Every finding on record at Osage Rehab and Health Care Center

Based on record review, observation, and staff interview, the facility failed to provide a private space for residents to make telephone calls for 2 sampled residents (Resident #6 and Resident #15). Specifically, the facility lacked a designated private area for calls during non-business hours, forcing residents to use the phone at the nursing station in the presence of other residents and staff. The facility reported a census of 28 residents. Findings include:1. Resident #6's Minimum Data Set (MDS) Assessment, dated 2/5/26, identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment.An observation on 3/31/26 at 6:40 PM showed Resident #6 making a phone call at the nursing station. During the call, another resident was audible in the background yelling for help, and several residents and staff members walked past Resident #6 as she talked on the phone.During an interview on 4/1/26 at 8:50 AM, Resident #6 voiced that it's often loud at the nursing station when she makes phone calls, but she noted that is the only place available to her so she gets used to it.2. Resident #15's MDS Assessment, dated 1/7/26, identified a BIMS score of 15, indicating intact cognition.During an interview on 3/31/26 at 6:55 PM, Resident #15 reported she didn't have a personal phone and there was no private place to use the facility phone. She stated she didn't like the lack of privacy when making phone calls.During an interview on 4/1/26 at 10:17 AM, the Administrator reported that residents could use her office or the Director of Nursing (DON) office during business hours. However, she confirmed that during off-hours, weekends, or when management is away, there's no private place for residents to make telephone calls.

Based on record review, staff interviews and policy review the facility failed to revise the comprehensive, person-centered care plan that addressed a resident's wandering behaviors for 1 of 1 sampled residents (Resident #2). Specifically, despite clinical documentation showing the resident frequently wandered into other residents' rooms, the facility didn't update the care plan with interventions to manage this behavior or protect the privacy and safety of others. The facility reported a census of 27 residents. Findings include:Resident #2's Minimum Data Set (MDS) Assessment, dated 2/5/26, identified a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The MDS documented diagnoses of dementia, primary insomnia (a common sleep disorder that can make it hard to fall or stay asleep), and depression.Resident #2's Progress Notes, from 1/23/26 to 3/28/26, documented on several occasions that the resident wandered the hallways and required redirection out of other residents' rooms.Resident #2's Care Plan, dated 2/17/26, lacked documentation of the wandering or the behavior of entering other residents' rooms. The plan included no interventions to address these specific behaviors.During an interview on 3/31/26 at 4:40 PM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) reported they knew Resident #2 walked the hallways at night because he couldn't sleep and believed he worked at the facility. The DON reported she wasn't aware staff were charting that he wandered into other resident rooms. Both the DON and ADON acknowledged that the wandering behavior wasn't on the care plan and no new interventions were added after the resident entered other residents' rooms.The facility policy titled Comprehensive Care Plan, dated 2025, documented the facility will develop and implement a comprehensive person-centered care plan for each resident. The policy required the plan to include measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs.

Based on clinical record review, resident interviews, staff interviews, and facility's policy review, the facility failed to ensure residents received scheduled bathing and failed to maintain accurate documentation of hygiene services for 2 of 6 sampled residents (Resident #11 and Resident #14). One resident missed scheduled baths over a three-month period, while another reported feeling dirty and odorous due to infrequent showering. The facility reported a census of 28 residents. Findings include: 1. Resident #11's January 2026 Documentation Survey Report v2 documented not applicable for bathing on 1/16/26 and 1/23/26.Resident #11's February 2026 Documentation Survey Report v2 documented not applicable for bathing on 2/17/26, 2/20/26, 2/24/26, and 2/27/26.Resident #11's March 2026 Documentation Survey Report v2 lacked documentation for bathing on 3/3/26 and 3/29/26. It documented not applicable for bathing on 3/13/26, 3/17/26, and 3/20/26.Review of the February 2026 Visual Assessment forms showed they were completed on 2/3/26, 2/6/26, 2/10/26, and 2/13/26. The forms lacked documentation for 2/17/26, 2/20/26, 2/24/26, and 2/27/26.Review of the March 2026 Visual Assessment forms showed they were completed on 3/3/26, 3/6/26, 3/10/26, 3/15/26, and 3/18/26.During an interview on 4/1/26 at 3:45 PM, the Assistant Director of Nursing (ADON) reported she wasn't sure why Resident #11's baths weren't charted for dates in February and March. She stated she was unsure if Resident #11 received the baths.2. Resident #14's Minimum Data Set (MDS) Assessment, dated 3/6/26, identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The MDS revealed Resident #14 required substantial or maximal assistance for bathing.During an interview on 3/31/26 at 11:00 AM, Resident #14 reported she received baths on 3/15/26 and 3/29/26. She stated she had doctor appointments on other days and staff didn't offer a shower before or after those appointments. She reported being told she had to wait until her next scheduled shower day. Resident #14 stated she felt dirty and odorous, and her hair appeared greasy.During an interview on 3/31/26 at 11:10 AM, Resident #14's Representative reported the hair of Resident #14 looked dirty and greasy during their daily visits.Resident #14's Documentation Survey Report v2 recorded bathing occurred on 3/19/26 and 3/29/26. The Documentation Survey Report v2 revealed not applicable was documented on 3/3/26, 3/6/26, 3/10/26, 3/13/26, 3/17/26, 3/22/26, and 3/26/26.During an interview on 4/1/26 at 12:12 PM, the Administrator indicated she expected the staff to complete showers twice a week.The facility's undated Resident Showers policy instructed residents will be provided showers as per request or per facility schedule protocols. It noted that partial baths may be given between regular shower schedules.

Based on record review, policy review and staff interviews, the facility failed to transcript admission orders after a resident admitted to the facility for the facility staff to implement the orders for 1 of 3 residents reviewed (Resident #3). The facility reported a census of 26 residents. Findings include:Resident #3's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of 1/13/26 from a short-term general hospital. The MDS identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The MDS included diagnoses of peripheral vascular disease (PAD), diabetes, and atherosclerosis of native arteries of the other extremities with ulceration (severe form of PAD where plaque builds up causing pain and slow wound healing due to reduced blood flow). The MDS documented seven venous and arterial ulcers present at admission. Resident #3's Transfer Summary from the hospital dated 1/13/26 documented admission orders for collagenase Santyl ointment (a cream applied to the skin to remove dead tissue from long-term wounds) treatment to the right heel and betadine to eschar (dead skin, usually black in coloring) areas to the right foot daily. In addition, the Summary included orders to give Juven (a therapeutic nutritional drink powder designed to support wound healing) twice daily. Resident #3's January 2026 Medication Administration Record and Treatment Administration Record lacked documentation of the Juven and the treatment orders for the right foot and heel. On 2/11/26 at 8:40 AM the Interim Director of Nursing (IDON) reported she didn't transcribe the admission order properly; she missed the orders for the wound care and Juven. The undated facility policy titled Provision of Physician Ordered Services directed to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. The policy lacked direction of the transcription and implementation of orders.

Based on facility documents, schedule review, and staff interviews, the facility failed to provide a Registered Nurse (RN) in the facility for eight (8) consecutive hours per day as required by the Federal Regulations. In addition, the facility failed to have a full time Director of Nursing. The facility reported a census of 25 residents. Findings include:Review of the daily schedule for July 2025 lacked an RN on the 3rd, 14th, and 27th.The daily schedule for November 2025 lacked a RN for the 17th and 19th. On 12/17/25 at 2:55 PM the Interim Director of Nursing (DON) reported the facility did not have an RN on July 3rd, 14th 27th and November 17 and 19. The interim DON reported she knew of the lack of RN coverage, but she didn't become Interim until December 1, 2025.Review of the facility's New Hire and Termination List lacked a DON from 10/18/25 until 12/1/25.On 12/18/25 10:32 AM the Administrator reported the facility didn't have a DON from 10/18/25 until 12/1/25. They didn't have anyone in place at the time to cover.

Based on record review, staff interview, and policy review, the facility failed to notify the Resident or the resident's representative in advance of the risks verses benefits for psychotropic medication, the treatment alternatives or other options the representative preferred for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 25 residents. Findings include:1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS included diagnoses of schizophrenia (a chronic brain disorder that makes it difficult for a person to distinguish between what is real and what is not), dementia, diabetes, heart failure, anxiety, depression, and adult failure to thrive. Review of the Medication Administration Record (MAR) revealed the following orders: Paxil (a type of antidepressant that affects chemical in the brain to influence a person's mood, thinking, and behavior) 10 MG daily for depression starting on 12/16/23. Buspirone (an antianxiety medication that affects your brain to help balance your mood and reduce anxiety symptoms) 5 mg 2 times a day related to anxiety starting on 8/13/25. Lorazepam (an antianxiety medication that affects the brain and changes how you feel, think, and act) 0.25 mg 2 times a day related to anxiety starting on 8/13/25. Trazodone (an antidepressant medication that affects the brain and is used to treat mental health conditions like depression and anxiety) 25 Mg 3 times a day for depression starting on 9/2/25. Resident #1's Progress Notes from 12/1/23 to 12/15/25 lacked documentation of notifying them or their representative in advance of the risks versus benefits of Paxil, buspirone, lorazepam, and trazodone medications. In addition, the documentation lacked treatment alternatives or other options and let them choose the option they preferred prior to administering the medication on a routine basis as ordered. Resident #1's December 2025 Medication Administration Record (MAR) documented they received Paxil 16 times, buspirone 33 times, lorazepam 33 times, and trazodone 50 times. On 12/17/25 at 3:15 PM the interim Director of Nursing (DON) reported the facility didn't complete a consent form with Resident #1's Representative for Paxil, buspirone, lorazepam, or trazodone prior to starting the medications. The interim DON reported she would expect the facility staff to educate and document if the resident or resident representative received education about the medications risks vs. benefits. 2. Resident #19's MDS assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The MDS included diagnoses of cerebral infarction (a type of stroke where a blood clot blocks a brain artery, cutting off oxygen and nutrients, causing brain cells to die), neuralgia (a sharp, stabbing, or burning pain along a nerve's path, caused by nerve irritation, damage, or inflammation, often feeling like an electric shock and following the nerve's course), neuritis (a nerve inflammation, like a swollen, irritated wire in your body's electrical system, causing pain, tingling, numbness, or weakness in the area the nerve serves), aphasia (a communication problem that affects using and understanding language caused by brain injury), and dementia. Resident #19's December 2025 Medication Administration Record (MAR) listed an order for olanzapine (an antipsychotic that works in your brain and affects your mood, thoughts, and behavior) 5 mg daily for major depressive disorder starting on 7/4/25. The documentation indicated Resident #19 received olanzapine 17 times. Resident #19's Progress Notes from 7/1/25 to 12/15/25 lacked documentation of notifying them or their representative in advance of the risks versus benefits of the Olanzapine medication order. In addition, the documentation lacked treatment alternatives or other options and let them choose the option they preferred prior to administering the medication on a routine basis as ordered. On 12/17/25 at 3:15 PM the interim Director of Nursing (DON) reported the facility didn't complete a consent form with Resident #19 or their representative prior to starting the olanzapine medication. The interim DON reported the staff should speak with the family about risks vs benefits and document it. The undated facility policy titled Antipsychotic Medication Used lacked direction on notifying the resident or resident representative to educate and discuss the risks vs. benefits of antianxiety, antipsychotic, and antidepressant medications. In an interview on 12/22/25 at 3:42 PM with the Assistant Director of Nursing (ADON) explained the residents' electronic health record should include the medications consents under Assessments. They were working on getting them all in the system.

Based on record review, staff interview, and policy review, the facility failed to document the release of a seat belt every 2 hours, failed to obtain an informed consent for the use of a seat belt in a wheel chair from the resident's representative in advance of potential risks and benefits of all options under consideration including using a restraint, not using a restraint, and alternatives to restraint use for 1 of 1 residents reviewed (Resident #8). The facility reported a census of 25 residents. Findings include: Resident #8's Care Area Assessment Worksheet dated 2/12/25 listed them as severely impaired with making decisions regarding tasks of daily life. They had difficulty making themselves understood or understanding others. Resident #8 had a functional limitation in range of motion. They had a seizure disorder. Resident #8 took antianxiety medications. The progress noted revealed the following:a. On 7/29/25 at 8:51 AM to the physician asking for an order to release the resident's seatbelt when he is in his w/c.b. On 7/29/25 at 13:36 a fax was received back regarding seatbelt ok The Care Plan Problem revised 11/14/24 indicated Resident #8 had a self-care deficit as evidenced by the need to have assistance with activities of daily living (ADLs), impaired balance during transitions requiring assistance and/or incontinence. The Interventions directed the following:a. Revised 5/8/25: When in wheelchair reposition Resident #8 and release his seatbelt every 2 hours.b. 11/14/24: Resident #8 didn't ambulate (walk) and used a reclining wheelchair that staff propel. Release his seat belt when in the wheelchair every 2 hours. Review of the Electronic Health Records (EHR) orders revealed the following orders:a. Started 7/29/25 and discontinued 12/16/25: Release seatbelt with no directions specified.b. Started 4/25/25 and discontinued 7/13/25: When in the wheelchair, release wheelchair every shift for protocol seatbelt and reposition resident every 2 hours with directions every shift for protocol. The General Progress Note dated 7/29/25 indicated the facility asked Resident #8's primary care provider (PCP) for a seatbelt while in the wheelchair. The General Progress Note dated 7/29/25 at 1:36 PM reflected the PCP replied okay to the use of seatbelt. Resident #8's N Restraint/Medical Device Comprehensive/Quarterly assessment dated [DATE] at 7:24 AM documented the use of a seatbelt on the wheelchair as a physical restraint/non-restraint. Previous attempts to use a less restrictive device included medication adjustments, Occupational Therapy, and a specialized wheelchair. The benefits of the restraint/nonrestraint device included:Prevent Injury to themselvesEnhances functional status/abilityProvides medically necessary proceduresMaintains correct positionReduce risk of fallingMaintain integrity of feeding tube.Resident #8 didn't have complications with the use of the seatbelt. The recommendations for restraint/nonrestraint reduction decision listed the seatbelt as a restraint. Resident #8's December 2025 Treatment Administration Record (TAR) included an order dated 12/16/25 to release his seatbelt when in wheelchair every 2 hours, related to epilepsy. The facility lacked any documentation of family or resident education or consent for seat belt orders from 4/25/25 through 12/18/25. On 12/18/25 at 8:04 AM observed Resident #8 resting quietly in his bed. On 12/18/25 at 10:14 AM witnessed Resident #8 sitting in his wheelchair wearing his seatbelt, smiling and watching TV in the lounge area. On 12/17/25 at 3:15 PM the interim Director of Nursing (DON) reported they didn't have an informed consent for the use of the seat belt. The interim DON stated she would expect to have an informed consent for the use of the seat belt. During an interview on 12/22/25 at 4:00 PM the Assistant Director of Nursing (ADON). The ADON revealed that she was not aware of any consents for the use of the seat belt. The ADON stated she would expect the facility to obtain a consent for the use of a seat belt.

Based on record review and staff interviews the facility failed to complete Minimum Data Set (MDS) assessment and Care Area Assessment (CAA) worksheet for pressure ulcers for 1 of 1 resident reviewed (Resident #4). In addition, the facility failed to complete 1 of 2 residents CAA worksheet for Nutrition (Resident #24). The facility reported a census of 25 residents. Findings include: 1. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) of 15, indicating no cognitive impairment. The MDS documented 2 unstageable pressure ulcers (a severe skin wound where the base is hidden by dead tissue, making its true depth and severity impossible to determine until the dead tissue is removed). The MDS listed the 2 unstageable pressure ulcers as not present during her admission to the facility and were acquired during her stay at the facility. Review of the MDS Care Area Assessment (CAA) worksheet dated 9/28/25 related to pressure ulcers revealed the facility MDS Coordinator checked the box Resident #4 pressure ulcer areas needed implemented on the Care Plan, but failed to complete the section that describes the impact it will have, rationale for care planning, risk factors, and if a referral to other health professionals would be needed. In an interview on 12/18/25 at 11:45 AM Resident #4 explained she didn't have new pressure ulcers form since her admission to the facility. In an interview on 12/22/25 at 12:13 PM Staff C, Registered Nurse (RN), described Resident #4's pressure ulcers as getting better. She added Resident #4 didn't have a new pressure ulcer since her admission to the facility. She reported the MDS Coordinator worked offsite and not at the facility. 2. Resident #24's MDS assessment dated [DATE] identified a BIMS score of 3, indicating severe cognitive impairment. The MDS included diagnoses of Parkinson's, dehydration, and depression. The MDS listed a weight of 230 pounds (lbs.). Review of the MDS Care Area Assessment (CAA) worksheet dated 10/3/25 related to nutritional status revealed the facility MDS Coordinator indicated nutritional status should be addressed on the Care Plan, but failed to complete the section that described the impact it will have, rationale for care planning, risk factors, and if a referral to other health professionals would be needed. The Weight / Skin Summary Note dated 12/5/25 at 11:47 AM documented a meeting with the Assistant Director of Nursing and the Dietician. The not listed his weight on 12/2/25 as 190.4 lbs. The nurse reflected he lost 9% of his body weight in 1 month, admitted to hospice level of care, ate very poorly, and refused many meals. Recommend to have provider document the weight loss as unavoidable. Resident #24's MDS assessment dated [DATE] documented a weight of 190 lbs., not on a physician prescribed weight-loss regimen. The MDS indicated he received Hospice level of care. In an interview on 12/22/25 at 3:42 PM the Assistant Director of Nursing (ADON) reported the facility's company started an internal audit for the CAA's on 12/19/25 after learning of the incomplete worksheets. An unsuccessful attempt to contact the facility's MDS Coordinator occurred on 12/23/25 at 4:03 PM. As of 12/29/25, no return call received.

Based on clinical record review, staff interview, and Preadmission Screening and Resident Review (PASRR) manual, the facility failed to accurately code the PASRR Level ll on the Minimum Data Set (MDS) assessment for 1 of 2 residents with a PASRR Level II (Resident #2). In addition, the facility failed to accurately code pressure ulcers were not acquired at the facility for 1 of 1 resident with pressure ulcers (Resident #4). The facility reported a census of 25. Findings include:1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] reflected they didn't have a state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The MDS identified a Brief Interview of Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS included diagnoses of schizophrenia (a chronic brain disorder that makes it difficult for a person to distinguish between what is real and what is not), anxiety, depression, dementia, neurocognitive disorder with Lewy bodies (a disease process that scrambles the brain's ability to think, move, and function correctly), and heart failure. Resident #2's Level Il PASRR dated 9/18/25 indicated the need for ongoing psychiatric medication management by a psychiatrist or psychiatric Advanced Registered Nurse Practitioner (ARNP) to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders, and to evaluate the ongoing need for additional behavioral health services. Resident #2's PASSAR dated 9/18/25 identified services required based on the diagnosis of schizoaffective disorder, depressive. On 12/18/25 at 8:44 AM the interim Director of Nursing (DON) stated the MDS didn't accurately reflect the PASSAR level ll status and she would expect the PASSR to be coded correctly on the MDS. 2. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) of 15, indicating no cognitive impairment. The MDS documented 2 unstageable pressure ulcers (a severe skin wound where the base is hidden by dead tissue, making its true depth and severity impossible to determine until the dead tissue is removed). The MDS listed the 2 unstageable pressure ulcers as not present during her admission to the facility and were acquired during her stay at the facility. Review of the MDS Care Area Assessment (CAA) worksheet dated 9/28/25 related to pressure ulcers revealed the facility MDS Coordinator checked the box Resident #4 pressure ulcer areas needed implemented on the Care Plan, but failed to complete the section that describes the impact it will have, rationale for care planning, risk factors, and if a referral to other health professionals would be needed. In an interview on 12/18/25 at 11:45 AM Resident #4 explained she didn't have new pressure ulcers form since her admission to the facility. In an interview on 12/22/25 at 12:13 PM Staff C, Registered Nurse (RN), described Resident #4's pressure ulcers as getting better. She added Resident #4 didn't have a new pressure ulcer since her admission to the facility. She reported the MDS Coordinator worked offsite and not at the facility. In an interview on 12/22/25 at 3:42 PM with the Assistant Director of Nursing (ADON) reported Resident #4 didn't acquire new pressure ulcers at the facility and they were coded inaccurately. The ADON added Resident #4 had the 2 unstageable pressure ulcers present on Admission. Resident #4 Progress Notes from 9/24/25 to 9/28/25 lacked documentation of new acquired pressure ulcers during her stay at the facility.

Based on clinical record review, policy and staff interview, policy review, the facility failed to incorporate the recommendation from the PASARR level ll determination and the evaluation report into the resident's assessment and care planning for 1 of 2 residents with new mental health diagnoses (Resident #2). Pre-admission Screening and Resident Review (PASRR) Level II (a in-depth federal assessment for individuals applying to or residing in Medicaid-certified nursing facilities, determining if they have a Serious Mental Illness or Intellectual Disability/Related Condition and need specialized services, this ensures they aren't inappropriately placed and receive care in the most integrated setting possible, involving comprehensive evaluations by mental health/disability experts). The facility reported a census of 25. Findings include: Resident #2's Minimum Data Set (MDS) assessment dated [DATE] reflected they didn't have a state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The MDS identified a Brief Interview of Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS included diagnoses of schizophrenia (a chronic brain disorder that makes it difficult for a person to distinguish between what is real and what is not), anxiety, depression, dementia, neurocognitive disorder with Lewy bodies (a disease process that scrambles the brain's ability to think, move, and function correctly), and heart failure. Resident #2's PASARR dated 9/18/25 identified services required based on the diagnosis of schizoaffective disorder, depressive. Resident #2's clinical record lacked PASARR level ll. On 12/18/25 at 8:44 AM the interim Director of Nursing (DON) explained the PASARR level ll didn't get correctly coded on the MDS. The interim DON reported she would expect the PASARR level ll to be coded correctly on the MDS. In an interview on 12/22/25 at 4:05 PM the Social Worker (SW) admitted she didn't know until the previous week on 12/17/25 or 12/18/25 the PASRR recommendations listed on Resident #2 PASRR Level II need implemented into his Care Plan. In addition, she knew he saw psychiatry services. She added the facility hadn't trained her since she became the SW over a year ago, which recommendations need to be on the Care Plan for PASRR Level II residents.

Based on record review, staff interview and policy review the facility failed to implement interventions for 1 of 1 resident with unstageable pressure ulcers. The facility reported a census of 25 residents. Findings include: 1. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) of 15, indicating no cognitive impairment. The MDS documented 2 unstageable pressure ulcers (a severe skin wound where the base is hidden by dead tissue, making its true depth and severity impossible to determine until the dead tissue is removed). The MDS listed the 2 unstageable pressure ulcers as not present during her admission to the facility and were acquired during her stay at the facility. The Care Plan Problem revised 12/12/25 indicated Resident #4 admitted with pressure areas to her coccyx (area in the lower back just above the buttock), left ischium (hip), and right ischium. In addition, she had pressure area to her left lateral (side) ankle, right lateral ankle, and both sides of her coccyx. The Interventions lacked resident specific interventions to promote and prevent further deterioration of pressure ulcer sites, such as but not limited to; type of treatments or medications and supplies; residents input for when treatments should be completed, pain interventions for wound care, and external wound care providers interventions. In an interview with the Assistant Director of Nursing (ADON) on 12/22/25 at 3:42 PM reported the facility implemented a comprehensive Care Plan for Resident #4. The Care Plan included interventions for an alternating air pressure mattress and repositioning every 2 hours. Review of the facility's Pressure Ulcers/Injury Overview policy dated 2001 lacked instructions on Care Planning and completion of the facility's process to complete assessments.

Based on observations, facility document review and staff interviews, the facility failed to post the daily staff posting with the census and facility name. The facility reported a census of 25 residents. Findings include:An observation on 12/15/25 at 3:17 PM observed the facility didn't have the daily staff posting didn't contain the resident census or the facility name. An observation on 12/16/25 at 3:20 PM observed the facility didn't have the daily staff posting didn't contain the resident census or the facility name. An observation on 12/17/25 at 3:42 PM observed the facility didn't have the daily staff posting didn't contain the resident census or the facility name. During an interview on 12/18/25 11:41 AM, the Administrator reported the overnight nurses did the daily staff postings. She reported the nurses fill out the nurses and CNA number of staff and hours totaled each shift. She reported she didn't believe the staff put the census of it. On 12/18/25 at 11:44 AM observed with the Administrator the daily staff posting didn't contain the resident census or the facility name.

Based on facility record review, staff interview and policy review, the facility failed to have the minimum required members at the Quality Assessment and Assurance (QAA) meetings to identify issues with respect to which quality assessment and assurance activities are necessary. The facility reported a census of 25 residents.Findings include:Review of the facility QAA sign in sheets revealed the facility didn't have the Infection Preventionist present at the March, May, August or November quarterly meetings. In addition, the facility didn't have the Director of Nursing (DON) present at the May or November quarterly meetings. The Administrator didn't attend the August quarterly meeting. On 12/17/25 at 10:30 AM the Administrator reported she didn't know the facility didn't have all required staff at the QAA meetings. She reported the facility struggled with staffing. Review of the facility's Quality Assurance and Performance Improvement (QAPI) Committee dated July 2016 lacked direction on the required amount needed at the QAA meetings.

Based on observation, staff interviews, record review, and policy review the facility failed to use enhanced barrier precautions (EBP infection control measures, requiring healthcare workers to wear gowns and gloves for high-contact care) when providing routine catheter care for 1 of 1 resident reviewed (Resident #9). The facility reported a census of 25 residents. Findings include:Resident #9's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) of 15, indicating no cognitive impairment. The MDS listed her as dependent (staff does all the effort) on staff for toileting hygiene (perineal hygiene). The MDS documented she used a catheter. The MDS included a diagnosis of neurogenic bladder (a condition where nerve damage to the brain, spinal cord, or peripheral nerves disrupts the signals controlling bladder function, leading to loss of control, incontinence, urinary retention, or incomplete emptying) Resident #9's Order Summary Report dated 7/14/25 documented an order to change her catheter every 30 days and clean around the suprapubic catheter (a tube inserted through a small cut in your lower belly into the bladder to drain urine) every day. An observation on 12/16/25 at 10:47 AM of Resident #9 lying in her bed in her room with her catheter bag (a bag that collects urine and is connected by a tube to the catheter) clipped to the bed. The tube hung below the catheter bag causing urine to backflow (when urine flows backward from the drainage bag into the bladder, increasing infection risk (UTI) by allowing bacteria to travel up). The room smelled throughout of a strong pungent urine odor. On 12/18/25 at 9:31 AM observed Resident #9's catheter tube below the catheter bag causing the urine to backflow. On 12/22/25 at 2:13 PM observed Staff B, Certified Nurse Aide (CNA), apply gloves and perform routine emptying of the catheter bag into a graduate (container used to measure output of urine). Staff B changed their gloves, lifted the blanket up, and removed Resident #9's briefs to access her suprapubic catheter site to start to clean the area. She picked up a wet washcloth from a water basin and applied foam soap to the washcloth, then proceeded to rub the washcloth back and forth on her skin around the suprapubic site 3 to 5 times with the same part of the washcloth. Staff B grabbed the catheter tubing and washed down the tubing and back up with the same location of the washcloth. With the same gloves, Staff B grabbed a new wet washcloth from the water basin and wiped the washed sites. Without changing their gloves or completing hand hygiene, Staff B put back on Resident #9's brief and covered her up with her blanket. In an interview on 12/22/25 at 2:24 PM Staff B confirmed she should have worn a gown when she emptied Resident #9's catheter bag and cleaned around the suprapubic catheter site. In an interview on 12/22/25 at 3:42 PM the Assistant Director of Nursing (ADON) explained the staff should wear EBP protective equipment, gown, and gloves when providing catheter care. In addition, she added the staff should change the site they wash and gloves after cleansing the site prior to using the rinsing the wash cloth. Review of the facility's Catheter Care policy dated 4/3/25 instructed the following: Ensure drainage bag is located below the level of the bladder to discourage backflow of urine. For females, perform hand hygiene, apply gloves, wipe from front to back with a clean cloth moistened with water and perineal cleaner (soap). Use a new part of the cloth or different cloth for each side. With a new moistened cloth, starting at the urinary meatus moving out, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter. Dry area with towel. Bag and gather all supplies used, discarding disposable items in the trash can. Assist resident to a comfortable, appropriate position. Ensure their call light is within reach. Return room back to the original order. Perform hand hygiene.

Based on facility policy and staff interviews, the facility failed to have a qualified Infection Preventionist to monitor and provide oversight to the facility's infection prevention program. The facility reported a census of 25 residents.Findings include: On 12/15/25 at 10:10 AM, the Administrator reported the facility didn't have a qualified Infection Preventionist for the building. The Administrator reported the Assistant Director of Nursing (ADON) started taking the classes but had not completed them. On 12/18/25 at 10:35 the ADON reported she is currently taking the classes to become a qualified Infection Preventionist. The facility policy titled Infection Prevention and Control Program documents the program is coordinated and overseen by an Infection Prevention Specialist.

Based on record review, policy review and staff interviews, the facility failed to provide pneumococcal vaccine as requested for 2 of 5 residents reviewed (Resident #4 and #15). The facility reported a census of 25 residents.Findings include: 1. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated Resident #4 didn't receive a pneumococcal vaccine due to the facility not offering the vaccine. A Pneumococcal Conjugate Informed Consent form dated 9/24/25, signed by the Resident #4, indicated that she received information and gave consent to receive the vaccine. Resident #4's Electronic Health Record (EHR) lacked documentation of receiving the pneumococcal vaccine. On 12/17/25 at 2:58 PM the interim Director of Nursing (DON) reported Resident #4 didn't get the pneumococcal vaccine as consented. The undated facility policy titled Infection Prevention and Control Program documented to try and help prevent the spread of infections to immunize residents. 2. Resident #15's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated Resident #15 didn't receive a pneumococcal vaccine due to the facility not offering the vaccine. A Pneumococcal Immunization Informed Consent form dated 6/6/25, signed by Resident #15's Representative, indicated they received information and gave consent for Resident #15 receive the vaccine. Resident #15's Electronic Health Record (EHR) lacked documentation of receiving the pneumococcal vaccine. On 12/17/25 at 2:58 PM the interim Director of Nursing (DON) reported Resident #15 didn't get the pneumococcal vaccine as consented.

Based on clinical record review, staff and family interview, the facility failed to provide transportation for a resident from a physician's appointment for which resulted in the family member transporting the resident back to the facility for 1 of 4 resident reviewed. (Resident #1) The facility identified a census of 26 residents. Finding include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE]. The MDS identified a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. The resident required partial to moderate assistance for activity of daily living (ADL) and used a wheelchair for mobility. The MDS included diagnoses of hypertension (high blood pressure), aphasia (difficulty talking), cerebrovascular accident (damage to the brain from interruption of its blood supply), hemiplegia (paralysis of one side of the body, resulting from brain damage) and anxiety. Resident #1's admission Orders dated 10/7/24 listed they had a follow up appointment scheduled on 1/2/25 at 9:15 AM with a neurology Physician Assistant (PA). Review of the facility's monthly calendar indicated Resident #1 had an appointment scheduled on 3/5/25 at 10:15 AM. The calendar indicated the facility rescheduled Resident #1's appointment with neurology. Review of the facility's monthly calendar listed Resident #1's appointment rescheduled to 5/23/25 at 3:40 PM. The Progress Note dated 5/23/25 at 2:22 PM, Staff A, Licensed Practical Nurse (LPN), documented Resident #1 left the facility with her paperwork for an appointment with a transport van service and driver. The Progress Note dated 5/23/25 at 8:48 PM, Staff B, LPN, documented Resident #1 had an appointment with neurology. Resident #1 had an order-pending, for a sleep study and a heart monitor, but no medication changes. Interview on 6/10/25 at 10:45 AM, Staff C, Registered Nurse (RN), verified the facility expected the staff to make sure a staff member goes with a resident to all appointments. Interview on 6/10/25 at 12:30 PM, the Interim Administrator, stated the facility didn't have a policy regarding transportation for residents going to a physician's appointment, but they expected staff to go with all residents to appointments. Interview on 6/10/25 at 3:10 PM, Resident #1's Representative, stated they met Resident #1 at the physician's appointment but understood they had a staff member with them. When the appointment finished the family texted the facility's Social Worker to make sure the transportation service returned to pick up Resident #1. When the family member failed to get a response, they took Resident #1 home with them for supper and then brought her back to the facility.

Based on record review, observation, photos taken during observation, resident, and staff interview, the facility failed to ensure all residents who resided on the East end of the building resided in a clean, sanitary, and homelike atmosphere. The facility identified a census of 28 residents. Findings include: According to a Department of Health and Human Services Centers For Medicare and Medicaid Services form 2567 with a survey completion date of 11/18/22, the facility received a deficiency for F584. The deficiency referred to a buildup of a black substance with the appearance of mold on the pipes of the heating elements in resident rooms on the East end of the building. The Maintenance Supervisor at the time indicated the heating and cooling elements in all of the rooms on the East side of the building contained hot water that flowed through the pipes in the winter and each box in the resident's rooms the hot water flowed through the pipes and in the summer the water changed from hot to cold. Related to the setup of the system the water condensed which caused moisture build up so the pipes contained mold. The facility reported they installed the current system in the 1960's. According to an email dated 4/9/25 at 10:04 PM the current Maintenance Supervisor agreed with the above description of the heating and cooling system. An observation on 4/3/25 at 12:30 PM revealed the same buildup of the black substance with the appearance of mold on all of the heating/cooling unit pipes for all 16 rooms on the East side of the building. As well as other specified issues listed below: a. room [ROOM NUMBER], occupied by Resident #2 contained an active toilet leak. The floor appeared to have standing water around the toilet itself, which ran across the bathroom floor. Resident #2, identified by the facility as interviewable, indicated his toilet leaked for a long time. Resident #2 confirmed he used the toilet on a regular basis but it didn't bother him, however, it still needed fixed. During an interview on 4/3/25 at 1:10 PM Resident #5 in room [ROOM NUMBER] A, identified by the facility as interviewable confirmed her toilet leaked off and on. Staff C, Housekeeping, present during the interview confirmed the facility had a long-standing problem of the toilets leaking. Staff C indicated the facility completed various interventions such as toilet ring but the toilets continued to leak on the East (older) end of the building. During an interview on 4/3/25 at 1:58 PM Staff A, Certified Nursing Assistant (CNA), confirmed she observed mold on heating/cooling elements in resident rooms on the East end of the building that had been there since she started work two (2) years ago. During an interview on 4/3/25 at 2:29 PM Staff B, CNA, confirmed she observed the toilets leak in the rooms of Resident #2 (room [ROOM NUMBER]) and Resident #4 (room [ROOM NUMBER]) located across the hall from each other on the East end of the building and the last rooms on the South end).

Based on resident interview, staff interview, Alarm Response Report forms, and facility policy review, the facility failed to answer resident call lights in a timely manner and within the regulated 15-minute time frame for 2 residents reviewed (Residents #6 and #1). The facility identified a census of 28 residents. Findings include: 1. During an interview on 4/3/25 at 3:23 PM Resident #6 confirmed she timed her call light on for over 15 minutes, which pissed her off. Review of the facility's Alarm Response Report form for a one (1) week period of time from 3/27/25 thru 4/2/25 revealed the facility failed to answer her call light within the allotted 15-minute time frame on the following dates: a. 3/27/25 at: i. 11:10 AM for 21:42 minutes ii. 5:44 PM for 18:49 minutes iii. 9:53 PM for 19:50 minutes iv. 9:53 PM for 10:30 minutes v.10:13 PM for 26:02 minutes. b. 3/30/25 at 1:23 AM for 17:03 minutes. 2. During an interview on 4/3/25 at 2:50 PM Resident #1, identified by the facility as interviewable, confirmed she recently timed her call light as on for two (2) hours on an unknown evening shift as she used the clock on her wall. She reported the call lights as especially bad when the facility had agency staff scheduled. Resident #1 explained after supper the staff assisted all of the other residents to bed and then they answered her call light. When asked how she felt she replied, she's used to it by now but questioned what would happen if she had an emergent situation? By the time they arrived it could have been too late. Review of the facilities Alarm Response Report for a 1-week period of time from 3/27/25 thru 4/2/25 revealed the facility failed to answer the resident's call light within the allotted 15-minute time frame on the following dates: a. 4/1/25 at 2:43 PM 18:40 minutes. b. 3/28/25 at i. 1:40 PM - 22:44 minutes ii. 11:07 AM - 18:28 minutes. During an interview on 4/3/25 at 1:58 PM Staff A, Certified Nursing Assistant (CNA), confirmed the staff failed to answer the residents' call lights within 15 minutes due to staffing. Staff A described the situation as worse on the 2 PM until 10 PM shift. She added the agency staff refused to answer the residents' call lights. During an interview on 4/3/25 at 2:29 PM Staff B, CNA, confirmed the staff failed to answer residents' call lights within 15 minutes due to resident behaviors and staffing issues. The facility's Answering the Call Light Policy dated 2001 described the Purpose of the procedure as an assurance of timely call light responses to resident's requests and needs.

Based on observation, clinical record review, staff interview and resident interview, the facility staff failed to maintain appropriate nursing supervision to prevent a cat bite which resulted in a wound infection for one (1) resident reviewed. (Resident #3) The facility identified a census of 31 residents. Findings include: Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief interview for Mental Status (BIMS) score of 6, indicating severely cognitive impairment. The MDS listed Resident #3 as independent with most activities of daily living (ADLs). The MDS included diagnoses of cerebrovascular accident (CVA or stroke), anxiety, depression, disorientation, and mild cognitive impairment. Resident #3's Baseline Care Plan (BCP) dated 1/28/25 and locked at 1:36 PM reflected she had a confused cognition. The Interventions to address her cognition listed to redirect as she continued to say she is going home. The BCP reflected Resident #3 had intact skin with a goal to maintain her intact skin. During an interview on 3/3/25 at 4:25 PM Resident #3's Durable Power of Attorney (DPOA) confirmed the cat bit her as she grabbed it and placed it in the crate to take it to Resident #3 at the nursing facility. The DPOA described the cat as a devil cat. The DPOA indicated at the time she didn't know of the cat's vaccination status so she called the veterinarian and learned the cat didn't have their vaccines up to date. A faxed Physician Order form signed by the Physician on 1/29/25 reflected Resident #3 received six (6) marks (bites) on her left arm from her cat that measured 0.1 centimeters (cm) by (x) 0.1 cm. The Physician ordered the staff to cleaned the areas on the resident's left hand with normal saline, apply by Triple Antibiotic Ointment (TAO) and cover with a bandage two (2) times a day (BID) and as needed (PRN) until healed. A Weekly Skin Assessment form dated 2/3/25 locked at 2:01 PM indicated Resident #3 sustained a scab on her left palm. The Health Status Note dated 1/30/25 at 11:33 AM reflected the Physician wrote an order for Augmentin (antibiotic) 875 milligrams (mg) 1 tablet by mouth (po) two (2) times a day (BID) for seven (7) days due to a cat bite. The Health Status Note dated 1/30/25 at 1:01 PM identified the Physician wrote an order to discontinue the Augmentin and to start Clindamycin (antibiotic) 300 mg three times a day (TID) for 7 days. The Health Status Note dated 1/30/25 at 7:44 PM indicated Resident #3 took antibiotics for a urinary tract infection and a cat bite on her left palm and wrist. The area looked slightly pink, raised, with mild tenderness, and no warmth. During an interview on 2/27/25 at 3:00 PM the Administrator explained they told her the cat had their vaccinations up to date but after the phone call with the Veterinarian, they learned the last time the cat went to the office was back in 2012. During an interview on 2/27/25 at 1:07 PM Staff A, Licensed Practical Nurse (LPN), confirmed the DPOA brought in Resident #3's cat because she exhibited exit seeking behaviors and wanted to see her cat. So, they had the animal brought to the facility as a means of comfort her but she could only have it in her room. Staff A indicated around 4ish, maybe on the 29th a Certified Nurse Aide (CNA) who worked with Resident #3 came out of her room and said the cat growled at her. Staff A went to Resident #3's room and found the cat under the bed. Resident #3 entered the room and sat by her chair far away from the cat who hissed and attempted to claw Staff A. The cat sat/laid way back in the corner under the bed. Staff A asked Resident #3 to leave her room while she called the Office Manager and told her the cat hissed at Resident #3 and she couldn't get the cat removed so the Office Manager went to the room with a CNA and attempted to remove the cat. Resident #3 followed the staff members to her room as Staff A attempted to redirect her without success as she sat in her recliner. The staff moved Resident #3's bed out and had carrier right close. The cat darted out and ran to the side of the recliner as Resident #3 reached down and tried to console the cat as it bit her on the left wrist palm area, along the meaty section. Staff A assessed 5 6 teeth/puncture marks so she cleaned the area with soap and water, applied TAO, and covered the area with a dressing. When questioned if it hurt, Resident #3 said it stung a bit. Staff A described Resident #3 as upset about the cat so the staff member attempted to console her as she told her that current cat bite wasn't the first time. The staff removed the cat from the resident's room in the carrier crate and placed it in the nurse's station until the DPOA picked it up around 9 9:30 that night. Staff A asked the Office Manager about the cat's vaccination status and she told her the DPOA verbally described the cat as vaccinated. Staff A confirmed the facility didn't have written proof of vaccinations, just verbal. An email 3/4/25 at 12:50 PM revealed the Office Manager confirmed she called the DPOA and told her as long as the cat appeared friendly and had their vaccinations up to date, she didn't have a problem with the cat staying with Resident #3. When the staff told her the cat became aggressive, she came to the facility after hours and caught the cat. She called the DPOA and informed her the situation didn't work and she needed to remove the cat from the facility. During an interview on 2/27/25 at 1:50 PM Staff C, CNA, confirmed she peeked at Resident #3's cat positioned under the bed as it hissed at her, so she reported the situation to the Administrator and Office Manager. Staff C didn't know of the cat's vaccination status. During an interview on 2/27/25 at 2:04 PM Staff D, CNA, confirmed she worked the evening/night of 1/28/25 when Resident #3's cat came to the facility around 8 PM. When the cat arrived with a friend in a cage she leaned down to see the cat and it hissed at her. The friend told her it took her all day to catch the cat and the cat bit her. Staff D texted the Administrator and told her the cat would be an issue. Staff D confirmed she didn't know the cat's vaccination status. During an interview on 2/27/25 at 2:26 PM Staff E, CNA, confirmed she worked the evening/night the cat arrived. She explained what happened as the DPOA brought the cat to the facility in a cage. The DPOA literally told staff it took her five (5) hours to get the cat in the crate and it bit her. The cat stayed overnight in Resident #3's room but she never had any contact with the cat. According to an undated and untimed email, the Administrator indicated the facility didn't have a policy or procedure for pets/animals in the building.

Based on clinical record review, staff interview, Physician interview, Emergency Medical Service (EMS) interview, and facility policy review, the facility failed to provide adequate care and services to maintain the highest functional status for 1 of 2 residents with gastronomy tube (GT) (Resident #2). Resident #2 had an order to have his head of bed elevated while receiving his feeding. As the nurse gave Resident #2 his feeding, they had the head of bed lowered. When Resident #2 started to vomit, the nurse stopped the feeding, but failed to elevate Resident #2's head of the bed. When the certified nurse aides attempted to assist the nurse, the nurse told them to have him lay flat. Resident #2 suffered from aspiration pneumonia and septic shock. With not having Resident #2's head of the bed raised during administration of his feeding, the facility placed Resident #2 at an immediate jeopardy due to the likelihood of serious harm and/or death. The facility identified a census of 33. The Department notified the facility of the immediate jeopardy on 7/16/24 at 11:45 AM, that started on 6/28/24. The facility removed the immediacy on 7/16/24 by completing the following information: a. The Director of Nursing (DON) completed observational audits on 7/16/24 related to receiving enteral (feeding via a feeding tube) and elevation of their head of bed during their feeding as required, with no concerns observed. b. The DON educated the licensed nurses between 7/15/24 and 7/16/24. Any nurse who didn't complete the education on 7/16/24 must complete the education prior to the beginning of their next scheduled shift. c. The DON or designed will conduct audits weekly for 12 weeks to ensure the licensed nurses continue to elevate the residents head of bed during enteral feeding as required. The scope lowered from J to D at the time of the survey after ensuring the facility implemented education and their policy and procedure. Findings include: Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Resident #2 rejected cares 1 to 3 days. Resident #2 required total assistance from staff with activities of daily living (ADL's), including repositioning. Resident #2 had functional limitation on both sides of his upper and lower extremities with range of motion (ROM). The MDS listed Resident #2 as non ambulatory. The MDS reflected Resident #2 had a catheter and a G tube (feeding tube). The MDS included diagnoses of pneumonia, pharyngeal phase dysphasia, drug induced secondary to parkinsonism, dysarthria, hypertension (htn or high blood pressure), schizophrenia, dementia, psychotic disorder, and delusions. The Care Plan included the following Focus areas and Interventions as dated: a. 12/27/23: Resident #2 used psychotropic medications related to (r/t) the disease process of Paranoid Schizophrenia. b. 5/16/23: Resident #2 required a tube feeding r/t swallowing problems. i. Revised 5/16/23: Dependent on staff with tube feedings and water flushes. ii. 5/16/23: Monitor, document and report to the Physician as needed (PRN) for the following: Aspiration, shortness of breath (SOB), abnormal breath/lung sounds and nausea and vomiting. iii. Revised 5/16/23: Resident #2 required the head of bed (HOB) elevated 45 degrees during and thirty minutes after a tube feeding. c. 2/1/24: A nutritional problem or potential for a nutritional problem r/t dysphasia and dependence on g tube feeds with met 100% of his needs. d. 2/5/24: An indwelling catheter. e. 3/21/24: Resistive to cares r/t Schizophrenia. f. 5/16/23: ADL self-care deficit. i. 5/16/23: Required two (2) staff assistance with bed mobility. (revised 5/16/23) ii. 5/16/23: Nothing by mouth (NPO). Resident #2's June 2024 Medication Administration Record (MAR) included a Physician's order for enteral feeding three times a day (TID) for 30 minutes before, after, and during meals at 9 AM, 1 PM, and 7 PM. Resident #2's Medication Admin Audit Report for 6/28/24 indicated he received his enteral feeding at 1:09 PM. During an interview on 7/16/24 at 2:19 PM Staff D, Certified Nursing Assistant (CNA), confirmed she repositioned Resident #2 before lunch and left him at a 30-degree angle. Staff D described Resident #2 as very tired that day, they described that as normal for him around that time. Staff D confirmed Resident #2 coughed a lot and sounded like he had stuff in his lungs, so they reported her observations to Staff B, Licensed Practical Nurse (LPN). During an interview on 7/15/24 at 2:27 PM Staff C, CNA, indicated Staff B came to her and reported Resident #2 just threw up and she needed assistance to reposition him. When the staff members entered Resident #2's room, they found him responsive but lethargic. Resident #2 requested they elevate his left arm the staff members repositioned him up further in the bed and elevated his arm on a pillow. Staff C confirmed Resident #2's HOB at approximately 15 degrees and that he threw up. Staff C cleaned up the emesis of tube feeding formula at which time Staff B directed her to lay Resident #2 flat. Staff C questioned Staff B why she wanted him lying flat and she replied, yes because he just threw up. Staff C only left Resident #2 flat for 1 2 minutes just long enough to pull out the chux pad out from under Resident #2. When she left Resident #2's room Staff C indicated she left Resident #2's HOB at a 30-degree angle. During an interview on 7/15/24 at 2:43 PM Staff B stated let me think when asked about the event on 6/28/24. Staff B recalled Resident #2 as congested and that she typically gave him his tube feeding at 1:00 PM. On 6/28/24 she found him more lethargic than normal but they had adjusted his pain medications, so she didn't think anything about it. Staff B checked Resident #2's gastric residual with no return prior to administering his tube feeding while positioned at a 30-degree angle. Staff B indicated she denied remembering any further events and requested time overnight to gather her thoughts. On 7/16/24 at 9:42 AM Staff B confirmed she administered Resident #2's feeding on 6/28/24 with the HOB elevated. When he had an emesis, she stopped the feeding and went to get Staff A, LPN, for a second opinion. Staff B described Staff A as a more experienced and very competent nurse, as she told him she planned to hold Resident #2's medications. Staff B reported that she couldn't recall anything else. During an interview on 7/15/24 at 1:23 PM Staff A indicated on 6/28/24 around 1:50 PM or 1:55 PM, Staff B came to him and said she planned on not administering Resident #2's medications because he threw. Staff A asked Staff B if he was OK, and she indicated he was fine. So, Staff A stated he would go talk to him. At approximately 2:05 PM, Staff A entered Resident #2's room he observed Resident #2 positioned in a supine position with his head on a pillow, tube feeding formula draining from his nose, and Resident #2 non responsive. Staff A immediately raised the HOB close to a 90-degree angle. Staff A assessed Resident #2 and found an O2 (oxygen) saturation rate of 84 88%, so he increased Resident #2's oxygen to 5 liters (L) because he first thought the low oxygen saturation level caused the non responsiveness. Staff A called the Physician from Resident #2's room and received an order within approximately four (4) minutes to have transferred Resident #2 via ambulance to the local hospital. Staff A remained in the room and completed a thorough assessment. Staff B described Resident #2's blood pressure (B/P) as low, an elevated pulse (P), and a low O2 saturation. Staff B failed to complete any assessment or intervention prior to informing Staff A about the medications or Resident #2's actual condition. Staff A described Resident #2's lungs sounds as congested in the upper lobes. Staff A instructed Staff B to stay with Resident #2 while he made all of the required calls and prepared the paperwork. Resident #2 had a code status of full code (wanted life-saving measures) and they shouldn't leave him alone. As Staff A prepared Resident #2 for transfer, he observed Staff B as she entered the nurse's station. Staff A asked her what she was doing, she replied she was thirsty. Staff A directed Staff B to take her drink back down to Resident #2's room immediately. During an interview on 7/15/24 at 1:49 PM the DON indicated she didn't recall the incident on 6/28/24 as Resident #2 had a lot going on and so did the facility. The DON indicated she spoke with Resident #2 prior and he didn't want to lay flat but rather requested the HOB at 45 degrees or less because of his pain. During an interview on 7/15/24 at 4:45 PM the facilities Interim Administrator indicated the DON informed her on 6/28/24 she escorted the EMS crew to Resident #2's room and observed his HOB elevated. After explaining to the Administrator that the DON didn't report that during her interview, the DON joined the interview. She confirmed she escorted the EMS crew to Resident #2's room but never entered the room. She added she identified Resident #2's HOB as elevated because she observed Resident #2's face as she stood in the doorway of his room. The Surveyor explained a person could observe Resident #2's face from the doorway even if he laid supine, the DON shook her head with the gesture (up and down) that indicated she agreed. An eInteract Transfer V3 form dated 6/28/24 at 2:52 PM included the following documentation but failed to address Resident #2's urinary status and catheter: a. Blood pressure (B/P) = 84/48 (low) (average 120/80). b. Pulse = 119 (high) (expected 80-100 beats per minute) c. Respirations (R) = not assessed d. Temperature (T) = 101.3 degrees Fahrenheit (F) (average temperature 98.6) e. Oxygen (O2) saturation = 84% (low) (expected greater than 90%). A County Emergency Medical Services (EMS) Patient Care Report indicated the facility called the EMS crew at 2:55 PM with an arrival time of 3:00 PM. The EMS crew found the patient as he laid in bed basically unresponsive but made noises when moved. The general impression of the patient had been an elderly man with Parkinson's and severe contractures. Staff reported they went to feed Resident #2 and he vomited. Resident #2 had a feeding tube and can't eat. Resident #2 had a temperature (T) of 104 degrees Fahrenheit (F). The crew transferred the patient to the gurney and transported him to the County Regional Hospital at 3:21 PM. During an interview on 7/15/24 at 3:57 PM one of the EMS crew members that responded to the call confirmed when they arrived on the scene, Resident #2 laid in a supine position. The EMS crew members reported finding him in bed like that, wasn't the 1st time the crew found the same resident in the supine position to transport him. The crew member verbalized concern over Resident #1's position. The County Regional Hospital emergency room (ER) Progress Notes dated 6/28/24 at 3:25 PM reflected Resident #2 presented nonresponsive with a fever. Resident #2 had a history of Methicillin resistant Staph coccus Aureus (MRSA) (infection resistant to some medications) sepsis (full-body blood infection) in February 2024 from aspiration presented unresponsive from the nursing facility with a T of 104 degrees F. According to Staff A, Licensed Practical Nurse (LPN), a nursing home nurse, the last time staff saw him well was around 10 AM. They brought in his G tube feeding that afternoon just prior to arrival, he vomited and became unresponsive. The patient moaned to verbal and painful stimuli. A Radiology Results dated 6/28/24 at 3:51 PM reflected Resident #2 had nonspecific opacities (hazy gray areas in the lungs caused by a decreased ratio of gas to soft tissue in the lungs) present in the right hemithorax (right side of the chest) most prominent in the medial (middle) lung base concerning for aspiration or pneumonia. The impression identified the new opacities in the right lung, most confluent in the lung base, concerning for aspiration or pneumonia. A County EMS Patient Care Report indicated the County Regional Hospital dispatched the crew at 5:18 PM, and they arrived on the scene at 5:30 PM. At 5:41 PM the crew transferred Resident #2 to a higher level of care hospital and arrived 6:19 PM. The Hospital's History of Present Illness report dated 6/28/24 indicated Resident #2 presented from the emergency department (ED) of an outlying facility for septic shock. The nursing facility found him unresponsive, covered with vomit, and running high fever of 104. This prompted an immediate transfer to the local ED. The last time they reported him as well at 10 AM on 6/28/24. He moaned to verbal and painful stimuli. His blood pressure on arrival at the outlying facility ED was 60s systolic (average systolic blood pressure 120), they gave 2 liters (L) of normal saline fluid bolus, but due to his persistent hypotension (low blood pressure), they started peripheral Levophed (medication used to increase blood pressure). His chest x-ray showed multiple patches likely concerning for aspiration pneumonia (infection caused by breathing particulates into the lungs. The nursing home reported Resident #2 had a blocked indwelling catheter, his bladder scan showed greater than 920 milliliters (ml), the ED flushed the catheter. Chocolate milk-like fluid returned after the flush. The ED gave him one dose of vancomycin (antibiotic), Zosyn (antibiotic), DuoNeb (nebulizer treatment to open the lungs), started on 6 L of high flow nasal cannula, and transferred him to a larger hospital for further management. Upon arrival to the critical care unit (CCU), Resident #2 noted unresponsive with a Glasgow coma score (GCS) of 4 (indicative of severe traumatic brain injury), fever of 102, blood pressure of 68/34 systolic (average 120/80) on 30 of Levophed and started vasopressin (medication used to increase blood pressure) and emergently intubated him. The team had difficultly intubating Resident #2 due to an enlarged tongue, when the team tried to intubate, his oxygen saturation dropped to 38% (expected greater than 90%). The team removed the laryngoscope (equipment used to visualize the throat while intubating a person) and bagged him with an Ambu bag (medical equipment used to breathe for a person), his oxygen saturation improved to 90%. During that time, Resident #2 had bilious vomitus (green or yellow vomit) coming out of his mouth. The team attempted to intubate with a D blade (curved intubation equipment), successfully. The team completed a bronchoscopy to suction out the vomitus from the lungs. The team started a central access and then started on broad-spectrum antibiotics. An Operative/Procedure Report form dated 6/28/24 at 5:27 PM indicated a Physician at the Hospital performed an Endotracheal Intubation for airway protection and respiratory failure. During an interview on 7/15/24 at 3:29 PM Resident #2's Physician confirmed he expected the staff elevate Resident #2's head of his bed as far as possible but agreed to 45 degrees for Resident #2's comfort. The Physician confirmed if Resident #2 laid flat that would have caused Aspiration. During an interview on 7/16/24 at 10:45 AM Resident #2's family member described Resident #2's current condition as gravely ill but still in the hospital. The staff at the hospital questioned brain damage due to oxygen deprivation. The family member also confirmed he observed Resident #2 positioned in a supine position during his tube feeding on two (2) separate occasions. He redirected the staff but he described them as incompetent and failed to listen. The Enteral Feeding policy and procedure revised May 2016 included the Purpose as administration of intermittent or continuous feeding by means of a tube when the oral route or oral intake had been insufficient. The form directed the staff to assist a resident/patient to a 30 45-degree semi-Fowler's position and notify the Physician of any changes or concerns

Based on staff interviews, record review, facility policy and procedure review, the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers from developing and from deteriorating on a resident with a history of pressure ulcers for one of two residents reviewed (Resident #2). The facility failed to identify the root cause and implement appropriate interventions. This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began April 13, 2023 on June 7, 2023 at 4:30 p.m. Facility staff removed the Immediate Jeopardy on June 8th, 2023 through the following actions: a. Head to toe assessments will be completed on 6/8/23 by the Regional Directors of Clinical Services (RDCS) or designee to ensure pressure injuries have been identified and treatment plans implemented. An audit was completed by the Regional Director of Clinical Services or designee to ensure preventive measures have been implemented for residents with pressure injuries or history/risk of pressure injuries. b. The RDCS or designee will complete education with licensed beginning 6/7/23-6/8/23 related to the requirements of implementation interventions to reduce the risk for pressure injuries for any residents with current pressure injuries or history/risk of pressure injuries. c. An audit will be completed by the Director of Nursing or designee weekly for 12 weeks to ensure licensed nurses continue to implement preventive measures for residents with pressure injuries or history/risk of pressure injuries. The results of these of these audits will be presented to the QAQI committee monthly for 3 months for review and recommendations as needed. The Director of Nursing is responsible for monitoring and follow-up as needed. The scope lowered from J to D at the time of the survey after ensuring the facility implemented education and their policy and procedure. The facility reported a census of 38 residents. Findings include: 1. An Admission Minimum Data Set (MDS) completed for Resident #2 with an Assessment Reference Date (ARD) of 3/12/23, documented diagnoses which included hypertension, neurogenic bladder, paraplegia, schizophrenia, and stage 2 pressure ulcers of sacral area. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no impaired cognitive decisions and no impairments for hearing or the ability to be understood and understand others. The resident required extensive assistance of one staff for dressing, toilet use, and personal hygiene and independent with bed mobility, transfers, and locomotion on and off the unit. The MDS also documented functional limitation in range of motion to lower extremities on both sides and a wheelchair as primary mode of transportation. The MDS also documented the resident admitted with 3 stage 2 pressure ulcers (partial thickness of dermis presenting as a shallow open ulcer with a red or pink wound bed without slough) and pressure reducing device for chair & bed and pressure ulcer/injury care. The Braden scale for predicting pressure sores, dated 2/27/23 at 2:17 p.m., documented a score of 16, which indicated low risk for developing pressure ulcers. The Care Plan with a focus area initiated 2/27/23, indicated the resident had (3) pressure ulcer or potential for pressure ulcer development related to history of ulcers, immobility. Interventions include: *Administer treatments as ordered and monitor for effectiveness *(3/4/23) Stage 2 pressure ulcer times 3: coccyx every Monday, Wednesday, Saturday: cleanse with wound cleanser, place Aquacel Ag on wound base cover with sacral border, and as needed. *(3/4/23) Assess/record/monitor wound healing weekly, measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing process. Report improvements and declines to the Medical Doctor. *(4/20/23) Cushion in wheelchair *(3/4/23) Follow facility policies/protocols for the prevention/treatment of skin breakdown. A Medical/Nursing Communications form dated 4/1/23 at 9:46 p.m., documented, after bathing during a transfer from chair to bed resident obtained a 0.3 cm by 0.3 abrasion to right ischeum. No bleeding or pain. Bumped on wheelchair pedal per resident reports. After cleansing, border dressing placed for protection. Will change on bath days and as needed until healed then will discontinue. The Non-Pressure Weekly Skin Record dated 4/2/23 at 10:47 a.m., documented, first observed on 4/1/23 a small bruise on right buttock. Measurements: 0.3 centimeters (cm) by 0.3 cm. A Physician Order dated 4/13/23, instructed staff to apply Mepilex to right hip reassure wound every day until healed. Monitor for signs of infection. Off load with position changes every 2 hours. A Nursing Home Progress Note dated 4/13/23 with no time, documented, nursing staff noticed a sore on his right hip. He has had a coccyxgeal sore that had been healing. He started to notice this area on his right hip and they did place a Mepilex on it last night. It has not had a lot of drainage. Denies any fevers or chills. *SKIN= Stage 2 pressure ulcer noted on the right hip. Measuring tool not available at time of evaluation but appears to be about 2 cm in diameter. No surrounding erythema or drainage. Mepilex placed back over the area. *PLAN= continue stage II pressure ulcer treatment with wound cleanser and Aquacel Ag in the wound base and then a sacral border every Monday, Wednesday, and Saturday until healed. Plan to do same cares to the Stage II pressure ulcer on the right hip. The Non-Pressure Weekly Skin Record dated 4/15/23 at 8:04 p.m., documented first observed on 4/15/23, a bruise to the right buttock, with the wound surface has a strong odor, measurements of 0.3 cm by 0.4 cm with no exudate, yes to odor, and progress as declining. A Physicians Order dated 4/16/23 with no time, instructed staff to cleanse the wound with cleanser, and Aquacel Ag to wound base of right hip pressure ulcer along with Mepilex every Monday, Wednesday and Saturday until healed. A Wound Clinic Progress Note dated 4/20/23 at 10:53 a.m., documented, diagnosis= pressure ulcer of right hip. Patient paraplegic currently in a loaner wheelchair with a gel cushion. He is getting custom wheelchair cushion when he discharges home which is possibly next week. He self transfers and is up in a wheelchair most of the day. Location= right hip Stage=unstageable Size=3.2 cm by 4.0 cm by 0.2 cm Drainage color= serosangionous Drainage amount=large Drainage odor=moderate Wound base= 90% slough. 10% pink Wound Care= Recommend new evaluation for wheelchair cushion. Instructed patient to lay down between meals and limit time spent in wheelchair. Reposition off wound while in bed every 2 hours. A Non-Pressure Weekly Skin Record dated 4/22/23 at 3:33 p.m., documented first observed on 4/3/23, a right buttock pressure ulcer, with wound measurements as 4.0 cm by 4.0 cm by 3.0 cm. Exudate=yes Type of Exudate= serosanguinous; thin, watery, pale, red/pink drainage Amount of Exudate= moderate Odor=yes Tissue Type/Wound Bed= slough A Pressure Injury Weekly assessment dated [DATE] at 3:42 p.m., documented pressure ulcer to right buttock which measures 3.0 cm by 4.0 cm by 2.5 cm as a Stage I. Exudate= serosanguinous, large amount Odor= present Wound bed appearance= slough A Pressure Injury Weekly assessment dated [DATE] at 12:43 p.m., documented pressure ulcer to right buttock which measures 4.0 by 4.0 by 3.0-4.0 as a Stage III Exudate= serosanguinous, large amount of purulent drainage Odor=present Wound bed appearance= slough, necrotic tissue A Pressure Injury Weekly assessment dated [DATE] at 8:45 p.m., documented pressure ulcer to right buttock which measures 5.0 cm by 3.0 cm by 3.0 cm, Stage IV. Exudate= purulent drainage, heavy amounts Odor=strong Wound bed appearance=necrotic Comments=current treatment is not effective, resident states he goes to see the wound doctor on Monday. A Wound Clinic Progress note dated 5/15/23 at 9:00 a.m., documented, patient is a paraplegic after falling off a ladder in October 2022, he has the wound for a month. Wound location= right buttock Wound Measurements= 3.5 cm by 4.5 cm by 4.9 cm Exudate=large Exudate type=purulent Wound odor=yes Slough=100% Assessment/Plan=Pressure injury of right buttock. Stage 4. Patient presents today for initially treatment evaluation in this clinic of the pressure injury on the lateral right buttock near the trochanter. The wound is 100% necrotic with a foul odor. Patient does not recall noting an odor of bleach with the dressing changes. Patient has the appropriate wheelchair waiting for him when he is discharged for m the nursing home. Apparently there is some rule that prevents the use of that chair in the facility. Explained to patient this is going to take along time to heal. Offloading= He will need a better wheelchair cushion, instructed to remain off of the right side while in bed as much as possible. Plan= This is a medical device related pressure injury from an old fitting wheelchair. A Wound Clinic Progress note dated 5/17/23, documented, chief complaint=pressure ulcer right hip, patient still in wheelchair from last week with no adjustments. Continue current treatment. Area worsened. Needs wheelchair adjustment or new wheelchair! A Pressure Injury Weekly assessment dated [DATE] at 1:48 p.m., documented a pressure injury on the right buttock which measures 10.0 cm by 7.0 cm by 5.0 cm an unstageable. Exudate=purulent and copious amounts Odor=very strong Wound bed appearance=completely covered with slough and eschar Comments= current treatment does not seem effective and wound progressively getting worse A Wound Clinic Progress note dated 5/23/23 at 10:00 a.m., documented, this patient presents for wound assessment. Wound location=right buttock Wound measurements=4.4 cm by 5.4 cm by 4.5 cm Exudate=large Exudate type=purulent Wound odor=yes Slough=100% Assessment/Plan= Patient presents for follow up of right buttock wound. He has not discharge from the rehabilitation facility yet. Tissue in the wound bed still consists of majority necrotic/slough. Discussed offloading/pressure relief, patient states he will try to remind himself to reposition more often. Discussed emergency room precautions. The Progress notes dated 3/23/23 at 11:49 a.m., documented, coccyx resolved. discontinue treatment. Education provided on support surfaces, may need different wheelchair cushion, if area reoccurs such as a Roho cushion. He will need pressure relieving mattress if he doesn't already have one. He is able to move himself in bed and turns from side to side at night. He already knows to reposition chair, lifts while in wheelchair. The Progress notes dated 4/1/23 at 9:41 p.m., documented, after bathing during a transfer from chair to bed he obtained a 0.3 cm by 0.3 cm abrasion to right ischeum. No bleeding or pain. Bumped on wheelchair pedal. he reports. After cleansing, bordered dressing placed for protection. Will change on bath days and as needed until healed then discontinue. The Progress notes dated 4/13/23 at 00:19 a.m., documented, Doctor notified of 2.6 cm by 0.7 cm open area to right ischeum with odor and drainage. I understand you will see him on rounds today. Do you desire wound nurse to see him? The Progress notes dated 4/13/23 at 9:04 a.m., documented, received physician orders paper after doctor complete rounds. Mepilex to right hip pressure wound every day until healed. monitor for signs of infection. Off load with position changes every 2 hours. The Progress notes dated 4/17/23 at 8:31 a.m., documented, received facsimile from doctor related to new physicians orders wound cleanser and Aquacel Ag to wound base of right hip pressure ulcer along with Mepilex every Monday, Wednesday and Saturday until healed. The Progress notes dated 4/20/23 at 1:02 p.m., documented, resident saw wound nurse today. Wound nurse assessed right hip at this time and cleansed with wound cleanser and Aquacel Ag to wound base and covered with border foam. Wound nurse recommended we get new wheelchair cushion which we have gotten. Wound nurse instructed patient to lay down between meals and decrease time spent in wheelchair. Repositioning often. The Progress notes dated 4/22/2023 at 1:38 p.m., documented, Return fax, new orders received from Doctor. Cleanse with wound cleaner, apply Aquacel AG and cover with Mepilex on Monday, Wednesday, Friday. The Progress Notes dated 4/26/2023 at 3:52 p.m., Wound Care Nurse: Weekly Assessment Note Text: wound nurse here to see resident. orders to cleanse area with Normal Saline. apply 1/4 strength Dakins solution moistened gauze into wound base, cover with abdomen pad and secure with tape. change 2 times a day and as needed. continue offloading area when in bed and laying down in between meals. will see again in 2 weeks The Progress notes dated 4/28/2023 at 3:18 p.m.,documented, Resident stated he is getting new custom wheel chair through insurance once he makes the move. Insurance will not cover custom chair until he moves out the facility The Progress notes dated 5/5/2023 at 4:59 a.m., documented,dressing change to left hip wound. Drainage purulent, strong order, necrotic wound bed,0.5 cm deep tunneling area normal surrounding wound color. Expressed concern to resident, wound nursing following. Will update DON in AM. Extensive time teaching the importance of off loading hip and mobilization. Verbalized understanding and was very receptive to teaching. The Progress notes dated 5/9/2023 at 00:18 a.m., documented, Continues with bactrim for treatment of skin concern right trochanter. No adverse reaction to antibiotic. Temperature 98.4. Good amount of fluid drank. Dressing is clean, dry, intact. The Progress notes dated 5/10/2023 10:30 p.m., documented, Continues with antibiotic to promote wound healing to right hip without adverse reaction. Wound nurse saw resident today; continue same treatment. M.D. updated. The Progress notes dated 5/11/2023 9:05 a.m., documented: seen by wound clinic on 5/10/23, progress note sent to doctor to review. The Progress notes dated 5/13/2023 1:14 a.m., documented: Continues with antibiotic for right hip wound without adverse reaction. Decreased drainage of wound noted. Temperature 97.4. The Progress notes dated 5/13/2023 3:02 p.m., documented: Resident continue with antibiotic therapy for right hip wound. Resident with no adverse effects to medication at this time. Resident without s/s of increased infection and remains afebrile. The Progress notes dated 5/15/2023 2:37 a.m., documented: Resident remains on antibiotic treatment to promote wound healing. Will be ending May 19, 2023. No adverse effects noted from therapy thus far. Resident remains afebrile, free of pain, and off loading of right hip. Able to verbalize needs, no concerns at this time. The Progress notes dated 5/15/2023 at 12:24 p.m., documented: resident returned from his wound care appointment with new orders: cleanse with Dakins and rinse with normal saline. then use Dakins soaked gauze roll for packing in the wound. secondary dressing is secured with tape. twice per day. it is important that half strength Dakins solution is used in this dressing change The Progress notes dated 5/17/2023 3:00 p.m., documented: Wound nurse here today for pressure ulcer to right hip. Resident with measurements of 4.7 x 5.0 x 5.0 cm with Serosanguinous drainage of moderate large amount. Foul odor,undermining noted at 3 and 7 at 2.5. 10% of wound bed is pink with 90% black and slough tissue. peri wound intact and edge is well defined The Progress notes dated 5/17/2023 at 3:07 p.m., documented: Orders to continue current treatment. Area worsened. Needs new wheel/ac or for his to be adjusted. Will be seen in 1 week if still facility. Has wound appointment set up with discharge. The Progress notes dated 5/23/2023 3:39 p.m., documented: Resident returned from wound appointment. Consultation form states to continue same wound care. Ensure packing is 1 whole piece and not multiple/separate pieces. Zinc oxide cream or skin barrier to surrounding skin to prevent breakdown. Periods of repositioning while in bed and in wheel/chair. Remind resident to reposition himself in the wheel/chair to relieve pressure. Interview on 5/24/23 at 3:05 p.m., the maintenance supervisor confirmed and verified that Resident #2 came into the facility with that wheelchair and that the black hard plastic piece is in the right place for an open area on the resident right hip and that the facility failed to intervene with an intervention to prevent a pressure ulcer from occurring. Interview on 5/24/23 at 9:05 a.m., Physical Therapy Assistant, confirmed and verified that Resident #2 came into the facility with that wheelchair and that the facility failed to do an evaluation on the recommendation from the Wound Clinic for a new pressure cushion and it is expected that staff follow through with that recommendation. In reviewing the wheelchair it is possible that the black hard plastic positioning device could be the culprit of the pressure ulcer and that it is expected that the staff notify the therapy department of any new orders or evaluation for positioning. Interview on 5/24/23 at 2:05 p.m., Staff A, Certified Nursing Assistant (CNA), stated that Resident #2 would position themselves on the right side of the buttocks and would need to be reminded to position in the center of the wheelchair seat and keep the right hip off the hard black plastic piece on the right side of the wheelchair. Resident #2 would use a slide board and transfer from the bed to the wheelchair independently. Interview on 5/24/23 at 1:05 p.m., Staff B, Certified Medication Aide (CMA), stated that Resident #2 was independent with self transfer by the use of a slide board and would need reminded to center the buttock in the center of the wheelchair due to Resident #2 would position the right hip on the hard black plastic piece on the right side of the wheelchair. Interview on 5/24/23 at 1:30 p.m., Staff C, Licensed Practical Nurse (LPN), stated that Resident #2 would transfer from the bed to the wheelchair independently with the use of a slide board and would need reminded to position the buttock in the center of the wheelchair cushion to take the pressure off the right hip that would be positioned on the hard black plastic piece on the right side of the seat of the wheelchair. Interview on 5/25/23 at 12:05 p.m., Staff E, (Physician) confirmed and verified that the pressure ulcer on the right hip was a mechanical device pressure ulcer and that the pressure ulcer was avoidable if the facility would have followed the recommendation to look at the device in the wheelchair that was causing the pressure ulcer. Interview on 5/30/23 at 5:05 p.m., Staff D, Registered Nurse (RN), stated that Resident #2 would transfer from the bed to the wheelchair independently with the use of a slide board and would not position in the center of the wheelchair cushion and would need to be reminded to keep off the right hip. It is the expectation of the facility staff to intervene and attempt different interventions to keep a pressure injury from developing. Interview on 5/31/23 at 2:20 p.m., the facility corporate quality assurance nurse confirmed and verified that it is the expectation of the facility staff to intervene with alternative interventions to keep a pressure injury from developing and implementing measures or interventions from deteriorating. The Skin Care and Wound Management Treatment Protocol for Stage II Pressure Ulcer dated 9/11 documented: A Stage II pressure ulcer is defined as a partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Procedure: *Obtain a physician order for treatment. Verify resident/patient has an order for pain medication. *Implement treatment protocol as ordered. *Document wound measurements and characteristics on the Skin Grid-Pressure no less than weekly. More frequent documentation may be indicated based on change in condition of wound. *Review effectiveness of treatment plan every 2 weeks and revise as needed. The Skin Care and Wound Management Treatment Protocol for Stage III and IV Pressure Ulcer dated 6/15 documented: *A Stage III pressure ulcer is defined as a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. *A Stage IV pressure ulcer is defined as a full thickness loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Procedure: *Read and select the treatment protocol. Consider the type of wound, drainage, and depth when selecting the treatment options. *Obtain a physician order for treatment. *Implement treatment protocol as ordered. *Verify prevention interventions are in place. *Review effectiveness of treatment plan every 2 weeks and revise as needed.

Based on observation, clinical record review, staff and resident interview and facility policy review the facility failed to provide the necessary assessments for 1 of 7 residents reviewed with a condition change, (Resident #2). A determination was made the facility's non-compliance placed residents in the facility in immediate jeopardy, beginning on 9/17/22. The facility identified a census of 33 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 8/31/22 documented Resident#2 with diagnosis that included psychoactive substance abuse, bipolar, depression, deep vein thrombosis (DVT), hypertension (HTN) and a hip fracture. The assessment documented the resident with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (cognitively intact), with verbal behavioral syptoms directed towards others and rejection of cares 1-3 days a week in the look back period, non-ambulatory and required extensive assistance of two staff with bed mobility, transfers, dressing, toilet use and hygiene. The resident's Care Plan failed to address his illegal drug use. The residents Progress Notes entries included the following: a. On 9/13/22 at 3:22 p.m. - Received a fax from the resident's Physician for an order for a urinalysis (UA) with culture and a drug panel. The staff obtained the UA and sent it to the lab. 1. A Lab Report form dated 9/13/22 at 3:38 p.m. documented the resident as positive for methamphetamine. b. On 9/17/22 at 1:27 p.m. - The resident screamed at staff over a TV that he claimed was his that had been a facility TV but the resident changed rooms. The resident stated Get me my f'ing (explicit) tv right now or I am going to start breaking shit! The resident had a tv in his room already. The resident then went in to another resident's room and ripped off his oxygen. The staff told this resident to stay out of other resident's rooms, Resident #2 stated I don't give a f*$# (explicit), I am going to start tearing shit apart!' c. On 9/22/22 at 2:48 a.m. - A nurse documented the resident had been very difficult and the police came to the facility several times the past week but they could not do anything as the resident refused for the police or staff to go through his belongings. Earlier that evening the evening nurse walked into the resident's room while he smoked methamphetamine from a methamphetamine pipe. The police returned that evening and searched the room and found 3 methamphetamine pipes and white residue in a bag and in a bag on his knee scooter that tested positive for methamphetamine. d. On 10/12/2022 at 10:07 p.m. - A nurse documented I said I don't know but we did find Methamphetamine in your room with pipes it does bother me. e. On 10/28/2022 at 1:48 p.m. (the actual time of occurance 10 a.m.) - The staff approached this nurse to state it smelled bad in the resident's room which gave them a headache. This nurse went to the resident's room and could smell methaphetamine before entrance into the room. It smelled very strong. The resident had been advised to keep the door shut but he refused. When staff shut the door the resident opened the door back up. The residents record lacked documentation of staff assessment and/or intervention according to the given circumstance. f. On 10/28/2022 at 1:30 p.m. (the actual time of occurance 10:30 a.m. - 11 a.m.) - The resident in the morning had been found as he cleaned his room with a broom and then cleaned the toilet and sink with the dirty broom, he was also taking his clothes washing them in the sink and then putting them in the toilet and then back into the sink, when the staff went in to ask him if he needed help he told them to leave his room and that he would be fine without their help. The residents record lacked documentation of staff assessment and/or intervention according to the given circumstance. g. On 10/28/2022 at 12:55 p.m. - The Business Office Manager (BOM) and Social Services Designee (SSD) went into the resident's room to talk about discharge plans. The staff found the resident resting in his chair and hard to arouse with a lot of drool coming from his mouth. The resident would not open his eyes while they visited with him. The staff asked if he would like them to set up a treatment facility for discharge, he said I don't know. The staff attempted many times to ask what his plans had been for discharge and asked if he would accept help from Home Health and he had been unsure. The BOM and SSD left the room and let him know they would return. The residents record lacked documentation of staff assessment and/or intervention according to the given circumstance. h. On 10/28/2022 at 1:27 p.m. - Resident was in his room, positioned in his wheel chair, with his arms crossed and his head down, drooling and very hard to arouse. The resident answered the nurse but he had been alert that morning as he conversed with staff and cleaned his room and toilet with a broom. i. On 10/28/2022 at 1:28 p.m. - The staff placed a call the resident's physician related to his lethargy. j. On 10/28/2022 at 1:32 p.m. - Resident #2's vital signs were, Temperature - 97.8 degrees Fahrenheit (F), pulse 77, respirations16, oxygen saturation rate at 99% and his blood pressure registered 130/90. k. On 10/28/2022 at 1:35 p.m. - Staff assisted the resident to bed with 2 assistance. The resident assisted but continued with slurred speech. During an interview on 10/21/22 at 2:30 p.m. the resident confirmed staff caught him in his rom as he smoked methamphetamine not to long ago. According to an email dated 11/9/22 at 10:42 a.m. the Interium Director of Nursing documented the expectation when nurses performed skin assessments to have completed a head to toe assessments, with the proper form and measurements documented for each area identified. A Clinical Change in Condition Management form dated 6/2015 included the following procedural directives: a. Assessment of the resident's clinical status with a condition change to have included but not limited to: 1. Vital signs, lung sounds, pulse oximeter, mental/neurological satus, bowel sounds, skin color/turgor and temperature and pain. 2. Contact the Physician and family. On 10/28/22 at 2:15 PM the facility was notified of the immediate jeopardy at F684 and was given the IJ Template. The facility provided staff education on substance abuse disorder and education given to staff members to report to nurse if they observe any signs and symptoms. The nurse is to complete an assessment and notify doctor, family, and DON/Administrator if signs and symptoms exist. After the surveyor verified implementation of the removal plan the immediate jeopardy was removed on 10/29/22 and the scope and severity was lowered to a D.

Based on observation, clinical record review, staff interview and facility policy review the facility failed to provide sufficient staff with appropriate competencies and skills to provide nursing and related services to assure resident safety for one resident with psychosocial disorders, (Resident #2). A determination was made the facility's non-compliance placed residents in the facility in immediate jeopardy, beginning on 9/17/22. The facility identified a census of 33 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 8/31/22 documented Resident#2 with diagnosis that included psychoactive substance abuse, bipolar, depression, deep vein thrombosis (DVT), hypertension (HTN) and a hip fracture. The assessment documented the resident with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (cognitively intact), non-ambulatory and required extensive assistance of two (2) staff with bed mobility, transfers, dressing, toilet use and hygiene. The resident's Care Plan failed to address his illegal drug use. The residents Progress Notes entries included the following: a. On 9/13/22 at 3:22 p.m. - Received a fax from the resident's Physician for an order for a urinalysis (UA) with culture and a drug panel. The staff obtained the UA and sent it to the lab. 1. A Lab Report form dated 9/13/22 at 3:38 p.m. documented the resident as positive for methamphetamine. b. On 9/17/22 at 1:27 p.m. - The resident screamed at staff over a TV that he claimed was his that had been a facility TV but the resident changed rooms. The resident stated Get me my f'ing (explicit) tv right now or I am going to start breaking shit! The resident had a tv in his room already. The resident then went in to another resident's room and ripped off his oxygen. The staff told this resident to stay out of other resident's rooms, Resident #2 stated I don't give a f*$# (explicit), I am going to start tearing shit apart!' c. On 9/22/22 at 2:48 a.m. - A nurse documented the resident had been very difficult and the police came to the facility several times the past week but they could not do anything as the resident refused for the police or staff to go through his belongings. Earlier that evening the evening nurse walked into the resident's room while he smoked methamphetamine from a methamphetamine pipe. The police returned that evening and searched the room and found 3 methamphetamine pipes and white residue in a bag and in a bag on his knee scooter that tested positive for methamphetamine. d. On 10/12/2022 at 10:07 p.m. - A nurse documented I said I don't know but we did find Methamphetamine in your room with pipes it does bother me. e. On 10/28/2022 at 1:48 p.m. (the actual time of occurrence 10 a.m.) - The staff approached this nurse to state it smelled bad in the resident's room which gave them a headache. This nurse went to the resident's room and could smell methaphetamine before entrance into the room. It smelled very strong. The resident had been advised to keep the door shut and but he refused. When staff shut the door the resident opened the door back up. f. On 10/28/2022 at 1:30 p.m. (the actual time of occurrence 10:30 a.m. - 11 a.m.) - The resident in the morning had been found to be cleaning his room with a broom and then found to be cleaning the toilet and sink with the dirty broom, he was also taking his clothes washing them in the sink and then putting them in the toilet and then back into the sink, when the staff went in to ask him if he needed help he told them to leave his room and that he would be fine without their help. g. On 10/28/2022 at 12:55 p.m. - The Business Office Manager (BOM) and Social Services Designee (SSD) went into the resident's room to talk about discharge plans. The staff found the resident resting in his chair and hard to arouse with a lot of drool coming from his mouth. The resident would not open his eyes while they visited with him. The staff asked if he would like them to set up a treatment facility for discharge, he said I don't know. The staff attempted many times to ask what his plans had been for discharge and asked if he would accept help from Home Health and he had been unsure. The BOM and SSD left the room and let him know they would return. h. On 10/28/2022 at 1:27 p.m. - Resident is in his room, positioned in his wheel chair, with his arms crossed and his head down, drooling and very hard to arouse. The resident answered the nurse but he had been alert that morning as he conversed with staff and cleaned his room and toilet with a broom. i. On 10/28/2022 at 1:28 p.m. - The staff placed a call the resident's physician related to his lethargy. j. On 10/28/2022 at 1:32 p.m. - Resident #2's vital signs were temperature - 97.8 degrees Fahrenheit (F), pulse 77, respirations 16, oxygen saturation rate at 99% and his blood pressure registered 130/90. k. On 10/28/2022 at 1:35 p.m. - Staff assisted the resident to bed with 2 assistance. The resident assisted but continued with slurred speech. During an interview on 10/21/22 at 2:30 p.m. the resident confirmed he was caught in the room smoking methamphetamine in his room at the facility not to long ago. During an interview on 11/16/22 at 10:50 a.m., Staff J, nursing assistant (NA) confirmed the facility failed to educate her on how to manage residents with an active drug addiction prior to the most recent education provided. During an interview 11/16/22 at 10:52 a.m., Staff B, CNA/CMA confirmed the facility failed to educate her on how to manage residents with an active drug addiction prior to the most recent education provided. On 10/28/22 at 2:15 PM the facility was notified of the immediate jeopardy at F741 and was given the IJ Template. The facility provided staff education on substance abuse disorder and education given to staff members to report to nurse if they observe any signs and symptoms. The nurse is to complete an assessment and notify doctor, family, and DON/Administrator if signs and symptoms exist. After the surveyor verified implementation of the removal plan the immediate jeopardy was removed on 10/29/22 and the scope and severity was lowered to a D.

Based on observation, record review and staff interviews, the facility failed to monitor for the identification, assessment and prompt treatment to a coccyx pressure ulcer and further assess non pressure wounds for one of two residents reviewed with skin breakdown (Resident #1). The facility reported a census of 49 residents. Findings include: 1. Resident #1 had an MDS (Minimum Data Set) assessment with a reference date of 7/3/2012 which identified [DIAGNOSES REDACTED]. The MDS also documented the resident required extensive assistance of two for bed mobility and transfer. The MDS documented the resident had been at risk of developing pressure sores but had none, and had moisture associated skin damage which required the application of nonsurgical dressings and ointments/medications. The Interdisciplinary Care Plan dated 6/19/12, included a section for skin, which indicated the resident had moisture related skin breakdown, with the following interventions: a. Provide treatments as ordered. b. Keep skin folds as dry as possible. c. Air mattress to bed and pressure relieving cushion to wheel chair. The plan of care included no indication the resident had a pressure sore or open area on the coccyx, with interventions for it such as repositioning, treatment or assessment. Clinical record review revealed no documentation of any open area to the resident ' s coccyx, and no physician notification or order for a treatment to the area. A form (no title) for the month of July 2012, indicated the resident had numerous open areas which included the following non-pressure sores: a. Left posterior upper thigh, 2.5 by 1.4 x 0.1 (no unit of measurement indicated, i.e. centimeters) b. Gluteal fold: 4.1 by 0.7 by 0.2. c. Right abdominal fold: 1.5 by 0.7 by 0.1, 0.4 by 0.1 by 0.1, 0.6 by 0.2 by 0.1, and 0.7 by 0.3 by 0.1 d. Frontal abdominal fold: 17.2 by 0.3 by 0.1 e. Left abdominal fold: 5.5 by 2.0 by 0.1. The form had been initialed on 7/19/12, with no further assessments or measurements documented after that date. The form included no assessment or measurement of any open area to the coccyx (pressure ulcer). During observation on 7/31/12 at 1:39 p.m., the resident laid in bed on an air mattress with a sheet and cloth soaker pad resting on the mattress. The resident also wore an incontinent brief. On 8/1/12, observation revealed the resident in bed on his/her back from 5:35 a.m., until 9:35 a.m., at which time the resident had been transferred from the bed to a wheel chair. The resident had been in bed on an air mattress with an incontinent brief on, and a sheet and cloth soaker pad over the air mattress (multiple layers make a pressure relief less effective). During observation on 8/1/12 at 1:20 p.m., the resident sat in his/her room in a wheel chair and stated he/she wanted to lie down. Staff I (Certified Nurse Aide, CNA) verified no cares had been completed since observation of the morning cares. Staff I and Staff G (CNA) transferred the resident from the wheelchair to the bed. On 8/2/12 at 2:05 p.m., Staff B (Licensed Practical Nurse) measured an open area on the resident ' s coccyx and reported the area had not been new. Staff B measured the area to be 2.0 cm by 0.8 cm with a depth of 0.2 cm. On 8/2/12 at 3:30 p.m., Staff N (Assistant director of Nursing) provided the surveyor with a copy of a skin assessment sheet for the coccyx (tailbone area) which had previously been reviewed by the surveyor, but had indicated gluteal fold (crease separating upper thigh and buttock) and had been dated 7/19/12. The words gluteal fold had been crossed out and replaced with the word coccyx and dated 8/2/12. Staff N stated that staff B had made the change and thought the gluteal fold had been coccyx. Staff N verified the coccyx and gluteal fold were not the same area of anatomy, and he/she did not know why it had been changed. The form included Staff B ' s measurement of the open area on the coccyx for 8/2/12. On 8/3/12 at 8:32 a.m., Staff Q (Corporate Nurse Consultant) stated the resident simply shifting weight in a wheel chair would probably not be enough to reduce pressure. On 8/3/2012 at 11:10 a.m. Staff J (Administrator) was interviewed and stated the resident had been with Occupational Therapy on 8/1/12 at about 10:30 in the morning and had worked with the resident with repositioning.