/11/26 and again on 01/12/26. During an interview on 01/26/25 with Consultant Staff X at 03:51 PM she stated she did not have any proof the facility performed competency evaluations with certified staff. Review of the Sufficient Staff Policy dated 05/15/24 revealed the facility would provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being for each resident.

The facility reported a census of 34 residents. Based on interview and record review the facility failed to provide evidence of no less than twelve hours of in-service education provided to the Certified Nurse Aides annually, which were based on their individual performance reviews. This failure had the ability to affect the care of all 34 residents. Findings included:- The facility failed to provide evidence of competencies and evidence of annual in-service education for the Certified Nurse Aides, as requested from Administrative Staff A on 01/11/26 and again on 01/12/26. During an interview with Administrative Staff A on 01/13/26 at 03:10 PM she stated that they were still looking and could not locate the information, noting they looked through Administrative Nurse B's office but were not able to locate any documentation about annual CNA training based on performance reviews. During an interview on 01/26/25 with Consultant Staff X at 03:51 PM she stated she did not have any proof the facility performed competency evaluations with certified staff. Review of the Sufficient Staff Policy dated 05/15/24 revealed the facility would provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being for each resident.

The facility reported a census of 34 residents. Based on observation, interview, and record review revealed the facility failed to ensure effective administration in order to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This failure affected all 34 residents in the facility. Findings included:- During an extended recertification and complaint survey the following concerns were identified regarding the lack of administrative oversight, which contributed to the following three immediate jeopardy deficiencies as follows: Regarding Accident Hazards (See F689): Based on observation, interview, and record review the facility failed to prevent, identify, and intervene in Resident (R) 11's substance use disorder, which placed residents in immediate danger of serious harm or death R11 admitted to the facility after a referral from a regional hospital. The 08/13/25 hospital referral sheet for admission to the facility identified the resident with a history of alcohol and drug use with the resident reporting current drug use at the time of the referral. Administrative Staff A and Administrative Nurse B failed to ensure R11 had trained/competent staff with the skills to care for a resident with SUD, support resources (consultant psychiatric provider was not referred until 09/2025 weeks after admission and only saw the resident monthly), and/or care planned interventions to address his substance use disorder (SUD). On 08/29/25 the resident developed blisters to fingers on both hands, but the resident's record lacked follow up by Administrative Staff A and/or Administrative Nurse B to the injuries of unknown origin (the resident's record does not indicate the resident stated how he obtained the wounds) and/or investigation into the causal factors of the blisters. R11 was identified cutting scabs off of himself with a knife and with non-facility managed medication and Administrative Staff A and Administrative Nurse B failed to investigate or follow up on the identified concern, when the resident had undocumented medication and a known history of SUD and self-harming behaviors to address R11's SUD and his highest practicable well-being. On 12/26/25 staff found four pill bottles, a torch, a red lighter, a large knife, and a black pouch containing a drug pipe in R11's room. Administrative Staff A was notified and failed to follow up on the incident. During an interview on 01/13/26 at approximately 07:00 PM Administrative Staff A verified she was aware of the items staff found in R11's room and did not know what staff did with the drug pipe, pill bottles, lighter/torch, and knife. Administrative Staff A denied having knowledge of what was in the pill bottles. Administrative Staff A originally stated law enforcement picked up the drug pipe, but then said they did not and were not notified. Administrative Staff A stated she was unaware that a resident with known SUD having a drug pipe in his possession would require further investigation. On 01/10/26 dayshift staff reported to the nightshift nurse that R11 appeared to be intoxicated with pinpoint eyes and a very red face. Administrative Staff A gave permission for staff to search the residents room, although he declined. Upon a search of the resident's room staff found a crack pipe with the contents the facility identified as methamphetamine still present. During the events on 01/10/26 the methamphetamine spilled out of the pipe and onto the medication cart that housed the other residents who resided in the facility's medication. Facility administration failed to provide oversite in handling an illegal drug, until law enforcement could retrieve the substance. Facility administration failed to ensure staff had a system for monitoring R11 for overdose, withdrawal, and continued substance abuse. Facility administration failed to ensure all staff were aware R11 had drug paraphernalia on 12/26/25 and staff stated they wished they knew so they could have monitored the resident before he had an incidence of smoking methamphetamine in the facility, with other residents potentially present in the vicinity within hallways and their rooms. Administrative Staff A failed to initiate an investigation into R11 having drug paraphernalia, illegal drugs, knives, and lighters/torches in his possession and while intoxicated on an unpredictable illegal substance, which had the potential to impact all residents in the facility. On 01/13/26 at approximately 07:00 PM Administrative Staff A stated she was not aware if a resident smoking methamphetamine in the facility was reportable or required an investigation. During confidential interviews with staff, they reported they were fearful to report anything to administration out of fear of retaliation. Regarding Pharmacy Services (See F755):The facility reported a census of 34 residents. Based on observation, interview, and record review the facility lacked a system for records of receipt through disposition of all controlled medications, in sufficient detail to enable accurate reconciliation and ensure drug records were in order. The facility also failed to ensure a record system to account for all controlled medication which was maintained and periodically reconciled. The facility pharmacy lacked onsite presence in the facility to assist in the destruction of controlled narcotic substances from February 2025 until 01/09/26. The facility had a locked cabinet inside the medication room used for narcotic medications awaiting destruction. The administrator did not know who had the key for the locked cabinet and required maintenance staff to cut the lock off of the cabinet on 01/06/26, revealing the cabinet was full of narcotic controlled medications dating back to 2024. Through record review the facility could not account for 49 separate narcotic prescriptions, of an unknown quantity each, affecting 22 current and discharged residents. The pharmacy did not identify the increased use of e-kit narcotics used, increased frequent changes to narcotic prescriptions, and lack of destruction of the numerous narcotic medications delivered, or the lack of a facility system in place for the accurate accounting of controlled substances to include PRN and discontinued narcotic medication. On 01/12/26 review of resident chart revealed the facility did not have her hydrocodone and had to access the e-kit twice to provide pain medication for the residents. The lack of pharmacy services, procedures, and records placed all residents who received controlled narcotic medications in immediate jeopardy and at risk for unrelieved pain, discomfort, death, and the risk to the resident population which included a history of Substance Use Disorder. During the investigation, the surveyor asked for the count sheet for R36's oxycodone (narcotic pain medication) or evidence the resident took the medication home, since these were identifiable in the complaint photos. The facility could not provide a copy of the count sheet for the medication, and it was requested twice of Administrative Staff A, twice of Administrative Nurse B, and once of Licensed Nurse S. During an interview on 01/06/26 at 01:57 PM Administrative Staff A stated the facility did not have the count sheets for R36's oxycodone and did not have evidence that R36 took it home. Administrative Staff A stated she could not find it and it did not look like the facility had it. During an interview on 01/06/26 PM at 12:06 PM, Administrative Staff A stated she has never been in the facility when the narcotic medications were destroyed, stated she was not a nurse, and she does not have anything to do with medications. Administrative Staff A stated she never saw pharmacy in the facility to destroy narcotic medications and said Administrative Nurse B should have the narcotic destruction key. Administrative Staff A stated she had not asked Administrative Nurse B if she had key, but she should have it and thought she did. She further stated per the facility policy, narcotic medication destruction required a licensed nurse or nurse and certified medication aide or pharmacist. Administrative Staff A stated it could be an issue with Administrative Nurse B having a key and all count sheets going to her, as a single point. Administrative Staff A stated as far as she knew Administrative Nurse B had the key and she did not know who else would have it. Administrative Staff A stated as far as she knew the pharmacy had not been out, but said they may not check in with her when they do since she does not do anything with medications, but had never seen them. Administrative Staff A stated the pharmacist sent out pharmacy recommendations once a month, so she was in contact with them and stated there absolutely should be a record of what was destroyed, but was not positive if or where the record could be. She stated there should be a book of record of what was destroyed and she was not sure if it was at the nurses station or in her office, but there should be a record of it. Administrative Staff A stated she could see how it could be an issue with only Administrative Nurse B as the staff member with the key to the narcotic destruction cabinet and all counts sheet going to Administrative Nurse B. During an interview on 01/06/26 at 02:27 PM Administrative Staff A she was not sure about the key and no one she talked to knew where it was or knew who had it. During an interview on 01/06/26 at 03:27 PM Administrative Staff A stated they were going to cut the lock off and place a new lock to the narcotic destruction box and record new sheets of what was in the cabinet. Administrative Staff A stated the nursing supervisor was coming up with process and they would have the pharmacist come in on a regular basis, but for now Administrative Staff A would hang on to the only key to the narcotic destruction cabinet. Administrative Staff A stated that anything that needed to be destroyed would now be destroyed immediately. Administrative Staff A clarified the facility was doing an audit right now, then came back and said they would not destroy but will audit whatever is inside of the destruction cabinet. During an interview on 01/06/26 at 04:25 PM Administrative Staff A stated they finished the audit of current medications and found no discrepancies. She stated the facility would cut the lock off of the cabinet to see what was inside, place a new lock, and she would keep the key. She said it was not done yet, but it would be. During an interview on 01/06/26 at 07:39 PM Administrative Staff A stated it looked like the pharmacy did email herself and Administrative Nurse B, and Administrative Staff A said she never opened them, as she thought Administrative Nurse B opened them. Administrative Staff A stated the emails were encrypted so she could not see what was in them. During an interview on 01/07/26 at 01:42 PM Administrative Staff A stated the facility did not have all of the delivery sheets from the pharmacy to line up with all of the discontinued narcotic medications since March 2025. Administrative Staff A stated she had to contact the pharmacy to have that list sent and stated it might take a while to get it. She stated right now she was not sure if everything on the list made it to the facility. On 01/07/26 at 03:25 PM Administrative Staff A stated she could not find any record of pharmacy destruction sheets and could not find any facility medication destruction sheets. Administrative Staff A stated she had not seen anyone destroy medications since she started in February 2025. During an observation in the medication room on 01/06/26 at 05:30 PM, Maintenance Staff J cut the lock of the medication destruction cabinet in the presence of Administrative Staff A and LN S, and replaced the lock with a new one. Inside the medication destruction cabinet were stacks of medication cards with count sheets attached to them. The medication destruction cabinet had a slot on the right side and was made of wood. The slot on the side was not large enough for the boxes with morphine/Ativan/liquid meds in them to fit through, which were inside the cabinet. Some boxes with bottles were found inside the cabinet. A large metal box sat inside and at the bottom of the cabinet with two locks on it-- and the surveyor could not visualize the contents. LN S and Administrative Staff A said they did not know what was in the metal box and stated no one had keys. LN S attempted to unlock the box using all keys on the nurse key ring, button worked. LN S and Administrative Staff A stated it was likely left when the previous company owned the facility, but they are not sure how long it was in there. Per LN S and Administrative Staff A it was a metal sharps style bin and contained what appeared to be empty bottles of Ativan and Morphine and unable to visualize the resident labels on the bottle as only viewable from a slot on top of the bin. Appeared to be morphine and lorazepam bottle (6 morphine, 2 lorazepam, and 1 other bottle unable to discern). During an interview on 01/11/26 at 03:51 PM, Administrative Staff A revealed she finished the investigation, sent it to corporate, and said she has an open investigation with the police. Administrative Staff A revealed she would send a copy of the completed investigation once she got approval from corporate. Administrative Staff A stated the facility suspended Administrative Nurse B and overall determined the outcome to end Administrative Nurse B's employment, but stated the facility was waiting to terminate until they could get someone who had a nursing license. Administrative Staff A said they could not substantiate anything and apparently the narcotics were discontinued, and they took cards with narcotic sheets so she could not substantiate. Administrative Staff A said the staff could not find the key and now she has the only key locked in the safe behind two locks. She is the only one that has the key to the safe. Administrative Staff A stated the facility conducted a full audit of every resident here, did interviews with the residents, and no one refused medications, they were getting medications, felt like they had not missed medications, and did staff interviews. Administrative Staff A said they interviewed staff and some had no idea of what she was asking them about and stated a CMA thought it was the lockbox on the medication cart. Administration Staff A stated that everyone that is here is safe and no medications were missing from them. Administrative Staff A said the facility provided a list of medications they prescribed sent from the pharmacy they audited it with the list that were here and what was delivered. Administrative Staff A stated they know that there are medications the pharmacy said they sent, that are no longer in the facility, that we did not know were missing because they should have been in the box, but they were not. Administrative Staff A stated that some of the stuff [medications] in the destruction cabinet was very old and one of them was dated 2024. She stated she knew that the pharmacy had not destroyed medications. She stated inside the destruction cabinet was a metal box and she said it had empty bottles repeating they were all empty. When asked if she inventoried the items inside the metal box, she stated she did not inventory anything in there. Kinda looked in it and they were all empty. Administrative Staff A stated she saw the medications inside the cabinet and knew someone was accessing it as there was no way to toss in something form the top slot and get it into the metal box at the bottom. Administrative Staff A stated once she was notified of this incident she immediately suspended Administrative Nurse B, pending investigation, and then started her investigation. Administrative Staff A stated she was notified on 01/06/26 of the allegation. She said on 01/07/26 she asked Administrative Nurse B to complete a drug test by 04:00 PM on 01/07/26 but Administrative Nurse B did not complete a drug test because she missed the time. Administrative Staff A said she knew the time was running out on this and told Administrative Nurse B to complete a drug test by 09:00 AM on 01/08/26, but when Administrative Staff A called Administrative Nurse B at 10:00 AM on 01/07/26, she woke Administrative Nurse B up. She said Administrative Nurse B did not complete a drug test until after 02:00 PM on 01/08/26. Administrative Staff A stated a week before this other staff came to her with concerns regarding Administrative Nurse B and her performance and what she was and was not doing. Administrative Staff A stated she knew of things Administrative Nurse B was not taking care of and thought she just needed more training. Regarding Infection Control (See F880):Based on observations, interviews and record review facility administration failed to administer an effective infection prevention and control program. Observation of the facility on 01/11/26 revealed multiple resident rooms with clothing strung all over floor and the bed side tables of residents, with a strong smell of urine throughout the facility. The facility lacked a system to store soiled resident clothing in a manner to prevent the spread of potentially infectious organisms. Administrative Staff A walked throughout the facility, likely observing the clothing and failed to address the lack of infection control practices. Administrative Staff A further failed to ensure staff had the knowledge and cleaning supplies necessary to clean/disinfect multi resident use medical equipment after each use. Administrative Staff A further failed to ensure a complete and effective infection prevention and control program by the failure to track infections in the building, identify organisms present, implement enhanced barrier precautions for residents at risk for multi-drug-resistant organism due to wounds, catheter use, or other medical device use. On 01/11/26 Administrative Staff A reported not being a nurse so was unaware of Administrative Staff Bs role and responsibility if it had any nursing implications. Consultant Nurse C further failed to implement immediate corrective actions regarding infection control practices when on 01/12/26 she identified Administrative Staff B lacked documentation for tracking and trending of infections in the building, failed to identify organisms present while administering antibiotic medication to residents, and failure to provide oversight to ensure staff were aware of and adhering to infection control practices. Administrative Staff A failed to ensure the most recent facility assessment thoroughly addressed Infection Prevention. Administrative Staff A failed to maintain documentation that Administrative Nurse B had the education, experience, or certification to be designated as the facility Infection Preventionist. Administrative Staff A failed to provide oversight to ensure the facility maintained a water management program for the prevention and spread of waterborne infectious organisms, even though it was cited on the facility's most recent annual survey dated 04/2025. During confidential interviews with staff they reported they were fearful to report anything to administration out of fear of retaliation.

The census totaled 34 with 14 in the sample. Based on interview, and record review the facility failed to conduct an effective facility-wide assessment to determine the resources necessary to care for its residents competently during day-to-day operations. Findings included:- Review of the facility provided Facility Assessment Tool revised 11/2025 revealed the facility had 45 licensed beds with the average number of occupied beds being 32 the last quarter. Review of the Persons Involved in completing the assessment revealed the administrator, director of nursing, social services director, medical director and physical therapy. The document lacked evidence the facility included input from other members of the community as required in section 483.71(b)(1)(ii)(iii) of the State Operations Manual, which include (but not limited to) direct care staff (registered nurse, licensed practical nurse, nursing assistants), residents, resident representatives, and family members. The assessment further lacked a plan to maximize recruitment and retention of direct care staff. The Acuity section instructed the facility to describe resident's acuity levels that would help the facility understand potential implications regarding the intensity of care and services needed. Review of the Major RUG-IV Categories lacked a number/range of residents who required extensive services, special care high services, special care low services, clinically complex cares, behavioral symptoms and cognitive performance, and/or residents with reduced physical function. The facility provided Facility Assessment Tool instructed the facility to describe the staff training/education and competencies that were necessary to provide the level and types of support and care needed for the resident population. The facility noted they would do annual competencies (with no description), monthly in-services with education (without description or further development), and/or provide education as needed. The assessment further instructed staff to describe the staff education and competencies, staff certification requirements, testing policies, competency and how to evaluate the efficacy of these to ensure the facility was providing the level and types of support and care needed for the resident population. The facility identified the following: Cardiopulmonary Resuscitation (CPR- emergency lifesaving procedure performed when the heart stops beating) with no further description on how to evaluate competency and/or effectiveness of the training.Life Enrichment Directors with no further description on how to evaluate competency and/or effectiveness of the training.Culture Change/Person Centered Care with no further description on how to evaluate competency and/or effectiveness of the training.Infection Control-Stewardship with no further description on how to evaluate competency and/or effectiveness of the training.C.N.A (no less than 12 per year) with no further description on how to evaluate competency and/or effectiveness of the training.Dementia Management with no further description on how to evaluate competency and/or effectiveness of the training.Disaster Planning and Procedures with no further description on how to evaluate competency and/or effectiveness of the training.Medication Administration for all Licensed Nurses and CMTs with no further description on how to evaluate competency and/or effectiveness of the training.Resident Assessments with no further description on how to evaluate competency and/or effectiveness of the training.Measurements for vital signs, urine, I&O, glucose, and catheter care with no further description on how to evaluate competency and/or effectiveness of the training.Caring for residents with Alzheimer's (progressive mental deterioration characterized by confusion and memory failure), Dementia (progressive mental disorder characterized by failing memory, confusion), and Mental Illness with no further description on how to evaluate competency and/or effectiveness of the training.Specialized Care (undefined) with no further description on how to evaluate competency and/or effectiveness of the training.Unit Care including nonpharmacological interventions with no further description on how to evaluate competency and/or effectiveness of the training. The facility failed to provide evidence of any staff competencies performed since their last annual survey dated 04/2025. Review of infection control related content in the assessment revealed the facility identified their common diagnoses as skin and soft tissue infections, respiratory infections, tuberculosis (communicable disease), urinary tract infections, infections with multi-drug-resistant organisms, septicemia (systemic infection), viral hepatitis (inflammatory condition of the liver, clostridium difficile (infection involving the colon), influenza (highly contagious viral infection), and scabies (contagious infestation of the skin by burrowing mites). The facility identified an average range/number of isolation/quarantine residents with active infection as one to three. The facility noted they would need to provide residents with identification and containment of infections and prevention of infections. The assessment contained a section for the facility to evaluate their infection prevention and control program, which included effective systems for preventing, identifying, reporting, investigating and controlling infections and communicable diseases for all residents, staff, volunteers, visitors and other individuals that follow national standards, but the assessment lacked any evaluation, review, or development of their infection control program. (See F880, F881, F882, F883, and F887) Review of the Facility Assessment Policy and Tool dated [DATE] revealed the facility would conduct and document a facility wide assessment to determine what resources were necessary to care for its residents completely during both day-to-day operations and emergencies. The assessment will include staff competencies that were necessary to provide the level and types of care needed for the resident population. Individuals involved in creation of the assessment would include Administration, Environmental Operations Manager, Department Heads, and individual members of the direct care staff. The facility was also encouraged to seek input from residents, their representatives or families and consider information when formulating their assessment. The assessment would address infection control issues that required a change in infection prevention resources and methods.

The facility reported a census of 34 residents. Based on interview and record review the facility failed to implement and maintain a comprehensive Quality Assurance Performance Improvement (QAPI) program and plan, through the lack of effective involvement by governance and leadership. Administrative Staff A could not provide evidence the QAPI program was effective in the identification of quality concerns, when the current survey identified Immediate Jeopardy and Substandard Quality of Care. Findings included:- On 01/13/26 at 06:53PM Administrative Staff A brought the QAPI sign-in sheets to the surveyor. Review of the sign in sheets revealed the Director of Nursing did not attend the July 2025 through January 2026 meetings and the Medical Director had not attended quarterly. During an interview on 01/13/26 at 06:57 PM Administrative Staff A stated the facility did QAPI online on the computer and talked about the same thing every month, so she did not know how to print the prior agendas but pointed to the blank copy and stated it was the same agenda every month. Administrative Staff A stated that they had quarterly meetings, as they had QAPI monthly, but it was hit and miss on if the Medical Director attended as it depended on his schedule and when they had QAPI, but stated they had to have it by the 10th of every month. Administrative Staff A stated the plan had a place to put incidents and attach the summary of what it was. She said they did resident questions each month and went over survey or anything that they did not go over every month. Review of the QAPI Monthly blank answer form revealed the following QAPI format: An area for the facility name.A grey box with the following fillable areas: Date, Minute Recorded by Meeting CoordinatorAlso in the grey box was a section titled Meeting Purpose which had the following checkbox options:Scheduled, Resident Request, Guardian Request, IDT Member Req, Other, and a blank checkbox.The gray box contained a third area titled IDT Member Present for Meeting and had checkboxes for the following staff:Administrator, DON, RCC, Physician, Social Services, Other Nursing, Dietary Manager, Assistant Administrator, Guardian, Family Rep, Resident, MDS Coord., CP Coordinator, Pharmacy, Dietary Consultant, Financial, ADON, BOM, Activity Dir, Dietician, Antibiotic Stew, and two blank checkboxes.The next portion of the form revealed Best Practice Instructions which noted to assign which sections of the Health Services Review of IDT member to Audit each month. If noted during audit, sections are non-compliant, create action plan to correct. Review again during Monthly QAPI to ensure compliance is achieved for each section and fill box with color or mark as completed and in compliance. The form then contained the following areas:Physician VisitsBaseline and Annual EKG's (completed for all residents on psychotropic medications)Dental ServicesVision ServicesMammogramHearing ServicesInfluenza VaccinesRSV VaccinePneumovax(listed the CDC Guidelines)Covid VaccinesPodiatry ServicesColonoscopyReview of Monthly Wound ReportsReview of infection logInfection ControlAspiration List Review InstructionsMonthly Incident ReviewRequest for Physical TherapyRequest for Occupational TherapyRequest for Speech TherapyReview of Psychotropic, Antipsychotic, hypnotic, medications reviewReview of CathetersDischargesServices offered to residents upon dischargeMDS ReviewCare Plans Reviewed and updatedFacility medical equipment needsDNR ReviewPhysician Order Signature ReviewReview of User Defined AssessmentsReview Weight LossesReview Weight Gains Review of the facility provided Facility Assessment Tool revised 11/2025 revealed a section titled QAPI [Quality Assurance Performance Improvement] Program which indicated a QAPI meeting would be held monthly. The assessment tool stated the QAPI meeting is held monthly and attended by the Director of Nursing, Administrator, Business Office Manager, Activities Director, Medical Director, Therapy Director, Maintenance Director and Environmental Services Lead. The tool further indicated All staff is aware of when QAPI is held and welcome to attend. The meetings would be held to determine what things are working and what need improvement in the facility with resident care, staffing, maintenance, and all other areas. The facility would create policy improvement plans for problems identified that needed improvements. During the current survey Immediate Jeopardy was identified for the following regulations:Free of Accident Hazards/Supervision (Quality of Care- See F689)Pharmacy Services (See F755)Infection Control (See F880) And Substandard Quality of Care (SQC) identified in the following areas:Free of Accident Hazards/Supervision (Quality of Care- See F689)Influenza and Pneumococcal Immunizations (Infection Control- See F883)Activities Meet Interest/Needs of Each Resident (See F679) The facility could not provide evidence the QAPI program identified and/or addressed concerns to mitigate the onsite findings of immediate jeopardy and substandard quality of care. The facility provided a copy of the QAPI policy on 01/13/26. The facility provided policy was titled QAPI Plan and had an origination date of 05/14/21, revised 07/09/21. The policy included the guiding values or principles of QAPI plan included stewardship, integrity, respect, excellence, leadership, and personal growth. The plan provided guidance for the facility overall quality improvement program and noted quality assurance performance improvement principles will drive the decision making within the facility, and decisions will be made to promote excellence in quality of care, quality of life, resident choice, person directed care, and resident transitions. The QAPI meeting would be held on a monthly basis. All department heads, the administrator, the director of nursing, antibiotic steward, infection control and prevention officer, medical director, consulting pharmacist would provide QAPI leadership by being on the QAPI committee. Records of the actions taken at each meeting would be kept using the attached form instruction for IDP/CP/QAPI QA Meetings. Minutes should document what was reviewed, issues/problems addressed, plan of correction, the monitory process and the results. At least quarterly, all disciplines should have a representative at the QAPI meetings. The policy noted the overview of the QAPI process was to: identify and use data to monitor facility performance; establish goals and threshold to measure performance; utilize residents, staff and family input; identify and prioritize problems and opportunities for improvement; systematically analyze underlying causes of systemic problems and adverse events; develop corrective action or performance improvement activities. The QAPI Plan would be reviewed annually by the RCMC Director of Organizational Development with input from facility Administrators and Directors of Nursing. The QAPI Plan noted the committee would review resident reported concerns, grievances, and/or resident council meeting to help identify issues. The Data and Statistics section noted the QAPI committee would review data for all areas of the facility to assure systems were being monitored and maintained to achieve the highest level of quality and listed the following reports the QAPI committee may use: Infection Control Log and Infection Prevention and Control ProgramWound ReportsAntibiotic Utilization ReportsCMS Quality Measures, CASPER Reports and any other data to measure the facilityIncident Report Log including, but not limited to, Falls, RN Investigation, Medication/Treatment omissions, Elopement or WanderingWeight Loss Reports at 30, 90, and 180 daysAdvanced care planning auditsMedication administration auditsMedication room audits

The facility reported a census of 34 residents. Based on interview and record review the facility failed to show evidence the Quality Assurance Performance Improvement (QAPI) program developed and implemented action plans to correct identified quality deficiencies cited on prior and current survey, lacked evidence the QAPI program were aware of the systemic issues which rose to the level of Immediate Jeopardy and Substandard Quality of Care on the current survey, and lacked evidence the QAPI program were monitoring facility practices to prevent adverse events. Findings included:- Review of the citations found on the prior recertification survey dated 04/16/25 revealed the facility was cited for deficient practice for the following regulations:F0580 (Notify of Changes (Injury/Decline/Room, etc.) at a DF0623 (Notice Requirements Before Transfer/Discharge) at a DF0625 (Notice of Bed Hold Policy Before/Upon Transfer) at a E*F0689 (Free of Accident Hazards/Supervision/Devices) at a D*F0727 (RN 8 Hrs/7 days/Wk, Full Time DON) at a F*F0730 (Nurse Aide Peform Review-12 hr/yr In-Service) at a F*F0744 (Treatment/Service for Dementia) at a D*F0755 (Pharmacy Services/Procedures/Pharmacist/Records) at a F*F0756 (Drug Regimen Review, Report Irregular, Act On) at a FF0760 (Residents are Free of Significant Med Errors) at a D*F0761 (Label/Store Drugs and Biologicals) at a EF0801 (Qualified Dietary Staff) at a EF0812 (Food Procurement,Store/Prepare/Serve-Sanitary) at a F*F0867 (QAPI/QAA Improvement Activities) at a F*F0868 (QAA Committee) at a F*F0880 (Infection Prevention & Control) at a F*F0882 (Infection Preventionist Qualifications/Role) at a F*F0883 (Influenza and Pneumococcal Immunizations) at a E*F0947 (Required In-Service Training for Nurse Aides) at a FThe asterisk indicates the deficient practice was identified on the current survey, which concluded on 01/14/26. On 01/13/26 at 06:53PM Administrative Staff A brought the QAPI sign-in sheets to the surveyor. Review of the sign in sheets revealed the Director of Nursing did not attend the July 2025 through January 2026 meetings and the Medical Director had not attended quarterly. During an interview on 01/13/26 at 06:57 PM Administrative Staff A stated the facility did QAPI online on the computer and talked about the same thing every month, so she did not know how to print the prior agendas, but pointed to the blank copy and stated it was the same agenda every month. Administrative Staff A stated that they had quarterly meetings, as they had QAPI monthly, but it was hit and miss on if the Medical Director attended as it depended on his schedule and when they had QAPI, but stated they had to have it by the 10th of every month. Administrative Staff A stated the plan had a place to put incidents and attach the summary of what it was. She said they did resident questions each month and went over survey or anything that they did not go over every month. Review of the QAPI Monthly blank answer form revealed the following QAPI format:An area for the facility name.A grey box with the following fillable areas: Date, Minute Recorded by Meeting CoordinatorAlso in the grey box was a section titled Meeting Purpose which had the following checkbox options:Scheduled, Resident Request, Guardian Request, IDT Member Req, Other, and a blank checkbox.The gray box contained a third area titled IDT Member Present for Meeting and had checkboxes for the following staff:Administrator, DON, RCC, Physician, Social Services, Other Nursing, Dietary Manager, Assistant Administrator, Guardian, Family Rep, Resident, MDS Coord., CP Coordinator, Pharmacy, Dietary Consultant, Financial, ADON, BOM, Activity Dir, Dietician, Antibiotic Stew, and two blank checkboxes.The next portion of the form revealed Best Practice Instructions which noted to assign which sections of the Health Services Review of IDT member to Audit each month. If noted during audit, sections are non-compliant, create action plan to correct. Review again during Monthly QAPI to ensure compliance is achieved for each section and fill box with color or mark as completed and in compliance. The form then contained the following areas:Physician VisitsBaseline and Annual EKG's (completed for all residents on psychotropic medications)Dental ServicesVision ServicesMammogramHearing ServicesInfluenza VaccinesRSV VaccinePneumovax(listed the CDC Guidelines)Covid VaccinesPodiatry ServicesColonoscopyReview of Monthly Wound ReportsReview of infection logInfection ControlAspiration List Review InstructionsMonthly Incident ReviewRequest for Physical TherapyRequest for Occupational TherapyRequest for Speech TherapyReview of Psychotropic, Antipsychotic, hypnotic, medications reviewReview of CathetersDischargesServices offered to residents upon dischargeMDS ReviewCare Plans Reviewed and updatedFacility medical equipment needsDNR ReviewPhysician Order Signature ReviewReview of User Defined AssessmentsReview Weight LossesReview Weight Gains Review of the facility provided Facility Assessment Tool revised 11/2025 revealed a section titled QAPI [Quality Assurance Performance Improvement] Program which indicated a QAPI meeting would be held monthly. The assessment tool stated the QAPI meeting is held monthly and attended by the Director of Nursing, Administrator, Business Office Manager, Activities Director, Medical Director, Therapy Director, Maintenance Director and Environmental Services Lead. The tool further indicated All staff is aware of when QAPI is held and welcome to attend. The meetings would be held to determine what things are working and what need improvement in the facility with resident care, staffing, maintenance, and all other areas. The facility would create policy improvement plans for problems identified that needed improvements. During the current survey Immediate Jeopardy was identified for the following regulations:Free of Accident Hazards/Supervision (Quality of Care- See F689)Pharmacy Services (See F755)Infection Control (See F880)And Substandard Quality of Care (SQC) identified in the following areas:Free of Accident Hazards/Supervision (Quality of Care- See F689)Influenza and Pneumococcal Immunizations (Infection Control- See F883)Activities Meet Interest/Needs of Each Resident (See F679) The facility could not provide evidence the QAPI program monitored facility systemic concerns which were cited on prior surveys in order to correct and mitigate the onsite findings of immediate jeopardy and substandard quality of care found on the current survey. The facility provided a copy of the QAPI policy on 01/13/26. The facility provided policy was titled QAPI Plan and had an origination date of 05/14/21, revised 07/09/21. The policy included the guiding values or principles of QAPI plan included stewardship, integrity, respect, excellence, leadership, and personal growth. The plan provided guidance for the facility overall quality improvement program and noted quality assurance performance improvement principles will drive the decision making within the facility, and decisions will be made to promote excellence in quality of care, quality of life, resident choice, person directed care, and resident transitions. The QAPI meeting would be held on a monthly basis. All department heads, the administrator, the director of nursing, antibiotic steward, infection control and prevention officer, medical director, consulting pharmacist would provide QAPI leadership by being on the QAPI committee. Records of the actions taken at each meeting would be kept using the attached form instruction for IDP/CP/QAPI QA Meetings. Minutes should document what was reviewed, issues/problems addressed, plan of correction, the monitory process and the results. At least quarterly, all disciplines should have a representative at the QAPI meetings. The policy noted the overview of the QAPI process was to: identify and use data to monitor facility performance; establish goals and threshold to measure performance; utilize residents, staff and family input; identify and prioritize problems and opportunities for improvement; systematically analyze underlying causes of systemic problems and adverse events; develop corrective action or performance improvement activities. The QAPI Plan would be reviewed annually by the RCMC Director of Organizational Development with input from facilty Administrators and Directors of Nursing. The QAPI Plan noted the committee would review resident reported concerns, grievances, and/or resident council meeting to help identify issues. The Data and Statistics section noted the QAPI committee would review data for all areas of the facilty to assure systems were being monitored and maintained to achieve the highest level of quality and listed the following reports the QAPI committee may use:Infection Control Log and Infection Prevention and Control ProgramWound ReportsAntibiotic Utilization ReportsCMS Quality Measures, CASPER Reports and any other data to measure the facilityIncident Report Log including, but not limited to, Falls, RN Investigation, Medication/Treatment omissions, Elopement or Wandering.Weight Loss Reports at 30, 90, and 180 days.Advanced care planning auditsMedication administration auditsMedication room audits

The facility reported a census of 34 residents. Based on interview and record review the facility failed to ensure the required members attended the Quality Assurance Performance Improvement (QAPI) meetings at least quarterly, as required by federal regulation. This failure had the ability to affect all 34 residents. Findings included:- Review of the facility provided Sign in sheets, which appeared to be hand drawn with columns and lines, and had the following handwritten headings: Date, Print Name, Signature, and Title. For the QAPI JUNE handwritten on the top right of the page revealed the following attended:04/10/25 Therapy Staff M04/10/25 Dietary Manager JJ04/10/25 Certified Nurse Aide (CNA) N (served as SSD at the time)04/10/25 Medical Records II04/10/25 Administrative Nurse B04/10/25 Maintenance Staff JThe 04/10/25 meeting lacked evidence the Administrator, Pharmacy, or Medical Director attended. For the QAPI - May 2025 handwritten on the top right of the page revealed the following attended:05/09/25 Administrative Staff A05/09/25 Business Office Manager (BOM) L05/09/25 Administrative Nurse B05/09/25 Dietary Manager JJ05/09/25 Activities Director E For the QAPI - April handwritten on the top right of the page revealed the following attended:06/11/25 Medical Records II06/11/25 Activities Director E06/11/25 Administrative Nurse B06/11/25 Dietary Manager JJ06/11/25 Administrative Staff A06/11/25 BOM L06/11/25 Medical Director G For the QAPI July handwritten on the top right of the page revealed the following attended:07/08/25 Activities Director E07/08/25 BOM L07/08/25 Administrative Staff AThe 07/08/25 meeting lacked evidence the Director of Nursing, Social Services, Therapy, Dietary, Pharmacy, or Medical Director attended. For the QAPI August handwritten on the top right of the page revealed the following attended:08/07/25 Administrative Staff A08/07/25 Activities Director E08/07/25 BOM LThe 08/07/25 meeting lacked evidence the Director of Nursing, Social Services, Therapy, Dietary, Pharmacy, or Medical Director attended. For the QAPI Sept handwritten on the top right of the page revealed the following attended:09/09/25 Administrative Staff A09/09/25 Activities Director E09/09/25 BOM LThe 09/09/25 meeting lacked evidence the Director of Nursing, Social Services, Therapy, Dietary, Pharmacy, or Medical Director attended. For the QAPI Oct handwritten on the top right of the page revealed the following attended:10/07/25 Activities Director E10/07/25 BOM L10/07/25 Dietary Manager H10/07/25 Social Services Designee (SSD) D10/07/25 Administrative Staff AThe 10/07/25 meeting lacked evidence the Director of Nursing, Therapy, or Medical Director attended. For the QAPI Nov. handwritten on the top right of the page revealed the following attended:11/06/25 Administrative Staff A11/06/25 BOM L11/06/25 Dietary Manager H11/06/25 (dated, but lacked a name, signature, and title)11/06/25 SSD D11/06/25 Activities Director EThe 11/06/25 meeting lacked evidence the Director of Nursing, Therapy, or Medical Director attended. For the QAPI Dec. handwritten on the top right of the page revealed the following attended:12/09/25 Administrative Staff A12/09/25 SSD D12/09/25 BOM L12/09/25 Activities Director E12/09/25 Dietary Manager HThe 11/06/25 meeting lacked evidence the Director of Nursing, Therapy, or Medical Director attended. For the QAPI Jan. handwritten on the top right of the page revealed the following attended:01/09/26* BOM L01/09/26* SSD D01/09/26 Dietary Manager H01/09/26* Activities Director E01/09/26 Administrative Staff A* Indicated the date was handwritten over in the year to make it 26, but still legible was the year 25.The 01/09/26 meeting lacked evidence the Director of Nursing, Therapy, Pharmacy, or Medical Director attended. From 04/10/25 through 01/09/26 the Medical Director attended one meeting (on 06/11/25) in ten months, indicating the failure to attend quarterly. From 04/10/25 through 01/09/26 the Director of Nursing attending three meetings (04/10/25, 05/09/25, and 06/11/25) out of the 10 months offered, indicating the failure to attend at least quarterly. On 01/13/26 at 06:53PM Administrative Staff A brought a copy of the QAPI sign-in sheets to the surveyor. During an interview on 01/13/26 at 06:57 PM Administrative Staff A stated the facility did QAPI online on the computer and talked about the same thing every month, so she did not know how to print the prior agendas but pointed to the blank copy and stated it was the same agenda every month. Administrative Staff A stated that since they attended online, she would forget to send the sign in sheet to the medical director to sign. Administrative Staff A stated that they had quarterly meetings, as they had QAPI monthly, but it was hit and miss on if the Medical Director attended as it depended on his schedule and when they had QAPI, but stated they had to have it by the 10th of every month. The facility provided a copy of the QAPI policy on 01/13/26. The facility provided policy was titled QAPI Plan and had an origination date of 05/14/21, revised 07/09/21. The policy included the guiding values or principles of QAPI plan included stewardship, integrity, respect, excellence, leadership, and personal growth. The plan provided guidance for the facility overall quality improvement program and noted quality assurance performance improvement principles will drive the decision making within the facility, and decisions will be made to promote excellence in quality of care, quality of life, resident choice, person directed care, and resident transitions. The QAPI meeting would be held on a monthly basis. All department heads, the administrator, the director of nursing, antibiotic steward, infection control and prevention officer, medical director, consulting pharmacist would provide QAPI leadership by being on the QAPI committee. At least quarterly, all disciplines should have a representative at the QAPI meetings. The QAPI Plan would be reviewed annually by the RCMC Director of Organizational Development with input from facility Administrators and Directors of Nursing. The QAPI Plan noted the committee would review resident reported concerns, grievances, and/or resident council meeting to help identify issues.

The facility had a census of 34 residents with 14 in the sample. Based on observation, interview, and record review the facility failed to develop a program for antibiotic stewardship and failed to implement a system to monitor antibiotic use. Record review revealed the facility failed to follow up on prescribed antibiotics, the infectious organisms, and/or the use of antibiotics for residents identified with multi-drug-resistant organisms including methicillin-resistant Staphylococcus aureus (MRSA - per The Centers for Disease Control and Prevention MRSA is a type of staphylococcus that can be resistant to several antibiotics, which anyone can get or carry. The risk for MRSA increases for people in nursing homes, crowded areas, and/or unhygienic places) and multi-drug resistant ESBL (Extended-Spectrum Beta-Lactamases (ESBLs) are enzymes produced by certain bacteria, primarily Escherichia coli (E. coli)). These failures led to multiple resident hospitalizations/rehospitalizations, the amputation of an infected left lower extremity, chronic wounds that were slow or non-healing, and admission to hospice related to septicemia (systemic infection of the blood). Findings included:- Review of the Facility Assessment Tool dated 11/18/25 revealed the facility was licensed for 45 beds, with an average census of 32 residents. The facility identified their common diagnoses related to infectious disease as skin and soft tissue infections, respiratory infections, tuberculosis, urinary tract infections (communicable disease that effects the lungs), infections with multi-drug-resistant organisms, septicemia (systemic infection of the blood), viral hepatitis (inflammatory condition of the liver), clostridium difficile (infection of the colon), influenza (highly contagious viral infection), and scabies (contagious infestation of the skin by burrowing mites). The facility identified an average range/number of isolation/quarantine residents with active infection as one to three. The facility noted they would need to provide residents with identification and containment of infections and prevention of infections. The assessment contained a section for the facility to evaluate their infection prevention and control program, which included effective systems for preventing, identifying, reporting, investigating and controlling infections and communicable diseases for all residents, staff, volunteers, visitors and other individuals that follow national standards, but the assessment lacked any evaluation, review, or development of their infection control program. Review of the facility provided, electronic charting system generated, Infection Surveillance Monthly Report dated 01/12/26 revealed the facility had 25 total infections between 07/01/25 and 01/12/26. The report indicated no infections were present in November and December of 2025 and January 2026. The report contained a Summary by Infection Category, which included blood/systemic, bone/joint, cardiovascular, and ear/nose/mouth/throat that were all blank. Review of the Order Listing Report generated 01/12/26, with dates ranging from 06/01/25 to 01/12/26 revealed 48 separate physician ordered antibiotics and/or infection related treatments for 18 residents, who resided throughout the facility and included cellulitis, upper respiratory infections, wound infections, and methicillin-resistant Staphylococcus aureus (MRSA - per The Centers for Disease Control and Prevention MRSA is a type of staphylococcus that can be resistant to several antibiotics, which anyone can get or carry. The risk for MRSA increases for people in nursing homes, crowded areas, and/or unhygienic places) of an unknown location. Based on observation, interview, and record review the facility failed to ensure Resident (R) 11 who entered the facility with a urinary catheter received the appropriate treatment and services to prevent urinary tract infections and other catheter associated concerns of infected wounds to both inner thighs without the use of an anchor for the catheter. The resident admitted to the hospital on multiple occasions, received intravenous antibiotics, had a diagnosis of MRSA and returned to the facility with no monitoring or intervention to prevent further infection. Based on observation, interview, and record review the facility failed to implement their infection control and wound care policy/procedures when Resident (R) 9 was diagnosed with cellulitis (skin infection caused by bacteria), received antibiotic therapy on 08/21/25, and the facility failed to document the effectiveness of the antibiotics, any ongoing signs/symptoms of infection/antibiotic use, and the resident's reaction to the infection/antibiotic use. On 08/23/25, while still on antibiotics for cellulitis the resident had a change in mental status and refused transport to the hospital. The facility failed to document continued monitoring of the resident after the resident had a change in status. The facility further failed to document any education provided or reapproach provided after the resident's refusal to be seen. On 09/05/25 the facility notified the resident's provider the resident refused labs the prior day, with no follow up to the resident's refusal documented, no attempts to reapproach the resident, no education provided on the seriousness of obtaining the lab and/or additional monitoring of the resident. The resident's record continued to lack evidence the antibiotics started on 08/21/25 were effective and/or continued monitoring for the effectiveness in treating the infection. On 09/09/25 the resident asked to be transported to the hospital due to pain in the left lower extremity. While at the hospital the resident was diagnosed with extensive infection throughout the left lower extremity and ultimately experienced actual harm when his left lower extremity required amputation. Upon arrival back to the facility the facility failed to implement enhanced barrier precautions and/or wound care and days later the resident readmitted to the hospital for treatment of further infection to the stump. Based on observation, interview, and record review the facility failed to ensure effective interventions, accurate assessments, and consistent monitoring, to prevent the development of a facility acquired stage 3 (full thickness pressure injury extending through the skin into the tissue below) pressure ulcer/injury of the sacrum (large triangular bone/area between the two hip bones) for dependent and at risk Resident (R)7, who required hospitalization for wound care and intravenous antibiotics for sepsis (life threatening systemic reaction that develops due to infections which cause inflammation throughout the entire body). During an interview and review of infection control records on 01/12/26 at 03:44 PM Consultant Nurse C reported she found an Infection Control Binder dated 2024 and one dated 2025, which lacked any tracking of infections, antibiotic review, and/or infectious agent or organism involved. Consultant Nurse C provided an electronic charting software generated report titled Infection Surveillance Monthly Report indicating rises and falls acquired infections from February 2025 to January 2026. Consultant Nurse C stated the chart indicated the facility was possibly tracking and trending infections, however it lacked specific locations of the infections (resident room location in the building), infectious organisms, notation that at least one resident had a catheter and associated urinary tract infection, system for recording any infection control incidents with follow up/actions taken and/or where the infection originated (wound, dental, respiratory tract, etc.) Review of the Antibiotic Stewardship Program policy dated 06/29/23 revealed the facility would optimize antibiotic use in the nursing home and reduce unnecessary use of laboratory tests and antibiotics using a systemic approach. The antibiotic stewardship program would be run by the facility antibiotic steward, who would lead the antibiotic stewardship team (compromised of at least the Director of Nursing, a nurse with administrative duties, and a charge nurse. The antibiotic stewardship program would use a systematic evaluation of ongoing treatment. The facility would track and monitor antibiotic prescribing practices and resistance patterns among its residents. The antibiotic steward would review and generate an infection log in the facility electronic charting system and place it in the antibiotic stewardship binder removing the weekly reports each month. A report on antibiotic use and resistance would be reported to the monthly quality assurance committee, physicians, prescribing practitioners, pharmacy consultant, facility nurses, and other relevant staff. All antibiotics would be entered into physician orders, infection control tracking, and have an infection follow up completed.

The census totaled 34 with 14 in the sample. Based on observation, interview, and record review the facility failed to provide evidence they designated one infection preventionist who was qualified by education, training, experience and/or certification that worked at least part time on the facility infection control program and completed specialized training in infection prevention and control. This failure created the likelihood for the transmission of infectious agents, subsequent infection, and caused actual severe infection with significant outcomes. Findings included:- The facility identified Administrative Nurse B as the current Infection Preventionist. The facility failed to provide evidence Administrative Staff B was qualified to fill the role by education, training, experience or certification. Review of the Facility Assessment Tool dated 11/18/25 revealed the facility was licensed for 45 beds, with an average census of 32 residents. The facility identified their common diagnoses related to infectious disease as skin and soft tissue infections, respiratory infections, tuberculosis, urinary tract infections, infections with multi-drug-resistant organisms, septicemia (systemic infection of the blood), viral hepatitis (inflammatory condition of the liver), clostridium difficile (infection of the colon), influenza (highly contagious viral infection), and scabies (contagious infestation of the skin by burrowing mites). The facility identified an average range/number of isolation/quarantine residents with active infection as one to three. The facility noted they would need to provide residents with identification and containment of infections and prevention of infections. The assessment contained a section for the facility to evaluate their infection prevention and control program, which included effective systems for preventing, identifying, reporting, investigating and controlling infections and communicable diseases for all residents, staff, volunteers, visitors and other individuals that follow national standards, but the assessment lacked any evaluation, review, or development of their infection control program. Observations on 01/11/26 and 01/12/26 revealed laundry on resident floors with staff transporting the items down a hallway with other residents around with no infection control practices in place. Staff transported mechanical lifts from resident room to resident room with no cleaning in between residents and dusty footprints present along the bases. Upon initial observation only one room had signage indicating the use of Enhanced Barrier Precautions (EBP) (infection control interventions designed to reduce transmission of resistant organisms which employs targeted gown and glove use during high contact cares) and/or Personal Protective Equipment (PPE- gowns, face shields and/or eyeglasses/goggles, and gloves), and after entrance approximately five additional rooms were noted to have EBP signage and PPE located outside of the rooms. Resident's who lacked EBP upon entrance to the facility had current wounds, indwelling catheters, and known multidrug resistant organism infections. Staff carried clear bags with visibly soiled briefs swinging down the hall and into resident rooms, while dragging the thin bag along the wood handrails, which were present in the hallways for all residents to use. Review of the facility provided, electronic charting system generated, Infection Surveillance Monthly Report dated 01/12/26 revealed the facility had 25 total infections between 07/01/25 and 01/12/26. The report indicated no infections were present in November and December 0f 2025 and January 2026. The report contained a Summary by Infection Category, which included blood/systemic, bone/joint, cardiovascular, and ear/nose/mouth/throat that were all blank. Review of the Order Listing Report generated 01/12/26, with dates ranging from 06/01/25 to 01/12/26 revealed 48 separate physician ordered antibiotics and/or infection related treatments for 18 residents, who resided throughout the facility and included cellulitis, upper respiratory infections, wound infections, and methicillin-resistant Staphylococcus aureus (MRSA - per The Centers for Disease Control and Prevention MRSA is a type of staphylococcus that can be resistant to several antibiotics, which anyone can get or carry. The risk for MRSA increases for people in nursing homes, crowded areas, and/or unhygienic places) of an unknown location. The facility lacked any formal tracking and trending of resident infections. The facility lacked documentation of an antibiotic stewardship program. Review of resident electronic health records regarding infections from June 2025 to January 2026 revealed residents had various infections with significant outcomes (see F880, F684, F686, and 690). During an interview on 01/11/26 at 05:53 PM with Certified Medication Aide (CMA) BB she stated the facility was often short staffed. She reported when the facility was short staffed, care things were missed, like checking and showering residents. CMA BB stated before today the facility only had one resident who required PPE, including gown, mask, and gloves with cares due to an infection, but reported she was just told staff needed to wear the same PPE for emptying catheters and for residents with wounds. CMA BB reported if a resident had MRSA that was typically the reason staff were instructed to use gowns with resident cares before today (01/11/26). CMA BB also verified the additional PPE and EBP signs placed on both the east and west units after the initial tour were just placed today (01/11/26). During an interview and review of infection control records on 01/12/26 at 03:44 PM Consultant Nurse C reported she found an Infection Control Binder dated 2024 and one dated 2025, which lacked any tracking of infections, antibiotic review, and/or infectious agent or organism involved. Consultant Nurse C provided an electronic charting software generated report titled Infection Surveillance Monthly Report indicating rises and falls acquired infections from February 2025 to January 2026. Consultant Nurse C stated the chart indicated the facility was possibly tracking and trending infections, however it lacked specific locations of the infections (resident room location in the building), infectious organisms, notation that at least one resident had a catheter and associated urinary tract infection, system for recording any infection control incidents with follow up/actions taken and/or where the infection originated (wound, dental, respiratory tract, etc.) During an interview regarding the facility water maintenance program/legionella (Legionella is a bacterium which can cause pneumonia in vulnerable populations) prevention on 01/12/2026 at 04:03 PM with Maintenance Staff J and Administrative A revealed the facility did not have any evidence of testing for legionella as stated in their prior survey plan of correction/water management plan provided by the facility. Maintenance Staff J stated he did flushes (did not identify what was flushed) back in August or September, however then stated he did not have a log or documentation regarding flushing the water system. Maintenance Staff J stated he was unaware he needed to log any flushes of the water system that he performed and stated he documented water temperatures most days. Administrative Staff A interrupted and instructed Maintenance Staff J that he needed to have documentation for any of the water management tasks he performed. On 01/12/26 Administrative Staff A stated she was looking for documentation, which indicated Administrative Nursing Staff B (the facility's self-reported IP) completed any specialized training in infection prevention and control. During an interview with Administrative Staff A at approximately 07:16 PM on 01/13/26 she reported the facility was unable to locate any documentation, which indicated Administrative Nursing Staff B completed specialized training in infection prevention and control. Consultant Nurse C state she was unaware that Administrative Staff A did not have the documentation available. During an interview with Consultant Nurse C at 05:45 PM on 01/14/26 she reported the facility Director of Nursing or Social Services would complete the influenza immunization consent/declinations. She stated it was the responsibility of Administrative Nursing Staff B to oversee the immunizations and ensure they were administered. Once resident consent for the immunizations were obtained, she expected staff to administer the immunization and for staff to document the immunization administration in the Electronic Health Record. Review of the Infection Preventionist Policy dated 05/14/24 revealed the facility would employ one or more qualified individuals with responsibility for implementing the facility's infection prevention and control program, which would include an antibiotic stewardship program. The facility would base the number of hours the IP designated to the program on the facility assessment. The policy stated the IP would be sufficiently trained in infection prevention and control and would obtain specialized training or educational programs prior to assuming the role and would provide evidence of training through a certificate of completion or equivalent documentation. The responsibility of the IP included developing an infection control program, establish facility wide systems for prevention, identification, reporting and control of infections. The IP would further provide oversight of ensuring an antibiotic stewardship program, oversight of resident care activities, and approve infection prevention training topics for staff. The IP would participate on the quality assessment and assurance committee and report their activities to the committee.

The census totaled 34 with 14 in the sample. Based on interview, and record review the facility failed to provide evidence they offered influenza (highly contagious viral infection) immunizations to residents for the 2025 influenza season, when the vaccines were made available for the year and/or beginning approximately October 1st, 2025. The facility further failed to provide signed consents/declinations and/or evidence of vaccination administration related to the influenza and/or pneumococcal (type of bacterial infection) vaccine for Residents (R) 2, R6, R7, R11, and R16. Findings included:- Review of all resident Electronic Health Records, under the immunizations tab on 01/12/26 for influenza immunizations lacked evidence residents were offered and/or received influenza immunizations at the facility during the 2025 season. Resident charts either reflected the 2024 dates or noted refusals with no dates. Upon request on 01/14/26 at 10:32 AM, the facility was unable to provide influenza, pneumococcal, and Covid-19 vaccination signed consents or declinations or documentation of vaccination administrations for influenza and/or pneumococcal vaccinations for R2, R6, R7, R11, and R16. On 01/14/26 at 12:13 PM, Consultant Nurse C stated she was unable to find requested immunization documentation. During an interview with Consultant Nurse C at 05:45 PM on 01/14/26 she reported the facility Director of Nursing or Social Services would complete the influenza immunization consent/declinations. She stated it was the responsibility of Administrative Nursing Staff B to oversee the immunizations and ensure they were administered. Once resident consent for the immunizations were obtained, she expected staff to administer the immunization and for staff to document the immunization administration in the Electronic Health Record. Review of the 05/14/24 Influenza and Pneumococcal Immunizations policy revealed the facility would ensure all residents residing in the facility were offered influenza and pneumococcal immunizations to prevent infection and the spread of communicable diseases. The resident and/or their legal representative would be informed influenza immunizations were provided yearly (between 10/01 and 03/31) unless the immunizations were medically contraindicated, the facility had evidence the resident was already immunized during the time period, or the resident/legal representative refused the immunization.

The facility census totaled 34 with 14 in the sample. Based on interview and record review the facility failed to ensure staff had the appropriate competencies and skill sets related to the facility Quality Assurance and Performance Improvement (QAPI) program to provide nursing and related services to ensure staff were aware of goals and aspects of the program that assured resident safety and attained or maintained the highest practicable physical, mental and psychosocial wellbeing of each resident as determined by resident assessments, plans of care and utilizing the facility assessment. Findings included:- The facility failed to provide evidence of staff competency evaluations from Administrative Staff A as requested on 01/11/26 and again on 01/12/26. During an interview on 01/26/25 with Consultant Staff X at 03:51 PM she stated she did not have any proof the facility performed competency evaluations with certified staff. See F865, F867. and F868 for outcomes related to the facility's lack of QAPI training and follow up competency evaluations to ensure staff were aware of the facility goals, essential elements of the program. and input into training content updates. Review of the Sufficient Staff Policy dated 05/15/24 revealed the facility would provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being for each resident.

The facility identified a census of 38 residents. The sample included three residents for abuse. Based on record review, observations, and interviews, the facility failed to prevent an incident of resident-to-resident abuse and protect one resident, Resident (R) 2, from abuse. On 11/19/25 at 01:53 PM R1, a cognitively impaired resident with known aggressive behavior, entered the dining area and, without provocation, forcefully punched (with a closed fist) R2. There were approximately seven to eight additional residents in the dining area at the time of the altercation. R1 punched R2 two to three times in the left shoulder while R2 and others began shouting. R2 tried to block R1's punches, and both residents fell from their wheelchairs to the floor. Activity Staff Z, who was present in the dining area, was approximately ten feet from R1 and R2. Activity Staff Z ran toward the residents, yelled for help, and multiple staff members arrived to separate R1 and R2. The facility's failure to continuously monitor R1, as care-planned, placed R2 and other residents at risk for serious and potentially life-threatening injury, which resulted in immediate jeopardy.Findings included: - R1's Electronic Medical Record (EMR) documented R1 admitted [DATE], with diagnoses of Traumatic Brain Injury (TBI) with loss of consciousness (an injury to the brain caused by trauma, resulting in a loss of consciousness), major depressive disorder (known also as clinical depression, a mental health condition characterized by low mood, and a loss of interest in activities once enjoyed), anxiety disorder (a mental health condition that causes fear, dread and other symptoms that are out of proportion to the situation), and generalized anxiety disorder (a more severe form of anxiety disorder characterized by persistent excessive worry that interferes with daily functioning). R1's admission Minimum Data Set (MDS) dated [DATE] recorded R1 was unable to complete a Brief Interview for Mental Status (BIMS), and indicated R1 had severely impaired cognition. The MDS documented R1 had no behaviors during the seven-day assessment period, but indicated a mood score of 15, which indicated severe depression (feelings of sadness, despondency, dejection, severe enough to interfere with daily activities). The MDS assessment recorded that R1 received anti-psychotic (medication used to treat mental illness by altering neurotransmitters in the brain), anti-anxiety (medication used to treat worry, nervousness, uneasiness), anti-depression (medication to relieve feelings of sadness), and seizure control (medication ot control abnormal electrical activity in the brain which causes change in awareness and muscle control) medications.The Physician Order Sheet (POS) dated November 2025 recorded that R1 received the following psychoactive medications: quetiapine (an atypical antipsychotic used to treat schizophrenia, bipolar disorder, and major depressive disorder), Lorazepam (a benzodiazepine medication used to treat anxiety disorders), and Duloxetine (an antidepressant used to treat major depression). R1's Care Plan initiated on 08/20/25, recorded on 08/31/25, R1 was aggressive with another resident; R1 threw water on her and punched her. The updated 08/31/25 care plan recorded: One-on-one monitoring was initiated for R1 (no end/stop date for the one-on-one monitoring was noted), and staff were directed to monitor R1 when he was in the facility's common areas. R1's revised Care Plan dated 09/18/25, recorded R1's potential for aggression and directed staff to monitor behavior episodes and attempt to determine the underlying cause, consider location, time of day, person(s) involved, and situations. The plan of care directed staff to document behavior and potential causes. The care plan lacked further interventions related to R1's documented aggressive behaviors.Review of R1's Nurses Progress Notes revealed the following entries: On 09/01/25 at 10:39 AM the facility placed the resident on a one-on-one observation for an incident 08/31/25. At times, R1 would get restless and verbally aggressive. On 09/03/25 at 08:39 AM R1 was non-redirectable. R1 believed he was still in prison. R1 attempted to crawl onto the ground, and staff assisted R1 down to the floor, so he did not injure himself. R1 was fed, provided water, and toileted, but the behaviors continued. R1 became verbally aggressive with staff when staff attempted to redirect. Staff remained with R1 one-on-one for safety. On 09/06/25 at 06:51 PM R1 was verbally and physically aggressive. R1 ran into doors with his wheelchair. On 09/08/25 at 10:48 AM staff spoke to R1's Power of Attorney (POA) regarding finding placement elsewhere, due to the inability to meet R1's needs at the facility. R1 could become very restless due to his cognitive issues resulting from his TBI. The facility sent referrals out for alternative placement. On 09/14/25 at 03:17 PM R1 was chronically repetitive, disorganized, and became violent with staff members and other residents when agitated. R1 fixated on cigarette breaks, the topic of detectives, and correctional officers. R1 had a history of calling EMS/police and was resistant to reorientation. The resident was anxious, wandered the halls, and he knocked on/attempts to enter other residents' rooms disturbing them and/or frightening them. On 09/16/25 at 10:57 AM staff reported to the nurse that R1 touched her breast. The nurse educated R1 that it was inappropriate to touch staff or anyone else. R1 stated he was trying to touch her nipples. The nurse again educated R1 that it was an inappropriate action. On 09/23/25 at 12:56 PM staff heard another resident yelling for R1 to stop. Staff went toward the yelling and found R1 unplugging items and yelling at another resident. Staff tried to redirect R1, and he grabbed at the staff member and hit the staff member in several areas. R1 grabbed the staff members shirt as staff tried to back R1 up in his wheelchair to the hallway. R1 continued to hit staff. Other staff members came and assisted with R1, and they redirected R1 by asking him if he wanted to smoke. R1 allowed staff to push him down the hallway. On 10/17/25 at 11:42 AM R1 entered Administrative Staff A's office in his wheelchair, and demanded he go out to smoke. R1 started backing into shelves, knocking things over, and cursing. Two Certified Nurse's Aides (CNA) were able to get the resident out of the Administrative Staff A's office and take him to his room.Observation on 11/19/25 at 01:53 PM revealed R2 sat calmly, in the back of the dining room, facing forward toward the television. R1 wheeled directly toward R2's back left side and delivered two to three swift and forceful blows to R2's left shoulder. R2 turned left toward R1, blocking punches with his left arm, and while trying to push R1 away, both residents ended up on the floor. Other residents present in the dining room appeared with heightened emotions and yelled, Stop! Oh my! What happened? Staff responded and removed R1 and R2 to their rooms. On 11/19/25 at 02:55 PM, R2 was seated in his room, watching television with one-on-one supervision. R2 stated he just came in and hit me. R2 stated, I don't know why some people around here have issues.On 11/19/25 at 03:00 PM, R1 was observed in his room with one-on-one supervision. R1 was noted to have an abrasion over his right eye. R1 was alert but with a blank stare and/or flat affect. During an attempted interview at this time, R1 stated he did not know what happened (in the dining room) and began calling out for an unknown person. During an interview on 11/19/25 at 03:20 PM, Activity Staff Z stated she was in the dining room helping a resident with lunch and did not see what happened, but heard R2 state, Do not hit me. Activity Staff Z looked up and saw the fight and responded. Activity Staff Z stated she had not known R1 to be aggressive like that and noted he had been doing really well.During an interview on 11/19/25 at 03:30 PM, Licensed Nurse (LN) G stated R1 could understand direction at times and other times had a volatile mood. LN G stated R1 would yell at staff and sometimes call out for the CO (corrections officer). LN G believed R1 was in prison previously for a short time. LN G asked R1 why he did that, and he said he did not know. LN G asked Activity Staff Z and R2 if anything provoked R1, and they said no. Activity Staff Z said R1 just wheeled himself into the dining room, thought he was going to sit where he usually sat, and then he hit R2. During an interview on 11/19/25 at 04:00 PM, Administrative Nurse D stated R2 said he was just sitting there, and R1 rolled right in and hit him twice, and R2 swung back and brought R1 to the ground so he could end the fight. Administrative Nurse D indicated staff responded appropriately to the event, the physician was notified at 02:06 PM, and both residents were placed on one-on-one supervision. Both residents had a full-body skin assessment, and no injuries to R2 were noted. R1 had an abrasion or scratch-like mark over his left eye. Administrative Nurse D acknowledged the incident on 08/31/25, where R1 threw water on another resident, and stated R1 was placed on one-on-one supervision at that time, but had been doing well, since that time. Administrative Nurse D noted that R1 was no longer with one-on-one monitoring, as noted in R1's care plan, but could not provide a date when the one-on-one monitoring stopped. Administrative Nurse D stated that although staff were not trained particularly in dealing with residents with head injuries, evidence of all staff abuse, neglect, and exploitation training was provided on 10/07/25 and 10/13/25.During an interview on 11/19/25 at 04:00 PM, Administrative Staff A stated the incident on 08/31/25 was not reported to the State agency, as there was no intent and no harm, noted. Administrative Staff A acknowledged reporting today's incident to the State agency and was initiating an investigation and collecting witness statements.The facility's Abuse and Neglect Policy revised on 06/12/2024 documented various types, i.e., verbal, physical, sexual, mental, etc., and defined Abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff-to-resident and certain resident-to-resident altercations.The policy documented under Guidelines for identification: The facility will identify event occurrences, patterns, and trends that may constitute mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property as defined above.On 11/19/25 at 05:50 PM, Administrative Staff A was provided a copy of the IJ Template and notified that beginning on 11/19/25 at 01:53 PM, the facility's failure to prevent and protect a resident (R2) from an incident of abuse placed the resident(s) in Immediate Jeopardy. All residents have the potential to be affected by the deficient practice.1. Education will be completed by the Administrator and/or Designee before the start of the shift on care plan review. Monitoring of residents, abuse and neglect, and appropriate intervention and protection of trainers to remain free from abuse and neglect, starting on 11/19/25 at 02:30 PM and ongoing. No employee will be permitted to work until education has been completed prior to starting their next shift. 2. R1 was placed on 1:1 at 02:01 pm on 11/19/2025, to remain 1:1 for 24 hours and be reevaluated for further intervention. 3. R1's care plan was reviewed and updated to reflect the current resident status as of 11/19/25.4. Notification to R1's Responsible Party completed 11/19/25.5. Notification to physician for R2 completed 11/19/25.6. Notification to R2's Responsible Party completed 11/19/25.7. A full investigation was initiated on 11/19/25.8. R2 had a skin assessment completed on 11/19/25.9. R1 had a skin assessment completed on 11/19/25.10. The facility will validate competency with 3-5 employees per day of education provided. This will be done 2-3 times per week x2, weekly x2, and ongoing to validate compliance. The facility presented an acceptable plan for removal of the immediate jeopardy on 11/19/25 at 07:41 PM, which was verified by the surveyor on site. The deficient practice was lowered to a scope and severity of G for isolated harm following the removal of the immediate jeopardy.

The facility identified a census of 35. The sample included five residents, with three residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observations, record review, and interviews, the facility failed to follow physician orders to implement preventative wound interventions for Resident (R) 1. On 06/09/25, Consultant GG assessed R1 for a left heel ulcer, ordered suspension boots, and directed staff to clean the wound daily. Staff were to call the provider if the resident's left heel ulcer opened. The facility failed to input the order for suspension boots into R1's Electronic Medical Record (EMR) and further failed to implement the order or apply boots to R1's left heel. A wound assessment on 06/18/25 revealed the resident's left heel wound had opened up, and R1's EMR lacked evidence the facility had notified the resident's physician. The facility's failure to implement physician-ordered interventions to prevent worsening of R1's left heel wound resulted in a decline in the status of the wound, development of an additional wound, and R1 requiring the use of a wound vac (treatment method that uses suction to promote healing in complex wounds).Findings included:- R1's EMR documented diagnoses of diastolic congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), pressure ulcer of the left heel, diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and dementia (a progressive mental disorder characterized by failing memory and confusion) with agitation.The Quarterly Minimum Data Set (MDS) dated 06/13/25, documented R1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. R1 had impairment on one side of the lower extremities. R1 was independent rolling left and right. R1 required partial/moderate assistance for sitting up in bed. R1 had one deep tissue injury (DTI- purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear) and open lesions other than ulcers, rashes, or cuts. The MDS documented R1 did not have a pressure-reducing device for chair, a pressure-reducing device for bed, was not on a turning/repositioning program, had no nutrition or hydration interventions to manage skin problems, pressure ulcer/injury care, surgical wound care, and required no application of ointments/medications other than to the feet. The MDS documented R1 required application of nonsurgical dressings to areas of the body other than to the feet and application of dressings to the feet.The Significant Change MDS dated 09/05/25, documented R1 had a BIMS score of five, which indicated severe cognitive impairment. R1 had impairment on one side of the lower extremities. R1 required supervision or touching assistance with rolling left and right. R1 had one stage one pressure injury (area which appears reddened, does not blanche, and may be painful but is not open) and one unstageable (depth of the wound is unknown due to the wound bed being covered by a thick layer of other tissue and pus) with slough (dead tissue, usually cream or yellow in color) and/or eschar (dead tissue) pressure ulcer. R1 had other open lesions on the foot. The MDS documented R1did not have a pressure-relieving device for the chair, a pressure-relieving device for bed, was not on a turning/repositioning program, lacked any nutrition or hydration intervention to manage skin problems, surgical wound care, and application of nonsurgical dressings other than to feet. The MDS documented R1 required application of ointments/medications to areas of the body other than to the feet, and application of dressings to the feet (with or without topical medications).The Functional Abilities CAA dated 09/05/25, documented R1 experienced a decline in activities of daily living (ADL) function.The Pressure Ulcer/Injury CAA dated 09/05/25, documented staff assessed the location, size, stage, presence of drainage, presence of odors, condition of skin, and if eschar or slough was present to the resident's wound.R1's Care Plan dated 09/26/24, documented R1 was at risk for skin issues related to incontinence, impaired mobility, and DM.The Care Plan documented interventions, dated 09/26/24, that directed staff to follow facility protocols for treatment of injuries. The plan directed staff to identify and document potential causal factors of wounds and eliminate/resolve those factors where possible. The plan revealed staff would monitor/document location, size, and treatment of skin injuries and reported abnormalities, failure to heal, and signs/symptoms of infection to the resident's doctor.The Care Plan documented an intervention, dated 10/06/24 that was revised on 02/04/25, that directed staff to know R1 had a pressure-reducing mattress and he required substantial assistance from staff for turning/repositioning. The plan documented an intervention, dated 01/02/25 and revised on 02/04/25, that directed R1 had a cushion in his wheelchair, and he was able to offload while in his chair.The Care Plan documented an intervention, dated 08/15/25, noting R1 had an unstageable wound to his left heel, and hospice provided wound care orders.The resident's care plan failed to address the physician's order for heel protectors and/or interventions related to the resident's left heel wound identified on 05/28/25.R1's EMR revealed the following:On 05/28/25, a Skin and Wound assessment documented R1 had a DTI to his left heel that was 12 hours old and measured 0 centimeters (cm) by 0 cm.R1's EMR lacked evidence the facility notified Consultant GG of the DTI identified on 05/28/25.R1's EMR lacked evidence of any treatment to R1's left heel from 05/28/25 to 06/05/25.The Physician's Order dated 06/05/25 and discontinued on 06/09/25, directed staff to cleanse a wound to the resident's left heel with wound cleanser and pat dry. Staff would clean around (peri) the wound with skin prep (a solution when applied that forms a protective waterproof barrier on the skin) and apply a nickel thick amount of Santyl (a sterile enzymatic debriding ointment) to wound bed, cover with adhesive foam dressing, and float heels as tolerated. The order further directed staff to change R1's wound dressing daily and as needed (PRN).A Doctor's Progress Note dated 06/09/25 documented Consultant GG saw R1 for a left heel ulcer and noted black eschar tissue on the left heel. Consultant GG diagnosed R1 with a left heel decubitus (pressure) ulcer. Consultant GG ordered suspension boots, laboratory tests, and wound care orders to clean the pressure ulcer with betadine daily and call the provider if the area opened.A Health Status Note dated 06/09/25 at 07:24 AM, documented Consultant GG saw R1 and gave new orders to apply betadine to R1's left heel daily and to call the provider if the wound opened. The provider ordered laboratory tests for the next lab day. The note did not address the suspension boots ordered.R1's EMR lacked evidence staff placed the physician's order for suspension boots in R1's EMR and on the Treatment Administration Record (TAR) for staff to follow.R1's clinical record lacked evidence the facility implemented the suspension boots for R1 as ordered on 06/09/25.An order with a start date of 06/10/25 and discontinued date of 07/02/25 revealed staff were to apply betadine daily to the resident's left heel wound and to call R1's primary care provider if it opened.On 06/11/25, a Skin and Wound assessment documented R1 had a DTI to his left heel that was 14 days old and measured five cm by 3.92 cm.On 06/18/25, a Skin and Wound assessment documented R1 had an unstageable left heel pressure wound that was 21 days old and measured 4.83 cm by 4.36 cm.R1's EMR lacked evidence the facility notified Consultant GG of the change in condition of R1's left heel wound.On 06/25/25, a Skin and Wound assessment documented R1 had an unstageable pressure wound, with an onset date of 05/28/25, to his left heel that measured 3.9 cm by 3.85 cm. R1's EMR lacked evidence the facility notified Consultant GG of the change in condition of R1's left heel wound.On 07/02/25, a Skin and Wound assessment documented R1 had an unstageable pressure wound, with an onset date of 05/28/25, to his left heel. The assessment lacked measurements.A Physician's Order with a start date of 07/03/25 and discontinued date of 08/04/25, directed staff to clean the resident's heel with wound cleanser, clean stable surrounding tissue with skin prep, apply Santyl to the wound bed, and cover with silicone adhesive foam dressing every day.On 07/10/25, a Skin and Wound assessment documented R1 had an unstageable pressure wound, with an onset date of 05/28/25, to his left heel that measured 4.07 cm by 3.86 cm (an increase in size).On 07/16/25, a Skin and Wound assessment documented R1 had an unstageable pressure wound, with an onset date of 05/28/25, to his left heel that measured 3.97 cm by 2.97 cm.An Orders- Administration Note on 07/20/25 at 07:33 AM, documented the left heel was foul-smelling and produced brown drainage on the previous dressing. R1 verbalized pain.A Health Status Note on 07/21/25 at 07:00 AM, documented Consultant GG saw R1 and wrote new orders for a contract wound care company to evaluate and treat the resident's wounds.A Nutrition/Dietary Note on 07/21/25 at 03:49 PM, documented R1 had a stage two (partial-thickness skin loss into but no deeper than the dermis, including intact or ruptured blisters) pressure wound with treatment in place. R1's wound improved, and he continued on a regular diet.On 07/23/25, a Skin and Wound assessment documented R1 had an unstageable pressure wound, with an onset date of 05/28/25, to his left heel. The assessment lacked measurements.A N Adv (Nursing Advantage)- Skin Check note on 07/23/25 at 01:07 PM, documented R1 had a left heel pressure wound that measured 4.4 cm by 3.1 cm.A N Adv- Skin Check note on 07/27/25 at 09:01 AM, documented R1 had a stage two left heel pressure wound with orders in place. The note lacked measurements of the wound.A N Adv- Skin Check note on 07/30/25 at 03:05 PM, documented R1 had an unstageable left heel pressure ulcer that measured 4.1 cm by 2.9 cm.R1's clinical record lacked evidence the facility had notified or attempted to notify R1's representative of his left heel wound prior to 08/02/25.A Communication- with Family/NOK (Next of Kin)/POA (Power of Attorney) note on 08/02/25 at 02:03 PM, documented Administrative Nurse D attempted to call R1's POA to notify them of R1's change of wound status. Administrative Nurse D left a message after calling twice. She attempted to call R1's second point of contact with no answer as well.A Health Status Note on 08/03/25 at 01:46 AM, documented the nurse assisted the Certified Nurse Aide (CNA) with R1's bed change and observed white bugs crawling under R1's elevated left foot. R1 was not wearing heel protectors. The CNA lifted R1's leg slightly off the pillow so the nurse could view the dressing. R1's silicone dressing was not intact, and there were white bugs crawling out from under the section that was detached. The wound was not a new wound, but that was a change in wound status. The nurse notified Administrative Staff A and Administrative Nurse D at approximately 12:12 AM and administered PRN pain medication per R1's request at 12:15 AM. The nurse notified Consultant GG at 01:20 AM and received orders to clean with wound cleanser, apply Medihoney, then a wet-to-dry dressing. Consultant GG would evaluate for a wound vac on Monday morning when in the facility.A Health Status Note on 08/03/25 at 10:19 PM, documented the nurse changed R1's dressing per Consultant GG's orders and administered PRN pain medication. The nurse documented there was nothing moving at that time, and there was an odor present.A Doctor's Progress Note on 08/04/25 documented Consultant GG saw R1 for maggots in his stage four (a deep pressure wound that reaches the muscles, ligaments, or even bone) left heel wound. The plan of care included an order for wound care plus, an order for 125 millimeters of mercury (mmHg) continuous wound vac, an order for wet-to-wet (wound care technique where a moist gauze dressing is applied to a wound, allowing it to dry over time), with Medihoney (medical-grade honey used to aid wound healing) until wound vac started, an order for a low air-loss mattress, and a recommendation for hospice if he qualified.An order with a start date of 08/05/25 and a discontinued date of 08/08/25 directed staff to clean the resident's heel with wound cleanser, apply Medihoney, then wet-to-wet, cover with dressing daily for left heel wound.A Health Status Note on 08/05/25 at 11:27 AM, documented the nurse discussed with R1's representative that R1 was to have a wound vac placed on his left heel. R1's representative stated she was okay with the wound vac.On 08/06/25, a Skin and Wound assessment documented R1 had an unstageable pressure wound, with an onset date of 05/28/25, to his left heel that measured 3.06 cm by 2.7 cm.An order with a start date of 08/08/25 and discontinued date of 08/20/25, directed staff to clean the resident's heel with wound cleanser, apply Medihoney, then wet-to-dry (a wound care method used to mechanically debride wounds by removing dead tissue), cover with dressing daily for the heel wound. The order did not specify which heel to provide wound care to.A Hospice Note on 08/10/25 at 01:23 PM, documented hospice visited with R1 that day and the nurse requested pressure-reducing boots and wound dressing supplies from hospice.On 08/13/25, a Skin and Wound assessment documented R1 had an unstageable pressure wound, with an onset date of 05/28/25, to his left heel that measured 3.05 cm by 3.9 cm.An order with a start date of 08/16/25 and discontinued date of 08/23/25, for wound vac to left heel 125 mmHg continuous, black sponge, until healed, one time only for wound.Review of R1's August 2025 TAR revealed the wound vac order was signed off as completed on 08/17/25.An order with a start date of 08/17/25 and a discontinued date of 08/23/25, to monitor wound vac every shift and ensure the battery is charged during the night for the day shift.A History and Physical- New Admit Note on 08/17/25 documented R1 had a pressure ulcer on his left heel, which the facility treated, and he had a foul odor per staff. Consultant HH documented hospice care was involved with R1. Consultant HH documented R1's left heel wound needed to be debrided (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue) and that would be discussed with hospice.A Communication- with Resident note on 08/17/25 at 12:38 AM documented R1 picked the adhesive tape off of the wound vac. The nurse approximated the appliance and replaced the adhesive. R1 complained of anxiety and stated his pain was managed at that time.A Care Plan Note on 08/21/25 at 02:31 PM, documented the facility held a care plan meeting with R1, hospice, R1' representative, and facility staff. R1 was up for most meals and on a supplement. Hospice discussed with R1's representative that R1's wounds would not heal, and R1's representative agreed to have the wound vac discontinued.An order with a start date of 08/22/25 and discontinued date of 08/29/25, to cleanse left heel with wound cleanser, pat dry, skin prep wipe to periwound, sprinkle crushed metronidazole (antifungal medication) onto a calcium alginate (dressing which forms a soft, gel that absorbs when it comes into contact with wound exudate) pad and place over wound bed, cover with abdominal (ABD) pads and rolled gauze every Monday, Wednesday, and Friday for unstageable pressure ulcer of left heel.An order with a start date of 09/01/25, to cleanse the left heel with wound cleanser, pat dry, skin prep wipe to periwound skin, sprinkle crushed metronidazole onto a calcium alginate pad and place over wound bed, cover with ABD pads and rolled gauze every Monday, Wednesday, and Friday related to an unstageable pressure ulcer of the left heel.On 09/03/25, a Skin and Wound assessment documented R1 had a stage one [NAME] Terminal ulcer (KTU- a pressure-based injury that can develop quickly and is often a sign of terminal illness or impending death), location not set, that developed 05/28/25, and measured 3.42 cm by 2.53 cm.On 09/10/25, a Skin and Wound assessment documented R1 had a stage four left heel pressure ulcer that measured 2.59 cm by 2.28 cm.On 09/17/25, a Skin and Wound assessment documented R1 had a stage four left heel pressure ulcer that measured 2.57 cm by 2.02 cm.On 09/17/25 at 12:29 PM, R1 sat in his Broda chair (specialized wheelchair with the ability to tilt and recline) in the dining room. R1 wore bilateral heel protector boots.On 09/22/25 at 12:11 PM, R1's representative stated the facility had notified her about R1's left heel wound the first week of August. She stated she was unaware he had a sore until that point. R1's representative stated the facility wanted to put a wound vac on his left heel, and she knew that the wound had to have been there a while if it needed a wound vac. She stated that it was the first time they had reached out about R1's wound.On 09/17/25 at 01:20 PM, Administrative Nurse D stated R1 had heel protectors prior to going on hospice, and the Kardex (nursing tool that gives a brief overview of the care needs of each resident) should tell CNAs who needs heel protectors.On 09/17/25 at 03:10 PM, CNA M stated residents at risk for pressure wounds were those who were prone to being in bed, had heavy incontinence, or someone refusing cares. He stated he watched for signs of breakdown. CNA M stated the Kardex had prevention interventions in it and heel protectors would be on the Kardex. CNA M stated if he found a new skin issue, he reported it to the nurse or Administrative Nurse D. He stated he prevented skin issues with R1 by providing incontinence cares, checking him every two hours, repositioning R1, off-loading R1's feet, and, when in his Broda chair, leaning him back. CNA M stated he remembered back in June (2025), R1 had a DTI he noticed when getting R1 out of the recliner. He stated he was not sure if R1 had any heel protectors on his feet at that time. CNA M stated he did not know if R1 used heel protectors when the wound occurred, but knew he had heel protectors at the time of the interview.On 09/17/25 at 03:21 PM, Licensed Nurse (LN) G stated residents at risk for pressure wounds were those who had a weight decline, recent dehydration, any redness starting, were in bed more than usual, or had an acute illness. She stated the care plan should tell nursing any special interventions that were in place, such as repositioning every two hours, barrier creams, and heel protectors. She stated the CNA's Kardex would say if a resident used heel protectors. LN G stated if a provider ordered suspension boots, the order was placed in the computer and would go in the TAR for the nurses to sign off on. She stated any new skin issues were reported to the nurse, and the nurse did a skin assessment and then reported any changes to the provider for any new orders. She stated she reported any new change to the provider. She stated R1's left heel wound started out as a small opening, then it opened up. LN G stated the provider prescribed orders, made several changes, including adding a wound vac, then the facility discontinued the wound vac in agreement with the family. LN G stated R1 did not have an order in PCC for nurses to check on heel protectors. She stated she was not sure when the heel protectors were ordered.On 09/17/25 at 03:33 PM, Administrative Nurse D stated staff knew who was at risk for pressure wounds through communication and tasks for charting. She stated if a provider ordered suspension boots, she made sure the facility had them, and she put the order in PCC. Administrative Nurse D stated she expected the nurse to notify her of any new skin issues then notify the resident's representative and their provider. She stated R1's left heel wound started out as a DTI, and he had a treatment in place. She stated R1 did not have an order for heel protectors at that time. Administrative Nurse D stated she was not sure if the suspension boots were ordered by Consultant GG on 06/09/25 because if the order was not put in the computer, then she did not get notified of a new order. She stated she expected staff to document any notifications to the provider and family.The facility's Transcription of Orders/Following Physician's Orders policy, last revised 05/18/24, directed upon receiving a physician's order via telephone, fax, written order, verbal order, transcribed order, or other, the facility documented the order in the resident's EMR in the orders section.The facility's Pressure Injury Prevention and Management Policy, last revised 05/18/24, directed the facility established and utilized a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce, or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. The policy directed the facility implemented evidence-based interventions for prevention for all residents who were assessed at risk or who had a pressure injury present. Basic or routine care interventions included but were not limited to: redistribution of pressure; minimization of exposure to moisture; and providing appropriate, pressure-redistributing support surfaces. The policy directed the facility to document the interventions in the care plan and communicate the interventions to all relevant staff.

The facility identified a census of 23 residents. The sample included nine residents. Based on record review and interviews, the facility failed to immediately respond to a change in health status and failed to obtain physician involvement when Resident (R) 1 had a critical lab result and subsequently developed abnormal blood pressure, lower than the physician ordered parameter. The facility further failed to immediately act upon the resident and/or his representative's request to seek acute care for treatment of his declining health situation. On 08/13/24, R1 fell from a full body lift during transfer. On 08/14/24, R1 complained of intermittent back pain and shakiness. On 08/15/24, a laboratory technician notified Licensed Nurse (LN) H of R1's critical creatinine (lab test used to measure how well the kidneys performed their job of filtering waste from the blood) level at 10:50 AM. LN H entered a late entry note on 08/16/24 at 08:43 AM which indicated she called Consultant GG who gave orders on 08/15/24 at 11:37 AM to increase fluids one to two liters and recheck labs on the following Monday. LN H entered the increased fluid order into R1's EMR at 03:58 PM but staff did not keep track of his increased fluid intake. LN H continued neurological assessments related to the fall from the lift and staff noted that R1 spoke like he had a thick tongue and could not grip with his left hand. At 04:30 PM, R1's blood pressure was 88/64 millimeters of mercury (mmHg). The facility did not notify R1's physician of the low blood pressure. At 07:34 PM, R1's blood pressure dropped further to 72/65 mmHg. R1's representative called LN G and requested staff send R1 to the hospital. LN G stated to R1's representative that if they sent R1 to the hospital and they did not admit him, the facility would have difficulty transporting R1 back. R1's representative contacted Program of All-Inclusive Care for the Elderly (PACE), and PACE called the facility and instructed staff to send R1 to the hospital. Emergency Medical Services (EMS) received the 911 call at 08:33 PM. EMS reported R1's blood pressure as 60/40 mmHg and they administered fluids on the way to the hospital. The hospital admitted R1 with diagnoses of an acute kidney injury (sudden and often reversible reduction in kidney function) and dehydration. R1 currently remained in the Intensive Care Unit (ICU). The facility's failure to respond immediately to a critical lab value and a decline in health status including abnormally low blood pressures and the failure to notify and inform the physician of R1's changing status placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of acquired absence (amputation) of left leg above knee, heart failure (a condition with low heart output and the body becomes congested with fluid), and hemiplegia (paralysis of one side of the body) affecting the right dominant side. The Annual Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 required staff dependency for chair/bed-to-chair transfers. The Quarterly MDS dated [DATE], documented R1 had a BIMS score of 14, which indicated intact cognition. R1 required staff dependency for chair/bed-to-chair transfers. The Functional Abilities Care Area Assessment (CAA) dated 11/17/23, lacked an analysis of findings. R1's Care Plan, dated 01/12/21, documented R1 had an activities of daily living (ADL) self-care performance deficit and directed R1 required total assistance with a Hoyer lift (full body mechanical lift) to move between surfaces and as necessary. R1's EMR revealed Special Instructions that directed staff to notify R1's physician if the resident's vital signs were outside of parameters which included: systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) greater than 180 mmHg or below 90 mmHg; diastolic blood pressure (DBP- minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) greater than 100 mmHg or below 50 mmHg. Certified Medication Aide S's Investigation Statement of Facts on 08/16/24, documented on 08/15/24 at approximately 07:00 PM, LN H asked her to assist in obtaining R1's vital signs per his representative's request. She stated it took about 20 minutes to obtain vital signs due to low blood pressure readings. LN H stated at approximately 07:30 PM to 07:45 PM, LN H called the doctor who gave an order to send R1 to the emergency room (ER). CMA S stated EMS arrived around 08:30 PM to 08:45 PM. LN G's Investigation Statement of Facts on 08/16/24, documented on 08/15/24, he received report that R1's had low blood pressure and staff monitored it. He stated at approximately 07:30 PM, he received a call from R1's representative that she wanted R1 sent to the hospital. LN G stated he told R1's representative he needed permission from the provider as soon as he hung up, PACE called and said to send R1 to the ER. He stated he called EMS at approximately 08:00 PM and they showed up about 30 to 45 minutes later. LN G stated EMS told him if they could not bring R1's blood pressure up, they would go to a closer hospital. R1's medical record revealed the following: An Incident Note on 08/13/24 at 02:07 PM documented at approximately 12:45 PM, two Certified Nurse Aides (CNAs) were in R1's room preparing him for his shower. They had R1 up in the air with the Hoyer lift when the sling came loose, causing R1 to fall to the floor. The CNAs stated R1 hit the lower part of his back on one of the lift legs. When the nurse entered the room, R1 laid flat on his back and voiced extreme low back pain. R1 had abrasions and several skin tears noted to the top of his right forearm. The nurse did not assess R1's back due to waiting for paramedics to arrive. R1 transferred to the ER for evaluation and treatment at approximately 01:30 PM. A Nurse Note on 08/13/24 at 10:28 PM documented R1 returned to the facility. Computed Tomography (CT scan- test that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue, and blood vessels) scan of R1's lumbar and thoracic spine were negative. Staff received no new orders. A Psychosocial Note on 08/14/24 at 11:32 AM documented Social Services X spoke to R1. R1 stated his whole body hurt after the Hoyer lift fall. R1 expressed fear of using the Hoyer lift in the future. Social Services X noted R1 appeared tearful when speaking about the incident. Social Services X planned to follow up on a daily basis as long as R1 needed. A Nurse Note on 08/14/24 at 02:08 PM documented R1 spent the day in bed per his normal. R1 voiced occasional back pain and received as needed (PRN) Tylenol (pain medication) and PRN Oxycodone (pain medication). R1 stated he felt shakier than usual, and he felt tired. R1's Basic Metabolic Profile (BMP- lab test to help doctors check the body's fluid balance, level of electrolytes, and kidney function) on 08/15/24 at 07:35 AM documented a critical creatinine level of 4.33 milligrams per deciliter (mg/dL, with a reference range of 0.80 to 1.30 mg/dL) with a note at 10:50 AM that the lab technician notified LN H of the critical lab level. A Health Status Note on 08/15/24 at 11:37 AM, late entered on 08/16/24 at 08:43 AM, documented LN H received a call from the laboratory with R1's critical creatinine lab value of 4.33 mg/dL. LN H notified Consultant GG and received a call back with orders to increase R1's fluids one to two liters in the next 24 hours and repeat labs on 08/19/24. A Psychosocial Note on 08/15/24 at 01:03 PM documented Social Services X spoke to R1 in his wheelchair. Staff moved R1 from his bed to his chair via Hoyer lift. R1 complained of pain but he no longer voiced fear of using the lift. R1's EMR documented R1's blood pressure on 08/15/24 at 04:30 PM was 88/64 mmHg. A Nurse Note on 08/15/24 at 07:35 PM, late entered on 08/16/24 at 02:41 PM, documented LN G sent R1 by ambulance to the hospital per R1's representative and PACE request. R1's blood pressure was 72/65 mmHg, pulse was 65 beats per minute (bpm), and respirations were 16. R1 identified himself, place, and situation at time of transfer. An Emergency Department Note on 08/15/24 at 09:51 PM documented R1 presented to the ER with a complaint of low blood pressure and the facility reported a blood pressure of 70/69mmHg at 06:00 PM. R1 arrived at the ER at 09:45 PM. EMS reported they obtained 60/40 mmHg as R1's blood pressure and gave him 500 milliliters (mL) of normal saline with an increase to his blood pressure to 95/60 mmHg. R1 was awake and alert and only complained of low back pain. R1's temperature was 91.6 degrees F rectally. R1 was admitted for observation for slow hydration. A Nurse Note on 08/16/24 at 05:48 AM documented R1 admitted to the ICU with a temperature of 90 degrees Fahrenheit (F) and a systolic BP between 70 and 100 mmHg. An Internal Medicine Progress Note on 08/17/24 at 12:01 PM documented R1 admitted with hypotension (low blood pressure) due to sepsis (a systemic reaction that develops when the chemicals in the immune system release into the blood stream to fight an infections which cause inflammation throughout the entire body instead. Severe cases of sepsis can lead to the medical emergency, septic shock) and hypovolemia (low blood volume). R1 required medication to increase his blood pressure the day before but tapered off at 03:30 AM that morning. R1 produced urine better as well. R1 voiced he was still sore all over from his recent fall. R1 was critically ill and at a high risk of adverse outcomes from severe sepsis and although he improved, he likely needed a prolonged hospital stay to stabilize. R1's representative did not want R1 to return to the facility to which R1 agreed with wholeheartedly . An Internal Medicine Progress Note on 08/18/24 at 10:00 AM documented R1 admitted with hypotension due to sepsis and hypovolemia on the evening of 08/15/24 and moved to the ICU on the morning of 08/16/24. R1 downgraded to the medical/surgical unit yesterday afternoon. During an interview on 08/21/24 at 12:50 PM, LN G stated when he started his shift on 08/15/24, LN H reported a concern about R1's blood pressure dropping. He stated he took R1's blood pressure shortly after his shift started, around 06:10 PM, and his blood pressure was about 73/48 (mmHg). LN G stated LN H told him to monitor R1 and give him fluids. He stated he went to recheck R1's blood pressure again, around the same time R1's representative called. LN G stated R1's representative wanted R1 sent to the hospital, and he informed her he needed to call someone, and the facility had a hard time getting residents back if they did not get admitted to the hospital. LN G stated he received a call from PACE who instructed him to send R1 to the hospital. He stated he called EMS for R1, and they arrived to the facility. He stated EMS stated to him that if they were unable to get R1's blood pressure up then they would transport him to a closer hospital. LN G stated R1's blood pressure started dropping around 04:30 PM but he already had an order to increase fluids due to a critical creatinine level. He stated if the nurse notified the physician, the nurse documented the notification in the notes. LN G stated R1 did not initially want to go to the hospital but staff convinced him to go. He stated, usually staff notified the physician as soon as a change in condition occurred or a resident's status started to change. During an interview on 08/21/24 at 01:27 PM, Administrative Nurse D stated on 08/15/24, Social Services X reported to her that R1 looked a little different and told her he could not grip with his left hand. Administrative Nurse D stated she talked to R1, and he seemed to be talking with a thick tongue. She stated she had not heard anything else about R1 until LN G notified her at 08:06 PM that he needed to print off paperwork for R1 to go to the hospital. She stated LN G texted her at 09:27 PM that EMS reported to him they were transporting R1 to a closer hospital due to being unable to increase his blood pressure. Administrative Nurse D stated LN H passed on in report to LN G that R1's blood pressure had been low and to monitor it. She stated R1's representative called at 07:30 PM and requested LN G to send R1 to the hospital but LN G seemed hesitant and made a comment that if the hospital did not admit R1, it would be difficult to get R1 back to the facility. Administrative Nurse D stated LN G got off the phone and PACE called the facility and advised him to send R1 to the hospital. She stated she received a text from the CMA S at 07:52 PM that R1 did not really want to go to the hospital but they convinced him to go. Administrative Nurse D stated LN H should have notified the physician of R1's low blood pressure at 04:30 PM and LN G should have notified the physician of his low blood pressure after shift change. She stated she expected staff to document physician notifications in the progress notes and if they had a conversation with the resident about his desire to not go to the hospital, it should be documented as well. She stated if a resident or resident's representative requested the resident go to the hospital, she expected staff to notify the physician and tell them the resident was going out to the hospital. Administrative Nurse D stated she would rather EMS arrived to watch the resident and have to wait for paperwork than the nurse gather paperwork before the facility called EMS. During an interview on 08/21/24 at 01:59 PM, county dispatch stated the facility called for EMS on 08/15/24 at 08:33 PM related to a resident with low blood pressure and dispatch sent EMS out a couple of minutes later. During an interview on 08/21/24 at 02:38 PM, LN H stated on 08/15/24, she continued follow-up fall vital signs. She stated the CMA checked R1's blood pressure and reported it as being low. LN H stated she rechecked it and it was not low. She stated around lunch, R1 complained of being achy and she gave him oxycodone for pain. LN H stated she received a call back from PACE because she had called to notify them of R1's critical creatinine level. PACE told them they would call back after notifying Consultant GG. LN H stated PACE called back about 15 minutes later and directed her to push one to two liters of fluid over the next 24 hours and monitor R1. She stated around 04:30 PM, she checked his vital signs and R1's blood pressure was low again. LN H stated she reported to LN G during shift change that R1 had low blood pressure, and LN G needed to check it again after report. She stated LN G replied, he would recheck R1's blood pressure and would probably send R1 out if he had low blood pressure. LN H stated she put in the increased fluid order but did not document R1's fluid intake. She stated she did not notify R1's provider of his low blood pressure at 04:30 PM because it was only low once for her and the night nurse said he would check R1's blood pressure again. She stated if she had rechecked R1's blood pressure before the end of her shift and it was low, she would have thought about calling R1's physician. LN H stated she documented physician notifications in the progress notes. The facility's Acute Condition Changes- Clinical Protocol policy, revised 07/05/24, documented that staff contacted the physician based on the urgency of the situation and the attending physician responded in a timely manner to the notification of problems or changes in condition or status. The policy directed staff to monitor and document the resident's progress and responses to treatment. The policy directed the physician to review the status of the condition change and document their evaluation at the next visit. The facility failed to immediately respond to a change in health status and failed to obtain physician involvement when R1 had a critical lab result and subsequently developed abnormal blood pressure lower than the physician ordered parameter. The facility further failed to immediately act upon the resident and/or his representative's request to seek acute care for treatment of his declining health situation. R1 currently remained in the ICU. The facility's failure to respond immediately to a critical lab value and a decline in health status including abnormally low blood pressures and the failure to notify and inform the physician of R1's changing status placed R1 in immediate jeopardy. On 08/21/24 at 04:20 PM Administrative Staff A received a copy of the Immediate Jeopardy Template and was informed of the facility's failure to respond to and involve the physician in R1's change in condition, including a critical lab value with low blood pressures, placed R1 in immediate jeopardy. The facility submitted an acceptable plan for removal of the immediacy on 08/21/24 at 08:44 PM, which included the following: All current nurses, CMAs, and Certified Nurse Aides (CNAs), and applicable agency staff were educated on the following starting on 08/22/24: How to identify and respond to changes in condition Honoring a residents/responsible party right to direct their own healthcare. Notification of changes to the resident, responsible party and physician. How to respond, according to standard, related to critical labs. Blood pressure parameters and when to notify or act. All current residents had a chart review no later than 08/22/24 to ensure blood pressure parameters were noted within the clinical record. This was the responsibility of the Director of Nursing, with oversight by the Regional Nurse Consultant. All current residents, who had a clinical order for fluid monitoring, would have an additional task added to their record-to-record fluid intake. This occurred by 08/22/24. This task was the responsibility of Administrative Nurse D with oversight by the Regional Nurse Consultant. All current residents had chart reviews completed by 08/22/24 to ensure currently ordered labs were in the clinical record and a full assessment to identify the labs were drawn, report was received, and the resident, responsible party and physician were notified. This was the responsibility of the Director of Nursing with oversight by the Regional Nurse Consultant. The surveyor verified the implementation of the above immediacy removal plan while onsite on 08/22/24 at 05:35 PM. The deficient practice remained at a scope and severity of G, to reflect the actual harm experienced by R1.

The facility identified a census of 23 residents. The sample included nine residents. Based on observation, record review, and interview, the facility failed to provide appropriate treatment and care for Resident (R) 2's peripherally inserted central catheter (PICC-a thin, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein above the heart) including monitoring the resident's status for complications and providing a sterile dressing change per the standards of care for a PICC line at least every seven days. R2 admitted to the facility on [DATE] with a PICC line in place for administration of intravenous (IV - administered directly into the bloodstream via a vein) antibiotics. R2's clinical record lacked evidence that the staff had changed R2's PICC dressing while he was in the facility. On 08/19/24 R2 went to the acute care hospital for possible sepsis (a threatening systemic reaction that develops due to infections which cause inflammation throughout the entire body). The hospital staff identified R2's PICC dressing was 38 days old. The staff's failure to provide ongoing monitoring of the dressing status, the failure to identify the lack of dressing orders as well as failure to provide a sterile dressing change for over five weeks placed R2 in immediate jeopardy. Findings included: - R2's Electronic Medical Record (EMR) documented a diagnosis of cerebral infarction (stroke - the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), pressure-induced deep tissue damage (pressure ulcer - localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) of the sacral region (sacrum - large triangular bone/area between the two hip bones), open wound of lower back and pelvis, weakness, systolic congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). The Admission Minimum Data Set (MDS), dated [DATE], for R2 noted the Brief Interview for Mental Status (BIMS) assessment was unable to be completed. The MDS documented R2 had problems with short-term and long-term memory. The MDS further documented R2 had poor decision-making and required cues and supervision. The MDS documented R2 used a wheelchair and required substantial, maximal assistance for transition from lying to a seated position on the edge of a bed, sitting to stand, bathing, toileting hygiene, lower body dressing, and transfers. The MDS documented R2 was on antibiotics and had one stage four (a deep pressure wound that reaches the muscles, ligaments, or even bone) pressure ulcer. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/18/24, documented R2 had obvious long- and short-term memory deficits. The CAA documented R2 was admitted to the facility following a hospital stay secondary to a sacral wound with infection and was on IV antibiotics. The CAA further documented R2 required assistance with ADL completion and had a wound vacuum-assisted closure device (wound vac - a wound healing therapy that uses negative pressure to help wounds heal) in place to his sacral area. R2's Care Plan, with an initiated date of 07/23/24, documented R2 had an infection of his sacral wound. An intervention with an initiated date of 07/23/24, directed staff to administer IV medication through PICC as ordered and to flush the PICC line with 10 cubic centimeters (cc) of normal saline (NS - saline water solution for medical use) before and after use. R2's Care Plan lacked evidence of any further documentation related to R2's PICC line. R2's Care Plan lacked evidence of dressing changes related to his PICC line. R2's EMR recorded the following orders: A Physician's Order dated 07/12/24 directed staff to flush PICC with 10 cc of NS before and after administering the antibiotic. The order was discontinued on 08/05/24. A Physicians Order dated 07/12/24 for ceftriaxone two grams IV for wound infection. The order was discontinued on 08/05/24. A Physician's Order dated 08/05/24 directed staff to flush PICC with 10 cc or NS twice daily until removed. The order was placed on hold on 08/19/24. R2's EMR lacked evidence of an order to change R2's PICC line dressing. An Admission Note dated 07/12/24, documented R2 was oriented to his room and the facility. The note further documented R2 had a wound vac placed and medications ordered to start IV antibiotics in the morning. A Nurse Note dated 07/14/24 at 12:05 PM recorded R2 continued with IV antibiotics. R2 had a PICC line, the site was patent and flowing without concerns. There was no redness, edema or irritation noted. R2's dressing remained intact. R2's EMR lacked another PICC site assessment until 07/17/24. A Skilled Note dated 07/15/24 at 02:41 PM noted R2 continued with IV antibiotics per PICC line. R2 had a ground diet with thickened liquids and was dependent on staff to heat [sic]. R2's wound vac continued. A Skilled Note dated 07/16/24 at 02:45 PM noted R2 continued with the same diet and was adjusting to the environment. R2 received IV antibiotics per a PICC line. An Infection Note dated 07/17/24 at 10:30 AM noted R2 remained on IV antibiotics with no adverse reactions. The PICC line was patent and flowing. There was no redness or swelling to the insertion site. R2 remained afebrile (without fever). An Infection Note dated 07/18/24 at 03:59 AM noted R2 continued IV antibiotics with no adverse reactions. The PICC line was patent and flowing. There was no redness or swelling to the insertion site. R2 remained afebrile (without fever) and had no adverse reactions to the medications. A Nurse Note dated 07/19/24 at 02:47 PM noted staff attempted to flush both ports of the PICC line and was met with great resistance in both ports. Staff notified Consultant HH. Staff attempted to start a peripheral IV two times. The first attempt infiltrated after piercing the vein. The second attempt was not able to get into the vein. Staff applied pressure at the site of both insertion attempts until R2 was no longer bleeding, and then applied a dressing. Staff notified Consultant HH to inform him they were not successful in placing a peripheral IV. Staff awaited a return call. An Orders Administration Note dated 07/19/24 at 04:07 PM noted for the flush order, staff could not flush the PICC line due to stagnant blood in the line. Staff notified the physician and Administrative Nurse D. R2's EMR lacked notation of any follow up or treatments regarding this situation. An Orders Administration Note dated 07/20/24 at 09:32 AM noted IV ceftriaxone (antibiotic) two grams was administered. The PICC line was patent and flowing with no redness or edema at the site. R2's EMR lacked evidence of another PICC site assessment until 07/26/24. A Skilled Note dated 07/25/24 at 06:52 PM noted R2 was very cooperative and pleasant. He followed directions and assisted staff at times. He spent time with physical therapy (PT) and occupational therapy (OT) for therapies. He was only able to tolerate sitting up for short periods of time and asked to lie down in bed. He had a wound vac in place to the sacrum and a central line that was flushed daily with antibiotic infusion. A Skilled Note dated 07/26/24 at 03:25 AM noted R2 had a wound vac in place to the sacrum and a central line that was flushed daily with antibiotic infusion. R2 slept well throughout the night. A Skilled Note dated 07/26/24 at 07:17 PM noted R2 had a central line in the left upper arm. The IV line was flushed before and after antibiotics were infused. The IV site remained without redness, swelling, or pain and flushed easily. He also had a wound vac to the sacral area that was changed three times weekly and as needed. He had a Foley catheter (a tube inserted into the bladder to drain urine) that was draining brownish urine. He was on a fluid restriction, but he did not drink fluids and took much encouragement. He was repositioned in his bed and was encouraged to sit up in the chair for short periods as tolerated. A Skilled Note on 07/27/24 at 05:24 AM noted R2 had a wound vac in place to the sacrum and a central line that was flushed daily with antibiotic infusion. R2 slept well throughout the night. An Orders Administration Note dated 07/27/24 at 08:17 AM noted IV ceftriaxone two grams was administered. The PICC line was patent and flowing with no redness or edema at the site. An Orders Administration Note dated 07/28/24 at 08:48 AM noted IV ceftriaxone two grams was administered. The PICC line was patent and flowing with no redness or edema at the site. An Infection Note dated 07/28/24 at 11:11 AM noted R2 continued IV antibiotic for a wound infection with no signs or symptoms of adverse reactions. R2 was afebrile. The IV site was patent and intact, and no other concerns were noted. R2's EMR lacked evidence the PICC site was assessed again until 07/30/24. An Infection Note dated 07/30/24 at 02:30 PM noted R2 remained on IV antibiotic with no adverse reactions noted. There was no redness or swelling noted to the IV site. R2 was afebrile. R2's EMR lacked evidence the PICC site was assessed again until 08/03/24. An Infection Note dated 07/31/24 at 11:49 AM noted R2 continued taking IV antibiotic medication for the treatment of a wound infection. R2 had no adverse reactions and was afebrile. An Infection Note dated 07/31/24 at 04:01 AM noted R2 continued taking antibiotic medication via IV for the treatment of a wound infection. R2 had a wound vac in place on his sacrum wound. R2 had no adverse reactions to the medication. An Infection Note dated 08/01/24 at 03:11 AM noted R2 remained on IV antibiotics for the treatment of a wound infection. R2 had a wound vac in place on his sacrum. R2 did not have any adverse reactions to his medication. A Nursing Quarterly Evaluation Note dated 08/02/24 at 04:51 AM documented a review of systems but made no mention of the PICC line. An Infection Note dated 08/02/24 at 05:34 AM noted R2 remained on IV antibiotics for the treatment of a wound infection. R2 had a wound vac in place on his sacrum. R2 did not have any adverse reactions to his medication. A Skilled Note dated 08/02/24 at 02:45 PM noted R2 was up in his wheelchair for lunch and tolerated it well. R2 was dependent in eating his meals. He just looked at his food and did not try to eat. R2 stated, I have trouble swallowing some foods and I need it soft. R2 had a central IV line for the administration of antibiotics daily. He had a wound vac to the sacrum for a Stage 4 pressure ulcer which was present on admission. An Infection Note dated 08/03/24 at 08:07 AM noted R2 remained on IV antibiotics treatment for a wound. R2 did not have any adverse reactions at that time. R2's IV was patent and flowing slowly. There was no redness or edema to the PICC line site. An Orders Administration Note dated 08/03/24 at 08:13 AM noted IV ceftriaxone two grams was administered. The PICC line was patent and flowing with no redness or edema at the site. An Infection Note dated 08/04/24 at 09:47 AM noted R2 remained on IV antibiotics treatment for a wound. R2 did not have any adverse reactions at that time. R2's IV was patent and flowing slowly. There was no redness or edema to the PICC line site, and no other concerns were noted. R2's lacked evidence the PICC site was assessed again until 08/08/24. An Infection Note dated 08/05/24 at 03:41 AM noted R2 remained on IV antibiotics for the treatment of a wound infection. R2 had a wound vac in place on his sacrum. R2 did not have any adverse reactions to his medication. A Nurse Note dated 08/05/24 at 09:58 AM noted staff called Consultant HH regarding the order to discontinue R2's Rocephin (ceftriaxone) and asked whether to leave the PICC line in or remove it. Staff awaited a return call. A Nurse Note dated 08/05/24 at 01:33 PM noted staff received a call back from Consultant HH's office with orders to leave the PICC line in and flush twice daily. Staff were directed to call back in 48 hours and ask Consultant HH at that point whether to remove the PICC or keep it in. R2's EMR lacked evidence this follow-up call was placed. A Nurse Note dated 08/08/24 at 05:25 PM noted R2 had a central line to the left upper arm. One port flushed easily but the other port always had trouble flushing since he was admitted . The central line site was without erythema (redness), drainage, or swelling at that time. A Nurse Note dated 08/08/24 at 07:15 PM noted the PICC flush was not done due to the nurse was not IV certified. A Nurse Note dated 08/12/24 at 12:59 PM noted R2's representative was concerned that R2 was dehydrated and asked for IV fluids. Staff called Consultant HH's office with the request. A Nurse Note dated 08/12/24 at 02:45 PM noted staff received a return call from Consultant HH's office with orders for 250 cc of NS over three hours one time only to be administered the following day when it arrived from the pharmacy. R2's August 2024 Medication Administration Record /Treatment Administration Record (MAR/TAR) lacked evidence the 250 cc NS was administered on 08/13/24 as initially ordered. The MAR/TAR recorded R2 received the 250 cc NS on 08/14/24 at 09:55 AM. R2's August 2024 MAR/TAR lacked evidence the PICC flush was administered in the evening of 08/15/24 and the morning of 08/16/24. An Order Note dated 08/19/24, documented R2 had a decline in alertness, his blood pressure had decreased, and his pulse increased from his normal range. The note documented R2 refused to eat or drink much and his wound to the coccyx was black in color with a strong foul smell. Staff placed a call to the provider and an order was received to send R2 to the emergency room . A Nurse Note dated 08/19/24 documented an ambulance arrived at the facility and transported R2 to the emergency room at 01:10 PM. R2's Emergency Department Note dated 08/19/24 recorded R2 had an old PICC line with a dressing dated 07/13/24 still in place in R2's left upper arm. R2's clinical record from 07/12/24 through the survey date 08/26/24 lacked evidence a PICC dressing was completed. On 08/21/24 at 04:23 PM, Hospital Nurse II stated R2 was admitted for sepsis. Hospital Nurse II stated when R2 arrived at the hospital, the nursing staff identified improper PICC line care since the dressing had not been changed since 07/13/24. Hospital Nurse II went on to say that failing to change the dressing could have contributed to R2's sepsis but it was hard to say for sure since R2's sacral wound was also in very bad condition when he arrived. Hospital Nurse II stated R2's wound was really bad and showed signs of neglect. Hospital Nurse II confirmed R2 had transferred to another hospital for a higher level of care. On 08/22/24 at 11:25 AM Licensed Nurse (LN) H stated she had not received any education related to PICC line care or dressing changes at the facility. LN H stated she had prior emergency room experience and knew how to take care of a PICC line; however, she further stated she had not received any competency check-off to ensure she knew how to care for a PICC line at the facility prior to caring for a resident that had a PICC line. LN H stated this is a skilled facility and we need to have the skills and training. LN H stated in the hospital setting she would change a PICC line dressing once a week but was not sure about the guidelines in the long-term care setting. She stated staff were flushing R2's PICC line twice daily. LN H stated if a PICC line dressing had been done for R2, it would have been documented on the MAR, and TAR, and all dressing changes would have been documented in that location. LN H stated staff had missed putting in orders sometimes, but if she noticed a dressing needed changed, then she would change it, or if there were no orders she would contact the provider, obtain an order, and then change the dressing. LN H further stated if she noticed a PICC line dressing had a last changed date that was over a week old she would check the order, contact the provider to obtain an order if there was not one, and change the dressing. LN H stated she was unsure what order R2 had related to his PICC line dressing. She stated she had questioned it but was not sure if anything came of it. LN H stated even if staff were monitoring and assessing the site, that would not be enough, and the dressing would need to be changed. LN H stated if PICC line dressings are not changed, then the resident would have an increased risk of infection, and she further stated the risk to the resident would be greater due to the PICC being a central line. On 08/22/24 at 11:44 AM Administrative Nurse D stated the facility had just completed a skills fair for the staff on 07/20/24 to 07/21/24 and the facility included central line education during the skills fair. Administrative Nurse D stated all staff were required to attend. Administrative Nurse D stated she was unsure if the staff had received PICC line care education prior to their recent skills fair and there were no skills checks done to verify staff knew how to care for a PICC line prior to staff providing care. Administrative Nurse D stated she had asked a few of their nurses, and they reported to her that they had not received the education at the facility previously. Administrative Nurse D stated the training should have been done once per year. Administrative Nurse D stated PICC line dressings would have been changed once per week and documented in the MAR and TAR when it was completed, and the new dressing should have been dated when it was changed. Administrative Nurse D stated if staff noted a PICC line dressing had a last changed date that was a week or more old, the expectation was for staff to change the dressing and that it was policy. Administrative Nurse D stated that even if there was no order for the dressing change, it would still need to have been changed. Administrative Nurse D stated doctors do not typically order PICC line dressing changes; however, staff are still able to place an entry in the resident's EMR that would have notified staff to change the dressing that they could have charted against. Administrative Nurse D stated if a PICC line dressing was not changed for over a week or more, the resident would have been at an increased risk of infection. Administrative Nurse D further stated staff would not have been able to fully assess the insertion site if they were not changing the dressings each week. A policy related to PICC line care was not provided by the facility. On 08/22/24 at 02:16 PM, the facility received the Immediate Jeopardy [IJ] Template and was informed that the facility's failure to provide appropriate treatment and care for R2's PICC including monitoring the resident's status for complications and providing a sterile dressing change per the standards of care, placed R2 in immediate jeopardy. On 08/22/24 at 06:05 PM, the facility provided an acceptable plan for removal of the immediacy. On 08/26/24 the facility completed corrective actions which included halting admission immediately of any resident who would require a PICC line or other IV as part of their care. No individuals with a PICC line or other type of IV will be admitted to the facility until re-education with all current licensed has been completed, and return competency demonstrated. Responsibility for the education of the staff was assigned to the Director of Nursing (DON) and/or designee. The Regional Consultant nurse ensured the competency of the DON prior to educating staff. Competency and education were provided to IV-certified RNs and LPNs by DON and/or designee. There were no residents in the facility with a PICC line or other type of IV as of 08/26/24. The surveyor verified the implementation of the corrective actions and removal of the immediacy onsite on 08/26/24 at 02:00 PM. The deficient practice remained at a scope and severity of D.

The facility identified a census of 23 residents. The sample included nine residents. Based on record review and interviews, the facility failed to provide Resident (R) 2 with wound care consistent with standards of practice when staff failed to ensure physician involvement for wound status changes and appropriate treatment orders, and failed to assess wound characteristics consistently and when treatment changes were made. These failures resulted in the deterioration of the wound and the worsening of the infectious process. This also placed R2 at risk for increased pain and other wound-related complications. Findings included: - R2's Electronic Medical Record (EMR) documented a diagnosis of cerebral infarction (stroke - the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), pressure-induced deep tissue damage (pressure ulcer - localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) of the sacral region (sacrum - large triangular bone/area between the two hip bones), open wound of lower back and pelvis, weakness, systolic congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). The Admission Minimum Data Set (MDS), dated [DATE], noted R2 had problems with short-term and long-term memory. The MDS further documented R2 had poor decision-making and required cues and supervision. The MDS documented R2 used a wheelchair and required substantial, maximal assistance for transition from lying to a seated position on the edge of a bed, sitting to stand, bathing, toileting hygiene, lower body dressing, and transfers. The MDS documented R2 was on antibiotics and had one stage four (a deep pressure wound that reaches the muscles, ligaments, or even bone) pressure ulcer. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/18/24, documented R2 had obvious long- and short-term memory deficits. The CAA documented R2 was admitted to the facility following a hospital stay secondary to a sacral wound with infection and was on intravenous (IV- administered directly into the bloodstream via a vein) antibiotics. The CAA further documented R2 required assistance with ADL completion and had a wound vacuum-assisted closure device (wound vac - a wound healing therapy that uses negative pressure to help wounds heal) in place to his sacral area. R2's Care Plan, with an initiated date of 07/23/24, documented R2 had a stage four pressure ulcer to his sacrum. An intervention with an initiated date of 07/23/24 documented R2 had a wound vac to his sacral wound. Staff were to change the resident's wound vac three times a week and as needed. An intervention with an initiated date of 07/23/24 directed staff to assess, record, and monitor wound healing weekly and as needed. Measure the wound length, width, and depth where possible. Assess and document the status of the wound perimeter, wound bed, and healing progress. Report improvements and declines to the doctor (MD). An intervention with an initiated date of 07/23/24 directed staff to administer treatments as ordered and monitor for effectiveness. An intervention with an initiated date of 07/23/24 directed staff to monitor the dressing every shift to ensure it was intact and adhering, report loose dressing to the treatment nurse, and replace wound vac as needed. An intervention with an initiated date of 07/23/24, documented weekly treatment documentation was to include measurement of each area of skin breakdown's width, length, depth, type of tissue, and exudate (the fluid that leaks out of body vessels and tissues). R2's Care Plan, with an initiated date of 07/23/24, documented R2 had an infection of his sacral wound. An intervention with an initiated date of 07/23/24, directed staff to change wound vac dressing three times a week and as needed. R2's Care Plan, with an initiated date of 08/08/24, documented R2 had actual impairment to skin integrity of the skin surrounding the pressure ulcer related to a possible reaction to Tegaderm (transparent, film dressing that can be used to protect wounds) that secured the wound vac. An incomplete intervention with an initiated date of 08/08/24 documented R2 needed (SPECIFY: pressure relieving/reducing mattress, pillows, sheepskin padding, etc.) to protect the skin while in bed. R2's EMR documented the following: An Admission Note dated 07/12/24 documented R2 was oriented to his room and the facility. The note further documented R2 had a wound vac placed and medications ordered to start IV antibiotics in the morning. A Nursing: Weekly Skin Evaluation dated 07/14/24, documented R2 had an open wound to the sacrum. The evaluation description related to the sacral wound documented tunneling (a wound that's progressed to form passageways underneath the surface of the skin) pressure ulcer, with a wound vac in place. The evaluation lacked further sacral wound evaluation including peri-wound (skin surrounding the wound), drainage, odor, and other signs of infection, and wound measurements related to the sacral wound. A Physician's Order with a start date of 07/15/24, documented to change the sacral wound vac, settings: 150 (negative pressure) continuous. Three times weekly on the day shift and as needed. Every Monday, Wednesday, and Friday. (Order placed on hold 08/07/24) R2's EMR lacked an order or dressing instructions to staff in the event the wound vac malfunctioned or could not be placed. A Weekly Pressure Injury Skin Report dated 07/17/24, documented R2 had a stage four pressure wound to his sacrum with a length of 6.5 centimeters (cm), width of 4.6 cm, and depth of 2.3 cm. The assessment documented a moderate amount of serosanguineous (semi-thick blood-tinged drainage) exudate, with no foul odor documented. The note described the wound bed as dark pink or red tissue with slough (dead tissue, usually cream or yellow in color). The note further documented the surrounding skin as normal for skin, and the assessment was marked as no change from the previous assessment and directed to continue the current treatment as ordered. The comment box on the assessment was blank. A Weekly Pressure Injury Skin Report dated 07/24/24, documented R2 had a stage four pressure wound to his sacrum with a length of 6.5 cm, width of 4.6 cm, and depth of 2.3 cm. The assessment documented a moderate amount of serosanguineous exudate, with no foul odor documented. The wound bed was described as dark pink or red tissue with slough. The surrounding skin was documented as normal for skin, progress from the previous assessment was marked as no change and directed to continue the current treatment as ordered. The comment box on the assessment documented the site was beefy red with some minimal bleeding noted to the surrounding skin when the clear film dressing was removed. R2's EMR lacked evidence the changes and bleeding to the peri-wound was reported to the physician. A Weekly Pressure Injury Skin Report dated 07/26/24, documented R2 had a stage four pressure wound to his sacrum with a length of 6.5 cm, width of 4.6 cm, and depth of 2.3 cm. The assessment documented a moderate amount of serosanguineous exudate, with no foul odor documented. The wound bed was described as dark pink or red tissue with slough. The surrounding skin was documented as normal for skin, progress from the previous assessment was marked as no change and directed to continue current treatment as ordered. The comment box on the assessment was blank. A Weekly Pressure Injury Skin Report dated 07/31/24, documented R2 had a stage four pressure wound to his sacrum with a length of 6.5 cm, width of 4.6cm, and depth of 2.3cm. The assessment documented a moderate amount of serosanguineous exudate, with no foul odor documented. with the wound bed was described as dark pink or red tissue with slough. The surrounding skin was documented as normal for skin, progress from the previous assessment was marked as no change and directed to continue current treatment as ordered. The comment box on the assessment documented redness, with skin breakdown noted surrounding the wound. Skin-prep (liquid skin barrier) was applied. R2's EMR lacked evidence the physician was notified of the skin breakdown. A Nursing: Admission Eval dated 08/03/24, under section C skin evaluation, documented R2 had an unstageable pressure ulcer to his sacrum with a length of 6.0 cm, width of 4.0 cm, and depth of 2.0 cm. No further description of the sacral wound was documented in the assessment. A Nursing: Weekly Skin Evaluation dated 08/04/24, documented R2 had an open wound to his sacrum. The evaluation description related to the sacral wound documented a continued tunneling pressure ulcer with a wound vac in place. The evaluation lacked further sacral wound description and lacked wound measurements related to sacral wound. An Infection Note dated 08/05/24 at 03:41 AM noted R2 remained on IV antibiotics for the treatment of a wound infection. R2 had a wound vac in place on his sacrum. R2 did not have any adverse reactions to his medication. A Nurse Note dated 08/07/24 at 02:55 PM, documented the skin surrounding R2's pressure ulcer that was covered with Tegaderm had become reddened with areas of breakdown. The note documented that staff was unable to attach and seal the wound vac due to the area of breakdown. The note further documented the writer consulted with a certified wound nurse who recommended a treatment to use until the physician gave further orders. A Physician's Order with a start date of 08/07/24, documented a sacral dressing and directed to cover the wound bed with calcium alginate antimicrobial silver (dressing with antimicrobial properties used on infected wounds or wounds that are at a high risk of infection), apply Xeroform gauze (sterile non-adhering fine mesh gauze treated with a bacteriostatic agent) dressing, cover with ABD (large pad to absorb drainage) and paper tape. Change twice weekly until the resident could be seen by Veterans Affairs (VA). (This order was discontinued on 08/12/24). R2's August 2024 Medication Administration Record /Treatment Administration Record (MAR/TAR) lacked evidence the dressing was applied on 08/07/24 when initially ordered. The MAR/TAR recorded the dressing was first applied on 08/10/24 and then discontinued on 08/12/24. R2's EMR lacked evidence physician was contacted or made aware of R2's complications related to the wound vac and new dressing change order until 08/12/24. A Nursing: Weekly Skin Evaluation dated 08/10/24, documented R2 had an open wound to the sacrum. The evaluation description related to the sacral wound documented a continued tunneling pressure ulcer. The evaluation lacked further sacral wound description and lacked wound measurements related to sacral wound. A Health Status Note dated 08/12/24 at 09:58 AM documented Consultant HH was at the facility and saw R2. The note documented the plan of care was reviewed, new orders noted, and the dressing to R2's sacral area was changed to saline wet to wet twice daily (BID). A Physician's Order with a start date of 08/12/24, documented a sacral dressing, cleanse with wound cleanser then apply saline wet to wet to the wound; cover and change BID every day and night shift for wound. (Order placed on hold 08/19/24) A Weekly Pressure Injury Skin Report dated 08/14/24, documented R2 had a stage four pressure wound to his sacrum with a length of 6.5 cm, width of 4.6 cm, and depth of 2.8 cm. The assessment documented a moderate amount of serosanguineous exudate, with no foul odor documented. The wound bed was described as dark pink or red tissue with slough. The surrounding skin was documented as reddened, progress from the previous assessment was marked as deteriorated and noted to continue the current treatment as ordered. The comment box on the assessment documented dark red, and purple tissue surrounding the wound. R2's EMR lacked evidence the physician was notified of the changes in the wound and/or peri-wound. A Nursing: Weekly Skin Evaluation dated 08/17/24, lacked documentation related to R2's sacral wound and contained no wound measurements. An Order Note dated 08/19/24, documented R2 had a decline in alertness, his blood pressure had decreased, and his pulse increased from his normal range. The note documented R2 refused to eat or drink much and his wound to the coccyx was black in color with a strong foul smell. Staff placed a call to the provider, and they gave an to send R2 to the emergency room . A Nurse Note dated 08/19/24 documented an ambulance arrived at the facility and transported R2 to the emergency room at 01:10 PM. R2's Emergency Department Note dated 08/19/24 recorded R2 presented to the emergency department for possible sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body). The note further documented R2's sacral wound measurements were approximately 10 cm by 14 cm, and the wound was necrotic (pertaining to the death of tissue in response to disease or injury) with tunneling present. On 08/21/24 at 03:40 PM, in a phone interview with Consultant JJ, a nurse for Consultant HH, Consultant JJ stated she reviewed all the call logs from 08/07/24 and stated that there were no logged calls from the facility on that day related to R2 at all. On 08/21/24 at 04:23 PM, Hospital Nurse II stated R2 admitted for sepsis. Hospital Nurse II stated R2's sacral wound was in very bad condition when he arrived. Hospital Nurse II stated R2's wound was really bad and showed signs of neglect. Hospital Nurse II confirmed R2 had transferred to another hospital for a higher level of care. On 08/22/24 at 03:33 PM, Licensed Nurse (LN) H stated she was unsure why R2's wound vac was removed, but said she believed it was related to the tape used on the wound vac and R2's skin breakdown around the site where the wound vac dressing was placed. LN H stated wound assessments were supposed to be completed weekly and that included assessing the wound and taking measurements. LN H further stated staff were supposed to measure the wounds to know if they were changing in size, assess tissue to note if the wound had worsened or improved, and know if the physician needed to be notified. LN H stated the last time she saw R2's wound, it was horrible and was deep enough to see his tailbone. LN H stated she would reassess a wound if new treatments or dressings were ordered. LN H stated she believe R2's wound began deteriorating after the wound vac was removed. She stated at first the site around the wound was pink; however, as time went on, staff believed the dressing was irritating R2's skin, and it gradually got worse, and the wound vac was removed. LN H stated she saw the wound when R2 first arrived at the facility and the wound had some small necrotic tissue around the opening; however, she stated it was much smaller and was not as severe. LN H stated she was off work for a week, and when she returned R2's wound had worsened. She stated she had been a nurse for [AGE] years and this was the first time she gagged after seeing the wound without the wound vac. LN H stated if staff notice a breakdown in a wound, especially after a new treatment was ordered, they should notify the provider. On 08/26/24 at 12:15 PM Administrative Nurse D stated if staff noticed a wound was worsening, she expected staff to notify her or their wound nurse as they handle the wound care for the facility. Administrative Nurse D stated she expected staff to assess wounds, which included taking measurements and documenting them weekly. Administrative Nurse D stated she believed the wound vac dressings for R2 were done three times per week. Administrative Nurse D stated if there was a change in dressing types, she expected staff to at least document a progress note as to why the wound vac could not be put back in place while waiting for the doctor to notify staff of a change in treatment. Administrative Nurse D stated R2's skin was breaking down; it was raw and would not stick to the dressing to form a seal. Administrative Nurse D stated staff believed the wound vac dressing would have caused more damage if put back on. Administrative Nurse D stated their wound nurse attempted to use barriers to help with the seal; however, it did not work. She stated she believed the cause of R2's issues were related to the tape, or Tegaderm and not the staff's competency. Administrative Nurse D stated Administrative Nurse E was in the facility the day the wound vac was removed and Administrative Nurse E was a certified wound nurse. Administrative Nurse D stated they followed Administrative Nurse E's recommendation to change the wound dressing twice weekly while waiting for the doctor to decide how he wanted to address it. Administrative Nurse D stated the doctor changed the dressing to a wet to wet while the facility awaited a response from the VA for approval. Administrative Nurse D stated no one had mentioned to her that R2's wound had worsened prior to him being sent out to the ER. On 08/26/24 at 01:44 PM Administrative Nurse E stated she was asked to assess R2's sacral wound, and that she understood the wound was previously debrided (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue) at a hospital prior to admission. Administrative Nurse E stated R2's wound was a wicked wound with slough and eschar (dead tissue) and a wound vac could not be done on a wound with eschar. Administrative Nurse E stated she believed R2 should have had his wound debrided again at the hospital; however, they had to await approval through the VA. Administrative Nurse E stated the doctor was called to get a new dressing order to get by until R2 could be seen at the VA. Administrative Nurse E stated there was 80% slough and eschar in R2's wound when she saw it. Administrative Nurse E stated she believed Administrative Nurse D contacted Consultant HH for the dressing order. Administrative Nurse E stated if staff contacted a physician, then that staff should document that. Administrative Nurse E stated if it was not documented, then it was not done. On 08/26/24 at 02:02 PM Administrative Nurse D stated she consulted with Administrative Nurse E regarding R2's wound and wound vac issue. Administrative Nurse D stated she did not know who contacted Consultant HH to get an order for the dressing change on 08/07/24 when the wound vac was removed. Administrative Nurse D stated she was with Administrative Nurse E when Administrative Nurse E recommended the dressing change and gave it to the nurse. Administrative Nurse D stated she entered the dressing order into the system; however, she believed LN I was supposed to have contacted Consultant HH to get permission for the order. On 08/26/24 at 02:07 PM LN I stated she went to change R2's wound vac and his skin was broken down under the Tegaderm. LN I stated she cleaned and dried the site; however, the dressing would not adhere. LN I stated she did not have a lot of wound experience, so she got Administrative Nurse E and Administrative Nurse D for assistance. LN I stated Administrative Nurse E and Administrative Nurse D were going to get a hold of Consultant HH for an order until Consultant HH could come to see R2. LN I stated Administrative Nurse E recommended the twice-weekly order, and then Administrative Nurse D got ahold of Consultant HH to obtain the order. LN I said the following Monday, Consultant HH changed the dressing order to a wet-to-wet dressing twice daily. LN I stated she changed the dressing on 08/07/24. LN I stated she saw the wound when the wound vac was removed and was the nurse who sent R2 out to theER on [DATE]. LN I stated R2's wound looked worse. She stated R2's wound did not have necrotic skin when they removed the wound vac and the wound bed was a dark, deep red. LN I stated R2's wound later had blistering around the edges of the wound, was peeling, and had black spots in the wound bed. She further stated the wound had a stronger odor the day he was sent out. The facility's Wound Care policy with a revised date of 07/15/24, documented the following information should be recorded in the resident's medical record: the type of wound care given, the date and time the wound care was given, the name and title of the individual performing the wound care, any changes in the resident's condition, all assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound, any problems or complaints made by the resident related to the procedure, if the resident refused the treatment and he reasons why and the signature and title of the person recording the data. The facility failed to provide R2 wound care consistent with standards of practice when staff failed to ensure physician involvement for wound status changes and appropriate treatment orders, and failed to assess wound characteristics consistently and when treatment changes were made. These failures resulted in the deterioration of the wound and the worsening of the infectious process. This also placed R2 at risk for increased pain and other wound-related complications.

The facility identified a census of 23. The sample included nine residents. Based on record review and interviews, the facility failed to ensure Resident (R) 1 remained free from preventable accidents during a Hoyer lift (full body mechanical lift) transfer. This deficient practice resulted in impaired psychosocial well-being and placed R1 at risk for further complications. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of acquired absence (amputation) of left leg above knee, heart failure (a condition with low heart output and the body becomes congested with fluid), and hemiplegia (paralysis of one side of the body) affecting the right dominant side. The Annual Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 required staff dependency for chair/bed-to-chair transfers. The Quarterly MDS dated [DATE], documented R1 had a BIMS score of 14, which indicated intact cognition. R1 required staff dependency for chair/bed-to-chair transfers. The Functional Abilities Care Area Assessment (CAA) dated 11/17/23, lacked an analysis of findings. The Falls CAA dated 11/15/23, documented R1 required assistance with activities of daily living (ADLs). R1's Care Plan, dated 01/12/21, documented R1 had an ADL self-care performance deficit and directed R1 required total assistance with a Hoyer lift to move between surfaces and as necessary. Certified Nurse Aide (CNA) M's Investigation Statement of Facts, dated 08/13/24, documented she and Certified Medication Aide (CMA) R hooked R1 up to the Hoyer lift to transfer him to the shower chair. She stated one of R1's lift sling leads came unattached, and they thought it had ripped. CNA M stated R1 fell out of the sling, and they quickly got him off of the Hoyer lift leg to make sure he was okay while CMA R notified the nurse. The nurse assessed R1 and called EMS. CMA R's Investigation Statement of Facts, dated 08/13/24, documented she and CNA M put R1 in the Hoyer lift and as she started to turn around to put him in the shower chair, one side of the Hoyer lift sling snapped and R1 tipped while another sling loop slid off. R1 fell to the ground and his back landed on the Hoyer lift. R1's right arm bled, and CNA M covered it as she ran to get the nurse. R1 complained of back pain but they did not move him until the ambulance arrived. R1's medical record revealed the following: An Incident Note on 08/13/24 at 02:07 PM documented at approximately 12:45 PM, two CNAs were in R1's room preparing him for his shower. They had R1 up in the air with the Hoyer lift when the sling came loose, causing R1 to fall to the floor. The CNAs stated R1 hit the lower part of his back on one of the lift legs. When the nurse entered the room, R1 laid flat on his back and voiced extreme low back pain. R1 had abrasions and several skin tears noted to the top of his right forearm. The nurse did not assess R1's back due to waiting for paramedics to arrive. R1 transferred to the emergency room (ER) for evaluation and treatment at approximately 01:30 PM. A Nurse Note on 08/13/24 at 10:28 PM documented R1 returned to the facility. Computed Tomography (CT scan- test that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue, and blood vessels) scan of R1's lumbar and thoracic spine were negative. Staff received no new orders. A Psychosocial Note on 08/14/24 at 11:32 AM documented Social Services X spoke to R1. R1 stated his whole body hurt after the Hoyer lift fall. R1 expressed fear of using the Hoyer lift in the future. Social Services X noted R1 appeared tearful when speaking about the incident. Social Services X planned to follow up on a daily basis as long as R1 needed. A Nurse Note on 08/14/24 at 02:08 PM documented R1 spent the day in bed per his normal. R1 voiced occasional back pain and received as needed (PRN) Tylenol (pain medication) and PRN Oxycodone (pain medication). R1 stated he felt shakier than usual, and he felt tired. A Psychosocial Note on 08/15/24 at 01:03 PM documented Social Services X spoke to R1 in his wheelchair. Staff moved R1 from his bed to his chair via Hoyer lift. R1 complained of pain but he no longer voiced fear of using the lift. The facility's Investigation, dated 08/19/24, documented on 08/13/24 at approximately 12:40 PM, CMA R and CNA M entered R1's room to perform a Hoyer lift transfer from his bed to the shower chair. One operated the lift while the other held the shower chair steady. As the staff lifted R1 up with the Hoyer lift, R1 requested them to check his weight. CNA M told R1 they would obtain his weight after his shower. As staff turned the Hoyer lift from the bed to the shower chair, R1 slid out of the Hoyer sling and onto the floor. CNA M and CMA R noted two of the Hoyer sling loops had popped off of the lift hooks. Staff immediately notified Licensed Nurse (LN) I. LN I called the ambulance and reported the incident to Administrative Nurse D and Administrative Staff A. Both CNA M and CMA R reported R1 hit his back on the leg of the lift and R1 complained of back pain. Staff noted R1 had a skin tear to his right arm. The facility received an order to send R1 to the emergency room (ER) for evaluation. The hospital performed a CT scan on R1's back with no negative results. The hospital discharged R1 back to the facility with a diagnosis of mechanical low back pain. During the investigation, Administrative Nurse D, the Regional Nurse Consultant, and Administrative Staff A re-enacted the incident with CMA R and CNA M. During the re-enactment, CNA M and CMA R did not widen the Hoyer lift legs after they cleared the bed per manufacturer's instructions. As a result, the Hoyer lift became unsteady and R1 slid out of the Hoyer lift during the transfer. On 08/21/24 at 04:40 PM, Social Services X stated she went to R1's room on 08/14/24 to follow-up with him after the fall from the Hoyer lift. She stated R1 voiced being scared of the Hoyer lift and he appeared tearful and in pain. She stated on 08/15/24, she went to talk to R1 because he had been transferred to his wheelchair. She stated R1 was sometimes confused and because he did not mention being scared of the Hoyer lift, she did not remind him that he stated he was previously. On 08/21/24 at 05:16 PM, CNA N stated to prevent accidents with the Hoyer lift, staff placed the lift sling hooks and made sure the secondary hooks were in place too. She stated one staff operated the lift while the other stayed with the resident. CNA N stated the lift legs were closed under the bed and staff opened them up when moving the lift out from under the bed to steady the lift. She stated she completed lift competencies recently. On 08/22/24 at 02:24 PM, LN H stated two staff operated the Hoyer lift at all times and hooked up the same color loops of the lift sling to the Hoyer lift. She stated one staff operated the lift while the other guided the resident and staff opened the lift legs during the transfer for more support. On 08/22/24 at 05:35 PM, Administrative Nurse D stated she expected staff to use two people during Hoyer lift transfers, one to spot while driving the lift and the other to open the lift legs once they were clear of the bed. She stated she expected staff to have the correct sling size and correct sling placement. Administrative Nurse D stated she expected staff to use the appropriate sling lift loops and to make sure to use the back up loop on the sling. She stated staff used a shower lift sling with the Hoyer lift for R1's transfer. She stated one of the failures during R1's transfer included the staff's failure to widen the lift legs and one staff did not stay with R1 while the other operated the lift. On 08/26/24 at 02:57 PM, CMA R stated on 08/13/24, she and CNA M used the Hoyer lift to transfer R1 into the shower chair but as soon as she turned the lift to place R1 in the shower chair from his bed, one of the straps came off and as he fell , another loop came off. She stated it was R1's left side loops that came off. She stated R1 fell on to the floor and his back hit the lift leg. She stated CNA M tried moving the lift out of the way while she got the nurse. CMA R stated they did not use the last loop during Hoyer lift transfer because it did not lift the resident high enough. She stated R1 complained of his back hurting really badly and that he voiced being scared. CMA R stated she completed lift competencies after the incident. On 08/26/24 at 03:03 PM, CNA M stated on 08/13/24, she and CMA R got R1 ready to transfer to the shower chair. She stated they hooked up R1's lift sling to the Hoyer lift and made sure the loops were hooked up correctly. CNA M stated as soon as they lifted R1 and turned the lift toward the shower chair, they thought the lift strap broke. She stated it was his left side that came off, so she assumed his shift in weight caused it because of his left leg amputation. CNA M stated after the incident, Administrative Nurse D pulled her, and the other staff involved in the incident from the floor and went over what happened and did education on how to run the lift properly. She stated during the re-enactment, the Regional Consultant told her they did not open the legs of the lift when moving it and told them the legs needed to be opened for stability. CNA M stated she received lift competencies after the incident. The facility's Safe Resident Handling/Transfers policy, dated 2023, directed all residents required safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. The policy directed two staff members utilized a mechanical lift and staff received education on the use of safe handling/transfer practices to include the use of mechanical lifts upon hire and as the need arose. The facility failed to ensure R1 remained free from preventable accidents during a Hoyer lift transfer. This deficient practice resulted in impaired psychosocial well-being and placed R1 at risk for further complications. The facility put the following corrections into place: The facility updated R1's care plan on 08/13/24. Maintenance U inspected the Hoyer lift on 08/13/24. Physical Therapy (PT) evaluated R1 on 08/14/24. Direct care staff received mechanical lift, fall prevention, and abuse education on 08/14/24. Because the facility implemented and completed the corrections prior to the onsite survey, this deficient practice was cited as past noncompliance.

The facility identified a census of 31 residents. The sample included three residents. Based on observation, record review, staff and resident interview, the facility failed to maintain a safe and secure environment, resulting in the elopement of one (#1) resident which placed the resident in immediate jeopardy. Findings included: - On 8-8-11, the facility notified the State reporting agency of an elopement on 8-8-11 of resident #1. The resident eloped when resident #4, with whom he/she sat outside, went back into the facility. The facility staff were not aware of the elopement until notified by resident #4. The September 2011 physician's orders [REDACTED]. The 7-3-11 Quarterly Minimum Data Set (MDS) noted the resident had clear speech; the resident understood and staff understood him/her; he/she scored 5 on the Brief Interview of Mental Status (BIMS) which indicated severe cognitive impairment; was independent for all Activity of Daily Living (ADL) tasks but required physical help with transfers for bathing; used a walker; had one non injury fall and one fall with injury since admission on 3-22-11; and determined that discharge to the community was not feasible. The 4-3-11 Care Area Assessment (CAA)for Cognition noted causal factors were due to dementia; the resident had short and long term memory loss; had a BIMS score of 4 (severe impairment), and a Mini Mental score of 19 out of 30; he/she did not take medications for dementia and was at risk for decline. The 4-3-11 CAA for Psychological Well-Being noted the resident was upset with nursing home placement; the resident stated he/she wanted to do what he/she wanted, when he/she wanted and could not do that here, and stated he/she was a farmer all of his/her life and did not like to stay cooped up in a house or a building like this. When asked what the facility could do to make his/her life better, the resident stated, "send me home." The 4-3-11 CAA for Falls noted the resident had falls related to balance problems; staff obtained orders for Physical Therapy (PT) to work on balance, strengthening and ambulation secondary to poor balance and fall risk; and the Fall Risk Assessment score of 6 indicated no fall risk. The 7-1-11 Fall Risk assessment score of 11 indicated the resident was a high risk for falls and indicated balance as a problem; the 8-8-11 assessment score of 8 indicated he/she was not a risk for falls (a score of 10 or above represented a high risk). The Wandering/Absent Without Leave (AWOL) Risk assessment dated [DATE] noted: - The resident was alert and oriented. - Had potential cognitive impairment. - Signed in and out per policy. - Not a risk for AWOL at this time. The 4-8-11 Care Plan for Alteration in Thought Process due to the [DIAGNOSES REDACTED]. - Communicate and reinforce directions - Tell the resident what you are going to do before you do it - Provide the resident all the time needed to process questions and answers The undated Care Plan that, The Resident Was Unhappy About Being Here, noted the goal was to make the resident happy or at least less mad about being here by having him/her attend social coffee once a week, Bingo once a week and attended a movie once a week. - The Care plan update on 8-8-11 noted the resident can sit outside with staff or family supervision The 5-9-11 Care Plan for Falls noted on 5-9-11 that therapy worked with the resident, and on 6-27-11 related to a non injury fall, staff re-educated the resident in use of his/her walker and staff to monitored to be sure it was within his/her reach. The Social Service Notes on the 3-23-11 (not timed) admission 3-23-11 revealed the resident wanted to go home, but the family was not sure as they worried about him/her not being able to care for him/herself; and as the resident had trouble being at the nursing home, he/she wanted to go home and just do what he/she wanted to do. The 3-23-11 Nurses Notes revealed the resident had some confusion. The 3-30-11 Nurses Notes revealed the MDS noted short and long term memory deficit with poor recall of person and place. During an interview on 9-8-11 at 12:34 P.M., licensed nursing staff D said he/she signed the 3-23-11 AWOL assessment, but did not review the social service notes before filling out the assessment. Staff D said that after reading the 3-23-11 Social Service notes he/she, "would have assessed the resident differently on 3-23-11." The 6-30-11 Nurses Notes revealed the resident had poor short and long term memory depending on the day; the resident was able to recall the location of his/her room; the resident went daily to the front door and attempted to go outside; and he/she looked at the security number pad and pushed the door. During an interview on 9-9-11 at 10:05 A.M., licensed nursing staff C said he/she wrote the 6-30-11 Nurses Note regarding the door seeking behavior, and said he/she had no concerns about elopement as the staff usually re-directed the resident. The 7-1-11 AWOL Risk Assessment noted the resident was not a risk at this time for AWOL. On 9-8-11 at 1:18 P.M., licensed nursing staff A said he/she signed the 7-1-11 AWOL assessment and did read the Social Service notes, but did not consider it a concern as the resident did not attempt an elopement. The 7-26-11 at 4:30 P.M. Social Service note revealed the resident was very determined to go home in the past 2 days, he/she talked about waiting for a ride, sat outside and stated he/she might go looking for his/her car so he/she could go home. Staff heard remarks of the resident stating that he/she might just walk home. The Administrator asked the resident's family to speak with the resident. Staff kept a close eye on the resident. The 8-3-11 at 8:00 A.M. Social Service Notes revealed the resident was upset when he/she returned from the county fair with family because the family would not get his/her car, and he/she did not understand that he/she could not drive any longer. The 8-8-11 at 3:45 P.M. Nurses Notes revealed the resident sat outside with another peer enjoying the weather. The peer came back inside and left the resident outside alone. When the staff looked outside to check on the resident a few minutes later, the resident was no longer there and his/her walker was. Direct care staff completed a room to room search. The administrator and Physical Therapist (PT) checked around the facility, and found the resident approximately 5 blocks away by the grade school. The resident ambulated back into the facility, stated he/she was all right, that he/she checked traffic before crossing the intersection and denied falling. A complete head to toe assessment revealed no reddened, bruised or abraised areas. The resident's vital signs were stable with a pulse of 95, respirations of 20, temperature of 99.8 Fahrenheit (F), and oxygen saturation of 92 %. The resident accepted a glass of water and staff encouraged him/her to drink it all and to sit for a while. The Administration informed the resident that he/she could only go out and sit now if accompanied by the staff or a family member. The resident responded that "he/she understood that." The resident felt he/she needed to be at home helping in the fields. The elopement, as reported to the State reporting agency on 8-8-11, at 5:11 P.M. revealed that on 8-8-11 at approximately 3:20 P.M., resident #4 informed administrative staff A that resident #1 was no longer on the porch outside where he/she left the resident alone approximately 5-10 minutes before. Administrative staff A initiated a search inside and then outside the facility. According to the weather channel.com, the temperature was 84 degrees F with 44 % humidity. At 3:22 P.M., the facility initiated the outside search for the resident. At 3:29 P.M., the facility received a call from Physical Therapy (PT) staff A that he/she found the resident and was in route to the facility with him/her. On 9-8-11 about 4:45 P.M. the National Weather Service reported the temperature was on 8-8-11 was 84.0 degrees F. On 9-9-11 at 10:17 A.M., PT staff A identified the location where he/she found the resident during the 8-8-11 elopement, a distance of 0.35 miles; the location was approximately 25 feet from the grade school parking lot driveway. The grade school bordered on a busy two lane State highway. To arrive at this location, the resident crossed another State highway which was a through street running through town with a stop sign at the intersection which the resident crossed. On 9-8-11 at 4:10 P.M. PT staff A said he/she worked with the resident after his/her falls, and as balance was an issue, put the resident on a walker. The day of the elopement, staff A went to look for the resident; it was a fairly hot day; he/she found the resident walking without his/her walker on the side of the road as there were no sidewalks; the resident told staff A he/she was going home, got into staff A's vehicle and returned to the facility. Staff A said they knew the potential for elopement was there when the resident was outside daily, because of his/her memory, more so than others, but they felt the resident was safe if they kept an eye on him/her. During an interview on 9-8-11 at 12:45 P.M. administrative staff B said, when the resident came on 3-23-11, he/she was upset and wanted to go home, he/she did not want to be here. The updated 8-8-11 Care Plan for At Risk for Door Seeking noted: - Monitor what the resident said and any door seeking behaviors - Give reality orientation as needed - Offer choices to redirect, if he says NO, do not repeat as it tends to agitate. Staff to re-approach later if needed. - Staff to offer to walk outside or sit on front porch with the resident if wanting to go outside. Notify charge nurse if taking the resident outside. - Notify family for phone conversation with resident or possible visits PRN. The 8-10-11 updated Wandering Assessment noted: - The resident was alert and oriented - Was cognitively impaired - Did not sign in and out - Did not wander (defined as locomotion with no discernible, rational purpose, without regard to physical or safety needs) - Had a pattern of AWOL , noted he/she left the faciity on [DATE] - The assessment for risk noted he/she was at risk; he/she liked to sit outside, and staff to sit with him/her when he/she wanted to go outside. A review of the Nurses Notes revealed the resident usually had normal temperatures of 97.4 F 3-23-11, 97.5 F on 6-30-11, 99.0 F on 7-17-11. On 9-8-11 at 3:30 P.M. licensed nursing staff B said that the staff documented the vital signs in the Nurses Notes and this resident seemed to have a trend of 97 F in the mornings increasing to about 98 F in the evenings. Staff B did not think the 99.0 F temperature was out of line for this resident. During an observation on 9-8-11 at 9:55 A.M., the resident ambulated rapidly throughout the facility with a four wheeled walker and was steady on his/her feet. During a brief interview, the resident knew his/her name, but not the place and time. During an interview on 9-8-11 at 10:45 A.M., resident #4 revealed he/she knew the key code to the door lock and went outside whenever he/she wanted to. Resident #4 said he/she did not understand why resident #1 could not go outside by him/herself as there were residents that sat outside all the time and they did not have staff with them. On 9-8-11 at 3:41 P.M. resident #5 said residents went outside without staff all of the time. On 9-8-11 at 3:34 P.M. resident #6 said there were residents that went outside and sat by themselves without any staff and that it was always like that. During an interview on 9-8-11 at 11:00 A.M. licensed nursing staff B said there were only two residents who had the key pad code and all the other residents had to go outside with a staff member; the day that resident #1 eloped, he/she went outside with resident #4 who was one of the two residents with the keypad code. An interview on 9-8-11 at 1:35 P.M. with administrative staff A revealed the resident went outside by him/herself and sat on a bench in front of the office; and all the staff knew that he/she wanted to go home but as he/she did not door seek, he/she was not trying to elope. Licensed nursing staff B on 9-8-11 at 4:24 P.M. said the resident usually sat on a bench outside the business office and the staff monitored the residents through the window; the day that this resident eloped, we noticed he/she missing at 3:07 P.M. and PT staff A called us at 3:15 P.M. to say the resident was safe; and it was resident #4 who told us the resident was not outside any longer, so the staff did not notice he/she was gone. The facility was notified on 9-8-11 at 5:10 P.M. that they were in Immediate Jeopardy. The facility failed to provide supervision for this cognitively impaired resident with a documented desire to return home and episodes of door seeking behavior, when the resident was outside of the facility and therefore placed this resident in immediate jeopardy. The facility abated the Immediate Jeopardy on 9-12-11 at 9:30 A.M. when it implemented the following: The facility letter of 9-8-11 to the State reporting agency noted: 1) The immediate intervention for the elopement on 8-8-11 was that the resident was only allowed to go outside with a family member or facility staff. 2) Facility staff was immediately instructed of the resident's change in plan of care and risk of elopement. This instruction was noted in the nursing report of 8-8-2011 and 8-9-2011 and also documented in the nursing communication book on 8-8-11 and 8-10-11. 3) Other residents will have a revised elopement risk assessment done 9-9-11. Residents identified to be at risk for elopement will have appropriate interventions implemented and care planned. 4) An inservice on elopement was conducted at an all staff in service 8-22-11. The Wandering Policy reviewed 9-8-11 noted: The Purpose: To assure the safety for the wandering and/or door seeking resident. The Procedure: 1) Residents will be assessed by a licensed nurse upon admission, quarterly, and with any significant change for wandering and/or door seeking behaviors to identify causal factors and patterns. 2) Residents who attempt door seeking will be but not limited to redirection, offered activities, offered snacks, offered toileting, ambulate with resident, bring resident to common area for observation and 1:1 with resident. 3) 15 minute checks for 72 hours will be initiated. If no further door seeking, the resident will then be checked every 30 minutes for four days. If no further door seeking after four days then the checks will be discontinued. 4) It the resident did not respond to the redirection, another staff member may be invited to assist, one that the resident is especially fond of or is preferred, or notify family for a phone conversation with the resident or a possible visit with the resident. If it becomes necessary, physician and family will be notified for a care planning meetings. 5) A list of at risk residents will be reviewed during the Quality Assurance (QA) meeting. The 9-9-2011 Wandering/Elopement Risk Assessment noted: Completed upon admission, quarterly, or with significant change. Resident Assessment included: - Was the resident cognitively impaired with poor decision making skills - does the resident ambulate independently with/without the use of an assistive device - Does the resident have any visual or auditory deficits - Does the resident verbally express the desire to go home - Does the resident have a history of elopement - Does the resident have a history of leaving the facility without informing staff or signing out - Does the resident wander aimlessly - Is the resident a new admission (within past 30 days) and not accepting the new situation - Does the resident receive any medications that increase restlessness or agitation - Is this a new behavior, has there been a medication change - Is the resident experiencing pain - Has the resident sustained [REDACTED]. - Is the resident wandering/seeking to find spouse and/or family The Inservice and Meeting Report dated 9-10-11 noted the facility reviewed the new/revised Wandering/Elopement risk assessment, the Wandering/Elopement risk policy, and staff checked with the charge nurse before allowing a resident to go outside unattended. All facility staff attended the inservices, and signed that they understood the revised policy and the new assessment and would ask the Charge Nurse prior to allowing resident's outside without attendance. All staff were inserviced by 9/12/11 at 9:30 A.M. The deficient practice remains at a scope and severity of a D.

The facility identified a census of 31 residents. The sample included 3 residents. Based on observation, interview and record review, the facility failed to provide a safe environment for 3 residents. (#1, #2, #3) Findings included: - Resident #1 ' s physician order [REDACTED]. The minimum data set (MDS) 3.0 dated 3/22/11 recorded the resident with severe cognitive impairment, disorganized thinking and delusions. The MDS further recorded the resident required extensive assistance for transfers, locomotion, bed mobility, dressing and toileting. The MDS further recorded the resident required a side rail while in bed. The Alzheimer ' s care plan dated 3/24/11 directed staff: ? Communicate and reinforce directions ? Use simple sentences when communicating with resident ? Tell resident what you are going to do before you do it ? Allow the resident timed needed to process questions and answers ? Offer simple choices as much as possible ? Allow resident to participate as much as possible in self care ? Use task segmentation The falls care plan dated 3/24/11 directed staff the resident was at risk for falls related to dementia, end stage Alzheimer ' s Disease, and antidepressant drug use. It further directed the resident had a personal alarm on at all times, and was on the falling leaf program. The care plan did not address the use of the electric lift chair. Observation on 4/28/11 at 11:30 A.M. revealed the resident in his/her room in bed, and laid on the right side, with the side rail up on the wall side. The family was present in the resident ' s room. The fall investigation dated 4/19/11 recorded on 4/13/11 the resident was found on the floor in his/her room and his/her electric lift chair seat was raised all the way up, and the heat and massaging features were turned on. (An electric lift chair lifted the resident from a sitting to a standing position, and was operated by a controller unit attached to the chair.) The investigation further recorded the resident complained of pain in his/her left leg and hip and was sent to the emergency room where it was diagnosed the resident ' s left leg was broken. During interview on 4/28/11 at 8:45 A.M., administrative staff A stated the facility did not assess residents for their ability to safely use electric lift chairs. Administrative staff A further stated the facility did not have a policy for electric lift chair use. Administrative staff A continued the facility did not assess residents for electric lift chair use before, but started to yesterday. During interview on 4/28/11 at 10:55 A.M., direct care staff E stated staff kept the resident ' s controller for the lift chair in the pocket on the side of the resident ' s chair when the resident was in the chair, and the staff kept it in the pocket for as long as direct care staff E could remember, for the past 6 months to 1 year. Direct care staff E stated staff did that because the resident played with the buttons, and moved the seat (up and down) with the buttons on the controller. Direct care staff E continued staff would " catch " the resident as he/she moved the chair seat up and down and took the controller away from him/her. During interview on 4/28/11 at 2:20 P.M.,licensed staff C stated the resident sat usually in his/her lift chair after meals. Licensed staff C further stated the staff kept the controller for the lift chair in the side pocket of the chair, because staff worried the resident was not able to use the controller safely, and might fall from the chair. During interview on 4/28/11 at 3:02 P.M., direct care staff F stated the resident used to sit in his/her lift chair after meals. Direct care staff F further stated for about the past year, the resident was able to use the controller at times when he/she was not confused, and when the resident was confused, he/she pushed buttons that would push the chair seat up. Direct care staff F continued, " we would catch (him/her) before (he/she) fell , and put the controller where (he/she) could not reach, and I reported it to the charge nurse. Everybody took the controller away from (the resident) " . During interveiw on 4/28/11 at 4:55 P.M., direct care staff G stated they did not give the resident his/her controller for the lift chair, because the resident did not know how to use it. Direct care staff G further stated the staff put the controller out of the resident ' s reach because the resident might have used the controller and fell out of the chair, " just like (he/she) did " . Direct care staff G continued that all staff including the charge nurses knew about keeping the controller out of the resident ' s reach. During interview on 4/28/11 at 9:15 A.M., the resident ' s family member stated when he/she came to visit, the lift chair controller was hanging over the side of the chair, and staff kept it out of reach. The family member further stated the resident told him/her they could get out of the lift chair if they wanted to. During interview on 4/28/11 at 328 P.M., administrative staff B stated they were aware the resident sat in the electric lift chair, and the resident had a personal alarm on at all times. Administrative staff B further stated they were not aware the staff kept the resident ' s controller out of the resident ' s reach. Administrative staff B further stated they thought the resident was able to use his/her controller, and thought the resident could pick up the controller from the side of the chair. The facility failed to assess or care plan this cognitively impaired, dependent resident for safety using the electric lift chair controller, which resulted in the resident ' s fall and broken leg. - Resident # 2 ' s physician's order [REDACTED]. The admission Minimum Data Set (MDS) 2.0 dated 09/28/10 recorded the resident with short term memory problems and modified decision making skills. The resident was extensive assistance with bed mobility, transfers, walking, dressing, toilet use and personal hygiene. The resident had fallen and had a fracture in the previous 180 days. The Resident Assessment Protocol for activities of daily living dated 09/28/10 recorded the resident with a recent hospitalization for a fractured left clavical which was sustained at home in a fall. The resident required assistance with bed mobility, transfers, walking, locomotion, dressing, toileting, bathing and to get out of bed. The resident ' s gait was slow and steady using a hemiwalker. The resident was working with therapy. The quarterly MDS 3.0 dated 03/15/11 recorded the resident was cognitively intact. The resident required limited assistance with bed mobility and extensive assistance with transfer, walking, locomotion, dressing, toilet use and personal hygiene. The resident was unsteady moving from a seated position, walking, turning around, moving off the toilet and with surface to surface transfers. The resident used a walker and a wheelchair. The resident did not have any recent falls. Review of the fall assessment dated [DATE] revealed the resident was a high risk for falls. Review of the resident ' s medical record revealed a lack of any assessment regarding the resident ' s safety with the use of an electric lift chair prior to the date of 04/27/11 when a facility assessment Electric Lift Chair Use Demonstration/Assessment Form dated 04/27/11 recorded the resident was able to operate the chair controls safely. Review of the care plan for activities of daily living with a review date of 03/18/11 recorded the resident with an actual self care deficit due to a fractured left clavicle. The care plan directed staff to provide 1 staff assistance as needed or requested for repositioning, transfers, ambulation, dressing and with toileting. The care plan for falls with a review date of 03/18/11 directed staff to answer call light promptly, assist the resident to ambulate and transfer, check the resident frequently during rounds and the resident was on a falling leaf program. Nursing staff failed to address the resident ' s electric lift chair until an intervention was added on 04/27/11 which directed the resident had an electric lift recliner in the room which he/she could operate. During observation on 04/28/11 at 9:15 A.M. direct care staff E entered the resident ' s room in response to the resident ' s call light. The resident sat up in the lift chair. Staff used the lift chair remote to raise the resident up to standing. Staff placed a gait belt around the resident and placed the resident ' s walker in front of him/her. The resident began to attempt to stand before the chair was all the way up and staff told the resident to wait until the chair was in the full upright position. Staff then provided standby assistance holding onto the gait belt as the resident used the walker to ambulate to the bathroom. During staff interview on 04/28/11 at 12:05 P.M. nursing staff C reported staff monitored residents with lift chairs to make sure they were safe to use them, but this was not documented in the clinical record. The facility provided a list of resident ' s who used electric lift chairs which indicated this resident had a lift chair on 04/19/11. The facility nursing staff failed to assess resident # 2 ' s safe use of an electric recliner in a timely manor for this dependent resident with a fracture and a history of falls. - Resident # 3 ' s physician's order [REDACTED]. The annual Minimum Data Set 3.0 dated 04/05/11 recorded the resident as cognitively intact. The resident was independent with bed mobility, transfers and walking and limited assist with dressing. The resident used a walker and wheelchair. The resident did not have any falls in the previous 6 months. The Care Area Assessment for activities of daily living dated 04/06/11 recorded the resident with safety issues and required limited assistance with dressing and bathing. He/she had a slow and steady gait using a rolling walker. Review of the resident ' s medical record revealed a lack of any assessment regarding the resident ' s safety with the use of an electric lift chair prior to the date of 04/27/11 when a facility assessment Electric Lift Chair Use Demonstration/Assessment Form dated 04/27/11 recorded the resident was able to operate the chair controls safely. The care plan for activities of daily living dated 04/11/11 directed the resident was independent with bed mobility, transfers and ambulation. Staff were to keep the resident ' s call light in his/her reach. The care plan failed to address the resident ' s use of a lift chair until an intervention was added by nursing staff on 04/27/11 which directed the resident had an electric recliner and was able to use it. The care plan failed to direct nursing staff to monitor the resident ' s safety during use of the recliner. The facility provided a list of resident ' s who used electric lift chairs which indicated this resident had a lift chair on 04/19/11. During observation on 04/28/11 at 9:30 A.M. the resident sat in the lift chair and used the control to lift the chair up into the air which raised him/her up to a standing position. Using the walker the resident ambulated over to the bathroom independently. During interview on 04/28/11 at 2:32 P.M. direct care staff G reported the resident was able to use the lift chair on his/her own safely because he/she demonstrated use of the chair and was able to remember to be safe with the chair. Staff G reported if he/she noticed the resident was acting more confused and unsafe them he/she would put the lift chair controls out of the resident ' s reach so he/she couldn ' t use the lift mechanism and then the charge nurse would be notified. During interview on 04/28/11 at 1:58 P.M. administrative staff B reported a lot of times a resident ' s family requested a lift chair for the resident. The facility did supply some resident ' s with a lift chair if the facility had an available chair and the resident could demonstrate safe use of the chair. The facility provided electric lift chairs using nursing judgment only and nothing was documented on paper. Administrative staff B reported recently the Demonstration Assessment form was started in response to another resident who fell and fractured his/her leg. That assessment should be done quarterly and with a significant change. Now instead of nursing judgment only, nursing staff also would use the assessment form to determine safe use of an electric lift chair. He/she expected staff to inform him/her if a resident with a lift chair was unsafe. The facility nursing staff failed to assess this resident for the safe use of an electric lift chair prior to the use of the lift chair.