Every finding on record at Oakhurst Health & Rehabilitation

Based on staff interview, clinical record review, and facility document review, the facility staff failed to notify the physician or responsible party of a change in condition and/or need to alter treatment for two of seven residents, Residents #1 and #2. The findings include: 1. For Resident #1 (R1) the facility staff failed to notify the responsible party of change in condition. R1 diagnoses include but were not limited to Alzheimer's disease (1), aphasia (2) dysphagia (3), and protein-calorie malnutrition (4). On the most recent minimum data set (MDS), nursing home discharge of 6/6/2026, the resident's BIMS (brief interview for mental status) score was not entered. Section C-Cognitive Patterns documented the resident's daily decision making as moderately impaired-decisions poor; cues/supervision required. It further documented R1 having a weight loss of 5% or more in the last month or loss of 10% or more in last six months. Additionally, Section M-Skin Conditions documented the resident with unhealed pressure injuries. The progress notes for R1 documented in part, -6/3/2026 13:40 (1:40 PM), Note: seen today for follow-up and review of laboratory results obtained on 06/01/2026 for monitoring of cirrhosis. The patient was admitted to the skilled nursing facility following hospitalization on 05/19/2026 for acute clinical deterioration. Since his return to the SNF (skilled nursing facility), vital signs have been stabilizing with blood pressure improving from 90/52 mmHg at the time of hospitalization to the 120s/70s range, most recently 128/70 mmHg on 06/01/2026. Heart rate has remained stable in the 80s. Oxygen saturations have improved from the 80s on room air during the hospitalization to 94-98% on current monitoring. Weight was documented at 141.5lbs on 06/01/2026, decreased from 161.5lbs on 04/02/2026, likely reflecting diuresis achieved during and after hospitalization. Liver function panel obtained on 06/01/2026 demonstrates worsening hepatic function compared to prior values. ALT(5) (alanine aminotransferase) has increased to 166. At the SNF initial visit on 05/28/2026, the patient remained lethargic with decreased alertness from baseline, with +1 pitting edema bilateral feet. GENERAL- Lethargy, Change in alertness from baseline, No weight changes, No fatigue, No fever, No night sweats, No chills, No dizziness. RESPIRATORY- No shortness of breath, No cough, No wheezing, No chest pain with breathing, No sputum, No blood in sputum. NEUROLOGICAL- Decreased alertness from baseline, non-verbal. Lethargy and decreased alertness from baseline noted on today's examination; no acute agitation or behavioral changes reported. Nursing staff to monitor for agitation or behavioral changes and document triggers or safety concerns, and to notify provider if symptoms worsen. Follow-up chest x-ray to document resolution of left lower lobe pneumonia (recommended 02/2026, remains outstanding)- Continue monitoring bilateral foot edema and right lower extremity petechiae(6); report worsening swelling, new petechiae, or signs of bleeding - Continue nutritional monitoring with periodic albumin and weight assessments; albumin decreased from 3.2 to 3.0 to 2.9 g/dL - Continue monitoring LFTs (liver function test) and platelet counts per facility schedule - Monitor for changes in alertness and lethargy following hospitalization. -6/4/2026 19:22 (9:22 PM), Note: seen today for general decline. Collateral information was obtained from nursing staff, as the patient is aphasic and non-verbal at baseline. His functional status has declined since re-admission to the facility following recent hospitalization. Nursing reports the patient is intaking less than 25% of meals, pocketing food at the lowest gradable diet consistency, and pocketing medications. Nutritional parameters reflect progressive decline. Weight has decreased from 161.5lbs on 04/02/2026 to 141.5lbs on 06/01/2026. Serum albumin has trended downward from 3.2 g/dL on 02/18/2026 to 3.0 g/dL on 05/19/2026 to 2.9 g/dL on 06/01/2026, consistent with ongoing protein-calorie malnutrition. Liver function panel obtained on 06/01/2026 demonstrates worsening hepatic function: ALT 166 U/L, AST (aspartate aminotransferase) 136 U/L, alkaline phosphatase 248 U/L, total bilirubin 1.4 mg/dL, direct bilirubin 0.85 mg/dL, GGT (gamma-glutamyl transferase) 287 U/L, and albumin 2.9 g/dL. These values represent continued upward trending of transaminases, alkaline phosphatase, bilirubin, and GGT, with progressive decline in albumin, reflecting ongoing hepatic inflammation and progressive synthetic dysfunction in the setting of cirrhosis. Given the patient's overall clinical decline with progressive functional deterioration, poor nutritional status, and worsening hepatic synthetic dysfunction, the responsible party will be notified to discuss goals of care, with recommendations for palliative care consultation and hospice transition. -6/5/2026 20:51 (8:00 PM), Note: Notified RP; [RP's name] regarding clinical concerns regarding overall physiological decline. VM (voice message) left. On 7/2/2026 at 2:23PM, an interview was conducted with Nurse Practitioner (NP). NP stated there was nutritional declined. NP stated they left a voice message for the RP (responsible party) to recommend transference to hospice for palliative care. NP stated that the RP didn't contact them back and that they never got a chance to discuss end of life planning. On 7/2/2026 at 2:50 PM, an interview was conducted with the Attending Physician (AP). AP stated that they usually try to talk with the RP about a change of condition but because R1 was doing better they did not speak with the RP about end-of-life planning. When the AP was asked who is responsible for discussion of end-of-life planning such as hospice/PEG (percutaneous endoscopic gastrostomy) tubes and IV (intravenous) fluids, the AP stated themself as the admitting physician or the NP. The facility's policy Change in a Resident's Condition documented in part, The facility will promptly notify the representative of changes in resident's medical/mental condition and /or status.except in medical emergencies, notification will be made within twenty-four hours of a change occurring in the resident's medical condition. On 7/2/2026 at 9:30 AM, Administrator, Regional Clinical Services Director and the Director of Nursing were notified of the findings. No further information was provided prior to exit. References: 1. Alzheimer's Disease-Alzheimer's disease (AD) is the most common form of dementia among older people. Dementia is a brain disorder that seriously affects thinking and memory skills. https://medlineplus.gov/alzheimersdisease.html 2. Aphasia-Aphasia is a language disorder that makes it hard for you to read, write, and say what you mean to say. Sometimes it makes it hard to understand what other people are saying, too. Aphasia is not a disease. It's a symptom of damage to the parts of the brain that control language. https://medlineplus.gov/aphasia.html 3. Dysphagia- a swallowing disorder, you may have difficulty or pain when swallowing. https://medlineplus.gov/swallowingdisorders.html 4. Protein-Calorie Malnutrition-is a condition caused by a lack of adequate dietary intake of protein, calories (energy), or both. It leads to poor growth, weight loss, muscle wasting, diminished immunity, and impaired organ function. https://my.clevelandclinic.org/health/diseases/22987-malnutrition 5.ALT (aspartate aminotransferase)- The aspartate aminotransferase (AST) blood test measures the level of the enzyme AST in the blood. https://medlineplus.gov/ency/article/003472.htm 6.Petechiae- tiny, pinpoint red, purple, or brown spots caused by minor bleeding under the skin or mucous membranes. https://www.ncbi.nlm.nih.gov/books/NBK482331/ 2. For Resident #2 (R2), the facility staff failed to notify the physician of medications not administered when the resident was out of the facility for scheduled appointments on multiple dates reviewed in May and June 2026. On the most recent minimum data set (MDS), a significant change assessment with an assessment reference date (ARD) of 5/22/2026, the resident was assessed as receiving dialysis while a resident. It further documented R2 receiving scheduled pain medication, an antipsychotic, antidepressant, opioid and anticonvulsant medication. Review of the physician orders documented the following orders: - Acetaminophen Oral Tablet (1) 500 MG (Acetaminophen) Give 2 tablet by mouth three times a day for pain. Order Date: 12/11/2025. - Amlodipine Besylate (2) Oral Tablet 10 MG (milligram) (Amlodipine Besylate) Give 1 tablet by mouth in the morning for HTN (hypertension). Order Date: 04/15/2026. - Calcium Acetate (Phos Binder) (3) Oral Capsule 667 MG (Calcium Acetate (Phosphate Binder)) Give 2 capsule by mouth three times a day for ESRD. Order Date: 12/11/2025. - Cetirizine HCl (4) Tablet 10 MG Give 0.5 tablet by mouth one time a day every Mon, Wed, Fri for Allergy symptoms Total dose: 5mg. Order Date: 12/12/2025. - Docusate Sodium (5) Oral Capsule 100 MG (Docusate Sodium) Give 1 capsule by mouth one time a day for constipation. Order Date: 12/11/2025. - Eliquis (6) Oral Tablet 2.5 MG (Apixaban) Give 1 tablet by mouth two times a day related to acute on chronic diastolic (congestive heart failure); acute embolism and thrombosis of left popliteal vein; acute embolism and thrombus of right popliteal vein. Order Date: 12/11/2025. - Ipratropium-Albuterol Solution 0.5-2.5 (7) MG/3ML 3 ml inhale orally via nebulizer three times a day related to Chronic obstructive pulmonary disease, unspecified. Order Date: 12/11/2025. - Lactobacillus (8) Oral Tablet 0.05-0.05 MG (Lactobacillus) Give 1 tablet by mouth one time a day for constipation. Order Date: 12/11/2025. - Lidocaine Pain Relief External Patch (9) 4 % (Lidocaine) Apply to Shoulders bilaterally topically one time a day for Pain On in the morning. Order Date: 12/11/2025. - Lurasidone HCl (10) Oral Tablet 40 MG (Lurasidone HCl) Give 1 tablet by mouth in the morning for Schizophrenia . Order Date: 4/24/2026. - Methocarbamol (11) Oral Tablet 750 MG (Methocarbamol) Give 1 tablet by mouth three times a day for Chronic pain. Order Date: 12/11/2025. - Metoprolol Succinate ER (extended release) (12) Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 1 tablet enterally one time a day related to Essential (primary) Hypertension. Order Date: 01/25/2026. - Midodrine HCl (13) Oral Tablet 5 MG (Midodrine HCl) Give 5 mg by mouth two times a day for symptomatic hypotension symptomatic hypotension (SBP <90); hold if SBP >110 or DBP>70; check BP prior to each dose and 1 hour post-dose; do not administer within 4 hours of bedtime; notify provider if SBP <80, persistent symptoms after 2 doses. Order Date: 04/24/2026. - Revatio (14) Oral Tablet 20 MG (Sildenafil Citrate (Pulmonary Hypertension)) Give 2 tablet by mouth one time a day related to Pulmonary Hypertension, Unspecified. Order Date: 12/11/2025. - Renal Oral Capsule (15) 1 MG (B-Complex w/ C &Folic Acid) Give 1 capsule by mouth one time a day for Supplement. Order Date: 12/12/2025. - Sertraline HCl (16) Oral Tablet 25 MG (Sertraline HCl) Give 3 tablet by mouth one time a day for Depression related to Depression, Unspecified. Order Date: 12/11/2025. Review of the eMAR (electronic medication administration record) for R2 dated 5/1-5/31/2026 documented the resident missing nine doses of the Docusate and Metoprolol,10 doses of the Amlodipine, Lactobacillus, Revatio, Eliquis and Calcium acetate, 11 doses of the Cetirizine, Lurasidone, Renal capsule, Sertraline, Midodrine and Methocarbamol, 12 doses of the Lidocaine patch and Ipratropium-Albuterol nebulizer and 13 doses of the Tylenol during the month at scheduled morning doses. The eMAR notes documented the resident was out at dialysis or out of the facility and failed to evidence notification of the physician of the multiple missed medications. Review of the eMAR for R2 dated 6/1-6/30/2026 documented the resident missing 10 doses of the Amlodipine, Lactobacillus, Lurasidone, Metoprolol, Sertraline, 11 doses of the Cetirizine, Docusate, Renal capsule, Eliquis, Midodrine, 12 doses of the Revatio, Tylenol, Methocarbamol, 13 doses of the Lidocaine patch, 14 doses of the calcium acetate and 15 doses of the Ipratropium-Albuterol nebulizer. The eMAR notes documented the resident was out at dialysis or out of the facility and failed to evidence notification of the physician of the multiple missed medications. On 7/1/2026 at 2:02 PM, an interview was conducted with registered nurse (RN) #2 who stated that R2 left for dialysis early and was not given any medications from the day shift before leaving. She stated that the medication administration times were 7-11 AM and it was out of the timeframe when R2 got back which was usually a little after 1:00 PM. She stated that the physicians and nurse practitioner were already aware of R2 not getting the medications on dialysis days, so they just wrote notes that the resident was out. She stated that the nurse practitioner had told them in the past that the medications would be dialyzed out of the resident anyway. On 7/1/2026 at 2:29 PM, an interview was conducted with the nurse practitioner who stated that R2 should be getting the medications ordered prior to dialysis before she left the building and if the others were scheduled while she were at dialysis she would expect them to be given when the resident returned. The facility policy Change in a Resident's Condition documented in part, .The nurse will notify the resident's Attending Physician/practitioner or physician on call when there has been a(an): .need to alter the resident's medical treatment significantly; refusal of treatment or medications two (2) or more consecutive times . On 7/1/2026 at approximately 5:06 PM, the interim Administrator, the Administrator in training, the Director of Nursing and the Regional Director of Clinical Services were made aware of the concern. No further information was provided prior to exit. Reference: (1) Acetaminophen is used to relieve mild to moderate pain and to reduce fever. Acetaminophen is in a class of medications called analgesics (pain relievers) and antipyretics (fever reducers). It works by changing the way the body senses pain and by cooling the body . This information was obtained from the website: Acetaminophen: MedlinePlus Drug Information (2) Amlodipine is used to treat high blood pressure . Amlodipine: MedlinePlus Drug Information (3) Calcium acetate is used to control high blood levels of phosphorus in people with kidney disease who are on dialysis (medical treatment to clean the blood when the kidneys are not working properly). Calcium acetate is in a class of medications called phosphate binders. It binds phosphorus that you get from foods in your diet and prevents it from being absorbed into your blood stream . This information was obtained from the website: Calcium Acetate: MedlinePlus Drug Information (4) Cetirizine is used to treat allergy symptoms . Cetirizine: MedlinePlus Drug Information (5) Docusate Sodium- Stool softeners are used on a short-term basis to relieve constipation . Stool Softeners: MedlinePlus Drug Information (6) (Eliquis)Apixaban is used to: prevent strokes or blood clots in people who have atrial fibrillation (a condition where the heart beats irregularly and can lead to clots and stroke) in adults. prevent deep vein thrombosis (DVT; a blood clot, usually in the leg) and pulmonary embolism (PE; a blood clot in the lung) in certain situations. treat DVT and PE . Apixaban: MedlinePlus Drug Information (7) The combination of albuterol and ipratropium is used to prevent wheezing, difficulty breathing, chest tightness, and coughing in people with chronic obstructive pulmonary disease (COPD . Albuterol and Ipratropium Oral Inhalation: MedlinePlus Drug Information (8) Lactobacillus (probiotic) . This information was obtained from the website: Dietary Supplement Fact Sheets (9) Prescription lidocaine transdermal (Dermalid, Lidoderm, Ztildo) is used to relieve the pain of post-herpetic neuralgia (PHN; burning, stabbing pains, or aches that may last for months or years after a shingles infection) . This information was obtained from the website: Lidocaine Transdermal Patch: MedlinePlus Drug Information (10) Lurasidone is used to treat the symptoms of schizophrenia . Lurasidone: MedlinePlus Drug Information (11) Methocarbamol is used with rest, physical therapy, and other measures to relax muscles and relieve pain and discomfort caused by strains, sprains, and other muscle injuries. Methocarbamol is in a class of medications called muscle relaxants. It works by slowing activity in the nervous system to allow the body to relax . This information was obtained from the website: Methocarbamol: MedlinePlus Drug Information (12) Metoprolol is used to treat high blood pressure, angina (chest pain) and heart failure. Metoprolol also is used to improve survival after a heart attack . Metoprolol is in a class of medications called beta blockers. It works by relaxing blood vessels and slowing heart rate to improve blood flow and decrease blood pressure . This information was obtained from the website: Metoprolol: MedlinePlus Drug Information (13) Midodrine is used to treat orthostatic hypotension (sudden fall in blood pressure that occurs when a person assumes a standing position). Midodrine is in a class of medications called alpha-adrenergic agonists. It works by causing blood vessels to tighten, which increases blood pressure . This information was obtained from the website: Midodrine: MedlinePlus Drug Information (14) Sildenafil (Liqrev, Revatio) is used to improve the ability to exercise in adults (Liqrev, Revatio) and children 1 year of age and older (Revatio) with pulmonary arterial hypertension (PAH; high blood pressure in the vessels carrying blood to the lungs, causing shortness of breath, dizziness, and tiredness). Sildenafil is in a class of medications called phosphodiesterase (PDE) inhibitors . This information was obtained from the website: Sildenafil: MedlinePlus Drug Information (15) Renal Caps is indicated in the wasting syndrome of chronic renal failure; uremia and impaired metabolic functions of the kidney. Renal Caps is also highly effective as a stress vitamin . This information was obtained from the website: Renal Caps: Package Insert / Prescribing Information (16) Sertraline is used to treat depression, obsessive-compulsive disorder (bothersome thoughts that won't go away and the need to perform certain actions over and over), panic attacks (sudden, unexpected attacks of extreme fear and worry about these attacks), posttraumatic stress disorder (disturbing psychological symptoms that develop after a frightening experience), and social anxiety disorder (extreme fear of interacting with others or performing in front of others that interferes with normal life) . This information was obtained from the website: Sertraline: MedlinePlus Drug Information

Based on staff interview, clinical record review, and facility document review, the facility staff failed to implement dietician recommendations for one of 7 residents in the survey sample, Residents #1. The findings include:For Resident #1 (R1) the facility staff failed to implement dietician's recommendations. R1 diagnoses include but were not limited to Alzheimer's disease (1), aphasia (2) dysphagia (3), and protein-calorie malnutrition (4).On the most recent minimum data set (MDS), nursing home discharge of 6/6/2026, the resident's BIMS (brief interview for mental status) score was not entered. Section C-Cognitive Patterns documented the resident's daily decision making as moderately impaired-decisions poor; cues/supervision required. It further documented R1 having a weight loss of 5% or more in the last month or loss of 10% or more in last six months. Additionally, Section M-Skin Conditions documented the resident with unhealed pressure injuries (5).The comprehensive care plan for R1 documented in part, resident is at risk for dehydration, weight loss, or malnutrition related to advanced age, chronic disease. Date Initiated: 4/29/2025. Revision on 6/10/2026.Physician orders documented an order for resident to eat with maroon spoon for all meals to control PO intake on 3/24/2025 and an order on 2/23/2026, for mechanical diet soft texture, regular/thin consistencyA nutritional assessment for R1 dated 5/24/2026 documented in part, weekly weights times four to re-establish a baseline weight on 5/24/2026. Re-admit. CBW(current base weight): 171lbs (5.4.26). BMI: 23.8, WNL. Wt (weight) is up 5.6% over the past month. Diet: Regular diet, mechanical soft texture, thin consistency. Intakes: 100% (2126 kcal, 84 g PRO). Appears to not meet est energy needs of 2330 kcal/day (30kcal/kg/day), 77 g PRO daily (1 g/kg/day), 2330 mL fluid daily (30 mL/kg/day). Despite not meeting needs wt is up over the past month.Review of R1's monthly weight documented in part, on 1/6/2026, the resident weighed 156.5lbs (wheelchair); on 2/5/2026, the resident weighed 156.5 (wheelchair); on 3/4/2026, the resident weighed 158.5 (wheelchair); on 4/2/2026, the resident weighed 161.5 (wheelchair); on 5/4/2026, the resident weighed 171.0 (mechanical lift); on 6/1/2026, the resident weighed 141.5 (wheelchair). A review of the weight summary revealed, weekly weights times four to re-establish a baseline weight were not done. Review of the ADL (activities of daily living) documentation for R1 documented that May 29th-31st, R1 was dependent with eating, June 2nd R1 required maximum assistant with eating and June 3rd-6th R1 was dependent with eating. R1 ate 26-50% of meals May 29th-31st and June 2nd-3rd 25 of meals.The progress notes for R1 documented in part, -6/1/2026 at 12:15 PM Note: Intaking less than 25% of meals; pocketing foods at the lowest gradable diet as well as medications.-6/3/3026 at 13:40 (1:40 PM) Note: Weight was documented at 141.5lbs on 06/01/2026, decreased from 161.5lbs on 04/02/2026, likely reflecting diuresis achieved during and after hospitalization.-6/4/2026 at 19:22 (9:22 PM) Note: Weight decreased from 161.5lbs to 141.5 lbs. Escalate nutritional interventions and continue close monitoring. Escalate nutritional support given oral intake below 25% of meals - Monitor medication administration given pocketing of medications and food at lowest gradable diet.On 7/1/2026 at 10:10 AM, an interview was conducted with certified nursing assistant (CNA) #8, who stated: when R1 returned from the hospital, the resident was weak and not feeding himself. The resident was pocketing food. Some days R1 would have energy to feed themself. R1 required supervision and redirection.On 7/1/2026 at 11:56 AM, an interview was conducted with CNA #3, who stated R1 required help with feeding and drinking. CNA #3 stated that they took care of R1once or twice during day shift. CNA #3 stated that when R1 came back from the hospital, R1 looked bad and it looked like R1 was about to die. CNA #3 stated that previously R1 wasn't like that and R1 went quick. After R1's hospitalization CNA #3 further stated the resident required more care and wasn't eating.On 7/1/2026 at 12:22 PM, an interview was conducted with CNA #6, who stated they took care of R1 a lot and when R1 came back from the hospital R1 wasn't eating or holding their head up and that R1 was lethargic. CNA #6 stated R1 had lost a lot of weight. CNA stated R1 required prompting for taking in water. CNA #6 further stated they could get the resident to eat 25-30% of R1's food.On 7/1/2026 at 12:40 PM, an interview was conducted with CNA #5, who stated they didn't work with R1 a lot. CNA #5 stated they remembered a lot of decline in R1 not eating. CNA #5 stated when they would feed R1 the resident would hold food in his mouth or it would come out of R1's mouth.On 7/1/2026 at 3:29 PM, the Regional Director of Clinical Services (RDCS) informed the surveyor that they do not have any weights per the dietician recommendations. On 7/2/2026 at 9:15AM, an interview was conducted with the dietician, who stated that on 5/24/2026, R1 was trending upward and there wasn't any weight loss, so no changes were made. When asked why were weekly weights times four ordered to establish a baseline weight, they stated because R1 had been readmitted to the facility and they wanted to track and trend his weight for a baseline. The dietician stated that they communicate their recommendations to the facility via a portal system and the facility receives a notification that they have sent the recommendation.The facility's policy Weight Assessment and Intervention document in part, The interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Weights will be recorded in the resident's medical record. The designated dietary staff will review the weight records [based on frequency of weights] to follow individual weight trends over time. (a). The treatment team will evaluate negative trends whether or not the criteria for significant weight change has been met.On 7/2/2026 at 9:30 AM, Administrator, Regional Clinical Services Director and the Director of Nursing were notified of the findings.No further information was provided prior to exit.References:1. Alzheimer's Disease-Alzheimer's disease (AD) is the most common form of dementia among older people. Dementia is a brain disorder that seriously affects thinking and memory skills. https://medlineplus.gov/alzheimersdisease.html2. Aphasia-Aphasia is a language disorder that makes it hard for you to read, write, and say what you mean to say. Sometimes it makes it hard to understand what other people are saying, too. Aphasia is not a disease. It's a symptom of damage to the parts of the brain that control language. https://medlineplus.gov/aphasia.html3. Dysphagia- a swallowing disorder, you may have difficulty or pain when swallowing. https://medlineplus.gov/swallowingdisorders.html4. Protein-Calorie Malnutrition-is a condition caused by a lack of adequate dietary intake of protein, calories (energy), or both. It leads to poor growth, weight loss, muscle wasting, diminished immunity, and impaired organ function. https://my.clevelandclinic.org/health/diseases/22987-malnutrition5. Pressure Injuries- Bedsores, also known as pressure ulcers, pressure injuries, pressure sores, and decubitus ulcers, result from prolonged pressure that cuts off the blood supply to the skin, causing the skin and other tissue to die. https://skinsight.com/skin-conditions/pressure-ulcer-decubitus-ulcer/?Imiw9cApl=1

Based on observation, resident interview, clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to provide care and services to promote healing of a pressure injury (1) for one of seven residents in the survey sample, Resident #2. The findings include: Based on observation, resident interview, clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to provide care and services to promote healing of a pressure injury (1) for one of seven residents in the survey sample, Resident #2. The findings include: For Resident #2 (R2), the facility staff failed to A) clean an unstageable DTI (deep tissue injury) pressure injury prior to applying treatment during wound care observation on 6/30/2026 and B) evidence weekly monitoring of the unstageable DTI wound including location, staging, sizing, and description of the wound. On the most recent minimum data set (MDS), a significant change assessment with an assessment reference date (ARD) of 5/22/2026, R2 was assessed as scoring 14 out of 15 on the BIMS (brief interview for mental status) indicating they were cognitively intact for short term recall and oriented to year, month and day. The assessment documented no rejection of care behaviors and R2 having one unstageable deep tissue injury that was not present on admission. On 6/30/2026 at approximately 12:21 PM, an interview was conducted with R2 who stated that she had a diaper rash wound on her buttocks and staff put cream on it and told her that it was getting better. R2 stated that it had been there for a little while but could not recall when the wound developed. Review of the physician orders documented the following orders - Stage Unstageable DTI- wound, Right, Ischium; 1- Alginate Calcium w/silver/Once Daily 2- Superabsorbent Gelling Fiber w/Silicone Border; Faced/Once Daily one time a day for wound care. Order Date: 06/01/2026.- Peri: Skin Prep / Once Daily one time a day for wound care. Order Date: 06/01/2026. The most recent wound physician note dated 6/18/2026 documented in part, .DRESSING TREATMENT PLAN, Primary Dressing(s): Alginate calcium w/silver apply once daily and as needed: if saturated, soiled, or dislodged. For 23 days. Secondary Dressing(s): Superabsorbent gelling fiber w/ silicone bdr & faced apply once daily and as needed: if saturated, soiled, or dislodged. For 23 days. Peri Wound Treatment: Skin prep apply once daily and as needed: if saturated, soiled, or dislodged . The comprehensive care plan for R2 documented in part, SKIN IMPAIRMENT: the resident has a skin impairment of DTI to right ischium. Date Initiated: 05/08/2026. A) On 6/30/2026 at 3:40 PM, an observation was made of the Director of Nursing (DON) performing wound care to R2's right ischium DTI pressure injury. R2 was observed laying on the bed on her side and was assisted by the Director of Nursing and Assistant Director of Nursing to pull her pants down and undo an adult brief to expose the DTI wound which was not dressed at that time. The Director of Nursing was observed to apply a skin prep wipe to the area surrounding the wound and then placed a bordered gauze with a calcium alginate pad onto the wound area. The wound area was not cleaned prior to placement of the dressing. On 6/30/2026 at approximately 4:00 PM, the DON stated that she did not clean the pressure injury because the physician's order does not say to clean it with anything. She stated that if it said to clean it with normal saline or wound cleanser then she would have used one of those. On 7/1/2026 at 12:13 PM, an interview was conducted with the wound physician who stated that the nursing staff should use their judgement for cleaning the pressure injury and in general they could use either wound cleanser or house stock saline. On 7/1/2026 at 2:02 PM, an interview was conducted with registered nurse (RN) #2 who stated that when she performed wound care to R2's pressure injury she cleans it with normal saline or wound cleanser. She stated that she cleaned the wound due to infection control because you always cleaned a wound prior to treatment and did not want to stick something new on something that is dirty. B) Review of the wound physician evaluations for R2 documented the wound assessed on the following dates, 5/7/2026, 6/11/2026, 6/18/2026. The wound physician notes documented a refusal to be assessed on 5/29/2026. The wound physician notes also documented the following on the following dates:- 5/22/2026: .The patient's visit has been rescheduled as she had gone to a Dialysis appointment .- 6/5/2026: .The patient's visit has been rescheduled. Pt is at dialysis .- 6/26/2026: . The patient's visit has been rescheduled as she was out of the facility . The clinical record failed to evidence additional assessments or refusals of assessments to the right ischium DTI. On 6/30/2026 at 1:58PM, a request was made to the Administrator in Training for evidence of weekly assessment of the pressure injury for R2 from first discovery to the present. At approximately 3:00 PM, the wound physician notes listed above were provided. On 6/30/2026 at 4:10 PM, the DON stated that the weekly wound assessments were the responsibility of the assistant director of nursing and were previously done by the director of nursing. She stated that the weekly monitoring was completed to make sure the wounds were progressing and not deteriorating. On 6/30/2026 at 4:55 PM, the Administrator in Training stated that they did not have any more assessments to provide and they relied solely on the wound physician for the assessments of wounds at the facility. On 7/1/2026 at 12:13 PM, an interview was conducted with the wound physician who stated that when he could not see R2 because they were out at dialysis appointments he saw them the next week. He stated that he expected the nursing staff to assess and measure the wound when he could not see it that week. The facility policy Pressure Injury Prevention and Management documented in part, The intent of this organization is to develop and maintain systems and processes to ensure that the resident does not develop pressure ulcers/injuries (PU/PIs) unless clinically unavoidable and that the facility provides care and services consistent with professional standards of practice to: Promote the prevention of pressure ulcer/injury development; Promote the healing of existing pressure ulcers/injuries (including prevention of infection to the extent possible); and Prevent development of additional pressure ulcer/injury . Evaluation/assessment of pressure ulcer/injury will be completed weekly and with significant change in condition of the ulcer/injury by a licensed nurse and/or practitioner. 2. Documentation of the evaluations/assessment of the pressure ulcer/injury will [sic] maintained in the resident's medical record. Documentation may include: a. Location of ulcer/injury b. Date that the ulcer/injury was acquired [when known] c. Description of the ulcer/injury to include stage, measurements [length, width, depth], presence/absence of any tunneling or undermining, type of tissue [epithelial, granulation, slough, necrosis, etc.], presence/absence and type of drainage, surrounding tissue description, and presence/absence of pain with the ulcer/injury. d. Treatment and interventions to promote healing . On 7/1/2026 at approximately 5:06 PM, the interim Administrator, the Administrator in training, the Director of Nursing and the Regional Director of Clinical Services were made aware of the concern. No further information was provided prior to exit. Reference:(1) A pressure sore is an area of the skin that breaks down when something keeps rubbing or pressing against the skin. Causes: Pressure sores occur when there is too much pressure on the skin for too long. This reduces blood flow to the area. Without enough blood to nourish the skin, the skin can die and a sore may form . Pressure sores are grouped by the severity of symptoms. Stage I is the mildest stage. Stage IV is the worst.Stage I: A reddened, painful area on the skin that does not turn white (blanch) when pressed. This is a sign that a pressure ulcer may be forming. The skin may be warm or cool, firm or soft.Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated.Stage III: The skin now develops an open, sunken hole called a crater or ulcer. The tissue below the skin is damaged. You may be able to see body fat in the ulcer.Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints.There are two other types of pressure sores that don't fit into the stages.Sores covered in dead skin that is yellow, tan, green, or brown. The dead skin makes it hard to tell how deep the sore is. This type of sore is unstageable.Pressure sores that develop in the tissue deep below the skin. This is called a deep tissue injury. The area may be dark purple or maroon. There may be a blood-filled blister under the skin. This type of skin injury can quickly become a stage III or IV pressure sore . This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000740.htm

Based on staff interview, clinical record review, and facility document review, the facility staff failed to promote a resident's highest level of well-being for two of seven residents, Residents #1and #2.The findings include:1. For Resident #1 (R1) the facility staff failed to promote a resident's highest level of well-being by delaying transition of care. R1 diagnoses include but were not limited to Alzheimer's disease (1), aphasia (2) dysphagia (3), and protein-calorie malnutrition (4).On the most recent minimum data set (MDS), nursing home discharge of 6/6/2026, the resident's BIMS (brief interview for mental status) score was not entered. Section C-Cognitive Patterns documented the resident's daily decision making as moderately impaired-decisions poor; cues/supervision required. It further documented R1 having a weight loss of 5% or more in the last month or loss of 10% or more in last six months. Additionally, Section M-Skin Conditions documented the resident with unhealed pressure injuries.-6/6/2026 17:47 (5:47PM), Third Eye Note: Primary Chief Complaint: Respiratory: Hypoxia(5) History Present Illness: Consult received for hypoxemia. Patient is aphasic and nonverbal at baseline, limiting symptom assessment. Nursing noted oxygen saturation of 88% on room air. Patient was placed on 2 liters per minute of supplemental oxygen with improvement in oxygen saturation to 92%. Nursing reports mild expiratory wheezing. Patient is currently receiving nebulizer treatments. No fever, tachycardia (6), or hypotension (7) has been observed. Due to the patient's baseline nonverbal status, subjective symptoms such as shortness of breath cannot be reliably assessed. Pt is aphasic and nonverbal at baseline. Per nurse and/or patientVital Signs: T (temperature): 97.7 ( F); HR (heart rate): 95 (bpm) (beats per minute); BP (blood pressure) Sys (systolic): 125 (mm/Hg)/Dia (diastolic): 88 (mm/Hg); RR: 25 (rpm); SpO2: 88(%); Sp02 Levels: Room Air. Physical Exam: Exam findings per nurse and video observation Physical Exam - Notes: Gen (general): not in distress, non verbal, with NC (nasal canula) oxygen, no abdominal breathing. Diagnosis, Assessment/Plan : J9601 - Acute respiratory failure with hypoxia (Primary) Condition is stable 1. Hypoxemia.- Oxygen saturation 88% on room air.- Improved to 92% on 2 L (liter) supplemental oxygen. Monitor oxygen saturation, respiratory effort, and vital signs. Notify provider for worsening hypoxemia, respiratory distress, fever, or acute clinical changes. -6/6/2026 21:44 (9:44 PM), Nursing Note: at 1350hrs resident had shortness of breath, SPO2 (peripheral oxygen saturation) checked, it was 88%; placed in a high Fowler's position; vital signs, checked: BP (blood pressure)-125/86, PR (pulse rate)-96, RR (respiration rate)-25. T (temperature)-97.7, oxygen instilled at 2LPM (liters per minute) via nasal cannula; Ipratropium-albuterol nebulization, given as PRN (as needed) medication q4; Third Eye (on-call physician services), informed and gave order to notify a clinician of any change in condition, continue oxygen therapy and nebulization as ordered, obtain cxry (chest x-ray), CBC (cell blood count) , CMP (comprehensive metabolic panel) and Urinalysis and to monitor the resident; 2 doses of nebulization given at 2pm and 6pm; monitored for signs of desaturation and respiratory distress; SPO2 reached 91-92% and the resident still with shortness of breath; Third Eye, updated but no reply; family, informed and responsible person decided to send the resident to the hospital; EMS (emergency medical services) arrived at 2020hrs and accompanied the resident to (initials of hospital).On 7/2/2026 at 2:23PM, an interview was conducted with Nurse Practitioner (NP). When asked what can you tell me about R1's decline, NP stated R1 was last seen on 6/4/2026 by them. R1 couldn't communicate their needs, there was functional decline and quite a bit of weight loss. NP stated ultimately that R1 was sent out to the emergency department (ED) and transitioned to hospice from the hospital. When asked if a nurse calls a doctor twice about a change in condition with additional changes what would be your recommendation? NP stated, send the resident out to the ED without question. On 7/2/2026 at 2:50 PM, an interview was conducted with the Attending Physician (AP). When asked what can you tell me about R1's decline, AP stated that they saw the resident twice for HNP (history and physical) and follow-up acute visit. R1, was sitting with a blank stare and the LE were not very swollen. Labs were reviewed on 6/7/2026 and were abnormal. When asked what are some causes for hypernatremia, AP stated not drinking enough water, some medication, cirrhosis of the liver and hepatic renal syndrome. When asked were you notified that R1 was not taking in PO (by mouth) starting on 6/2/2026, AP answered, no the resident was last seen on 6/3/2026. When asked if a nurse calls a doctor twice about a change in condition with additional changes what would be your recommendation? AP stated, send the resident to the emergency department. On 7/2/2026 at 3:00PM, an interview was conducted with the DON (Director of Nursing). When asked what they remembered about R1, they stated that the resident went to the hospital twice between May and June. They stated regarding the first admission there was general decline that the staff noticed. DON stated R1's family was offered hospice but declined. DON stated that when R1 returned to the facility R1 continued to decline and was admitted to the hospital a second time and discharged from there to home with hospice. When asked who is responsible for reporting to the RP about a resident's decline the DON stated the DON/ADON (assistant director of nursing) is responsible. A facility policy was not provided. On 7/2/2026 at 9:30 AM, Administrator, Regional Clinical Services Director and the Director of Nursing were notified of the findings.No further information was provided prior to exit.References:1. Alzheimer's Disease-Alzheimer's disease (AD) is the most common form of dementia among older people. Dementia is a brain disorder that seriously affects thinking and memory skills. https://medlineplus.gov/alzheimersdisease.html2. Aphasia-Aphasia is a language disorder that makes it hard for you to read, write, and say what you mean to say. Sometimes it makes it hard to understand what other people are saying, too. Aphasia is not a disease. It's a symptom of damage to the parts of the brain that control language. https://medlineplus.gov/aphasia.html3. Dysphagia- a swallowing disorder, you may have difficulty or pain when swallowing. https://medlineplus.gov/swallowingdisorders.html4. Protein-Calorie Malnutrition-is a condition caused by a lack of adequate dietary intake of protein, calories (energy), or both. It leads to poor growth, weight loss, muscle wasting, diminished immunity, and impaired organ function. https://my.clevelandclinic.org/health/diseases/22987-malnutrition5. Hypoxia- Hypoxia-Hypoxia occurs when there is not enough oxygen getting to the brain. https://medlineplus.gov/ency/article/001435.htm6. Tachycardia- When your heart beats faster than normal, it's called tachycardia. https://medlineplus.gov/arrhythmia.html7. Hypotension- Low blood pressure occurs when blood pressure is below normal. This means the heart, brain, and other parts of the body may not get enough blood. In adults, the normal blood pressure is between 90/60 mmHg and 120/80 mmHg. https://medlineplus.gov/ency/article/007278.htm 2. For Resident #2 (R2), the facility staff failed to evidence monitoring of the blood pressure prior to administration and one hour after administration of Midodrine (1) per the physicians order. Review of the physician orders documented the following orders Midodrine HCl Oral Tablet 5 MG (Midodrine HCl) Give 5 mg by mouth two times a day for symptomatic hypotension, symptomatic hypotension (SBP <90) (systolic blood pressure); hold if SBP >110 or DBP>70 (diastolic blood pressure); check BP (blood pressure) prior to each dose and 1 hour post-dose; do not administer within 4 hours of bedtime; notify provider if SBP <80, persistent symptoms after 2 doses. Order Date: 04/24/2026. Review of the eMAR (electronic medication administration record) for R2 dated 5/1-5/31/2026 and 6/1-6/30/2026 failed to evidence documentation of the blood pressure readings prior to administration of the Midodrine or one hour post administration of the medication. On 7/1/2026 at 2:02 PM, an interview was conducted with registered nurse (RN) #2 who stated that when she administered R2's Midodrine she checked the blood pressure to ensure it was in the parameters for administration prior to giving the medication. She stated that she went back and rechecked the blood pressure after administration following the order but was not sure if it was documented. RN #2 stated that there should be a note that popped up for them to enter the blood pressure prior to administration and the one hour follow up blood pressure that would show on the eMAR and progress notes, but she was not sure if it showed for R2 or not. On 7/1/2026 at approximately 3:29 PM, the regional director of clinical services stated that they did not have any evidence of the blood pressure readings prior to administration of the Midodrine or one hour post administration to provide. The facility policy [Name of facility corporation] Medication Administration Policy documented in part, .Before removing the medication package/container from the cart/drawer . Review necessary vital signs or tests required before administration . Obtain and document any necessary vital signs or monitoring parameters before administration . On 7/1/2026 at approximately 5:06 PM, the interim Administrator, the Administrator in training, the Director of Nursing and the Regional Director of Clinical Services were made aware of the concern. No further information was provided prior to exit. Reference:(1) Midodrine is used to treat orthostatic hypotension (sudden fall in blood pressure that occurs when a person assumes a standing position). Midodrine is in a class of medications called alpha-adrenergic agonists. It works by causing blood vessels to tighten, which increases blood pressure . This information was obtained from the website: Midodrine: MedlinePlus Drug Information

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to maintain a homelike environment on one of four unit hallways, the 300's hallway.The findings include:On 6/30/2026 at 11:39 AM, an observation of the lower portion of the 300's hallway between rooms 303-306 revealed a strong stale urine odor in the hallway.Additional observations on 6/30/2026 at 12:21 PM and 2:45 PM revealed the same strong stale urine odor in the same area. At 2:45 PM, a wet floor sign was observed in the hallway and a faint deodorizing scent was noted however the stale urine odor scent remained.On 7/1/2026 at 8:16 AM the hallway between rooms 303-306 was noted to have the stale urine odor. On 7/1/2026 at 4:18 PM, an interview was conducted with the director of housekeeping (DOH) who stated that they were new to the facility and still learning the processes there. She stated that to control odors in the facility the housekeeping staff used Virex disinfectant, Odoban odor eliminiator and a spray air freshener. She stated that they tried to identify any hot spot rooms from the staff so they could take care of any odors right away. The DOH stated that she was aware of problem areas down the 300 hallway at the end and they had changed a mattress in one resident room with urine saturation from a leaking urine collection bag. She stated that the odor lingered, and they could not seem to detect where it was coming from. An observation was made of the 300's hallway with the director who stated that she had recently ordered a new enzymatic product adn was hopeful that it would help to remove the stale urine odor on the hallway but the smell was better now than when she first started working there.The facilit policy Homelike Environment documented in part, .The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment; b. comfortable (minimum glare) yet adequate (suitable to the task) lighting; c. inviting colors and decor .On 7/1/2026 at 5:06 PM, the interim Administrator, the Administrator in training, the Director of Nursing and the Regional Director of Clinical Services were made aware of the concern. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, the facility staff failed to thoroughly investigate a behavioral incident with an allegation of mistreatment for one of seven residents in the survey sample (Resident #201).The findings include:Resident #201 (R201) was admitted to the facility with diagnoses that included cerebral infarction, diabetes, hypertension, peripheral vascular disease, history of myocardial infarction with defibrillator/pacemaker, dysarthria, anxiety, depression, chronic pain syndrome, heart failure, adult failure to thrive, history of prostate cancer, and congestive heart failure. The minimum data set (MDS) dated [DATE] assessed R201 as cognitively intact. R201's clinical record documented a psychiatry nurse practitioner note dated 7/30/25 documenting an assessment of R201 due to a verbal altercation between the patient and staff members this morning. This note documented that R201 reported that he called for assistance at 5:00 a.m. because he spilled urine on himself and that staff did not provide him with assistance. This noted documented, .Patient [R210] admits that when he was assisted up by staff, he went to the nurses station and demanded to speak to the charge nurse. Patient admits that he became belligerent towards other staff . This note documented the resident reported that law enforcement was called and that the administrator said she was afraid of R201. This note documented that R201 admitted to raising his voice, reported he had done nothing to harm others, that he felt his rights had been violated and that he had a right to freedom of speech. The facility's investigation of R201's incident of verbal aggression on 7/30/25 was reviewed. The investigation included statements from the nurse caring for R201 at the time of the incident (registered nurse #1), a certified nurse's aide (CNA #1) working on the unit, the maintenance director (other staff #1) that witnessed the incident, the former director of nursing (DON - administration #5) and the former administrator (administration #4). RN #1's statement dated 7/30/25 documented, .[R201] became highly aggressive and verbally threatening toward multiple staff members, including myself .[CNA #1], maintenance worker [other staff #1] . Statements from RN #1, the maintenance director and CNA #1 documented R201 made multiple verbal threats to slap staff members, physically attack them when they were not looking, have his family come with guns to shoot everyone in addition to calling staff members vulgar names. Statements documented attempts to redirect and calm R210 were unsuccessful with the verbal aggression/threats toward staff lasting over one hour.The former administrator (administration #4) and the former DON (administration #5) documented the police were contacted due to R201's aggressive verbal threats with the R201 accompanied by the administrator to an office. The former administrator documented an emergency custody order was attempted with the magistrate indicating the resident/situation did not meet the criteria for involuntary removal of R201 from the facility. The former administrator documented R201 calmed down after the police talked with the resident. The former administrator documented the police did not deem R201's verbal threats as credible. The former administrator stated R201 returned to his room after talking with police, was monitored by staff with the resident calming and demonstrating no further aggressive behaviors on 7/30/25. The psychiatry nurse practitioner assessed R201 on 7/30/25 after the incident and assessed no credible threat harm to self or others.The facility's investigation included no statement from the CNA assigned to R201 on the early morning of 7/30/25 (CNA #2) and documented no investigation addressing R201's allegation that assistance was not provided or that rights had been violated. The investigation included no interviews with residents about the incident, did not document if any residents witnessed the incident or if any residents heard R201's verbal threats and vulgar language. On 9/9/25 at 9:40 a.m., the maintenance director (other staff #1) that witnessed the 7/30/25 incident was interviewed. The maintenance director stated R201 made verbal threats of physical violence toward him and the nursing staff. The maintenance director stated R201 directed aggressive comments toward the staff members but that there were several residents in the area when the incident took place. On 9/9/25 at 12:00 p.m., the current administrator and regional nurse consultant (administration #3) were interviewed about the reporting/investigating of the 7/30/25 incident of verbal aggression. The administrator stated he was not working in the facility at the time of the incident and that the former administrator conducted the investigation. The administrator stated the investigation included statements from staff about R201's aggressive behaviors and described events surrounding R201's behaviors. The administrator presented no documentation the investigation addressed R201's report that assistance was not provided by staff. On 9/9/25 at 3:18 p.m., CNA #2 that cared for R201 at the time of the incident on 7/30/25 was interviewed. CNA #2 stated, prior to today, she had not been interviewed or asked to provide a statement about the events on 7/30/25.The facility's policy titled Abuse Investigation and Reporting (10/01/21) documented, .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown and [are] thoroughly investigated by facility management .The individual[s] conducting the investigation may, at a minimum .Review the resident's medical record to determine events leading up to the incident .Interview any witnesses to the incident .Interview the resident (as medically appropriate) .Interview the staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .Interview the resident's roommate, family members, visitors .Review all events leading up to the alleged incident .This finding was reviewed with the administrator and regional nurse consultant on 9/9/25 at 3:50 p.m. with no further information provided prior to the end of the survey.

Based on staff interview, facility document review and clinical record review, the facility staff failed to report to the state agency and adult protective services, a behavioral incident with an allegation of mistreatment for one of seven residents in the survey sample (Resident #201).The findings include:Resident #201 (R201) was admitted to the facility with diagnoses that included cerebral infarction, diabetes, hypertension, peripheral vascular disease, history of myocardial infarction with defibrillator/pacemaker, dysarthria, anxiety, depression, chronic pain syndrome, heart failure, adult failure to thrive, history of prostate cancer, and congestive heart failure. The minimum data set (MDS) dated [DATE] assessed R201 as cognitively intact. R201's clinical record documented a psychiatry nurse practitioner note dated 7/30/25 documenting an assessment of R201 due to a verbal altercation between the patient and staff members this morning. This note documented that R201 reported that he called for assistance at 5:00 a.m. because he spilled urine on himself and that staff did not provide him with assistance. This noted documented, .Patient [R210] admits that when he was assisted up by staff, he went to the nurses station and demanded to speak to the charge nurse. Patient admits that he became belligerent towards other staff . This note documented the resident reported that law enforcement was called and that the administrator said she was afraid of R201. This note documented that R201 admitted to raising his voice, reported he had done nothing to harm others, that he felt his rights had been violated and that he had a right to freedom of speech. The facility's investigation of R201's incident of verbal aggression on 7/30/25 was reviewed. The investigation included statements from the nurse caring for R201 at the time of the incident (registered nurse #1), a certified nurse's aide (CNA #1) working on the unit, the maintenance director (other staff #1) that witnessed the incident, the former director of nursing (DON - administration #5) and the former administrator (administration #4). RN #1's statement dated 7/30/25 documented, .[R201] became highly aggressive and verbally threatening toward multiple staff members, including myself .[CNA #1], maintenance worker [other staff #1] . Statements from RN #1, the maintenance director and CNA #1 documented R201 made multiple verbal threats to slap staff members, physically attack them when they were not looking, have his family come with guns to shoot everyone in addition to calling staff members vulgar names. Statements documented attempts to redirect and calm R210 were unsuccessful with the verbal aggression/threats toward staff lasting over one hour.The former administrator (administration #4) and the former DON (administration #5) documented the police were contacted due to R201's aggressive verbal threats with R201 accompanied by the administrator to an office. The former administrator documented an emergency custody order was attempted with the magistrate indicating the resident/situation did not meet the criteria for involuntary removal of R201 from the facility. The former administrator documented R201 calmed down after the police talked with the resident. The former administrator documented the police did not deem R201's verbal threats as credible. The former administrator stated R201 returned to his room after talking with police, was monitored by staff with the resident calming and demonstrating no further aggressive behaviors on 7/30/25. The psychiatry nurse practitioner assessed R201 on 7/30/25 after the incident and assessed no credible threat for harm to self or others. There was no report to the state agency or adult protective services (APS) regarding R201's verbal threats/aggression on 7/30/25 that included police involvement, an attempted emergency custody order and allegations from R201 regarding lack of assistance and violation of rights. On 9/9/25 at 12:00 p.m. the current administrator and regional nurse consultant (administration #3) were interviewed about reporting/investigating of the 7/30/25 incident of verbal aggression. The administrator stated he was not working in the facility at the time of the incident and that the former administrator conducted the investigation. The administrator stated he thought the incident had not been reported to the state agency or APS because the verbal threats were directed toward staff members and not residents. The facility's policy titled Abuse (revised 10/20/22) documented, .The organization will maintain systems to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility .to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) . This finding was reviewed with the administrator and regional nurse consultant on 9/9/25 at 3:50 p.m. with no further information provided prior to the end of the survey.

Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide timely incontinence care for one of seven residents in the survey sample (Resident #201).The findings include:Resident #201 waited approximately 35 to 40 minutes for staff assistance with incontinence care/spilled urine.Resident #201 (R201) was admitted to the facility with diagnoses that included cerebral infarction, diabetes, hypertension, peripheral vascular disease, history of myocardial infarction with defibrillator/pacemaker, dysarthria, anxiety, depression, chronic pain syndrome, heart failure, adult failure to thrive, history of prostate cancer, and congestive heart failure. The minimum data set (MDS) dated [DATE] assessed R201 as cognitively intact, occasionally incontinent of bladder and frequently incontinent of bowel.R201's clinical record documented a psychiatry nurse practitioner note dated 7/30/25 documenting an assessment of R201 due to a verbal altercation between the patient and staff members this morning. This note documented R201 reported that he called for assistance at 5:00 a.m. because he spilled urine when using the urinal and that staff did not provide him with assistance. On 9/8/25 at 1:50 p.m., R201 was interviewed about his concern with lack of staff assistance on 7/30/25. R201 stated in the early morning of 7/30/25, his brief was wet, and he had urine on the bed sheets from dropping his urinal. R201 stated he rang the call bell around 5:00 or 5:30 a.m. and waited 40 minutes for a staff person to clean/assist him with the urine spill. R201 stated he got loud, asked the nurse where the aide was and was told by the nurse that the CNA (certified nurse's aide) would come when she finished with another resident. R201 stated a CNA eventually came after about 40 minutes, who cleaned him and assisted him out of bed. R201 stated the CNA offered no explanation of why she did not respond earlier to his request for assistance and that he felt staff should have responded sooner since he was wet.On 9/9/25 at 3:18 p.m., CNA #2 that cared for R201 during the early morning on 7/30/25 was interviewed. CNA #2 stated she cared for R201 from 7/29/25 at 7:00 p.m. until 7/30/25 at 7:00 a.m. CNA #2 stated she changed R201's brief twice during the first part of that shift. CNA #2 stated prior to 4:00 a.m., she checked on R201 and the resident did not want his brief checked/changed at that time because he wanted to sleep. CNA #2 stated at around 5:00 a.m., she began getting several residents up, including one resident with an early appointment. CNA #2 stated R201 rang for assistance around 5:00 a.m. to 5:30 a.m. CNA #2 stated she went to R201 and told him she was assisting another resident that had an early appointment and that she would be back to assist him after getting the other resident ready. CNA #2 stated R201 said he was ok and agreed for me to finish and then assist him. CNA #2 stated the resident with the appointment wanted things in a certain order and it took a long time to get her ready. CNA #2 stated she returned to R201, cleaned him then assisted him with dressing and getting out of bed. CNA #2 stated R201's brief was wet and had leaked slightly on the sheets. CNA #2 stated R201 reported that he spilled his urinal, but that urine was still in the bottle, and she emptied the urinal during the care. CNA #2 stated R201 waited approximately 35 minutes before she assisted him with the wet brief/spilled urine. CNA #2 stated R201 thanked her and expressed no complaints to her but proceeded to the nursing desk and started cursing at the nurse about not getting assistance. CNA #2 stated the nurse was aware that R201 rang for assistance. CNA #2 stated she had not asked for assistance from other staff on the unit. CNA #2 stated R201 waited about 35 minutes for assistance because she took longer than anticipated with the other resident.On 9/10/25 at 11:50 a.m., the administrator, director of nursing (DON) and regional nurse consultant (administration #3) were interviewed about R201 waiting 35 to 40 minutes for assistance with incontinence care/urine spill. The administrator stated staff members needed to work as a team to provide timely assistance for residents. The DON stated that CNAs could ask for help from other aides and that nurses were also able to provide care if needed. The regional nurse consultant stated assistance could have been provided for the early appointment resident so that CNA #2 could help R201 more timely. The administrator stated again that staff members needed to work together to meet resident needs and requests.R201's plan of care (revised 6/2/25) documented the resident required assistance with activities of daily living (ADL) due to chronic health conditions, muscle weakness, bladder incontinence and used a urinal at times. Interventions to provide incontinence care and maintain ADLs included, Physical assist as needed with ADL care .resident uses disposable briefs. Change q [every] 2 hr [hours] and prn [as needed] .Provide supervision and cuing [cueing] as needed with ADL care .The facility's policy titled Answering the Call Light (undated) documented, The facility will maintain a functional call light system and will make all reasonable efforts to ensure timely responses to the resident's requests and needs .'Timely Response': is not defined by a 'pre-set' measure of minutes but rather is defined that the response time was appropriate to situation and/or need. Response time varies based on each situation and is impacted from the resident's need and perception/understanding of the urgency and time lapse .If the resident needs assistance, indicate the approximate time it will take for you to respond .If you are uncertain as to whether or not a request can be fulfilled or if you cannot fulfill the resident's request, ask an appropriate staff member for assistance .This finding was reviewed with the administrator, DON and regional nurse consultant on 9/10/25 at 11:50 a.m. with no further information presented prior to the end of the survey.

Based on staff interview and clinical record review, the facility staff failed to obtain a physician ordered urinalysis with culture for one of seven residents in the survey sample (Resident #201).The findings include:Resident #201 (R201) was admitted to the facility with diagnoses that included cerebral infarction, diabetes, hypertension, peripheral vascular disease, history of myocardial infarction with defibrillator/pacemaker, dysarthria, anxiety, depression, chronic pain syndrome, heart failure, adult failure to thrive, history of prostate cancer, and congestive heart failure. The minimum data set (MDS) dated [DATE] assessed R201 as cognitively intact. R201's clinical record documented on 7/1/25 that the resident reported burning with urination and discolored urine. The provider was notified, and a physician's order was entered dated 7/1/25 for a urinalysis with culture and sensitivity. A nursing note dated 7/5/25 documented, urine sample being sent to lab. R201's clinical record documented no results of the urinalysis with culture ordered on 7/1/25.On 9/9/25 at 3:50 p.m., the regional nurse consultant (administration #3) was interviewed about results of the urinalysis ordered on 7/1/25. The nurse consultant reviewed the clinical record and stated she did not find results of the urinalysis with culture.On 9/10/25 at 10:55 a.m., the regional nurse consultant stated she contacted the lab. The regional nurse consultant stated the lab picked up samples from the facility on 7/5/25, but there was no record that R201's urine sample was picked up or processed by lab personnel. A lab listing for R201 was presented with no urine sample sent or picked up by the lab in response to the 7/1/25 order. The regional nurse consultant was not sure why the sample was not provided to the lab.This finding was reviewed with the administrator and regional nurse consultant on 9/10/25 at 11:30 a.m. with no further information presented prior to the end of the survey.

Based on staff interview, facility document review and clinical record review, the facility staff failed to follow abuse prevention policies for reporting and thoroughly investigating a behavioral incident with an allegation of mistreatment for one of seven residents in the survey sample (Resident #201).The findings include:An incident of verbal aggression/threats toward staff and an allegation of mistreatment by R201 was not thoroughly investigated or reported to the state agency and adult protective services as required in the facility's abuse prevention policies. Resident #201 (R201) was admitted to the facility with diagnoses that included cerebral infarction, diabetes, hypertension, peripheral vascular disease, history of myocardial infarction with defibrillator/pacemaker, dysarthria, anxiety, depression, chronic pain syndrome, heart failure, adult failure to thrive, history of prostate cancer, and congestive heart failure. The minimum data set (MDS) dated [DATE] assessed R201 as cognitively intact. R201's clinical record documented a psychiatry nurse practitioner note dated 7/30/25 documenting an assessment of R201 due to a verbal altercation between the patient and staff members this morning. This note documented that R201 reported that he called for assistance at 5:00 a.m. because he spilled urine on himself and that staff did not provide him with assistance. This noted documented, .Patient [R210] admits that when he was assisted up by staff, he went to the nurses station and demanded to speak to the charge nurse. Patient admits that he became belligerent towards other staff . This note documented the resident reported that law enforcement was called and that the administrator said she was afraid of R201. This note documented that R201 admitted to raising his voice, reported he had done nothing to harm others, that he felt his rights had been violated and that he had a right to freedom of speech. The facility's investigation of R201's incident of verbal aggression on 7/30/25 was reviewed. The investigation included statements from the nurse caring for R201 at the time of the incident (registered nurse #1), a certified nurse's aide (CNA #1) working on the unit, the maintenance director (other staff #1) that witnessed the incident, the former director of nursing (DON - administration #5) and the former administrator (administration #4). RN #1's statement dated 7/30/25 documented, .[R201] became highly aggressive and verbally threatening toward multiple staff members, including myself .[CNA #1], maintenance worker [other staff #1] . Statements from RN #1, the maintenance director and CNA #1 documented R201 made multiple verbal threats to slap staff members, physically attack them when they were not looking, have his family come with guns to shoot everyone in addition to calling staff members vulgar names. Statements documented attempts to redirect and calm R210 were unsuccessful with the verbal aggression/threats toward staff lasting over one hour.The former administrator (administration #4) and the former DON (administration #5) documented the police were contacted due to R201's aggressive verbal threats with R201 accompanied by the administrator to an office. The former administrator stated an emergency custody order was attempted with the magistrate indicating the resident/situation did not meet the criteria for involuntary removal of R201 from the facility. The former administrator documented R201 calmed down after the police talked with the resident. The former administrator documented the police did not deem R201's verbal threats as credible. The former administrator documented R201 returned to his room after talking with police, was monitored by staff with the resident calming and demonstrating no further aggressive behaviors on 7/30/25. The psychiatry nurse practitioner assessed R201 on 7/30/25 after the incident and determined there was no credible threat for harm to self or others.There was no report to the state agency or adult protective services (APS) regarding R201's verbal threats/aggression incident of 7/30/25 that included police involvement, an attempted emergency custody order and allegations from R201 regarding lack of assistance and violation of rights. The facility's investigation included no statement from the CNA assigned to R201 on the early morning of 7/30/25 (CNA #2) and documented no investigation addressing R201's allegation that assistance was not provided or that his rights had been violated. The investigation included no interviews with residents about the incident, did not document if any residents witnessed the incident or if any residents heard R201's verbal threats and vulgar language. On 9/9/25 at 9:40 a.m., the maintenance director (other staff #1) that witnessed the 7/30/25 incident was interviewed. The maintenance director stated on 7/30/25, R201 made verbal threats of physical violence toward him and the nursing staff. The maintenance director stated R201 directed aggressive comments toward the staff members but that there were several residents in the area when the incident took place. On 9/9/25 at 12:00 p.m., the current administrator and regional nurse consultant (administration #3) were interviewed about reporting/investigating of the 7/30/25 incident of verbal aggression. The administrator stated he was not working in the facility at the time of the incident and that the former administrator conducted the investigation. The administrator stated he thought the incident had not been reported to the state agency or APS because the verbal threats were directed toward staff members and not residents. The administrator stated the investigation included statements from staff about R201's aggressive behaviors and described events surrounding R201's behaviors. The administrator provided no evidence that the investigation addressed R201's report that assistance was not provided by staff. On 9/9/25 at 3:18 p.m., CNA #2 that cared for R201 at the time of the incident on 7/30/25 was interviewed. CNA #2 stated, prior to today, she had not been interviewed or asked to provide a statement about the events on 7/30/25.The facility's policy titled Abuse (revised 10/20/22) documented, .This facility is committed to developing and operationalizing policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property . Designated staff will immediately review and investigate all allegations or observations of abuse. The results of all investigations are to be communicated to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident .The organization will maintain systems to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility .to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) . The facility's policy titled Abuse Investigation and Reporting (10/01/21) documented, .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown and thoroughly investigated by facility management. [Sic] Findings of abuse investigations will also be reported .The individual[s] conducting the investigation may, at a minimum .Review the resident's medical record to determine events leading up to the incident .Interview any witnesses to the incident .Interview the resident (as medically appropriate) .Interview the staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .Interview the resident's roommate, family members, visitors .Review all events leading up to the alleged incident .This finding was reviewed with the administrator and regional nurse consultant on 9/9/25 at 3:50 p.m. with no further information provided prior to the end of the survey.

Based on observation, staff interview, resident interview, clinical record review, and facility documentation review, the facility staff failed to identify a pressure ulcer until it was at an advanced stage, implement and treat a pressure ulcer for one resident, Resident #4 (R4) in a survey sample of six residents which resulted in harm for R4. The findings included: For Resident #4 (R4), the facility staff discovered an in-house acquired pressure wound, which was at an advanced stage upon discovery, as evidenced by having greater than 70% slough (dead tissue). Upon identification, the facility staff initiated a one-time treatment without a physician order and failed to obtain treatment orders for ongoing treatment of the wound. When the resident was seen five days later by a wound specialist provider, the wound required sharps debridement (surgical removal of the dead tissue). Approximately one month from discovery, R4's wound had 10% exposed bone, after the facility repeatedly delayed implementing orders for sacral wound care, repeately omitted the provision of wound treatment, and failed to obtain an x-ray that was ordered to rule out osteomyelitis for 18 days, all of which constituted harm. On 4/28/25 a tour of the nursing unit, 400 wing, was conducted. R4 was observed lying in bed on her back, with an alternating pressure mattress in place. R4 was observed to not have her feet/heels floated nor any pressure reducing boots in place on her feet. R4 was non-verbal and therefore uninterviewable. On 4/29/25 at 9:30 a.m., an observation of R4's sacral wound treatment was requested, but Licensed practical nurse LPN#1 said, All of R4's treatments were already done. On 4/29/25 at 9:30 a.m., R4 was observed laying on her back with her heel protectors on and chewing on the corner of a sheet. LPN#1 stated that R4 would chew on her sheets and that R4 has a diagnosis of pica. On 4/29/25 at 11:50 a.m., an observation of R4 was conducted. R4 was still in the same position on her back, heel protectors on but heels were not floating or off loaded from the bed surface. R4 was again observed chewing on the corner of her sheet. R4's certified nursing assistant was in the room assisting R4's roommate and stated that she would be over to provide care to R4 shortly. On 4/28/25-4/29/25, a review of R4's clinical record was conducted and revealed that on 3/22/25, there was documentation that R4 had been noted with a facility acquired pressure wound to the sacral/coccyx area that day. The 3/22/25 progress note written by RN#1 read, Patient brief changed after bm [bowel movement], noted an unstageable pressure ulcer to sacrum/coccyx. Wound bed >70% slough 25% beefy red granulating tissue. Dark red bruising to peri wound. Wound measures 2 cm x 2 cm x 0.2 cm. This RN#1, using aseptic technique cleansed with wound cleanser, patted dry with 4x4, applied Medi honey to wound bed, covered with silver alginate and bordered sacral foam dressing. Patient tolerated well. Review of the physician orders and TAR [treatment administration record] revealed no physician order for the wound care treatment performed by RN #1 on 3/22/25 or physician notification of the new sacral wound. According to the progress notes, assessment tab and documents tab of R4's clinical record revealed no further documentation regarding the sacral wound following the identification on 3/22/25 by RN #1, until 3/27/25. According to the provider's progress note dated 3/27/25, R4 was seen by a wound specialist nurse practitioner, who documented the following, . Staff have asked this writer to evaluate new concern for injury to pt's [patients] sacrum . Staff report the new injury to sacrum was noted this past weekend while staff were completing routine care and deny any changes to pt's elimination routine. Staff note applying foam dressing since injury first noted .Sacrum/coccyx: full thickness ulceration that measures 5.0 x 3.5 x 0.2 cm. Wound base 80% slough, 20% granular prior to debridement, 50% adherent slough, 50% granular after. Edges adherent to wound base, moderate non-odorous serous drainage, peri wound without erythema, no induration, no cellulitis. Patient does not demonstrate evidence of pain when area is palpated. (Please note, when debridement is completed, measurements are always taken post debridement.) Plan: SACRUM/COCCYX - unstageable PI contributing factors to dx: poor mobility, type 2 DM, dementia, LE contractions, malnutrition, dysphagia, LTC, incontinence Wound care to SACRUM/COCCYX as follows:- Cleanse site with normal saline or sterile water (Do not use wound cleanser, this may decrease effectiveness of Santyl (collagenase).- Apply Santyl (collagenase) ointment (nickel thickness) to wound base- (tx [treatment] for enzymatic debridement).- Apply alginate. - Cover with foam dressing. - Provide this care daily and as needed for saturation or soilage . As patient allows and tolerates, recommend the following interventions: Turn/reposition at least every 2 hours . PROCEDURE: Performed excisional debridement of COCCYX wound(s) consisted of: Ulceration site(s) was/were prepped, and conservative sharp debridement was performed. Depth of debridement was at level of subcutaneous tissue, and within wound margins. Removal of devitalized necrotic [dead] tissue with a 5mm curette [scalpal]. There was scant bleeding that quickly subsided with light pressure and cleansing. Patient appeared to tolerate procedure without pain or signs of discomfort. On 3/31/25, the wound specialist nurse practitioner documented the following note in R4's chart, . On exam, wound to COCCYX is enlarged compared to last week. Staff report pt frequently prefers to remain in her wheelchair. Wheelchair is reclinable with pressure redistribution mattress to support offloading. Still recommend side lying placement in bed routinely throughout the day to offload SACRUM . SACRUM/COCCYX (+) full thickness ulceration that measures 7.0 x 4.0 x 0.2 cm. Wound base 30% intact deep maroon and purple intact, with two open areas consisting of 50% slough, 20% granular prior to debridement, 30% intact, 50% thinner adherent slough, 20% granular after. Edges adherent to wound base, moderate non-odorous serous drainage, peri wound without erythema, no induration, no cellulitis. Patient does not demonstrate evidence of pain when area is palpated . PLAN: Wound care to SACRUM/COCCYX as follows:- Cleanse site with normal saline or sterile water (Do not use wound cleanser, this may decrease effectiveness of Santyl (collagenase).- Apply Santyl (collagenase) ointment (nickel thickness) to wound base- (tx for enzymatic debridement).- Apply zinc to peri wound.- Apply alginate. - Cover with foam dressing. - Provide this care daily and as needed for saturation or soilage . As patient allows and tolerates, recommend the following interventions: Turn/reposition at least every 2 hours . PROCEDURE: Performed excisional debridement of COCCYX wound(s) consisted of: Ulceration site(s) was/were prepped, and conservative sharp debridement was performed. Depth of debridement was at level of subcutaneous tissue, and within wound margins. Removal of devitalized necrotic tissue with a 5mm curette. There was scant bleeding that quickly subsided with light pressure and cleansing. Patient appeared to tolerate procedure without pain or signs of discomfort According to the physician orders and treatment administration record, there was no documented change in orders to reflect the wound specialist's new treatment that included the zinc regimen. On 4/10/25, R4's wound was evaluated and treated by the wound specialist nurse practitioner. The note documented the following, which read in part, . On exam, wound to coccyx is slightly enlarged, but intact skin no longer with maroon and purple. Recommend x-ray to sacrum to r/u OM [rule out osteomyelitis] . SACRUM/COCCYX (+) full thickness ulceration that measures 9.0 x 6.0 x 0.2 cm. Wound base 30% intact, 20% eschar, 50% adherent yellow slough prior to debridement, 30% intact, 15% eschar, 55% adherent slough after. Edges adherent to wound base, moderate non-odorous serous drainage, peri wound without erythema, no induration, no cellulitis . Plan: Recommend x-ray to rule out OM. Site declined, CHANGE care- Wound care to SACRUM/COCCYX as follows: - Cleanse with NS or wound cleanser, pat dry. - Apply 1/4 strength Dakin's moistened gauze to wound bed. - Cover with foam dressing. - Provide this care daily and as needed for saturation or soilage . PROCEDURE: Performed excisional debridement of COCCYX wound(s) consisted of: Ulceration site(s) was/were prepped, and conservative sharp debridement was performed. Depth of debridement was at level of subcutaneous tissue, and within wound margins. Removal of devitalized necrotic tissue with a #10 scalpel. There was scant bleeding that quickly subsided with light pressure and cleansing. Patient appeared to tolerate procedure without pain or signs of discomfort. This note documented that the wound deteriorated, as evidenced by the increased wound size and the concerns suspecting an emerging bone infection. R4's clinical record revealed no evidence the facility obtained a physician's order to refelct the recommended xray to rule out the suspected bone infection. On 4/17/25, R4 was again treated by the wound specialist. The note documented the following findings, . SACRUM/COCCYX (+) full thickness ulceration that measures 6.5 x 6.0 x 1.5 cm. Wound base 100% thick slough prior to debridement, 100% thinner slough after. Edges adherent to wound base, moderate mildly malodorous serous drainage, peri wound without erythema, no induration, no cellulitis . Recommend x-ray to rule out OM. Site improved, depth increased d/t removal of necrotic tissue, wound is cleaner with decreased length, continue care- Wound care to SACRUM/COCCYX as follows: - Cleanse with NS or wound cleanser, pat dry. - Apply 1/4 strength Dakin's moistened gauze to wound bed. - Cover with foam dressing. - Provide this care daily and as needed for saturation or soilage This evaluation determined wound deterioration, as evidenced by the findings of 100% slough. On 4/24/25, R4's wound was evaluated and treated by the wound specialist. The note documented the following, .Of note, wound base is now visible and can now be staged as stage 4 PI [Pressure Injury] d/t the presence of exposed bone. Recommend a 21-day course of Doxycycline 100 mg BID d/t dusky color and mild malodor noted to the wound bed, and increased peri wound erythema. Also recommend an XRAY to rule out OM . SACRUM/COCCYX (+) full thickness ulceration that measures 6.2 x 6.5 x 3.5 cm. Wound base 15% eschar, 85% slough prior to debridement, 5% eschar, 15% thinner slough, 70% dusky granular, 10% exposed bone after. Edges adherent to wound base, moderate mildly malodorous serous drainage, peri wound erythema, no induration, no cellulitis . PLAN: Please treat empirically for wound infection with Doxycycline 100mg PO BID x 21 days. Recommend x ray to rule out OM. Site declined, increased depth related to removal of necrotic tissue, d/t malodor and peri wound erythema, CHANGE care- Wound care to SACRUM/COCCYX as follows: - Cleanse with NS or wound cleanser, pat dry. - LIGHTLY PACK silver alginate to wound bed. - Apply zinc to peri wound. - Cover with foam dressing. - Provide this care daily and as needed for saturation or soilage . On 4/25/25, R4's physician orders for treatment of the sacrum/coccyx pressure ulcer were discontinued prior to the treatment being done that day, and no new treatment was ordered/provided until 4/27/25, leaving R4's pressure ulcer with exposed bone without any form of wound treatment since 4/24/25. According to R4's clinical record, the x-ray recommended by the wound specialist on 4/10/25, 4/17/25, and 4/24/25, was never ordered until 4/25/25, and read, X ray of patient with sacral pressure wound with concerns for osteo. Please perform x-ray of sacrum and coccyx one time only for sacral wound for 16 days. According to R4's TAR, this order for the sacral/coccyx xray was signed off as completed on 4/26/25. There was no other evidence within the clinical record that the x-ray had been completed, nor were any x-ray results on file. There was a progress note dated 4/24/25 that read, : DON [director of nursing] spoke to patients POA [power of attorney], [POA's name redacted], on Wednesday afternoon. [POA's name redacted] is aware that the sacral wound is not improving [sic]. Per IDT [interdisciplinary team] discussion .will place pt on abx [antibiotic], place foley, culture wound, CBC [complete blood count- a lab test], BMP [basic metabolic panel- a lab test] and sacral xray to assess for osteo have been ordered . On 4/28/25, there was another progress note that read, Called [contracted mobile x-ray company name redacted] regarding X-ray, will call facility on expected date and time. On 4/29/25 at 9:40 a.m., an interview was conducted with LPN#1. LPN#1 said, A hole in the MAR [medication administration record] or TAR [treatment administration record] means it wasn't done. When a wound is found, we report it to the doctor, complete a change in condition, report to the unit manager and director of nursing, and obtain a treatment order from the doctor. We are to put the information in the wound provider book to schedule evaluation with wound provider. LPN#1 stated that the mobile xray company comes to the facility timely but sometimes it was taking long periods of time. LPN#1 stated that xray results were received in the same day, if obtained early morning but at least within 24 hours. LPN#1 stated that orders were put into the system by the provider. LPN#1 stated that the wound provider recommendations were reviewed by the in-house nurse practitioner (NP) and if they agree, an order was written. On 4/29/25 at 9:50 a.m., an interview was conducted with LPN#2. LPN#2 said, Holes in the treatment and med record means it was not done. LPN#2 stated that the wound care provider was coming to the facility weekly. She stated that the wound care provider was uploading her orders as a document and the nurses were to follow up and put the orders into the resident's record/chart. LPN#2 stated that when a xray was ordered that it would be obtained within one hour if stat, but non-stat orders were taking up to one to two days to be obtained. LPN#2 stated that if results were not received within 24 hours the nurses would follow up with the results being sent to the facility. LPN#2 stated that R4 had an order for repositioning every 2 hours, which was being monitored by the unit manager and the charge nurses. LPN#2 stated that there was no documentation about R4's repositioning being completed every two hours. On 4/29/25 at 10:00 a.m., an interview was conducted with the director of nursing (DON). The DON said, A blank on the MAR means it wasn't given and, on the TAR, means it wasn't done. The DON stated that when the nurse found a new wound, that it was to be reported to me and the unit manager, cleaned with soap and water, nurse practitioner notified, treatment orders obtained until the wound provider evaluated the wound, and the responsible party notified of the findings. The DON stated that weekly skin sweeps were completed by 2 nurses, and that one must be a registered nurse (RN). When questioned about evidence of repositioning, the DON stated that there was no documentation for the repositioning of R4 every two hours and that the nurses talk with the aides to make sure it was done. The DON stated that she checked every morning that xray's and labs were obtained when ordered and results were received in a timely manner. The DON said, I review the wound specialist nurse practioner's documentation. The wound provider recommendations are put in as orders and reviewed by our in-house NP. The NP agrees with the wound providers' recommendations. The DON said, Wound care provider orders and recommendations are put into the system the next business day, within 24 hours. If an order is obtained on the 28th the treatment should begin on the 28th. On 4/29/25 at 10:45 a.m., a meeting was conducted with the administrator, the DON and corporate staff. During this meeting, they were informed of the above findings, including the failure to identify the sacral wound until late, and the failure to manage R4's wound management timely, may be considered harm. The regional director of clinical services (RDCS), who was present in the meeting, stated that the facility was working on a QAPI (Quality Assurance Performance Improvement) Action Plan for wounds. The RDCS and facility staff were then asked to present all the evidence and any new information that they had to provide. The RDCS then stated that R4's xray was obtained that morning at 5:00 a.m. and subsequently provided a copy of the xray report, which indicated that it was obtained on 4/29/25 at 5 a.m. On 4/29/25 at 10:50 a.m., the RDCS presented a form that was titled, QAPI Action Plan. The form was dated 3/15/25, but notably the issue/concern area was blank, the root cause analysis/related factors area was blank, there was no responsible person listed to perform the tasks, there was no projected completion date listed, and the section with the review (date and status report) was blank. The RDCS was informed that the provided form appeared to be a blank template, with the only information completed being the date. On 4/29/25 at 10:55 a.m., the administrator provided a second QAPI form for review that had the persons responsible section filled out, along with one projected date of 3/30/25 for skin sweeps, noting that an audit would be performed to check that each identified impairment has a current, appropriate treatment order and/or interventions, and that an audit for each resident with skin impairment has a corresponding care plan. On 4/29/25 at 11:00 a.m., the DON, who was assigned as the responsible person for the submitted QAPI action plan, was asked if she had completed the indicated audits. In response, the DON shrugged her shoulders and stated that she would check at the nurse's station in the wound notebook. At 11:10 a.m., the DON stated that she was not able to find any audits that she completed. The DON went on to show the survey team in a skin/wound book, containing weekly skin sheets listing residents with wounds, that she was signing and dating those sheets that she reviewed weekly. Upon reviewing the skin impairment weekly report, the DON had signed off on only one form with the findings of skin impairment, but there was nothing submitted to indicate root cause analysis, appropriate treatment orders had been completed, or that care plan measures had been implemented. The DON also provided evidence of a skin sweep that was conducted on 4/28/25, which was not included on the provided QAPI form and did not include any of the areas indicated on the QAPI. On 4/29/25 at 11:15 a.m., the DON was interviewed about R4's xray not being otained timely. The DON was asked why there were repeated recommendations by the wound specialist on 4/10/25, 4/17/25 and 4/24/25, which was not ordered until 4/25/25, but the xray was not obtained until 4/29/25. The DON said, Our in-house NP did not agree with doing the xray, thought it was too early to obtain an Xray. The DON stated that she texted the in-house nurse practitioner and would find the documentation about the in-house NP not agreeing with the recommendation for R4's xray. When not able to provide any documentation by the in-house NP's not wanting the xray obtained, the DON said, That was a miss on my behalf, usually they [mobile xray] don't take that long to come. They were here over the weekend getting chest x-rays on two residents and we questioned why it was not done. They came and it resulted this morning. The DON was interviewed about the QAPI Action Plan that was provided for review and was asked what specific area had been identified as the issue. The DON first stated, When we noticed R4's wound getting worse was when we QAPI'ed that. Then the DON stated that R4 . was the only one we had with a pressure ulcer. When again asked what the identified issue was since that area was blank on the submitted QAPI form, the DON said, Lack of documentation and poor documentation was the issue. The DON stated that education was being provided to the nursing staff. The DON said, A lot was wrapped around agency staff saying they did not know who to call but our numbers are posted at the desk, the unit managers and mine. The DON was asked to provide evidence of education. The DON provided an in-service sheet, without a topic listed, no date on the sheet, which read, See attached but no attachment was included. When asked about the education given, the DON said, We weren't getting any documentation done or any change in condition. No paper, just verbalized about the change in condition; didn't give a policy or anything, just verbalized about change in condition. The in-service sheet indicated that only six staff had signed and one of those was a certified nursing assistant. The DON also provided evidence of a skin sweep, which was not signed by who completed the audit or dated as to when it was completed. A Midnight Census report dated 4/27/25, with a print date of 4/28/25 at 7:27 p.m., that was color coded to indicate if a resident had refused the skin evaluation, had wounds or no skin impairments. On 4/29/25 at 11:45 a.m., the RDCS provided a medical progress note to be reviewed. The progress note read in part, .Being seen per nursing request for high risk for skin breakdown. High risk for skin breakdown - Severe protein/calorie malnutrition- significant weight loss- c/w [continue with] Prostat- follow wound team recommendations for sacral/coccyx wound-LTC [long term care] supportive care, assistance with ADL's [activities of daily living] DNR [do not resuscitate] Rehab potential: fair. When asked if she expected a wound to be found at the advanced stage that it needed debridement (removal of dead tissue by scalpal), the RDCS said, I would not necessarily expect a wound to be found at needing debridement for the wound. The RDCS stated that the staff was working with her family to get R4 on hospice because of her condition and has not been able to get that started due to the responsible party issues the family was having. The RDCS was informed that there was no evidence in R4's clinical record of hospice care being discussed. No additional information was offered at that time. On 4/29/25 at 12:00 p.m., a review of the facility document titled, Pressure Injury Prevention and Management, included, .develop and maintain systems and processes to ensure that the resident does not develop pressure ulcers/injuries (PU/PIs) unless clinically unavoidable and that the facility provides care and services consistent with professional standards of practice to: promote the prevention of pressure ulcer/injury development; promote the healing of existing pressure ulcers/injuries (including prevention of infection to the extent possible); and prevent development of additional pressure ulcer/injury. On 4/29/25 at 12:10 p.m., a review of the facility document titled, Skin and Wound Guidelines, included, .the purpose to the pressure injury/skin breakdown clinical protocol is to assist facilities to implement interventions to prevent pressure ulcers and/or enhance the wound healing process, to accurately assess/monitor a residents risk for alteration in skin integrity, to maintain and promote healthy skin integrity of residents and to establish guidelines for the prevention and treatment of pressure sores/alterations in skin integrity. On 4/29/25 at 12:15 p.m., a meeting was conducted with the administrator, the DON and the RDCS. During this meeting, the facility was again informed of the above indications of harm regarding R4's sacral wound being identified at such an advanced stage that it required sharp debridement (removal of dead tissue by scalpal), the lack of treatment orders being implemented when the wound was identified, the delay in implementing treatment and x-ray orders from the wound specialist, as well as the concerns with missing treatments and the inadeqacies of the submitted QAPI plan, particularly that it had not been filled out or completed in full prior to the survey team's arrival on-site. No additional information was provided prior to the exit conference.

Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to protect the resident's right to be free from neglect by failure to provide timely identification and management of a pressure wound for one resident, Resident #4 (R4) in a survey sample of six residents, which deprived the resident of needed care to avoid physical harm of severe wound deterioration. by facility staff with regards to identification and treatment of a pressure ulcer until it was at an advanced stage and neglected to implement and treat a pressure ulcer for one resident, Resident #4 (R4) in a survey sample of six residents which resulted in harm for R4. The findings included: For Resident #4, the facility staff neglected to identify an in-house acquired pressure wound until it was at an advanced stage, as evidenced by having greater than 70% slough (dead tissue), and then facility staff neglected to obtain and implement treatment orders for ongoing treatment of the sacral/coccyx wound. When the resident was seen five days later by a wound specialist provider, the wound required sharps debridement and 33 days after discovery R4 had 10% exposed bone in the wound. The facility neglected to implement wound care orders and failed to obtain an x-ray that was ordered to rule out osteomyelitis for 18 days, all of which constituted harm. On 4/28/25 a tour of the nursing unit, 400 wing, was conducted. R4 was observed lying in bed on her back, with an alternating pressure mattress in place. R4 was observed to not have her feet/heels floated nor any pressure reducing boots in place on her feet. R4 was non-verbal, so no interview was conducted with the resident. On 4/29/25 at 9:30 a.m., an observation of R4's sacral wound and treatment was requested. Licensed practical nurse (LPN#1) said, All of [R4's name redacted] treatments were already done. On 4/29/25 at 9:30 a.m., R4 was observed laying on her back with her heel protectors on and chewing on the corner of a sheet. LPN#1 stated that R4 would chew on her sheets and had a diagnosis of pica. On 4/29/25 at 11:50 a.m., an observation of R4 was conducted. R4 was still in the same position, lying on her back, chewing on the corner of her sheet, with heel protectors on, but heels were not floating or off loaded off the bed. R4's certified nursing assistant was in the room assisting R4's roommate and stated she would be over to take care of R4 shortly. On 4/28/25-4/29/25, a review of R4's clinical record was conducted and noted that on 3/22/25, there was documentation that R4 had been newly identified with a facility acquired pressure wound that day. A progress note written by RN#1 was reviewed. On 3/22/25 RN#1 found a pressure ulcer on R4's sacral area and wrote a progress note that read, Patient brief changed after bm [bowel movement], noted an unstageable pressure ulcer to sacrum/coccyx. Wound bed >70% slough 25% beefy red granulating tissue. Dark red bruising to peri wound. Wound measures 2 cm x 2 cm x 0.2 cm. This RN#1, using aseptic technique cleansed with wound cleanser, patted dry with 4x4, applied Medi honey to wound bed, covered with silver alginate and bordered sacral foam dressing. Patient tolerated well. Review of the physician orders and TAR (treatment administration record) revealed the facility staff neglected to obtain a physician order for the wound care treatment performed by RN #1 on 3/22/25. According to the progress notes, physician orders, assessment tab and documents tab of R4's clinical record, the facility staff neglected to assess or provide any treatment to the sacral wound following the identification on 3/22/25 by RN #1, until 3/27/25. On 3/27/25, R4 was seen by a wound specialist nurse practitioner. That provider's progress note read in part, . Staff have asked this writer to evaluate new concern for injury to pt's [patients] sacrum . Staff report the new injury to sacrum was noted this past weekend while staff were completing routine care and deny any changes to pt's elimination routine. Staff note applying foam dressing since injury first noted .Sacrum/coccyx: full thickness ulceration that measures 5.0 x 3.5 x 02 cm. Wound base 80% slough, 20% granular prior to debridement, 50% adherent slough, 50% granular after. Edges adherent to wound base, moderate non-odorous serous drainage, peri wound without erythema, no induration, no cellulitis. Patient does not demonstrate evidence of pain when area is palpated. (Please note, when debridement is completed, measurements are always taken post debridement.) Plan: SACRUM/COCCYX - unstageable PI contributing factors to dx: poor mobility, type 2 DM, dementia, LE contractions, malnutrition, dysphagia, LTC, incontinence Wound care to SACRUM/COCCYX as follows:- Cleanse site with normal saline or sterile water (Do not use wound cleanser, this may decrease effectiveness of Santyl (collagenase).- Apply Santyl (collagenase) ointment (nickel thickness) to wound base- (tx [treatment] for enzymatic debridement).- Apply alginate. - Cover with foam dressing. - Provide this care daily and as needed for saturation or soilage . As patient allows and tolerates, recommend the following interventions: Turn/reposition at least every 2 hours . PROCEDURE: Performed excisional debridement of COCCYX wound(s) consisted of: Ulceration site(s) was/were prepped, and conservative sharp debridement was performed. Depth of debridement was at level of subcutaneous tissue, and within wound margins. Removal of devitalized necrotic tissue with a 5mm curette. There was scant bleeding that quickly subsided with light pressure and cleansing. Patient appeared to tolerate procedure without pain or signs of discomfort. On 4/29/25, a review of the progress notes, care plan, assessments, TAR [treatment administration record] and physician orders was completed. From 3/22/25 through 3/29/25, there were no treatment orders for R4's pressure ulcer/wound. There was no evidence of any treatment being provided to R4's sacral wound from 3/23/25-3/29/25. The first treatment order was written on 3/27/25 by the wound care provider and the facility staff neglected to implement the order until 3/30/25. On 3/31/25, R4 was seen again by the wound specialist nurse practitioner. The progress note read in part, . On exam, wound to COCCYX is enlarged compared to last week. Staff report pt frequently prefers to remain in her wheelchair. Wheelchair is reclinable with pressure redistribution mattress to support offloading. Still recommend side lying placement in bed routinely throughout the day to offload SACRUM . SACRUM/COCCYX (+) full thickness ulceration that measures 7.0 x 4.0 x 0.2 cm. Wound base 30% intact deep maroon and purple intact, with two open areas consisting of 50% slough, 20% granular prior to debridement, 30% intact, 50% thinner adherent slough, 20% granular after. Edges adherent to wound base, moderate non-odorous serous drainage, peri wound without erythema, no induration, no cellulitis. Patient does not demonstrate evidence of pain when area is palpated . PLAN: Wound care to SACRUM/COCCYX as follows:- Cleanse site with normal saline or sterile water (Do not use wound cleanser, this may decrease effectiveness of Santyl (collagenase).- Apply Santyl (collagenase) ointment (nickel thickness) to wound base- (tx for enzymatic debridement).- Apply zinc to peri wound.- Apply alginate. - Cover with foam dressing. - Provide this care daily and as needed for saturation or soilage . As patient allows and tolerates, recommend the following interventions: Turn/reposition at least every 2 hours . PROCEDURE: Performed excisional debridement of COCCYX wound(s) consisted of: Ulceration site(s) was/were prepped, and conservative sharp debridement was performed. Depth of debridement was at level of subcutaneous tissue, and within wound margins. Removal of devitalized necrotic tissue with a 5mm curette. There was scant bleeding that quickly subsided with light pressure and cleansing. Patient appeared to tolerate procedure without pain or signs of discomfort According to the physician orders and treatment administration record, the facility staff neglected to change the pressure ulcer treatment orders following the wound specialist seeing the resident on 3/31/25 and staff were not applying the zinc to the peri wound as ordered. Reviewing the TAR revealed that the staff neglected to provide wound care treatments on 4/21/25, 4/23/25, 4/25/25, and 4/26/25. R4 had an active physician order dated 2/25/25 that read, offloading boots to BLE [bilateral lower extremities], as tolerated every shift for skin integrity. Another physician order dated 4/3/25, that remained active read, reposition q2h [every 2 hours]. The order did not include the wound specialis's recommendations for side-lying positioning to offload pressure to the wound. On 4/10/25, R4's wound was seen and treated by the wound specialist nurse practitioner. According to the note, which read in part, . On exam, wound to coccyx is slightly enlarged, but intact skin no longer with maroon and purple. Recommend x-ray to sacrum to r/u OM [rule out osteomyelitis] . SACRUM/COCCYX (+) full thickness ulceration that measures 9.0 x 6.0 x 0.2 cm. Wound base 30% intact, 20% eschar, 50% adherent yellow slough prior to debridement, 30% intact, 15% eschar, 55% adherent slough after. Edges adherent to wound base, moderate non-odorous serous drainage, peri wound without erythema, no induration, no cellulitis . Plan: Recommend x-ray to rule out OM. Site declined, CHANGE care- Wound care to SACRUM/COCCYX as follows: - Cleanse with NS or wound cleanser, pat dry. - Apply 1/4 strength Dakin's moistened gauze to wound bed. - Cover with foam dressing. - Provide this care daily and as needed for saturation or soilage . PROCEDURE: Performed excisional debridement of COCCYX wound(s) consisted of: Ulceration site(s) was/were prepped, and conservative sharp debridement was performed. Depth of debridement was at level of subcutaneous tissue, and within wound margins. Removal of devitalized necrotic tissue with a #10 scalpel. There was scant bleeding that quickly subsided with light pressure and cleansing. Patient appeared to tolerate procedure without pain or signs of discomfort. On 4/17/25, R4 was again seen by the wound specialist. The note read, . SACRUM/COCCYX (+) full thickness ulceration that measures 6.5 x 6.0 x 1.5 cm. Wound base 100% thick slough prior to debridement, 100% thinner slough after. Edges adherent to wound base, moderate mildly malodorous serous drainage, peri wound without erythema, no induration, no cellulitis . Recommend x-ray to rule out OM. Site improved, depth increased d/t removal of necrotic tissue, wound is cleaner with decreased length, continue care- Wound care to SACRUM/COCCYX as follows: - Cleanse with NS or wound cleanser, pat dry. - Apply 1/4 strength Dakin's moistened gauze to wound bed. - Cover with foam dressing. - Provide this care daily and as needed for saturation or soilage . On 4/24/25, R4's wound was seen and assessed by the wound specialist. According to the note, it read in part, .Of note, wound base is now visible and can now be staged as stage 4 PI d/t the presence of exposed bone. Recommend a 21-day course of Doxycycline 100 mg BID d/t dusky color and mild malodor noted to the wound bed, and increased peri wound erythema. Also recommend an XRAY to rule out OM . SACRUM/COCCYX (+) full thickness ulceration that measures 6.2 x 6.5 x 3.5 cm. Wound base 15% eschar, 85% slough prior to debridement, 5% eschar, 15% thinner slough, 70% dusky granular, 10% exposed bone after. Edges adherent to wound base, moderate mildly malodorous serous drainage, peri wound erythema, no induration, no cellulitis . PLAN: Please treat empirically for wound infection with Doxycycline 100mg PO BID x 21 days. Recommend x ray to rule out OM. Site declined, increased depth related to removal of necrotic tissue, d/t malodor and peri wound erythema, CHANGE care- Wound care to SACRUM/COCCYX as follows: - Cleanse with NS or wound cleanser, pat dry. - LIGHTLY PACK silver alginate to wound bed. - Apply zinc to peri wound. - Cover with foam dressing. - Provide this care daily and as needed for saturation or soilage . On 4/25/25, R4's physician orders for treatment of the pressure ulcer were discontinued prior to the treatment being done that day, and no new treatment was implemented until 4/27/25. Leaving R4's pressure ulcer with exposed bone without any evidence of any wound care treatment for two days. According to the wound specialist notes and physician orders, the x-ray ordered by the wound specialist on 4/10/25, 4/17/25, and 4/24/25, but there was no corresponding physician's order. The facility staff neglected to transcribe and initiate R4's physician order for the xray until 4/25/25, which read, X ray of patient with sacral pressure wound with concerns for osteo. Please perform x-ray of sacrum and coccyx one time only for sacral wound for 16 days. According to the treatment administration record, the staff signed off that the x-ray was completed on 4/26/25. There was no other evidence within the clinical record that the x-ray had been completed, or any x-ray results were on file. There was a progress note dated 4/24/25 that read, : DON [director of nursing] spoke to patients POA [power of attorney], [name redacted], on Wednesday afternoon. [POA name redacted] is aware the the sacral wound is not improving [sic]. Per IDT [interdisciplinary team] discussion .will place pt on abx [antibiotic], place foley, culture wound, CBC [complete blood count- a lab test], BMP [basic metabolic panel- a lab test] and sacral xray to assess for osteo have been ordered . On 4/28/25, there was another progress note that read, Called [contracted mobile x-ray company name redacted] regarding X-ray, will call facility on expected date and time. On 4/29/25 at 9:40 a.m., an interview was conducted with LPN#1. LPN#1 said, A hole in the MAR [medication administration record] or TAR [treatment administration record] means it wasn't done. When a wound is found we report to the doctor, complete a change in condition, report to the unit manager and director of nursing and obtain a treatment order from the doctor. We are to put the information in the wound provider book to schedule evaluation with wound provider. LPN#1 stated that the xray company will come to the facility timely and sometimes it was taking long periods of time. She stated that xray results were received in the same day if obtained early morning but at least within 24 hours. LPN#1 stated that orders were put into the system by the provider. LPN#1 stated that wound provider recommendations were reviewed by the in-house nurse practitioner (NP) and if they agree an order was written. On 4/29/25 at 9:50 a.m., an interview was conducted with LPN#2. LPN#2 said, Holes in the treatment and med record means it was not done. LPN#2 stated that the wound care provider was coming to the facility weekly. She stated that the wound care provider was uploading her orders as a document and the nurses were to follow up and put the orders into the resident's record/chart. LPN#2 stated that when a xray was ordered that it will be obtained within one hour if stat, but non-stat orders were taking up to one to two days to be obtained. She stated that if results were not received within 24 hours the nurses would follow up with the results being sent to the facility. LPN#2 stated that R4 had an order for repositioning every 2 hours and that was being monitored by the unit manager and the charge nurses. LPN#1 stated that there was no documentation about R4's repositioning being completed every two hours. On 4/29/25 at 10:00 a.m., an interview was conducted with the director of nursing (DON). The DON said, A blank on the MAR means it wasn't given and, on the TAR, means it wasn't done. The DON stated, When the nurse found a new wound that it was to be reported to me and the unit manager, cleaned with soap and water, nurse practitioner notified and obtain treatment orders until the wound provider evaluated the wound and the responsible party notified of the findings. Weekly skin sweeps were completed by 2 nurses, and one must be a registered nurse. When questioned further, the DON stated there was no documentation for the repositioning of R4 every two hours and that the nurses were . talking with the aides to make sure it was done. The DON stated that she checked every morning that xray's and labs were obtained when ordered and results were received in a timely manner. The DON said, I review the wound provider recommendations and her documentation. Wound provider recommendations were put in as orders and reviewed by our in-house NP. The NP agrees with the wound providers' recommendations. The DON said, Wound care provider orders and recommendations are put into the system the next business day, within 24 hours. If an order is obtained on the 28th the treatment should begin on the 28th. On 4/29/25 at 10:45 a.m., a meeting was conducted with the administrator, the DON and corporate staff. They were informed of the above concerns and that R4's sacral wound may be considered harm. The regional director of clinical services (RDCS) was present in the meeting and stated that the facility was working on a QAPI (Quality Assurance Performance Improvement) Action Plan for wounds. The RDCS was asked to present all the evidence and any new information that they wanted to provide. The RDCS stated the xray was obtained that morning at 5:00 a.m. and was asked to provide the survey team with a copy of the xray report. According to the xray report, the x-ray was obtained on 4/29/25 at 5 a.m. On 4/29/25 at 10:50 a.m., the RDCS presented a form that was titled, QAPI Action Plan. The form had the date of 3/15/25 on the top of the form. The issue/concern area was blank, the root cause analysis/related factors area was blank, there was no responsible person listed to perform the tasks, there was no projected completion date listed, and the section with the review (date and status report) was blank. The RDCS was informed that the submitted form was blank, appeared to be a template, and the only information completed on the form was the date at the top of the form. On 4/29/25 at 10:55 a.m., The administrator provided a second form that was filled out with the persons responsible section, one projected date of 3/30/25 for skin sweeps to be performed, noting that an audit will be performed to each identified impairment has a current, appropriate treatment order and/or interventions and an audit for each resident with skin impairment has a corresponding care plan. On 4/29/25 at 11:00 a.m., the DON, who was assigned as the responsible person for the QAPI action plan submitted, was asked if she completed the audits, and she shrugged her shoulders and stated she would check at the nurse's station in the wound notebook. The DON stated at 11:10 a.m., that she was not able to find any audits that she completed. The DON went on to show the survey team in a skin/wound book, that the weekly sheets listing residents with wounds, she was signing the sheets and dating she reviewed those sheets weekly. Upon reviewing the skin impairment weekly report, the DON had signed off on only one form with the findings of skin impairment. The DON also provided evidence of a skin sweep that was conducted on 4/28/25, but wasn't noted on the submitted QAPI form. On 4/29/25 at 11:15 a.m., the DON was interviewed about the xray not being completed timely. The DON was asked why there was recommendations by the wound provider on 4/10/25, 4/17/25 and 4/24/25, which was not ordered until 4/25/25 but the xray was not obtained until 4/29/25. The DON said, Our in-house NP did not agree with doing the xray, though it was too early to obtain an xray. The DON stated she texted the in-house nurse practitioner. The DON said that she would find the documentation about the in-house NP not agreeing with the recommendation for an Xray. When she was not able to provide any documentation by the in-house NP not wanting the xray obtained, the DON said, That was a miss on my behalf, usually they don't take that long to come. They were here over the weekend getting chest x-rays on two residents and we questioned why it was not done. They came and it resulted this morning. The DON was interviewed about the QAPI Action Plan that was provided for review and was asked what they identified as the issue. The DON first stated that when .we noticed R4's wound getting worse was when we QAPI'ed that. When questioned further, the DON stated that R4 . was the only one we had with a pressure ulcer. When asked again what the QAPI issue was that was identified, since that area was blank on the form submitted, the DON said, Lack of documentation and poor documentation was the issue. The DON stated that education was being provided to the nursing staff. The DON said, A lot was wrapped around agency staff saying they did not know who to call but our numbers are posted at the desk, the unit managers and mine. The DON was then asked to provide evidence of education. The DON provided a sign in sheet, without a topic listed, and no date on the sheet, which read, see attached but no attachment was included. When asked about the education given, the DON said, We weren't getting any documentation done or any change in condition. No paper, just verbalized about the change in condition, didn't give a policy or anything just verbalized about change in condition. It was observed that only six staff had signed the in-service sheet and one of those was a certified nursing assistant. The DON also provided evidence of a skin sweep that was conducted but not signed by who completed the audit or dated when it was completed. This evidence was a Midnight Census report dated 4/27/25 that had a print date of 4/28/25 at 7:27 p.m. and was color coded to indicate if a resident had refused the skin evaluation, had wounds or no skin impairments. On 4/29/25 at 11:45 a.m., the RDCS asked if the survey team saw the note from the provider that stated the wound was unavoidable and provided a medical progress note to be reviewed. The progress note read in part, .Being seen per nursing request for high risk for skin breakdown. High risk for skin breakdown - Severe protein/calorie malnutrition- significant weight loss- c/w [continue with] Prostat-follow wound team recommendations for sacral/coccyx wound-LTC [long term care] supportive care, assistance with ADL's [activities of daily living] DNR [do not resuscitate] Rehab potential: fair. The RDCS was asked if she expected a wound to be found at the stage it needed debridement and the RDCS said, I would not necessarily expect a wound to be found at needing debridement for the wound. The RDCS stated that the staff was working with her family to get R4 on hospice because of her condition and has not been able to get that started due to the responsible party issues the family was having. The RDCS was told that there was no evidence in R4's clinical record of hospice care being discussed. No additional information was provided. On 4/29/25 at 12:00 p.m., a review of the facility document titled, Abuse Prevention Program, was reviewed and read in part, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation . As part of the abuse prevention, the facility will: . 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents . On 4/29/25 at 12:10 p.m., a review of the facility document titled, Abuse read in part, .Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . 2. Training: . c. Facility employees will be required to complete the comprehensive oritation program that includes the following information at a minimum: . iv. What constitues abuse, neglect, mistreatment of and misappropriation of resident's property . 3. Prevention: . f. A comprehensive assessment and individualized care plan will be developed for each resident to assist staff in providing effective interventions to prevent abuse, meet the resident's needs and promote quality of life for the resident . On 4/29/25 at 12:15 p.m., a meeting was conducted with the administrator, the DON and the RDCS. During this meeting they were made aware of the above concerns regarding R4's wound being identified at an advanced stage that required sharp debridement, the lack of treatment measures being implemented when the wound was identified, the delay in implementing treatment and x-ray orders from the provider as well as the concerns with the QAPI plan being submitted without evidence that it had been completed in full prior to the survey team's arrival on-site. No additional information was provided prior to the exit conference.

4. For R2, the facility staff failed to follow professional standards of nurse practice by failing to administer physician ordered medications within an hour of the scheduled time. On 4/28/25, an interview was conducted with R2. R2 denied any concerns about medications when asked. On 4/28/25, a clinical record review was conducted of R2's chart. According to the medication administration records, R2 had medications scheduled to be administered at 9 a.m., 5 p.m., 7 p.m., and 9 p.m. According to the physician orders, medication administration record and Medication Admin Audit Report, R2 had Valsartan, Hydrochlorothiazide, Quetiapine Fumarate, Pantoprazole Sodium, Clopidogrel Bisulfate, and Metoprolol Succinate ER [Extended release] scheduled to be administered at 9 a.m., and they were not given until 12:43 p.m. On 4/17/25 R2's morning medications scheduled for administration at 9 a.m., were not administered until 11:38 a.m. and on 4/18/25, the medications were not given until 10:41 p.m. On 4/20/25, the scheduled medications for 9 a.m., were not administered until 10:38 a.m. On 4/22/25, R2's morning medications, noted above, were scheduled to be given at 9 a.m., and were not administered until 4:54 p.m. R2 had Mirtazapine and melatonin scheduled to be administered at 7 p.m. and Quetiapine Fumarate and Metoprolol Succinate ER to be given at 9 p.m., On 4/2/25 the 7 p.m., scheduled medications were not administered until 11:45 p.m. and the 9 p.m. medications were given at 10:34 p.m. On 4/3/25, 7 p.m. and 9 p.m. medications were given together at 10:52 p.m. On 4/5/25, the 7 p.m. medications were given at 10:10 p.m. and the 9 p.m. medications were given at 8:35 p.m. On 4/7/25 the 7 p.m. and 9 p.m. medications were given together at 11:35 p.m. On 4/8/25, the melatonin was given with Quetiapine and Metoprolol Succinate ER at 1:31 a.m. on 4/9/25. The Quetiapine Fumarate scheduled for 7 p.m. on 4/8/25 was given on 4/9/25 at 3:28 a.m. On 4/9/25, the 7 p.m. medications were administered at 10:42 p.m. after the 9 p.m. medications were given at 10:12 p.m. From 4/10/25-4/26/25, R2's medications scheduled for 7 p.m., were given outside of the professional standard to give within 1 hour of the scheduled time on 14 occasions. There was no evidence within R2's clinical record to indicate that the ordering provider or attending physician was made aware of the instances that R2's medications were not administered timely. No additional information was provided prior to exit. Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to follow professional standards of nursing practice with regards to the management of an advanced pressure wound for one resident (Resident #4-R4), constituting harm, and the timeliness of medication administration for three residents (Resident #2 -R2, Resident #3-R3, and Resident #4-R4), in a survey sample of six residents. The findings included: 1. For R4, the facility failed to provide appropriate management of an advanced pressure wound per professional standards of care, subsequently resulting in further wound deterioration, which contstituted harm. On 4/29/25 at 10:00 a.m., an interview was conducted with the director of nursing (DON). The DON said, A blank on the MAR means it wasn't given and, on the TAR, means it wasn't done. The DON stated, When the nurse found a new wound, that it was to be reported to me and the unit manager, cleaned with soap and water, nurse practitioner notified, treatment orders obtained until the wound provider evaluated the wound, and the responsible party notified of the findings. The DON stated that weekly skin sweeps were completed by 2 nurses, and that one must be a registered nurse (RN). When questioned about evidence of repositioning, the DON stated that there was no documentation for the repositioning of R4 every two hours and that the nurses talk with the aides to make sure it was done. The DON stated that she checked every morning that xray's and labs were obtained when ordered and results were received in a timely manner. The DON said, I review the wound specialist nurse practioner's documentation. The wound provider recommendations are put in as orders and reviewed by our in-house NP. The NP agrees with the wound providers' recommendations. The DON said, Wound care provider orders and recommendations are put into the system the next business day, within 24 hours. If an order is obtained on the 28th the treatment should begin on the 28th. On 4/29/25 at 10:15 a.m., a review of R4's clinical record was conducted. A progress note written by RN#1 was reviewed. On 3/22/25 RN# found a pressure ulcer on R4's sacral area. RN#1 wrote a progress note that read, Patient brief changed after bm, noted an unstageable pressure ulcer to sacrum/coccyx. Wound bed >70% slough 25% beefy red granulating tissue. Dark red bruising to peri wound. Wound measures 2 cm x 2 cm x 0.2 cm. This RN#1, using aseptic technique cleansed with wound cleanser, patted dry with 4x4, applied Medi honey to wound bed, covered with silver alginate and bordered sacral foam dressing. Patient tolerated well. There were no physician orders for this treatment, nor were any wound care orders obtained to continue this treatment order. On 4/29/25 at 10:30 a.m., a comprehensive review of the TAR was conducted. Following the identification of the sacral/coccyx pressure wound on 3/22/25, there were no treatment orders or evidence that any sacral wound treatment was provided from 3/23/25 through 3/29/25. The first treatment order was written on 3/27/25 but was not implemented until 3/30/25. On 3/27/25, the wound specialist also recommended that R4 be positioned side-lying to offload pressure to the sacral/coccyx wound. On 3/31/25, the wound specialist recommended the use of zinc to the periwound, which was not implemented until 4/27/25. On 4/10/25, the wound specialist recommended an xray, given the documented findings of the wound deterioration with visible bone exposure, but the xray was not obtained until 4/29/25. On 4/10/25, the wound specialist also recommended new treatment with Dakin's solution, which was not started until 4/14/25. On 4/24/25, the wound specialist recommended a change in wound treatment that was not started until 4/27/25. Further review revealed that no treatment was documented on 4/21/25, 4/23/25, 4/25/25, and 4/26/25 to R4's sacral wound, which had been determined to be a Stage 4 - the most severe type. On 4/29/25 at 11:15 a.m., the DON was interviewed about R4's xray not being otained timely. The DON was asked why there were repeated recommendations by the wound specialist on 4/10/25, 4/17/25 and 4/24/25, which was not ordered until 4/25/25, but the xray was not obtained until 4/29/25. The DON said, Our in-house NP did not agree with doing the xray, thought it was too early to obtain an Xray. The DON stated that she texted the in-house nurse practitioner and would find the documentation about the in-house NP not agreeing with the recommendation for R4's xray. When not able to provide any documentation by the in-house NP's not wanting the xray obtained, the DON said, That was a miss on my behalf, usually they [mobile xray] don't take that long to come. They were here over the weekend getting chest x-rays on two residents and we questioned why it was not done. They came and it resulted this morning. On 4/29/25 at 10:40 p.m., a review of the facility document titled, Pressure Injury Prevention and Management, was reviewed and read in part, .develop and maintain systems and processes to ensure that the resident does not develop pressure ulcers/injuries (PU/PIs) unless clinically unavoidable and that the facility provides care and services consistent with professional standards of practice to: promote the prevention of pressure ulcer/injury development; promote the healing of existing pressure ulcers/injuries (including prevention of infection to the extent possible); and prevent development of additional pressure ulcer/injury. 2. For R3, the facility staff failed to follow professional standards of nurse practice to ensure medications were administered within an hour of the scheduled time. On 4/28/25 a clinical record review was conducted. R3's medication administration record (MAR) indicated that medications were ordered to be administered at 7:00 a.m., 9:00 a.m., 7:00 p.m., and 9:00p.m. According to the Medication Admin Audit Report, R3 was scheduled Tums, Thiamine, Divalproex Sodium, Levetiracetam, Vitamin D3, Folic Acid, Multiple Vitamins-Minerals, Aspirin, Fluoxetine, and Gabapentin for 9:00 a.m., but was administered at 11:37 a.m on 4/9/25. R3's Baclofen was scheduled at 7:00 a.m., but was administered at 12:59 p.m. on 4/10/25, administered at 12:21 p.m. on 4/11/25, administered at 9:07 a.m. on 4/12/25, administered at 8:49 a.m. on 4/14/25, and administered at 1:44 p.m. on 4/15/25. Documentation also revealed that R3 was scheduled Thiamine, Divalproex Sodium, Levetiracetam, Vitamin D3, Folic Acid, Multiple Vitamins-Minerals, Aspirin, Fluoxetine, Ciprofloxacin, Lactobacillus and Gabapentin for 9:00 a.m., but was administered on 4/15/25 at 10:22 a.m., on 4/16/25 at 10:32 a.m., on 4/17/25 at 10:40 a.m., and on 4/18/25 at 10:15 a.m. R3's 7:00 a.m. dose of Baclofen, was administered on 4/17/25 at 12:40 p.m., on 4/18/25 at 1:16 p.m., on 4/19/25 at 12:12 p.m., on 4/20/25 at 9:19 a.m., on 4/21/25 at 9:21 a.m., and on 4/22/25 at 11:56 a.m. R3's was scheduled Thiamine, Divalproex Sodium, Levetiracetam, Vitamin D3, Folic Acid, Multiple Vitamins-Minerals, Aspirin, Fluoxetine, Gabapentin and Calcium + Vitamin D3 was administered on 4/22/25 at 11:55 a.m., on 4/23/25 at 10:12 a.m., on 4/24/25 at 10:39 a.m., on 4/26/25 at 1:39 p.m., on 4/27/25 at 11:09 a.m., and on 4/28/25 at 10:45 a.m. R3's was scheduled Baclofen at 7:00 a.m., was administered on 4/23/25 at 10:12 a.m., on 4/24/25 at 11:56 a.m., on 4/25/25 at 9:47 a.m., and on 4/26/25 at 1:39 p.m. R3 was scheduled Atorvastatin and Baclofen at 7:00 p.m. and was administered at 9:24 p.m. on 4/5/25. On 4/6/25 R3 was scheduled Zonisamide, Baclofen, and Atorvastatin at 7:00 p.m., and was administered at 9:11 p.m. On 4/7/25 R3 was scheduled Zonisamide, Baclofen, Ciprofloxacin and Atorvastatin were administered at 9:31 p.m. On 4/8/25 Atorvastatin, Zonisamide, Baclofen and Melatonin were scheduled at 7:00 p.m., and was administered at 8:40 p.m., on 4/9/25 at 8:37 p.m., and on 4/10/25 at 8:36 p.m. On 4/9/25 Divalproex Sodium was scheduled at 5:00 p.m., and was administered at 6:26 p.m. On 4/10/25 R3 had ciprofloxacin scheduled at 7:00 p.m., and was administered at 7:03 p.m. On 4/11/25 R3 had Baclofen, Zonisamide, and Melatonin scheduled at 7:00 p.m., and administered at 10:21 p.m. On 4/11/25 R3 had Atorvastatin scheduled at 7:00 p.m., and was administered at 11:00 p.m., and Levetiracetam was scheduled for 9:00 p.m., and administered at 10:21 p.m. R3 had scheduled Atorvastatin, Zonisamide, Baclofen, and Melatonin at 7:00 p.m., was administered at 9:50 p.m., on 4/13/25, administered at 8:49 p.m., on 4/14/25, administered at 9:17 p.m., on 4/15/25, administered at 9:14 p.m., on 4/16/25, administered at 9:40 p.m., on 4/18/25, administered at 9:58 p.m. on 4/19/25, administered at 9:15 p.m., on 4/20/25, administered at 12:16 a.m., on 4/22/25. R3's Levetiracetam was scheduled for 9:00 p.m., and was administered at 12:16 a.m., on 4/22/25. R3 had scheduled Atorvastatin, Zonisamide, Baclofen, and Melatonin at 7:00 p.m., was administered at 10:17 p.m., on 4/22/25, administered at 11:36 p.m., on 4/23/25, administered at 10:01 p.m., on 4/24/25, administered at 8:59 p.m., on 4/25/25, administered at 10:01 p.m., on 4/26/25, and administered at 11:57 p.m., on 4/27/25.On 4/29/25 at 9:40 a.m., an interview was conducted with LPN. LPN#1 said, A hole in the MAR or TAR means it wasn't done. When a wound is found, we report it to the doctor, complete a change in condition, report to the unit manager and director of nursing, and obtain a treatment order from the doctor. On 4/29/25 at 9:50 a.m., an interview was conducted with LPN#2. LPN#2 said, Holes in the treatment and med record means it was not done. On 4/29/25 at 10:00 a.m., an interview was conducted with the director of nursing (DON). The DON said, A blank on the MAR [medication administration record] means it wasn't given and on the TAR [treatment administration record] means it wasn't done. The DON said, If an order is obtained on the 28th the treatment should begin on the 28th. The DON stated, When the nurse found a new wound that it was to be reported to me and the unit manager, cleaned with soap and water, nurse practitioner notified and obtained treatment until the wound specialist evaluated the wound and the responsible party notified of the findings. On 4/29/25 at 11:30 a.m., an interview was conducted with R3. R3 said, I missed some medications in the beginning of my stay, and I don't refuse any of my medications. 3. For R4, the facility staff repeatedly failed to administer the physician ordered medications within an hour of the scheduled time. On 4/28/25, a clinical record review was conducted. R4's medication administration record indicated that medications were to be administered at 6:00 a.m., 9:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m. According to the Medication Admin Audit Report, R4 was scheduled to receive Baclofen, Senna-S, Eliquis, Theradex M, and Cymbalta at 9:00 a.m., but they was administered at 12:43 p.m. on 4/3/25. R4 was scheduled to receive Oxycodone at 12:00 p.m., but it was administered at 1:42 p.m. on 4/17/25, and at 1:14 p.m. on 4/24/25. R4 was scheduled for Senna-S and Eliquis at 9:00 p.m., but they were administered at 11:46 p.m. on 4/2/25, was administered at 10:28 p.m. on 4/3/25, and was administered at 11:37 p.m. on 4/3/25. R4 was scheduled for Eliquis at 9:00 p.m., which was administered at 1:14 a.m. on 4/8/25. R4 was scheduled for Senna-s at 9:00 p.m. on 4/8/25, but it was administered at 3:28 a.m. on 4/9/25. R4 was scheduled Oxycodone at 12:00 a.m. on 4/9/25, but it was administered at 1:14 a.m. R4 was scheduled Senna-S and Eliquis at 9:00 p.m., and it was administered at 10:12 p.m., on 4/9/25, was administered at 11:03 p.m. on 4/16/25, and at 4:56 a.m. on 4/18/25. R4 was scheduled Oxycodone at 12:00 a.m., but it was administered at 4:56 a.m. on 4/18/25. On 4/28/25 at 1:00 p.m., a tour of the nursing unit on the 400 wing was conducted. R4 was non-verbal and not interviewable. On 4/28/25 at 4:32 p.m., an interview was conducted with a register nurse, RN#2. RN#2 stated that the medications were administered according to the physician orders. RN#2 said, If meds are ordered at 9 in the morning, then you can give one hour before or one hour after schedule time. If a med isn't given timely, then you notify your manager and call the doctor if important like IV's. On 4/28/25 at 4:40 p.m., an interview was conducted with a licensed practical nurse, LPN#1. LPN#1 said, If a med is ordered at 9 a.m., it should be given between 8 and 10. If giving too late, call the doctor to get an order for different time or hold it for the doctor notification. On 4/28/25 at 4:50 a.m., an interview was conducted with the unit manager, LPN#3. LPN#3 said, Meds ordered at 9 a.m. should be given between 8 a.m., and 10 a.m. Notify the doctor if late and a nursing note should have if the doctor was notified. On 4/28/25 at 5:00 p.m., a review of a facility document was conducted. The policy titled, General Guidelines for Medication Administration, read in part, .medications are administered as prescribed in accordance with good nursing principles and practices and only by legally authorized to administer. A facility document titled, Medication Orders, was reviewed and read in part, .the purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. The facility cited [NAME] as the resource used for professional nursing standards. Guidance was given by [NAME], Fundamentals of Nursing, which reads: To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to these rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation According to [NAME]'s Manual of Nursing Practice, the Eighth Edition, on page 18, the following was noted, Common Legal Claims for Departure from Standards of Care . Failure to administer medications properly and in a timely fashion, or to report and administer omitted doses appropriately . On 4/28/25 at 5:45 p.m., an end of day meeting was conducted with the administrator, the director of nursing and the corporate staff. They were informed of the above concerns. No additional information was provided.

Based on observation, staff interview, and facility documentation review, the facility staff failed to serve meals at a temperature that was palatable to multiple residents eating in their rooms on 4 of 4 wings. The findings included: On 4/28/25, a review of the resident council minutes and grievance logs from June 2024-April 2025 were reviewed and noted that in September 2024, November 2024, and February 2025, concerns were shared about food being cold when served in resident rooms. On 4/28/25, observations were conducted in the kitchen of the evening meal. The meal service began at 4:35 p.m. Residents eating in the dining room were served first and then trays for the residents eating in their rooms were prepared and placed in a transport cart. A test tray was prepared and placed on the cart. It was observed that the facility used insulated plate bottoms and lids but were not using the heated pellets under the plates to hold temperatures. When asked why pellets were not being used, said, They have thick insulated bottoms that hold heat and don't use the pellets. When they run out of the thick insulated bottoms, they will use pellets. Trays were observed being prepared with plates placed in both style bottoms without any heated pellets being used. When asked if the insulated bottoms are heated, the dietary manager said, No. The surveyor explained that she had seen both pellets used at other facilities and the thick insulated bottoms are heated and when the thinner bottom is used there is a metal pellet that goes inside which is heated. The dietary manager confirmed they don't do that. On 4/28/25 at 5:12 p.m., the last tray was placed in the transport cart and the cart exited the kitchen. At 5:14 p.m., the meal trays arrived on the unit. Multiple staff to include managers, began distributing trays to the residents. At 5:24 p.m., the last resident tray was removed from the cart and taken to a resident. On 4/28/25 at 5:24 p.m., as the last resident tray was being served, the dietary manager removed the test tray from the cart, and he obtained the temperature of the foods on the tray. They were as follows: the Swedish meatballs were 123.2 degrees Fahrenheit (F), rice 116 degrees F, green beans 114.6 degrees F, and the fruit dessert was 52.8 degrees F. The surveyor and dietary manager both sampled each of the food items and both agreed that the hot foods were lukewarm and not very appetizing in temperature, but the flavor was acceptable. The dietary manager stated that he likes his food hot and would not be satisfied with the food temperature served. According to the facility policy titled, Food and Nutrition Services, that read in part, . 7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature . On 4/28/25 at 5:45 p.m., during an end of day meeting with the facility administrator, director of nursing and corporate nurse, the above findings were reviewed. On 4/29/25, the corporate nurse notified the survey team that the pellets were being used that day. No additional information was provided.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to implement their infection prevention and control program by failure to implement precautions to prevent the transmission of diseases and infections in accordance with accepted national standards from the Centers for Disease Control and Prevention (CDC) for one resident (Resident #101-R101) in a survey sample of five residents. The findings included: For R101, who had multiple open wounds, the facility staff failed to implement and adhere to enhanced barrier precautions in accordance with their policy and nationally accepted standards from CDC. On 6/10/25 at 11:33 a.m., during a tour of the facility, two certified nursing assistants were observed to enter R101's room, without donning any PPE (personal protective equipment). Observations noted there was no signage on R101's room door to indicate she was on any type of precautions. On 6/10/25 at approximately 11:45 a.m., the certified nursing assistants exited R101's room, and one pushed the resident in a wheelchair to the dining room, at which time, the surveyor observed R101 had both feet wrapped with cling. On 6/10/25, a clinical record review was conducted of R101's chart. This review revealed that R101 had multiple wounds, which included but were not limited to a stage IV pressure ulcer to the sacrum and three stage III pressure ulcers to the right foot. Review of the physician orders revealed that R101 had orders for Catheter Care: change foley cath as needed for blockage, leaking or malfunctioning. According to the nursing notes, an entry on 6/6/25, noted that R101 had wounds and a foley catheter. There were no physician orders for enhanced barrier precautions. Review of R101's care plan revealed focus areas to include pressure ulcers and skin impairments and the foley catheter. There was no indication that R101 was on enhanced barrier precautions within the care plan. On 6/11/25 at 9:25 a.m., the surveyor noted R101's door closed, there was no signage to indicate the resident was on any precautions or notification to staff that PPE was to be worn during direct care activities. The surveyor knocked on the door and facility staff were providing care. On 6/11/25 at 9:30 a.m., an interview was conducted with a certified nursing assistant (CNA #1). CNA #1 stated that residents on precautions have signs on the door. CNA #1 reported that they currently had no one on precautions in the facility. On 6/11/25 at 9:35 a.m., an interview was conducted with certified nursing assistant #2 (CNA #2). When asked about precautions, CNA #2 explained that if a resident is on precautions or PPE is needed a sign is on their room door and in their care plan, which she stated everyone has access to. When asked about enhanced barrier precautions, CNA #2 explained that it is to protect residents from any possible exposure as well as protect yourself. Right now, the precautions for enhanced barrier precautions are due to tubing, like a foley, nephrology tubes, and such. On 6/11/25 at 9:40 a.m., while the surveyor was in R101's room, licensed practical nurse #1 (LPN #1) entered the room. LPN #1 confirmed she was R101's assigned nurse and said, I just did wound care, and the CNA was helping me with her. When asked if she wore any PPE during that process/wound care, LPN #1 confirmed she had only worn gloves. When asked if PPE has to be worn during care of R101, LPN #1 went on to state, As far as I've been told we use PPE with colostomies, for basic wound care there are no special instructions. When asked about enhanced barrier precautions, LPN #1 said, That is something new to me, her [R101's] wound doesn't have MRSA [Methicillin-resistant Staphylococcus aureus, a type of bacteria], it is just basic wound care so just wear gloves. On 6/11/25 at 9:45 a.m., an interview was conducted with the facility's director of nursing (DON), who is also the facility's designated infection preventionist. The surveyor asked the DON to explain enhanced barrier precautions (EBP), when they are used, the purpose, and so forth. The DON said, EBP is to protect patients with compromising skin issues, medical ports, foleys, etc. We don't want infections to happen. Or people with a history of MDRO's [multi-drug-resistant organisms]. Staff wear a gown and gloves during care, it is a protective process. When the surveyor discussed that R101 had multiple wounds and asked if she should be on EBP, the DON said, Yes, she should be on EBP. When asked if she was aware that R101 is not on EBP, the DON stated she was not aware as she had only started at the facility mid-day on Monday [2 days ago] and explained that she didn't have anyone doing infection control and that was one of the programs/processes she was working on. The DON said, I'm going to do a lot of education, there is a lot of agency staff that don't know. On 6/11/25 at 10 a.m., the facility administrator and regional nurse were made aware of the above findings. According to the Centers for Disease Prevention and Control (CDC), there is a guidance document titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) dated 4/2/24. The document read in part, .Updates as of July 12, 2022. Key Points:1: Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. 2. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. 3. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status Infection or colonization with an MDRO. 4. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care . Accessed online at: https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html The facility administration provided a facility policy titled, Enhanced Barrier Precautions (EBP) Policy dated 3/28/24. According to the policy, which read in part, . 1. Criteria for Implementing EBP: . Residents with wounds and/or indwelling medical devices, irrespective of MDRO infection or colonization status . 4. High-Contact Resident Care Activities Requiring EBP: EBP should be utilized during the following activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care . 6. Duration of EBP Usage: EBP should remain in place for the duration of a resident's say in the facility or until the resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk . No further information was provided prior to the conclusion of the survey.

Based on observation, staff interview and facility documentation review, the facility staff failed to ensure food was distributed in a manner to prevent contamination in the main kitchen. The findings included: In the main kitchen, the facility staff failed to ensure that hair restraints were worn by all staff in the food preparation and distribution areas. On 6/10/25 at 12:02 p.m., observations were conducted in the main kitchen of the lunch meal's plating of food and distribution. While the facility's dietary staff were plating food on the serving line, at 12:21 p.m., the facility's maintenance director entered the kitchen and walked over to the serving line without donning a hair net or beard guard. The dietary aide immediately said, Hey, you need a hair net. To which the maintenance director did not respond. The maintenance director went behind the serving line where the cook was plating food, and pulled out a cell phone. The dietary manager then approached the maintenance director and took the cell phone from the maintenance director, who then stepped away from the serving line. The dietary manager took a photo of the labels on the hood system and returned the phone to the maintenance director. The maintenance director then exited the kitchen. On 6/10/25 at 12:30 p.m., an interview was conducted with the dietary manager. The manager was asked if the maintenance director usually enters the kitchen without a hair net and the dietary manager said, Usually the staff stop at the door, I guess he was gung [NAME] on seeing when they [the hood inspectors] come back. The dietary manager confirmed that all persons entering the kitchen are to have hair coverings on. On 6/10/25 at 3:13 p.m., an interview was conducted with the facility's maintenance director. When asked about the purpose of his visit to the kitchen during the lunch meal service, he reported he needed the phone number of who inspects the hood system because the number he had was not correct. When asked if he frequents the kitchen often and if he puts on a hairnet, the maintenance director said, Like yesterday, I ran in there with the plumber to work on the sink. We just run in there and don't wear hairnets. I always just run in and out of there all the time. They always have stuff that needs to be fixed. I wasn't aware I needed a hair net; no one ever told me. I know now but they need to have them for me to get to. The surveyor explained where the hairnets are located, which was just inside the door. The surveyor explained that since he had a beard, he would also need a beard guard, while the surveyor saw dietary staff wearing beard guards and knows they are available, she did not know the location of them, and he would need to inquire about that. The maintenance director thanked the surveyor and said, Now I know, thank you for telling me. Review of the facility policy titled, Prevention of Infection- Dietary Department with a date of 10/1/21 was reviewed. The policy read in part, . 7. Dietary staff will wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food . On 6/10/25, during an end of day meeting, the facility administrator and regional nurse was made aware of the above findings. No additional information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide education and offer the COVID-19 spike vaccine booster for the 2023-2024 season, to 5 of 5 residents (Resident #6, 31, 3, 55, and 14) and 5 of 5 staff (RN #3, CNA #6, Other Employee #1, Other Employee #5, and Other Employee #7) sampled. The findings included: 1. For five residents (R6, R31, R3, R55 and R14), the facility staff failed to provide education and offer the COVID-19 spike vaccine booster for the 2023-2024 season. On 2/20/24 and 2/21/24, clinical record reviews were conducted of R6, R31, R3, R55 and R14's charts. This review revealed no evidence that any of the sampled residents had been offered the COVID-19 spike vaccine. On 02/21/24 at 10:11 a.m., an interview was conducted with the Director of Nursing (DON), who was the facility's Infection Preventionist (IP). During this interview, the DON accessed each of the sampled resident's charts, confirmed their immunization status, and then stated that none of them had been offered the COVID-19 spike vaccine. The review revealed the following: a. R6 had received the COVID primary series and a bivalent booster but had not received the spike vaccine. b. R31 had not received any COVID immunizations. When asked if R31 had been offered any of the COVID vaccines, the DON said, No. c. R3 had received the COVID primary series and bivalent booster. d. R55's records indicated he had not received any immunizations for COVID-19, and again the DON confirmed the facility had not offered any. e. R14 had received the COVID primary series immunization, as well as 2 booster doses, that included the bi-valent. R14 had not been offered or received the spike booster for the 2023-2024 season. During the above interview, the DON said, We can get our covid vaccines through our pharmacy now, I just found this out the other day. We haven't given the current boosters; we were supposed to get a local pharmacy to come but they don't do that. On 02/21/24 at 10:51 a.m., the CDCS (corporate director of clinical services) joined in the interview and stated, I just found out we can get the vaccine so we will start that process. On 2/21/24 at 4:00 p.m., the surveyor spoke with an employee working in the quality assurance department of the contracted pharmacy (Other Employee #9- OE #9), who reported that this has been the contracted pharmacy of this facility since 12/1/22. OE #9 also confirmed that the pharmacy has had available multi-dose vials and single dose vials of the 2023-2024 COVID spike immunization since November 20, 2023, when it was approved. OE #9 went on to say that prior to 11/20/23, it was available under the Emergency Authorization in place, and has always been available for the facility to order. OE #9 also confirmed that the pharmacy had not received any orders from this nursing facility for any of the COVID 2023-2024 spike immunization. Review of the facility policy titled; COVID-19 Vaccination for Residents was conducted. The policy read in part, . 1. Prior to admission, the facility will validate COVID-19 vaccination status. 2. Resident/resident representatives will be educated on: a. risk/benefits of COVID-19 vaccination. b. current CDC guidelines for vaccination of residents for COVID-19 and c. Symptoms, risks and benefits associated with the COVID-19 virus. 3. Residents will be encouraged to accept COVID-19 vaccinations in accordance with CDC guidance. 4. Residents will be screened prior to offering the vaccination for prior immunization, medical precautions, and contraindications as necessary for determining whether they are appropriate candidates for vaccination at any given time. 5. prior to the administration of the COVID-19 vaccine, consent will be obtained . and will be documented in the resident's medical record. 6. If the resident/resident representative declines administration of the COVID-19 vaccine, education will be provided, and declination form will be signed and placed in the resident's medical record . 7. COVID-19 vaccines will be administered according to the CDC, ACIP, FDA, and manufacturer guidelines. 8. Administration of the COVID-19 vaccination will be documented in the resident's medical record . The FDA (Food and Drug Administration) gives information about the 2023-2024 spike vaccine on their website, accessed at:https://www.fda.gov/vaccines-blood-biologics/coronavirus-covid-19-cber-regulated-biologics/novavax-covid-19-vaccine-adjuvanted. The guidance read, On October 3, 2023, the Food and Drug Administration amended the emergency use authorization (EUA) of Novavax COVID-19 Vaccine, Adjuvanted to include the 2023-2024 formula. The Novavax COVID-19 Vaccine, Adjuvanted, a monovalent vaccine, has been updated to include the spike protein from the SARS-CoV-2 Omicron variant lineage XBB.1.5 (2023-2024 formula). The Novavax COVID-19 Vaccine, Adjuvanted (Original monovalent) is no longer authorized for use in the United States. Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) is authorized for use in individuals [AGE] years of age and older as follows: Individuals previously vaccinated with any COVID-19 vaccine: one dose of Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) is administered at least 2 months after receipt of the last previous dose of an original monovalent (Original) or bivalent (Original and Omicron BA.4/BA.5) COVID-19 vaccine. Individuals not previously vaccinated with any COVID-19 vaccine: two doses of Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) are administered three weeks apart . On 2/21/24, during an end of day meeting the facility administration was made aware of the above findings. No additional information was received. 2. For 5 of 5 staff (RN #3, CNA #6, Other Employee #1, Other Employee #5, and Other Employee #7) sampled, the facility staff failed to provide education and information regarding the 2023-2024 COVID spike vaccine. On 2/21/24 at 10:11 a.m., an interview was conducted with the Director of Nursing (DON), who was also the facility's infection preventionist. When asked about COVID vaccines for employees, the DON said, HR [human resources] asks for immunization cards upon hire but it is not a requirement to work with [facility's corporate name redacted]. When asked if they were providing any education to staff regarding the COVID immunizations, the DON said, No. During the above interview, the DON said, We can get our covid vaccines through our pharmacy now, I just found this out the other day. We haven't given the current boosters; we were supposed to get a local pharmacy to come but they don't do that. On 2/21/24 at 2:38 p.m., an interview was conducted with the human resources manager (HRM), Employee #4. The employees selected for review were given to the HR manager and she pulled each employee's file. There was no information with regards to any of them being educated on or given information with regards to the 2023-2024 COVID booster. None of the employees selected had any record of having received the current COVID-booster. The HR manager was asked if the facility gives the employees any information on the COVID vaccine or offers the COVID vaccine. The HR manager said, I thought we moved away from that, so I am not too sure about that. On 2/21/24, in the afternoon, an interview was conducted with Other Employee #1, Other Employee #5, and Other Employee #7. All three stated that they had not received any information or education from the facility with regards to the current COVID booster. On 2/21/24, during an end of day meeting, the facility administration was made aware of the above findings. On 2/22/24, the facility staff provided the survey team with declination forms that Other Employee #5 and RN #3. Across the top of the form it read, 2023_2024 Staff Vaccine Acceptance/Declination Form. The form that RN #3 had signed was dated 10/27/22, which was prior to the 2023-2024 vaccine becoming available. The facility policy titled, Employee Infection and Vaccination Status was reviewed. The policy read in part, . Vaccinations: 1. Employees will be current with mandated vaccinations (i.e., TST, COVID-19) prior to performing direct resident care. 2. Employees will also be offered vaccinations per state or local agency policies/regulations. Employees will be provided with educational materials to make informed decisions for non-mandated vaccinations. If declined, a declination form will be completed and placed in the employee's health record . No additional information was provided.

Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain an accurate clinical record for one resident (Resident #25- R25) in a survey sample of 22 residents. The findings included: For R25, the facility staff failed to maintain a complete and accurate clinical record with regards to documentation of when showers were provided. On the afternoon of 02/21/24, during interview with R25's roommate, R25 expressed concerns with not getting showers. On 2/21/24, a review of R25's clinical record was conducted, which included review of ADL (activities of daily living) records. Bathing documentation revealed that R25 had 4 occurrences of showers being provided in January 2024 and 2 showers being provided in the month of February 2024. On 02/21/24 at 03:23 p.m., an interview was conducted with Certified Nursing Assistant #4 (CNA #4), who stated that showers are given twice weekly and are scheduled, which is on the CNA's assignment sheet. CNA #4 showed the surveyor the assignment sheet, which indicated R1 was scheduled to receive a shower on Wednesdays and Saturdays, on the 11 p.m. to 7 a.m. shift. When questioned further, CNA #4 explained that showers are documented in the computer, in the ADL (activities of daily living) section, for each resident, to indicate that the shower was given or if the resident refused. On 02/22/24 at 08:57 a.m., an interview was conducted with CNA #5. CNA #5 reported that showers are given twice weekly in accordance with a shower schedule. On the morning of 2/22/24, the facility administrator was made aware of the above concerns with regards to R25's absent shower documentation. On 2/22/24, the administrator provided the survey team with Skin Care Alert forms for R25. Each of the forms had written across it, Showered, to indicate R25 had received a shower on those dates. The dates were, 1/2/24, 1/9/24, 1/16/24, 1/20/245, 2/6/24, 2/9/24, and 2/13/24. The administrator was asked if this is the facility's protocol for documenting showers and if the provided forms were included in the clinical record. The Corporate Director of Clinical Services (CDCS) agreed that it is the company's protocol that showers be documented on the ADL sheets and the skin care alert forms were not part of the clinical record. During the above interview with the administrator and CDCS, it was discussed that R25's clinical record was incomplete and inaccurate. They both stated they would speak with the director of nursing and follow-up with the surveyor. On 02/22/24 at 11:10 a.m., the Assistant Director of Nursing (ADON) stated the skin care alerts do indicate that they the staff gave R25's showers and it was a documentation issue. Review of the facility policy titled; Shower/Tub Bath was reviewed. The policy read, in part, . Documentation- 1. The date and time the shower/tub bath was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath. 3. All assessment data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath. 4. How the resident tolerated the shower/tub bath. 5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. 6. The signature and title of the person recording the data . No additional information was provided.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility failed to review and revise the care plan for 2 of 22 residents (Resident #9 and #32) in the survey sample and failed to invite/involve 2 residents (Resident #6 and #25) in their care plan meeting. The findings included: 1. A review of Resident #9 (R9's) care plan dated 9/6/23 revealed that the care plan had not been revised to indicate a code status change from full code to Do Not Resuscitate (DNR). R9 had diagnoses that included nontraumatic intracerebral hemorrhage, dementia, atrial fibrillation, epilepsy, major depressive disorder, Alzheimer's disease and anxiety disorder. The most current minimum data set (MDS) was an annual assessment dated [DATE], which assessed R9 with severe cognitive impairment. Review of R9's clinical record revealed that R9's power of attorney signed a DNR form on 1/7/24 and the physician placed the DNR order on 1/8/24. R9's care plan, which was revised on 9/6/23, documented the resident's resuscitation status as full code and had not been revised with the change to DNR status. On 2/21/24 at 3:17 PM, the MDS coordinator, registered nurse #1 (RN#1) responsible for updating care plans was interviewed regarding R9's code status on the care plan. RN#1 stated that the care plan should have been updated 24-48 hours after the new order was received. RN#1 had no explanation as to why the care plan had not been updated. 2. R32's care plan initiated 8/17/23 had not been revised to indicate that a fluid restriction had been ordered. R32 had diagnoses that included congestive heart failure, chronic kidney disease, hypertension. The most current MDS (minimumdata set - the assessment tool) was a quarterly assessment dated [DATE], which assessed R32 as being cognitively intact. Review of R32's clinical record revealed a physician's order written on 2/5/24 for R32 to be placed on a 1500 ml fluid restriction per day. Review of R32's care plan dated 8/17/23 included no mention of the fluid restriction. Review of R32's medication administration record, treatment administration record, and activity of daily living record showed no documentation of a fluid restriction. On 2/21/24 at 3:17 PM, RN#1 was interviewed regarding updating and revising care plans. RN#1 stated that there were three opportunities to update a care plan: when the new order is written, during the morning meeting, and when the care plan was scheduled to be updated. When questioned about a change in orders, RN#1 stated the care plan should be updated within 24 to 48 hours after the order is received and is mostly based on nursing knowledge. When questioned about R32's fluid restriction, RN#1 agreed that the fluid restriction should have been added to the care plan but offered no explanation as to why it was not. On 2/21/24 at 3:35 PM, licensed practical nurse #2 (LPN#2), who was assigned to work with R32 on 2 /21/24, was interviewed regarding updating care plans. LPN#2 stated that both nurses and the MDS coordinator can update care plans. LPN#2 offered no explanation as to why R32's care plan had not been updated to include the order for the fluid restriction. On 2 22/24 at 8:25 AM, LPN #2 was interviewed regarding the documentation of fluid intake for residents on fluid restrictions. LPN #2 stated, We just give verbal report at each shift change, telling what the intake was for our shift. On 2/22/24 at 9:37 AM, registered nurse #2 (RN #2), who worked on the same unit that R32 resided, was questioned about documentation of fluid intake for residents on fluid restrictions. RN #2 stated that the intake is not documented, but verbal report is given at shift changes. On 2/22/24 at 12:40 PM, during the end of day meeting the facility administrator and regional nurse consultants were made aware of the above concerns. No additional information was provided. 41449 3. For Resident #6 (R6), the facility staff failed to hold quarterly care plan meetings and involve the resident in the development and review of the plan of care. On 02/20/24 at 10:48 a.m., an interview was conducted with R6. During this interview, R6 expressed that he was not aware of care plan meetings and was not invited to attend them. On 2/21/24, a clinical record review was conducted., which revealed no information with regards to care plan meetings being held or R6 being invited to and involved in them. On 02/21/24 at 01:37 p.m., an interview was conducted with Other Employee #1, the Social Worker (SW). The SW stated that the MDS (minimum data set - an assessment tool) nurse, sends out a MDS calendar and SW notifies the resident and family. The SW said, If the resident is their own representative, I let them know, and the ones who have legal guardians, I send a letter or email them. When asked if this information was documented, the SW said, I usually call them. When asked about the timing of the call and if they are notified ahead of time, the SW said, I try my best but sometimes my printer goes down or they don't answer their phone. When asked again, how this information is documented, the SW pulled out a folder that dated back to the summer of 2023, stating, Yes, I try to document it but I am trying to get it put into the computer. Every time I will sit to do it, I get interrupted or now I am doing appointments and just haven't gotten to them. During the above interview, the SW was asked when R6's last care plan meeting was. The SW looked through the file and noted that the last meeting was held on 7/19/23. There was no evidence that R6 was invited to attend or involved in the development of the plan of care. The SW was asked to provide any evidence of when R6 had care plan meetings from January 2023-present. Later on the afternoon of 2/21/24, when asked to explain the purpose of the care plan meeting, the SW said, To talk about their progress, if they have any needs, if there are any concerns, ask about their weight, if they are compliant with dietary and taking their meds, if they still meet criteria for long-term care, find out what they are able to do, talk of discharge or request for discharge, we talk about that as well. When asked why is it important for the resident and/or their representative to be involved, the Social Worker said, for self-care and so they can be patient directed and they can let us know what they want and preferences. On 2/21/24 at 02:02 p.m., an interview was conducted with RN #1, who was the MDS coordinator. When asked about the care plan meetings, RN #1 said, They are held every 90 days based on the date due, typically every 90 days unless there is a significant change. Asked who attends the care plan meetings, RN#1 stated, To my knowledge, therapy, social services, dietary activities and families, the resident and if hospice, a representative from hospice. When asked why is it important for the resident and family to be involved, RN #1 said, I feel it is important because you want the care plan to represent and encourage the resident to have their autonomy and voice is important so they can be reflected. The MDS coordinator stated, I set the schedule and then she [the social worker] sends the invites to everyone. On 2/21/24, during an end of day meeting, the facility Administrator was made aware of the above findings. On the morning of 2/22/24, the SW was again interviewed. The SW provided the surveyor with evidence that R6 had care plan meetings held on 2/21/23, 4/17/23 and 7/19/23. The SW also provided a letter that indicated R6 would have a care plan meeting on 7/19/23. It did not indicate when the resident was given this letter or any specific details at to the time or location of the meeting. There was no evidence that R6 had been invited to the care plan meetings held in February or April. A review of the facility policy titled, Care Planning- Comprehensive Person-Centered was reviewed. The policy read in part, . 6. The resident/resident representative [s] is encouraged to participate in the development of and revisions to the resident's care plan. a. An explanation will be included in the resident's medical record if the participation of the resident/resident representative is determined not practicable for the development of the resident's care plan . 10. Every effort will be made to schedule care plan discussions at the best time of the day for the resident/resident representative . No additional information was provided. 4. For Resident #25 (R25), the facility staff failed to provide quarterly care plan meetings and involve the resident and a representative from nursing in the meetings. On 02/20/24 at 11:37 a.m., R25 stated they were unaware of when care plan meetings were held and were not involved in the development of their plan of care. On 2/21/24, a clinical record review was conducted. This review revealed no information with regards to care plan meetings being held or R25 being invited to and involved in them. On 02/21/24 at 01:37 p.m., an interview was conducted with Other Employee #1, the Social Worker (SW). The SW stated that the MDS (minimum data set - an assessment tool) nurse, sends out a MDS calendar, and then SW notifies the resident and family. The SW said, If the resident is their own representative, I let them know and the ones who have legal guardians I send a letter or email them. When asked if this information is documented, the SW said, I usually call them. When asked about the timing of the call and if they are notified ahead of time, the SW said, I try my best but sometimes my printer goes down or they don't answer their phone. When again asked how this information is documented, the SW pulled out a folder that dated back to the summer of 2023, and stated, Yes, I try to document it but I am trying to get it put into the computer. Every time I will sit to do it, I get interrupted or now I am doing appointments and just haven't gotten to them. The SW was asked to provide information of when R25 had care plan meetings from January 2023-present. During the interview on the afternoon of 2/21/24, the SW was asked to explain the purpose of the care plan meeting. The SW said, To talk about their progress, if they have any needs, if there are any concerns, ask about their weight, if they are complaint with dietary and taking their meds, if they still meet criteria for long-term care, find out what they are able to do, talk of discharge or request for discharge, we talk about that as well. When asked, why is it important for the resident and/or their representative to be involved? The Social Worker said, for self-care and so they can be patient directed and they can let us know what they want and preferences. On 2/21/24 at 02:02 p.m., an interview was conducted with RN #1, who was the MDS coordinator. RN #1 was asked about the care plan meetings. RN #1 said, They are held every 90 days based on the date due, typically every 90 days unless there is a significant change. RN #1 was asked who attends the care plan meetings, and she stated, To my knowledge therapy, social services, dietary activities and families, the resident and if hospice, a representative from hospice. When asked why is it important for the resident and family to be involved, RN #1 said, I feel it is important because you want the care plan to represent and encourage the resident to have their autonomy and voice is important so they can be reflected. The MDS coordinator stated, I set the schedule and then she [the social worker] sends the invites to everyone. On 2/21/24, during an end of day meeting, the facility Administrator was made aware of the above findings. On the morning of 2/22/24, the surveyor was again questioned, met with the SW again. The SW provided the surveyor with evidence that R25 had care plan meetings held on 2/2/23, 7/12/23 and 9/27/23. The SW also provided a letter that indicated R25 was invited to the care plan meetings on 7/12/23 and 9/27/23. However, during the meeting held in July, there were notes that R25 was suspected of having COVID and the meeting needed to be rescheduled. There was no evidence the meeting was rescheduled at a time the Resident could attend. There were notes to indicate the meeting had proceeded to take place without R25. The care plan meeting held 9/27/23, noted that R25 did not attend and there was no one present to represent nursing. There were notes that the meeting was held but needed to be rescheduled. There was no evidence of the meeting being rescheduled. A review of the facility policy titled, Care Planning- Comprehensive Person-Centered was reviewed. The policy read in part, . 6. The resident/resident representative [s] is encouraged to participate in the development of and revisions to the resident's care plan. a. An explanation will be included in the resident's medical record if the participation of the resident/resident representative is determined not practicable for the development of the resident's care plan . 10. Every effort will be made to schedule care plan discussions at the best time of the day for the resident/resident representative . No additional information was provided.

Based on observation, resident interview, facility staff interviews, and facility documentation review, the facility staff failed to maintain a safe, comfortable, and homelike environment on 1 of 4 nursing units and in the main dining room. The findings included: 1. On the 300 unit of the nursing facility, the facility staff failed to ensure a safe and homelike environment, affecting multiple residents. 1a. For resident #58 (R58), the facility failed to maintain the room furnishings of a bedside table that was in good operating condition, which resulted in an environment that was not homelike. On 2/20/24, in the late morning, it was observed that R58's bedside table was missing 2 of the 3 drawers. R58 was not in the room at the time of this observation. On 2/21/24 at 9:28 AM, R58's bedside table was noted to still have only 1 drawer, the other 2 were missing. When questioned, R58 reported that it had been like that for weeks. On 02/22/24 at 08:53 a.m., an interview was conducted with CNA #5. CNA #5 confirmed the surveyor's observation that R58's bedside table was missing 2 drawers. CNA #5 confirmed that the drawers had been like that for weeks and stated, I think since he was going home, they just decided to not fix it. During the above interview with CNA #5, the CNA confirmed that everyone has access to a system on the computer where they can put in maintenance work orders for items that need repairs. On 02/22/24 at 8:30 a.m., an interview was conducted with the maintenance director (Other Employee #6- OE #6). OE #6 said he was unaware of the cabinet and could immediately replace it with a spare one that he has out back of the facility. 1b. For the bathroom shared between four residents residing in rooms [ROOM NUMBERS], the baseboard left a large, exposed hole in the wall. On 2/20/24, in the late morning, during facility observations, it was noted that the bathroom which was shared among the four residents residing in rooms [ROOM NUMBERS], there was a rather large, exposed hole in the wall behind the toilet. On 2/21/24 at 9:30 a.m., the hole in the bathroom wall was still noted. On 2/22/24 at approximately 8:45 a.m., the shared bathroom between rooms [ROOM NUMBERS], was still noted with no repairs having been made. On 02/22/24 at 08:53 a.m., an interview was conducted with CNA #5. CNA #5 stated that everyone has access to a system on the computer where they can put in maintenance work orders for items that need repairs. On 02/22/24 at 8:30 a.m., an interview was conducted with the maintenance director (Other Employee #6- OE #6). OE #6 was shown the bathroom noted above. OE #6 said no one had made him aware of it. OE #6 said he would be able to make repairs which would require him cutting a piece of sheet rock to repair the hole and then he could re-glue the baseboard. 1c. For the bathroom shared between the four residents residing in rooms [ROOM NUMBERS], there was a dislodged access panel cover, which left a large, exposed hole in the wall, and cold air was coming into the bathroom as a result. On 2/20/24, in the late morning, during facility observations, it was noted that the bathroom which was shared among the four residents residing in rooms [ROOM NUMBERS], there was a rather large, exposed hole in the wall behind the toilet. On 2/21/24 at 9:30 a.m., the access panel in the bathroom wall was still noted to be out of place and unsecured. On 2/22/24 at approximately 8:50 a.m., the bathroom between rooms [ROOM NUMBERS] was still noted to have the access panel out of place. On 02/22/24 at 8:30 a.m., an interview was conducted with the maintenance director (Other Employee #6- OE #6). OE was shown the bathroom and stated he had not been aware of the problem. He made multiple attempts to put the access panel back in place but was not able to make immediate repairs and reported to the surveyor that he would have to come back to it. 2. In the main dining room, the facility staff failed to maintain an environment in good repair and homelike, due to the cove baseboard being damaged and exposing holes in the wall. On 2/20/24 at approximately 12 noon, during observation of the lunch meal, it was noted that on the far back wall of the dining room which adjoined the kitchen, the cove baseboard was damaged and left large, exposed holes in the wall. Throughout the remaining days of survey, 2/21/24 and 2/22/24, the above was noted with no repairs having been made. On 02/22/24 at 8:12 a.m., an interview was conducted with the maintenance director (Other Employee #6- OE #6). OE #6 explained that the facility uses an electronic system for maintenance work orders. Any staff member can access it at any computer in the facility, enter what needs repairs and it will send an alert directly to OE #6's phone. OE #6 was asked about preventive maintenance and facility rounds. OE #6 said, I do an audit once a week. When asked about the wall in the main dining room, the maintenance director said, with that wall, we are in the process of getting a renovation, so I am waiting to see what they are going to do. When asked, how long has the wall been like that? OE #6 said, It is an ongoing issue, the staff push the food carts against the wall, and it causes the damage. The current damage has been like this for multiple weeks and repairs are not being made due to the upcoming renovation of the room. On the morning of 2/22/24, a review was conducted of the current maintenance work orders since January 1, 2024. None of the identified areas noted above were listed in the work order system to notify maintenance of repairs being needed. On 2/22/24 at approximately 9 a.m., the facility administrator was made aware of the above concerns. The administrator confirmed that the facility was going to be undergoing renovations and this would include replacing all the furniture in the resident rooms. No further information was provided.

Based on observation, staff interview, and clinical record review, the facility staff failed to provide adequate supervision and/or services to prevent accidents for 2 of 18 residents in the survey sample, Resident #48 and Resident #11. Resident #48 was not provided adequate monitoring/supervision, sustained an injury of unknown origin on his head that required 5 staples, resulting in harm. Resident #11 was not provided fall mats as required in her care plan. The findings include: 1. Resident #48 was admitted to the facility on [DATE] with diagnoses that included infarction, [CONDITION(S)] and [CONDITION(S)] affecting right dominant side, muscle weakness, dementia with behavioral disturbance, [CONDITION(S)], anxiety, hypertension, depression, dysphasia and [CONDITION(S)]. The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #48 as severely cognitively impaired for daily decision making with a score of 3 out of 15. Under Section G Functional Status the MDS assessed Resident #48 as requiring limited assistance with one person physical assistance for transfers, ambulation, eating and locomotion; extensive assistance with one person physical assistance for toileting, bed mobility, personal hygiene, and bathing. Under Section J1900. - Falls, the MDS assessed Resident #48 has having one fall with injury since the previous assessment. Resident #48's clinical record was reviewed on 10/05/2021. Observed within the progress notes was the following: 9/25/2021 09:00 Writer was alerted by CNA (certified nursing assistant) that resident had blood on his pillow. Upon assessment a medium size gash was noted to the back of his head. Resident stated I did not fall, the door hit me. [Medical Director] notified and orders were given to send resident to [Hospital] for sutures and evaluation. Resident had no change in LOC (level of consciousness) . [Ambulance Service] transported resident via stretcher. Facesheet, med orders, bed hold, and care plan all sent with resident. 09/25/2021 19:25 (7:25 p.m.) Resident arrived back to facility around 1530 (3:30 p.m.) via non emergency ambulance on stretcher. He has 5 staples to the laceration on the back of his head. PRN (as needed) Tylenol given due to c/o (complaints of) pain. MD and ADON (assistant director of nursing) aware of his arrival. Staples to be removed in 5 days per MD. resident took evening meds w/o (without) complications. Will continue to monitor. Observed in the clinical record was a Change in Condition form dated 09/25/2021 that documented the same information noted in the 9/25/2021 9:00 a.m. progress note, and documented notification to Resident #48's guardian. A review of the order summary documented the following orders: Wound Healing every shift for infection for 5 Days Clean the wound with wound cleanser, pat dry and apply [MEDICATION(S)] each shift for 5 days. Order Date: 09/25/2021. Start Date: 09/25/2021. End Date: 09/30/2021 Remove staples to back of head for wound healing 10/01/2021. Order Date: 09/25/2021. Start Date: 10/01/2021. End Date: 10/01/2021 . Resident #48's care plan documented the following: [Resident #48] is at risk for falls r/t (related to) Gait/balance problems, Incontinence, recent [CONDITION(S)], history of falls, Poor communication/comprehension. Date Initiated/Revision Date: 08/04/2020. Goal: Minimize risk of minor injury. Date Initiated 8/4/2020. Revision Date: 08/16/2020. Interventions: Anticipate and Meet [Resident #48] needs. Be sure [Resident #48] call light is within reach and encourage him to use it for assistance as needed. Bed in low position. Ensure that [Resident #48] is wearing appropriate footwear/non-skid socks when ambulating or mobilizing in w/c (wheelchair). Pt (physical therapy) evaluate and treat as ordered or PRN (as needed). A review of the IDT (interdisciplinary team) Fall Team Meeting Notes documented the following: 08/23/2021 12:02. he also had a fall later in afternoon, found on floor up against his drawers. No injuries, no c/o pain, ROM (range of motion) intact. new intervention: Ensure appropriate footwear. MD/RP aware of 2nd fall. 8/23/2021 11:25. IDT Fall Meeting Note: Resident observed sitting on the floor by the bedside unable to let staff know what happened due to cognition. Increase in behaviors and unable to be redirected. New intervention Frequent monitoring to ensure safety. MD/RP aware. Resident #48's care plan was not updated to include the intervention of frequent monitoring to ensure safety from the 8/23/2021 IDT meeting. The clinical record only included resident safety check sheets dated 08/21/2021 through 8/24/2021. A fall risk assessment dated [DATE] assessed Resident #48 as a high risk for falls with a score of 80. The assessment documented Resident #48 with a history of falls, having a weak gait, and overestimating/forgetting his limitations. The assessment documented call bell within reach and Q15 (every 15) minutes check as previous interventions that worked. On 10/05/2021 at 9:15 a.m., Resident #48 was observed self-propelling on the unit near the nurses station in a wheelchair. Resident #48 was observed speaking loud and fast in a foreign language and hitting the nurses station counter, pulling at his pants and attempting to stand up from the wheelchair. Various staff were observed asking the resident what was wrong and to speak in English. Resident #48 was overheard saying, English, Hell no. Staff members redirected Resident #48 and he was taken to his room. On 10/05/2021 at 5:34 p.m. during a meeting with the director of nursing (DON) and corporate consultant the above information was discussed. The DON was asked if the information was reported to the State Agency and for the investigation. On 10/06/2021 at 9:36 a.m., the assistant director of nursing (registered nurse - RN #2) was interviewed regarding the incident. RN #2 was asked if it was ever determined how Resident #48 sustained the injury. RN #2 stated, No, [Resident #48] is constantly moving. We have to monitor him frequently because he attempts to walk and/or transfer himself alone and he is a fall risk. During my shift he had a good day and didn't have any falls or any incidents. RN #2 was asked if the LPN (licensed practical nurse) and CNA who provided care to Resident #48 on 09/25/2021 were available for interview. RN #2 stated, The CNA is scheduled off today and the LPN will come into work at 3 p.m. today. I can see if I can reach them by phone and follow-up with you. On 10/06/2021 at 10:25 a.m. the director of nursing (DON) was interviewed regarding the injury sustained by Resident #48. The DON stated, No the incident was not reported to the State Agency. I am in the process of reporting it today. The investigation wasn't completed either. I started that on yesterday and will give you a copy of the witness statements. The DON was asked why the incident was not reported and why the investigation was not completed. The DON stated, I apologize I was not here and it got overlooked. As soon as it was brought to my attention I started the process . The DON was asked if she was able to determine what caused the injury of unknown origin. The DON stated, no unfortunately not. [Resident #48] is active and moves around a lot. I can't really say what happened to him. There should be resident safety check sheets uploaded in the clinical record. The DON was advised the clinical record only included resident safety check sheets dated 08/21/2021 through 8/24/2021. On 10/06/2021 at approximately 11:45 a.m., the DON was asked to contact the LPN and CNA who provided care to Resident #48 on 09/25/21 for an interview. The DON stated the LPN wasn't feeling well and had called out for her shift and the CNA was already scheduled off; however, she would try to reach them for a phone interview. On 10/06/2021 at 2:50 p.m., the above information was discussed during a meeting with the DON and Corporate consultant. The DON provided copies of the facility reported incident (FRI) dated 10/6/2021 sent to the State Agency and the witness statements. The DON was asked what was considered frequent checks since the clinical record documented frequent checks as an intervention for Resident #48. The DON stated, depending on the resident it can vary between every 15 minutes, 30 minutes, up to an hour. The corporate consultant stated, at least every 2 hours. A review of the resident safety sheets provided were dated for 09/26/2021 through 10/05/2021. There were no sheets provided for 9/24/2021 or 9/25/2021. The sheets included 15 minute interval slots for first, second and third shift. The following dates were not completed for each 15 minute slot for the entire first and second shift: 9/26/21, 9/27/21, and 10/2/21; 10/3/21 was not completed for the entire first shift. There was no documentation in the progress notes, safety sheets, or elsewhere in the clinical record evidencing that the staff had monitored or supervised Resident #48 prior to finding him with the injury to his head on 9/25/2021. A review of the witness statement from the CNA who provided care on 09/25/21 documented the following: On the morning of 9/25/21 I went into check on [Resident #48] and he was in his bed sleeping. I noticed blood on his pillow. I then looked at his head and he had a gash in the back of his head. I told the nurse immediately and they proceeded to care for him. A review of the witness statement from the LPN who provided care on 09/25/21 documented the following: I was alerted by the CNA that resident had blood on his pillow. Upon inspection a medium sized gash was noted to back of head, blood on pillow. Resident stated he did not fall & that the door went boom. Writer inspected both the bathroom door & outside room door & found no blood or any other indication that resident was injured by door. Bedroom floor, sink, & bed post were all inspected & also yielded no evidence of blood. Writer contacted ADON & MD, pressure applied to site & resident sent out to [ER]. The LPN and CNA who provided care on 09/25/2021 and wrote the witness statements were not available for interview during the survey. The above findings were discussed during a meeting on 10/06/2021 at 4:38 p.m. with the DON and corporate consultant. The staff were advised of the concerns of harm related to lack of supervision for Resident #48 who was identified as a fall risk and sustained an injury of unknown origin. The DON was asked if the facility had any additional information to present regarding the incident. The DON stated, No I think we have presented all that we have at this time. No other information was presented to the survey time prior to exit on 10/06/2021 at 5:15 p.m. 2. Resident #11 was admitted to the facility on [DATE] with a re-admission on 4/10/21. Diagnoses for Resident #11 included Alzheimer's, hypertension, dementia with behaviors, protein-calorie malnutrition, history of small intestine infarction, dysphagia and [CONDITION(S)]. The minimum data set (MDS) dated [DATE] assessed Resident #11 with severely impaired cognitive skills. Resident #11 was observed in bed on 10/5/21 at 10:50 a.m., 12:00 p.m. and 3:30 p.m. with no protective floor mats on either side of her bed. Resident #11's clinical record documented the resident had experienced previous falls from the bed. A nursing note dated 3/31/21 documented, Found on floor at foot of bed. Resident was on her bottom .Skin tear was observed on her right elbow following fall . A nursing note dated 5/26/21 documented, Writer heard residents roommate calling for help. When writer got to room resident had rolled out of bed on to the floor. Resident was on her stomach. The bed was in lowest position when resident rolled out .redness on residents face and under her left arm near armpit area . (Sic) Resident #11's plan of care (revised 8/31/21) listed the resident was at risk of falls and had experienced actual falls due to dementia and incontinence. Interventions to minimize falls included, .Mat to bilateral sides of bed . On 10/5/21 at 3:38 p.m., accompanied by certified nurses' aide (CNA) #1 that routinely cared for Resident #11, the resident was observed in bed with no mats in the floor. CNA #1 was interviewed at this time about mats. CNA #1 stated he was not aware the resident required floor mats. CNA #1 stated the resident had a history of falls but had not fallen in awhile. CNA #1 stated he did not recall any recent use of mats with Resident #11. Resident #11 was observed in bed on 10/6/21 at 8:11 a.m. without use of protective floor mats. On 10/6/21 at 8:14 a.m., the registered nurse (RN #2) working on Resident #11's unit was interviewed about the floor mats. RN #2 stated he was not sure about the mats. RN #2 stated the resident had mats in place at one time but he did not know if they were still required. On 10/6/21 at 10:37 a.m., RN #2 stated he checked Resident #11's care plan and the floor mats were supposed to be in place for fall/injury prevention. RN #2 stated, It is care planned. She [Resident #11] should have them [mats]. This finding was reviewed with the director of nursing and regional director of clinical services on 10/6/21 at 2:50 p.m.

Based on staff interview, clinical record review, facility document review and in the course of a complaint investigation, the facility staff failed to provide necessary behavioral health care and services to maintain the highest practicable physical, mental and psycho-social well-being for one of 19 residents in the survey sample, Resident #59. In (MONTH) of (YEAR), Resident #59 was assessed by the facility as having thoughts of self harm and an immediate threat to herself. The facility failed to develop a plan of care for the prevention of self harm, and Resident #59 was not provided with behavioral health care and services after this assessment. Resident #59 subsequently cut her wrist with a disposable razor and was sent to the hospital for treatment, resulting in harm. Findings include: Resident #59 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. An annual MDS (minimum data set) dated [DATE] documented the resident was a score of 15 for cognition, indicating the resident was cognitively intact for daily decision making skills. The resident was documented with a score of 23 (range ,[DATE]) for total severity of mood and was also assessed on this MDS as having potential for self harm. The resident was extensive assist with most ADLs (activities of daily living) with at least one person assist. The resident triggered for cognition, ADL function, urinary, mood, psychosocial, behavior, falls, nutrition, [MEDICAL CONDITION] drug use, and pain in the CAAS (care area assessment summary) section of this MDS. A quarterly assessment dated [DATE] was reviewed and documented the resident's cognitive score of 15 (intact for daily decision making skills) and the resident's total mood score was 20, still a high score of depressed mood. Section: D . Safety Notification: was blank. A significant change assessment dated [DATE] documented the resident with a cognitive score of 15 indicating the resident was intact for daily decision making skills. The total severity score for mood on this MDS was scored 16. The resident was also documented as having delusions and verbal behaviors toward others, with the presence of overall behavioral symptoms as worse. The resident was assessed as requiring limited assistance with at least one person assist for most ADLs (physical improvement from last MDS assessment). A complaint investigation was completed on Resident #59 on [DATE] through [DATE]. An allegation within the complaint alleged that Resident #59 injured self ([DATE]) with a disposable razor that was not a facility issued item, 911 was called and the resident was taken to the hospital and then readmitted back to the facility on [DATE]. Resident #59's closed clinical records were reviewed. The resident's physician order [REDACTED].vitamin B 12 deficiency, opioid abuse, MS, migraines, GERD, anxiety, major [MEDICAL CONDITIONS], chronic pai[DIAGNOSES REDACTED], [MEDICAL CONDITION], neuralgia and neuritis. The treatment/care plan was to: adjust to nursing facility placement for long term care .regular diet .may participate in activity and general conditioning program as desired, may attend religious and social activities without limitations or precautions unless otherwise notes . The resident's POS (Physician order [REDACTED].CPR .Regular mechanical soft diet .PAPER PLATES AND PLASTIC UTENSILS ONLY .bed against the wall . No orders for psychiatric services were found. A review of the clinical record revealed one psychiatric consult dated [DATE]. This consult documented, .seen evaluated .follow up depression last seen Nov. (YEAR) .today she looks much brighter than at previous visits . sleep: ok food: if you can call it food! .sitting up in bed .pleasant and cooperative with good eye contact .MOOD: 'This isn't any way to live' .looks brighter today .continue current meds. if depression symptoms persist, could increase .([MEDICATION NAME] 150 mg ER) to BID .can also consider trial of ([MEDICATION NAME] XR) in lieu of ([MEDICATION NAME]) .discuss pt status with POA .signature of psychiatry/neurobehavioral services. The resident's physician's orders [REDACTED]. On [DATE] at approximately 9:00 AM, the administrator was asked for the investigation regarding Resident #59's self harm. On [DATE] at 9:45 AM, the SW was interviewed regarding Resident #59. The SW was asked about the MDS information for this resident. The SW stated that he completes sections C (cognitive patterns), D (Mood), and E (behavior) on the MDS. The SW was asked about Resident #59's annual MDS assessment dated (MONTH) of (YEAR), specifically regarding the resident's high mood score along with documented concerns for self harm. The SW stated that if a resident answers the last question in that section with yes, then that triggers a response for the following self harm question which asked if there is a potential for resident self harm. The SW stated that is why that is marked yes, indicating knowledge of staff and/or the provider of potential for self harm regarding this resident. The SW was asked about the quarterly assessment in (MONTH) (Mood Score 20) and the significant change assessment in (MONTH) (Mood Score 16). The SW stated that the resident still had a high mood score, but did not voice hurting herself on those. The SW was asked if this type of information (self harm) should be care planned for the resident. The SW stated that it should be and thought it was for Resident #59. The SW was asked for the CAAS (care area assessment summary) worksheets for mood and behavior for the MDS assessments. The SW presented CAAS worksheet for the annual MDS assessment and for the significant change MDS assessment. The CAAS worksheet dated [DATE] documented, .psychosocial well being .The resident has a actual problem .often declines activities .depression .decline in ADL's .Mood or behavior problem that impacts interpersonal relationships .falls, pain .care planning for this problem, what is the overall objective: improvement .Describe impact of this problem .include complications and risk factors and the need for referral to other health professionals: Is a referral to another discipline warranted? No .Mood State: Resident has had thoughts that he/she would be better off dead, or thoughts of hurting him/herself as indicated by: Thoughts that you would be better off dead, or of hurting yourself in some way .yes .Analysis of Findings: has a actual problem with feeling hopeless .reported that at times she feels that she would be better off dead due to her illness .Relapse of an underlying mental health problem .Psychiatric disorder, anxiety, depression, [MEDICAL CONDITION] .pain .mental health and health issues contribute to thoughts of not living. The resident is often observed throughout the day in bed in and out of sleep .Mood State- care planning for this problem, what is the overall objective: improvement Behavioral Symptoms .has a actual problem with rejecting ADL care .needs several prompts and encouragement from staff for bathing and dressing .Seriousness of the behavioral symptoms: Resident is immediate threat to self - IMMEDIATE INTERVENTION REQUIRED .Resident's behavior status, care rejection, or wandering has worsened since last assessment .At times the resident has thoughts of being better off dead. The resident has a dx (diagnosis) of MS which contributes to feelings of hopelessness, stressed that she gets sad when she thinks about being 'crippled up in the bed' .Care plan consideration Will behavioral symptoms- functional status be addressed in the care plan? Yes .Improvement .Referral to Other Disciplines: Is a referral to another discipline warranted? No . The CAAS worksheet dated [DATE] documented, .psychosocial well being .verbal behavioral symptoms .actual problem with verbal behavior when she is unable to get her way .curses and calls staff names .has thrown food tray on the floor and thrown objects Depression .Mood or behavior problem that impacts interpersonal relationships .overall objective: improvement .minimize risks .Describe impact of this problem .include complications and risk factors .Is a referral to another discipline warranted? No .Mood State: has actual problem with regulating her mood .depression and anxiety .stressed that the pain caused by her MS and inability to walk makes her sad .Delusions .antipsychotics .improvement, slow or minimize decline .minimize risks .Care plan consideration Will Mood State- functional status be addressed in the care plan? Yes .Improvement .Is a referral to another discipline warranted? No .Referral: No . The resident's CCP (comprehensive care plan) was reviewed prior to self harm incident ([DATE]) and documented, .is dependent on staff for activities, cognitive stimulation, social interaction .engage in activities .explain the importance of social interaction, encourage participation .in room visits .music .provide a calm non rushed environment .reality orientation .report c/o (complaints of) pain, discomfort .or any other c/o that interferes with resident's ability to participate .to the nurse .needs assistance/escort to and from activity .impulsive behavior .history of throwing glass plates when she becomes upset .[MEDICAL CONDITION] med use .adaptive equipment .walker/wheelchair .anticipate and meet the residents needs .keep needed items .in reach .medication as ordered .(name of resident) needs a safe environment .Resident to received plastic silverware and Styrofoam plates/bowls for all meals .keep call bell in within easy reach .medication as per physician order [REDACTED].monitor and report to MD (medical doctor) s/sx (signs and symptoms) of depression. Obtain order for mental health consult if needed .monitor and report medication side effects and effectiveness every shift .ADL-Observe skin for redness, open areas, scratches, cuts, bruises and report changes to nurse .bathing: provide resident with a sponge bath when a shower can not be tolerated .provide the resident with assistance to bathe daily and as needed .psychoactive use .antidepressant .depression .antipsychotic .depression .antianxiety .anxiety/agitation . non drug interventions- monitor behavioral symptoms and side effects such as appetite changes, memory impairment .antidepressants: report .signs and symptoms of depression or problematic side effects to practitioner .antipsychotic- monitor behavioral symptoms . evaluate medication response and resident's response quarterly .if side effect present report to practitioner .medication as ordered .non drug interventions-see behavior care plan .educate patient .on consequences of poor behavior choices/non compliance .encourage group activities .encourage resident to express feelings .monitor for increase in behaviors or unsafe behaviors and report to physician as needed .impaired thought processes .monitor and report to MD any changes in cognitive function, specifically changes in decision making ability, memory, recall, and general awareness .distress of yelling out when she is not due for pain medications, emotional distress .throwing items and cursing staff and c/o chronic unrelieved pain .anticipate the resident's need for pain relief .assess coping strategies .attempt non pharmacological interventions .distraction .express feelings .monitor and report to nurse resident complaints of pain or requests for pain treatment .monitor and report to .nurse .mood/behavior changes, more irritable, restless, aggressive, squirmy, constant motion .psych consult as needed . No information was on the resident's CCP regarding any self harm, or statements of the resident stating, being better off dead', and there were no interventions to address these identified concerns. None of the information from the above MDS and/or CAAS Worksheets regarding this resident's risk for self harm was incorporated in any way into the resident's CCP. The progress and nursing notes were reviewed for this resident for (YEAR) and included the following: A progress note dated [DATE] documented, .continues to display inappropriate behaviors at times, she throws her food tray and other objects on the floor when she is unable to get her way, when upset .verbally abuses staff by cursing and calls them names based on skin color .prefers to lay in bed most of the day, struggles with staying safe .has had a few falls .signature of (social worker). A progress note dated [DATE] documented, .threw food tray full of food onto floor, when given medications she throw back (sic) at nurse .attempted to pinch/punch and bite nurse and CNA that was assisting back into her w/c. (name of resident) propels to the nursing station and made allegations of sexual assault .(name of resident) started chasing female nurse in w/c which led to the sheriff department being called .investigate allegations of sexual assault .(name of resident) she struggle with (sic) recalling the behavior she displayed and stated she never said anybody sexually assaulted her .new med order for [MEDICATION NAME] 1 mg will continue to monitor .SW A progress note dated [DATE] documented, Significant change .alert and oriented with some forgetfulness/confusion is able to recognize some staff by name, able to make needs known all needs met by nursing .often observed in bedroom by choice, this is often due to depression .Significant change due to ongoing behavior issues .SW A nursing note dated [DATE] documented, resident came out of room and demanded Tylenol. she then made rude statements and became agitated. Redirecting her didn't help .made paranoid statements about the Tylenol .went back to room and then came back out and accused us (staff) of removing pictures from her room . A nursing note dated [DATE] (no time stamp) documented, At approximately 10 AM this writer was alerted to the front lobby where I was met by a police officer, patient had called 911 stated that she was ringing her call light since 8:15 with no answer. Escort police officer X 3 to patients room patient stated that she had migraine (sic) and nurse would not provide me (sic) with medications for my migraine this nurse offered PRN (as needed) Zomig - schedule [MEDICATION NAME] patient refused stated, 'your not a nurse your uneducated go back to school, I'm gonna sue the doctor for malpractice police officer talked with patient to .while offered to send patient to ER (emergency room ) patient refused MD notified no new medication order per MD narcotic not appropriate for migraines - patient had requested 'strong' pain medication patient refused am medications - prior to police arrival patient had thrown tray across room when asked why she stated 'I can't eat that' per CNA (certified nursing assistant) statement she had placed breakfast tray in at approximately 8:00 AM and had been in room X 2 between then and 9:30 and nurse (LPN) stated that she had also been in patients room between those times patient aware of no new medications patient told this RN to get out of my room again stated that she was going to sue the MD no further behaviors this shift . A nursing note dated [DATE] at 3:45 PM documented staff reported resident requested to see nurse this nurse responded immediately to find resident cutting L (left) wrist inner with shaving razor this nurse repeatedly asked resident to stop she stated 'no I want [MEDICATION NAME]' this nurse removed razor from resident and applied towel with pressure to L inner wrist resident attempted to kick this writer yelling 'I have to wait 20 more minutes before I can have my medicine and I don't want to wait staff stayed 1:1 with resident while this nurse called 911 for transport to ED (emergency department), ADON (assistant director of nursing), notified immediately of incident, MD notified . On [DATE] at approximately 11:30 AM, the administrator, DON and corporate nurse were made aware of serious concerns with Resident #59 in a meeting with the survey team. The facility staff were made aware of the lack of interventions and/or services provided to prevent accidents/self harm for this resident. The facility staff were made aware that this resident had been identified by facility staff as having a high mood score for depression and as being a risk for self harm in (MONTH) of (YEAR), with no interventions developed or implemented for the prevention of accidents/self harm for this resident. The staff were asked for assistance in providing any, and all additional information or documentation regarding Resident #59. The investigation for this incident was again requested at this time. An investigation was presented at approximately 3:00 PM regarding Resident #59. The investigation was reviewed and documented that the resident was observed cutting her wrists with a disposable shaving razor. EMS was called and transported the resident to the emergency department. The summary documented that first aid was provided prior to the resident leaving the facility and staff remained with the resident until EMS arrived. The summary documented that an investigation was completed on [DATE] to include employee interviews and medical review. The root cause analysis in the summary documented it was determined that the cause of the resident's behavior was a reaction to the attending physician's decision to not use narcotics and that the resident has a history of engaging in attention seeking behavior. The actual investigation documented several witness statements from staff, including a statement from licensed practical nurse (LPN) #8. The statement by LPN #8 documented, Somewhere in (YEAR) during the last quarter of the year made a statement that she would rather die than not have her [MEDICATION NAME] pain medicine. She only made it once and never repeated it. This was reported to the, then DON who instructed this nurse not to worry about it .(LPN #8). A statement by CNA #2 documented, .realize something was wrong with (name of Resident #59) wrist while we were trying to put gloves on she was continuously using the shaving stick cutting on her wrist faster and faster .manage to take it away after putting her gloves on .(CNA #2). It was documented within the investigation that razors were found in patients room that were not facility issued or acquired. The investigation did not determine where the razor(s) came from or how the resident obtained the razor. The investigation did not have a statement from the resident. The resident was a 15 cognitively, but was not interviewed regarding the event. The resident was not interviewed prior to leaving the facility for the emergency department and was not interviewed after readmission to the facility. At approximately 3:30 PM, the survey team met with the administrator, DON and corporate nurse. They were again made aware of concerns of actual harm of this resident. The facility staff were also made aware that the investigation was not complete and accurate. The facility staff were asked how the resident got the razor or where did she get it from. The facility staff did not provide information on where or how the resident obtained a razor. The facility staff were asked if the resident was interviewed and the staff did not provide a response. No statements were found for Resident #59. On [DATE] at 4:49 PM, the survey team again met with the corporate nurse, administrator and DON. No other information or documentation was presented for this resident regarding this incident or investigation. The corporate nurse stated that there were no other psych consults found for this resident. On [DATE] at 5:20 PM, the administrator stated that the MD (medical director) may have information regarding Resident #59. The administrator and MD met with the survey team at this time. The MD stated that the resident did not like getting medications other than narcotics and that the resident had an opioid addiction at one time due to chronic pain. The MD stated, We'd (the facility) been trying to deal with drug seeking behaviors. The administrator and MD was asked if the resident was referred to a pain clinic or to psych services. The administrator stated that the resident was not referred to a pain clinic, but stated that the resident was seen regularly by psych and that the facility had made multiple referrals for this resident, which she refused. The administrator and MD were made aware that only one psych consult observed in the resident's clinical record dated ,[DATE], and that no referrals were found in the resident's chart, nor any documentation found that the resident refused any type of referral. The MD was asked about the resident attempting suicide by cutting her wrist with a disposable razor. The MD stated, It was simply a suicidal gesture, that's all. The MD was asked again about interventions for this resident and/or outside services to assist this resident with the multitude of problematic depressive/behavioral/suicidal ideation symptoms. The MD stated, that he believed we did all we could do. The MD was asked, along with the administrator, where the resident got the razor or how the razor was obtained by the resident. The administrator, nor the MD made any comments regarding this. The MD again stated, We had plenty of referrals and she refused if you look in the record, you'll see the documentation. The MD was made aware that no documentation was found in the resident's clinical record to support those statements. The resident's discharge summary from the hospital dated [DATE] documented, .Admission Primary Diagnosis: [REDACTED].history notable for [MEDICAL CONDITION], chronic migraines, depression [MEDICAL CONDITION], opioid use disorder and suicide attempt due to medication overdose who presented to the ED after attempted suicide .onset of a migraine 2 weeks ago .she reports she has not been sleeping for months. She says the pain was so bad that she decided to cut her wrist .she continues to endorse active suidical ideation .she attributed her suicidal ideation to her intractable severe migraines. Psychiatry evaluated the patient and felt her presentation was consistent with an adjustment disorder with mixed disturbance of emotions and conduct .she denied suicidal ideation when reevaluated by psychiatry on [DATE] .cleared for discharge back to her skilled nursing facility .ambulatory referral to (name of psychiatrist) or .may continue to follow with the psychiatrist's at the SNF. No further information and/or documentation was presented prior to the exit conference on [DATE] at 6:15 PM to evidence the facility staff provided supervision and interventions for the prevention of self harm for Resident #59, after the resident had been identified by facility staff as being at risk for self harm. THIS IS A COMPLAINT DEFICIENCY.