Every finding on record at Park Place Nursing & Rehabilitation Center

Based on interviews and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 6 of 7 medication carts reviewed for pharmacy services [1st Floor MA Cart, 1st Floor Nurse West/North (Odd) Cart, 2nd Floor MA West/North (Odd) Cart, 2nd Floor MA East/North (Even) Cart, 2nd Floor Nurse West/North (Odd) Cart, 2nd Floor East/North (Even) Cart]). The facility failed to ensure the nursing staff responsible for the safekeeping of narcotics performed and documented change of shift narcotic counts for the 1st Floor MA Cart, 1st Floor Nurse West/North (Odd) Cart, 2nd Floor MA West/North (Odd) Cart, 2nd Floor MA East/North (Even) Cart, 2nd Floor Nurse West/North (Odd) Cart, and 2nd Floor East/North (Even) Cart. This failure could place residents at risk for loss of medications and possible drug diversion. Findings included: Observation and record review on 06/28/2026 of the medication carts and June 2026 Narcotic Drug Shift Count Sheets indicated there were multiple missing signatures indicating change of shift narcotic counts were not completed as required from 06/01/2026 through 06/27/2026. The count sheets indicated the carts were to be counted at the beginning and end of each shift. Missing signatures for 06/01/2026 through 06/27/2026 were as follows: 1st Floor MA cart:10pm-6am shift - 54 missing signatures 2pm-10pm shift - 6 missing signatures 1st Floor Nurse West/North (Odd) cart: 6am-6pm shift - 19 missing signatures6pm-6am shift - 23 missing signatures 2nd Floor MA Cart West/North (Odd) cart:2pm-10am shift - 9 missing signatures 2nd Floor MA East/North (Even) cart :2pm-10pm shift - 5 missing signatures10pm-6am shift - 23 missing signatures 2nd Floor Nurse West/North (Odd) cart:6am-2pm shift - 4 missing signatures2pm-10pm shift - 8 missing signatures10pm-6am shift - 7 missing signatures 2nd Floor Nurse East/North (Even) cart:6am-2pm shift - 52pm-10pm shift - 110pm-6am shift - 17 missing entries During an interview on 06/28/2026 at 01:15 PM, MA-L said change of shift narcotic counts were important for ensuring there were no missing or unaccounted for narcotics. She said the missing signatures indicated the change of shift narcotics counts were not done. During an interview 06/28/2026 at 01:30 PM, MA-P said there was no acceptable excuse for not performing change of shift narcotic counts. She said change of shift narcotic counts were supposed to be done by 2 staff persons, the nurse or medication aide coming on duty and the medication aide or nurse going off duty. She said the change of shift narcotic count was important for making sure there were no narcotics missing drugs. During an interview on 06/28/2026 at 01:37 PM, LVN-R said the task of performing change of shift narcotic counts was important for ensuring all narcotics are accounted for. She said the signatures on the narcotic count sheets were proof the change of shift count was done. During an interview on 06/28/2026 at 02:05 PM, the DON said she was responsible for ensuring change of shift narcotic counts were being done every shift. She said the purpose of narcotic counts between the oncoming and off-going medication aides and nurses was to ensure all narcotics were accounted for and to reduce the risk of misappropriation or unaccounted for narcotics. A review of the facility's policy dated 2007 and titled Controlled Medication Storage indicated the following: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the nursing care center in accordance with federal, state, and other applicable laws and regulations. 6. At each shift change or when keys are surrendered, a physical inventory of all Schedule II, including refrigerated items, is conducted by two licensed nurses or per state regulation and is documented on the controlled substances accountability record or verification of controlled substances count report. The nursing care center may elect to count all controlled medications at shift change.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 1 of 1 facility kitchens.The facility failed to ensure 3 cans of beets and 1 box of soybean frying shortening were not on the pantry floor.The facility failed to ensure stainless steel steam table pans were not stacked wetThe facility failed to ensure DA A did not hand dry items placed on the drain rack at the 3-compartment sink to air dryThe facility failed to ensure the bulk sugar bin did not have a scoop laying inside the product.These failures could place residents who ate food from the kitchen at risk of foodborne illness.Findings included:During observations and interviews on 06/28/2026 of the kitchen the following was noted:*at 8:15 AM in the dry pantry 3- 6.5 lb. cans of beets and 1 partially used 35 lb. box of soybean frying shortening were being used to prop the pantry door open. DA A came into the pantry and began putting the cans on the shelves and the box of oil on the shelf in the pantry. She said the cans were on the floor because someone just did not want to put them where they belonged.*at 8:20 AM on the pan rack adjacent to the 3-compartment sink the following steam table pans were stacked wet:4-half size stainless steel 6 deep 4-quarter size stainless steel 6 deep 1-half size stainless steel 8 deep 3-full size stainless steel 8 deep *at 8:25 AM [NAME] B came to the 3-compartment sink area and saw the pans that were stacked wet and took one of the pans and placed it at the 3-compartment sink to be re-washed. She made a general loud announcement to staff that the pans cannot be stacked wet.*at 8:30 AM the bulk sugar bin under the prep table had a plastic scoop left inside the product.During an observation and interview on 06/28/2026 at 11:30 AM DA A was observed hand drying items with a kitchen towel on the 3-compartment sink drain rack that had just been pulled from the sanitizer sink in the 3-compartment sink. DA A was stopped by the DM from drying the items after surveyor intervention, the DM said the cans in the pantry should not have been on the floor and the pans and items washed and sanitized at the 3-compartment sink need to air dry and not be stacked wet or hand dried.Review of the undated facility policy titled Food Storage indicated .2. All foods or food items not requiring refrigeration shall be stored at least six (6) inches above the floor and at least eighteen (18) inches from sprinkler heads, on shelves, racks, dollies or other surfaces which facilitate thorough cleaning, in a well-ventilated room, not subject to sewage or wastewater backflow or contamination by condensation, leakage, rodents, or vermin. All packaged food, canned foods, or food items stored shall be kept clean and dry at all times.Review of the facility policy titled Mechanical Cleaning and Sanitizing of Utensils and Portable Equipment, dated October 1, 2018, indicated .9. Air dry all equipment and utensils after sanitizing. Handle clean and sanitized equipment and utensils and all single-service articles in a way that protects them from contamination.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary and comfortable environment for six (Residents #56, # 36, #27, #12, #73, and #71) of six residents reviewed for physical environment. The facility failed to maintain clean, sanitary, and safe conditions in rooms for Residents #56, #36, #27, #12, #73, and #71 to prevent accident hazards. Specifically, the facility allowed dirt and debris to accumulate on flooring, rugs, and floor signs, and improperly stored an extra bed in a resident room, creating a trip hazard. These failures could place residents at risk of living in an unsafe, unsanitary and uncomfortable environment.Findings included: 1. A record review of Resident #36's face sheet, dated 06/28/2026, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #36 had diagnoses of epilepsy, cerebral palsy, spastic hemiplegia (cerebral palsy or nerve condition that causes stiffness and weakness on one side of the body), convulsions, bipolar disorder (mood disorder), depression, and hypokalemia (low potassium). Review of Resident #36's MDS assessment, dated 4/30/2026, revealed the resident had a BIMS score of 3 which indicated sever cognitive impairment and wheelchair mobility assistance. Observation on 06/28/2026 at 8:10 a.m., Resident #36's room revealed the floor was poorly maintained, two floor tiles were missing, located next to bed on the right side. The floor appeared sticky with a visible accumulation of dirt, debris, and wax build-up along the surfaces. 2. A record review of Resident #56's face sheet, dated 06/28/2026, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #56 had diagnoses which included convulsions, autistic disorder, aphasia (neurological disorder that impairs your ability to speak), depressive disorder, essential hypertension (high blood pressure), and gastrostomy (feeding tube directly into the stomach). Review of Resident #56's MDS assessment, dated 3/19/2026, revealed the resident had a BIMS score of 0 which indicated sever cognitive impairment and wheelchair mobility assistance. Observation on 06/28/2026 at 8:15 a.m., of Resident #56's room revealed the floor was poorly maintained, the floor tiles appeared sticky with a visible accumulation of dirt, debris, and wax build-up along the surfaces. Additionally, significant scratching with embedded dirt were noted on the floor tiles directly beneath the resident's bed. 3. A record review of Resident #27's face sheet, dated 06/28/2026, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #27 had diagnoses which included encephalopathy (brain damage), HIV, cerebrovascular disease (conditions that affect the blood vessels and blood supply to the brain), nutritional deficiency, hyperlipidemia (high cholesterol), major depressive disorder, hypothyroidism, and hypertension (high blood pressure). Review of Resident #27's MDS assessment, dated 5/8/2026, revealed the resident had a BIMS score of 15 which indicated cognitive intact and independent mobility. Observation on 6/28/2026 at 8:30 a.m., of Resident #27's room revealed the floor was poorly maintained and covered with a sticky substance. Additionally, surveyors observed two unanchored area rugs in the resident's room: one 2' x 3' rug located next to the bed, and one 3' x 5' rug in front of the table. Observed Wet Floor caution signs in the middle of room with floor being dry. Observations on 6/28/2026 at 1:55 p.m., 6/29/2026 at 8:30 a.m., 6/29/2026 at 3:20 p.m., and 6/30/2026 at 8:45 a.m., Residents' #27, #56, and #36 room showed that the floors were completely dry, and 'Wet Floor' caution signs were placed in the center of the room. Room revealed that the floor showed dirt with wax built up and covered with sticky substance. 4. A record review of Resident #12's face sheet, dated 06/28/2026, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #12 had diagnoses of morbid obesity, chronic combined systolic and diastolic heart failure, cellulitis (bacterial skin infection), chronic obstructive pulmonary disease (a progressive, incurable lung condition that limits airflow), paroxysmal atrial fibrillation (irregular heartbeats that start and stop on their own), hypertension (high blood pressure), anxiety disorder, antisocial personality disorder, and depression. Review of Resident #12's MDS assessment, dated 5/2/2026, revealed the resident had a BIMS score of 15 which indicated cognitively intact and independent wheelchair mobility. 5. A record review of Resident #73's face sheet, dated 06/28/2026, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #73 had diagnoses Alzheimer's disease, heart failure, malnutrition, hypothyroidism (thyroid doesn't produce enough hormone), delusional disorder, hypertension (high blood pressure), glaucoma (eye disease leads to progressive vision loss), and muscle weakness, insomnia, depression, and tachycardia (abnormally fast heart rate). Review of Resident #73's MDS assessment, dated 3/22/2026, revealed the resident had a BIMS score of 2 which indicated sever cognitive impairment and dependent wheelchair mobility. Observation on 6/28/2026 at 8:40 a.m., revealed a bed fall mat next to Resident #73 had dirt built up, with several worn spots, and torn with quarter size hole in top covering and foam. 6. A record review of Resident #71's face sheet, dated 06/28/2026, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #71 had diagnoses of dementia, cerebral infarction (stroke), type 2 diabetes, heart failure, carcinoma of prostate (cancer of the prostate), depression, insomnia, contractures, and muscle weakness. Review of Resident #71's MDS assessment, dated 4/9/2026, revealed the resident had a BIMS score of 4 which indicated sever cognitive impairment and some assistance wheelchair mobility. Observation on 6/28/2026 at 8:30 a.m. and 1:55 pm Room occupied by Residents #12, #73, and #71 revealed that the floor was poorly maintained and that the floors were completely dry, and 'Wet Floor' caution signs were placed in the center of the room. Room revealed that the floor showed dirt with wax built up and covered with sticky substance. Room had occupancy for four residents with five beds in room. Two of the 5 beds were not occupied and were unmade with one having headboard on mattress. Interview on 6/28/2026 at 2:00 p.m., CNA J stated that she was wondering about the extra, unaccounted-for bed currently located inside room occupied by Residents #12, #73, and #71. She indicated that she does not know the reason why the bed is in the room and could not recall the exact duration of time it has been left there, though she estimated it has likely been present for a few days. Stated at this time she had not reported it to anyone. Interview on 6/28/2026 at 2:24 p.m., the Maintenance Director stated that the facility does not maintain a dedicated storage area for beds because beds are not typically stored, noting that the building maintains an exact count of beds to match the number of rooms. Upon being informed of environmental findings, he expressed that he was unaware that room occupied by Residents #12, #73, and #71 contained five beds and explicitly clarified that rooms are not permitted to hold extra beds. He explained that Hospice providers sometimes move facility beds when bringing in their own specialized equipment, but noted staff are normally required to notify him to coordinate the removal of the extra bed. The Maintenance Director was unaware of how long the additional bed had been present in that room and emphasized that extra beds cannot be stored in occupied resident rooms. He stated that he was unaware that room occupied by Residents' #27, #56, and #36 had a missing floor tile. He stated that such issues should be identified during Angle Rounds (routine inspections conducted by department heads)-and reported to his department for repair.Record reviews of charts for Residents' #12, #71, and #73 showed that residents were not receiving hospice. Observation on 06/29/2026 at 8:30 a.m., room occupied by Residents #12, #73, and #71 showed that the floors were completely dry, and 'Wet Floor' caution signs were placed in the center of the room. Room occupied by Residents' #27, #56, and #36 revealed that the floor showed dirt with wax built up and covered with sticky substance.Interview conducted 6/29/2026 9:30 a.m., with ADON stated that the standard process for handling extra equipment requires staff to notify the Maintenance Director, who is responsible for removing the items and storing them in a dedicated storage room located on the first floor. ADON stated the notification process was to ensure the environment remains clear and free of trip hazards for safety. She followed up by stating that any items that needed to be fixed should be reported to the maintenance director. Interview on 6/29/2026 10:20 a.m., LVN K stated that whenever maintenance issues arose or extra equipment was identified, she logged the information into the book located at the nurses' station. LVN K indicated that she would then contact the Maintenance Director regarding these matters. She stated that extra beds were not stored in residents' rooms. Observation on 06/29/2026 at 3:20 p.m., revealed in room occupied by Residents #56, #36, and #27 and room occupied by Residents #12, #73, and #71 that the 'Wet Floor' caution signs remained inside the rooms in the exact same positions as previously observed during the morning hours. However, the floors in both areas were completely dry at this time. Interview on 6/29/2026 at 3:30 p.m., the DON clarified that extra equipment, and wet floor signs were not supposed to be stored or left in resident rooms. She stated that staff should be notifying maintenance to remove an extra bed to storage, and she acknowledged that leaving items in rooms could be harmful, creating trip hazards that could potentially cause resident injuries. Interview and observation on 6/30/2026 at 8:45 a.m., the Housekeeping Supervisor said regarding the continuous presence of wet floor signs observed in Residents #56, #36, and # 27 room and Residents #12, #73, and #71 room. The supervisor stated that leaving the signs in the rooms could create a significant trip hazard. He acknowledged that this practice was unsafe because both rooms accommodated independent residents who were at risk of falling. Interview and observation on 6/30/2026 at 8:50 a.m., were conducted with the Maintenance Director regarding resident safety in Resident #27's room. Two throw rugs were identified on the floor by the residents' bed and table, causing a potential tripping hazard; these items were removed from the floor by staff during the observation. Additionally, when addressing environmental conditions in Resident #73's room, the Maintenance Director noted that the floor mat was not in good condition, stating that the nursing staff is responsible for evaluating nursing equipment and notifying the maintenance department when replacements are required. Interview on 6/30/2026 at 10:26 a.m., the DON stated that the nursing staff held the responsibility to review the condition of floor mats. She further clarified that nursing personnel were expected to determine if a fall mat required replacement due to wear and tear. Additionally, she noted that keeping floor mats in poor condition could cause safety issues for the residents. A record review of the facility's policy titled Maintenance Service, dated December 2025indicated the following: Policy StatementMaintenance department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times.Maintenance personnel shall follow established safety regulations to ensure safety and well-being of all concerned. A record review of the facility's policy titled LTC Housekeeping and Environmental Cleaning Policy. Policy StatementThe facility should maintain a clean, sanitary, safe, and comfortable environment for residents, staff, visitors, and others in the long-term setting. Housekeeping and environmental cleaning practices shall support infection prevention, resident dignity, order control, fall prevention, and overall quality of life.

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours for 1 of 5 residents (Resident #93) reviewed for care planning. The facility failed to develop a baseline care plan for Resident #93 within 48 hours of admission. This failure could place newly admitted residents at risk of delays in implementing individualized interventions necessary to address their immediate needs. The findings included: A record review of Resident #93's face sheet dated 06/28/2026 indicated a [AGE] year-old female admitted to the facility on [DATE]. Resident #93 had diagnoses which included Unspecified Viral Hepatitis C Without Hepatic Coma (a condition that causes inflammation of the liver), Anemia (a lack of healthy red blood cells which can cause fatigue, weakness, and shortness of breath), Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy Without Gangrene (a chronic condition where diabetes causes blood vessel damage in the extremities without tissue death), Hyperparathyroidism (a condition where the parathyroid glands produce too much parathyroid hormone leading to elevated calcium levels in the blood), End Stage Renal Disease (the final stage of chronic kidney disease where the kidneys can no longer function adequately to sustain life without treatment), Acquired Absence of Right Leg Above Knee (the permanent loss of the right leg at or above the knee joint) and Acquired Absence of Left Leg Above Knee (the permanent loss of the left leg at or above the knee joint). A record review on 06/28/2026 at 11:05 AM of Resident #93's electronic medical record revealed no evidence of a baseline care plan. Resident #93's electronic medical record indicated a completed Baseline Care Plan Acknowledgement dated 06/26/2026 at 4:00 PM signed by RN C which stated Resident #93 had been provided a copy of the baseline care plan. During an interview on 06/28/2026 at 12:45 PM, Resident #93 stated she was not aware of a baseline care plan and she did not receive a copy. During a telephone interview on 06/30/2026 at 8:29 AM, RN C stated she opened the baseline care plan but other disciplines had to complete their sections before it was finished. RN C stated she did not know why she would have signed that she provided Resident #93 with the baseline care plan if it was not completed. RN C stated she was not sure who was responsible to sign the baseline care plan to indicate it was completed. During an interview on 06/30/2026 at 9:17 AM, ADON D stated the admitting nurse was responsible for initiating the baseline care plan when a resident was admitted . ADON D stated SW was also able to initiate the baseline care plan. ADON D stated once the baseline care plan was initiated, each discipline completed their section and either the admitting nurse or the DON closed it. ADON D reviewed Resident #93's electronic medical record and stated there was no initiated baseline care plan for Resident #93. ADON D stated in the electronic medical record, the task for baseline care plan acknowledgement was produced prior to the initiation of the baseline care plan. ADON D stated typically the SW gave residents a copy of the baseline care plan. During an interview on 06/30/2026 at 9:30 AM, the SW stated when a resident was newly admitted the admitting nurse opened the baseline care plan and she completed the social services section. The SW stated she had completed Resident #93's baseline care plan on 06/29/2026. The SW stated Resident #93's baseline care plan was completed and it was probably just not closed. The SW reviewed Resident #93's electronic medical record and stated there was a baseline care plan initiated 06/30/2026 that was not completed. The SW stated she had not completed her section of the baseline care plan. The SW did not answer who was responsible for initiating the baseline care plan and stated Resident #93's baseline care plan was not available for her to complete when she checked for it. During an interview on 06/30/2026 at 10:18 AM, the DON stated the admitting nurse was responsible for initiating a baseline care plan. The DON stated when Resident #93 admitted on [DATE], it was a busy day and that was probably why it was missed. The DON stated typically on Monday morning, staff reviewed resident clinical information and that is when they might find any gaps in communication, but this did not occur due to the facility undergoing the annual relicensure/recertification survey. The DON stated she felt the risk to Resident #93 for not having a completed baseline care plan was low as staff met with her and her family on 06/26/2026 to discuss needs and discharge plans. The DON stated the overall risk to residents for not having a completed baseline care plan included things being missed or staff being unaware of the needs of residents. During an interview on 06/30/2026 at 11:06 AM, the ADM stated it was the MDS Coordinator's responsibility to initiate a baseline care plan when a resident was admitted . The ADM stated he was not sure why Resident #93 did not have a completed baseline care plan. The ADM stated the risk to residents for not having a completed baseline care plan included residents not being informed of their care. During an interview on 06/30/2026 at 11:14 AM, the MDS Coordinator stated he did not initiate or complete baseline care plans. The MDS Coordinator stated the admitting nurse completed baseline care plans. The MDS Coordinator stated he initiated Resident #93's baseline care plan because he saw it was missing, but typically he did not complete this task. A record review of Resident #93's undated baseline care plan indicated only that Resident #93 spoke English, had a code status of full code, and had no known allergies. A record review of facility policy dated March 2022 titled Care Plans - Baseline indicated the following: Policy StatementA baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. Policy Interpretation and ImplementationThe baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following:Initial goals based on admission orders and discussion with the resident/representative;Physician orders;Dietary orders;Therapy services;Social services; and PASARR recommendation, if applicable. The baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan (no later than 21 days after admission). The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 1 of 5 residents (Resident #57) reviewed for quality of life. The facility failed to ensure Resident #57 received nail care as observed on 06/28/2026, 06/29/2026, and 06/30/2026. This failure could place residents who are dependent on staff assistance at risk of not receiving care and services to meet their needs. The findings included: A record review of Resident #57's face sheet dated 06/29/2026 indicated an [AGE] year-old female admitted to the facility on [DATE]. Resident #57 had diagnoses which included Peripheral Vascular Disease (a circulatory condition where narrowed arteries reduce blood flow to the limbs, often causing pain or discomfort), Other Lack of Coordination, Muscle Weakness, Unsteadiness on Feet, Age-Related Physical Debility, Chronic Pain Syndrome, and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease (a kidney complication resulting in damage to the kidney's filtering system). A record review of Resident #57's most recent Quarterly MDS dated [DATE] indicated Resident #57 had a BIMS of 15, which indicated intact cognitive function with minimal or no impairment. The MDS indicated Resident #57 was dependent on staff for showering/bathing, and required supervision or touching assistance for personal hygiene. A record review of Resident #57's comprehensive care plan most recently revised 06/05/2026 indicated Resident #57 had an ADL self-care performance deficit and interventions included check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. If diabetic, the nurse will provide toenail care. Resident prefers to have longer nails and often refuses to have/allow nursing staff to perform appropriate nail care. The comprehensive care plan indicated Resident #57 had the potential for impairment to skin integrity and interventions included avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. During an observation and interview on 06/28/2026 at 9:30 AM, Resident #57 had fingernails extending beyond the fingertip on the first, second, and third digits of her right hand and all five digits on her left hand. Resident #57 stated she tried to keep her nails clean, but it was often difficult due to their length. During an observation and interview on 06/29/2026 at 8:34 AM, Resident #57 had fingernails extending beyond the fingertip on the first, second, and third digits of her right hand and all five digits of her left hand. Resident #57 stated she wanted them trimmed and that her pinky nail on her left hand was the longest. Resident #57 stated that it had been about a month since she got her nails trimmed, but it did not prevent her from eating or writing. Resident #57 stated her nails had gotten so long they would break off and it would hurt. During an observation and interview on 06/29/2026 at 9:08 AM, Resident #57's longest nail, the fifth digit of her left hand, extended 1.5 CM beyond her fingertip. Resident #57 stated she was scheduled for bathing on Tuesdays, Thursdays, and Saturdays. During an observation and interview on 06/30/2026 at 8:41 AM, Resident #57 had fingernails extending beyond the fingertip on the first, second, and third digits of her right hand and all five digits of her left hand. Resident #57 stated she had gotten a bath that morning and was not offered to have her fingernails trimmed by the CNA. Resident #57 stated when her nails broke they bled, but not enough to need a bandage. During an interview on 06/30/2026 at 8:45 AM, CNA E stated he had been instructed on performing nail care for dependent residents. CNA E stated prior to clipping nails he would check with the nurse in case the resident was diabetic or on blood thinners. CNA E stated a good time to trim nails was right after a resident showered. CNA E stated he had not trimmed any residents nails that day. CNA E confirmed he assisted Resident #57 with bathing that morning. CNA E observed Resident #57's fingernails and stated he did not and should have asked her if she wanted them trimmed. CNA E stated he was unsure if Resident #57 was care planned for nail care. CNA E stated that the risk to residents of not having appropriate nail care included scratching themselves. During an interview on 06/30/2026 at 9:06 AM, LVN F stated Resident #57's pinky fingernail on her left hand was really long, but they all needed to be trimmed. LVN F stated she expected CNA's to notify her if they had concerns with a residents nails being too long. LVN F stated she evaluated Resident #57 that morning and did not notice her fingernails. LVN F stated she was unsure if Resident #57 was care planned for nail care. LVN F stated she expected CNA's to notify the nurse so they can assist with nail care for Resident #57. LVN F stated the risk to residents for not having appropriate nail care included broken nails and the potential for scratching their skin. During an interview on 06/30/2026 at 9:23 AM, ADON D stated CNAs were supposed to provide nail care when they assist residents with showering or bathing, and if the resident was diabetic she expected the CNA to notify the nurse of their need for nail care. ADON D stated nursing staff should also be assessing nail length when obtaining blood sugar levels. ADON D stated Resident #57 would refuse nail care at times, but it should still have been offered. ADON D stated the risk to residents for not having appropriate nail care included broken nails and skin tears that could cause wounds in a diabetic resident. During an interview on 06/30/2026 at 10:16 AM, the DON stated she expected CNA's to assess residents nails and ask if they want them trimmed. The DON stated Resident #57 could be particular about her nails, but staff should be more diligent about ensuring she was offered nail care. The DON stated the risk to residents for not having appropriate nail care included skin breaks and scratches that could lead to infection. During an interview on 06/30/2026 at 11:08 AM, the ADM stated he expected staff to follow residents care plans and offer to trim their nails as necessary. The ADM stated it would not be sanitary for a resident to have long nails as they could get stuff under them. A record review of Skin Monitoring: Comprehensive CNA Shower Review indicated Resident #57 received a bath or shower on 06/27/2026, 06/25/2026, 06/16/2026, 06/11/2026, 06/09/2026, 06/06/2026, 06/04/2026, and 06/02/2026. None of the skin sheets indicated concerns with Resident #57's nails. A record review of the facility's policy titled Activities of Daily Living (ADL), Supporting revised March 2018 indicated the following: Policy StatementResidents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screening for 1 of 5 residents reviewed for resident assessments (Residents #75). The facility failed to ensure Resident #75 had an accurate PASRR Level 1 Screening indicating a diagnosis of mental illness and refer the resident to the state designated authority. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs. Findings included: Record review of a face sheet dated 06/29/2026 indicated Resident #75 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included depression (a mental disorder involving a depressed mood or loss of pleasure or interest in activities for long periods of time) and schizophrenia (a chronic mental health condition in which reality is interpreted abnormally and affects how the person thinks, feels, and behaves). Record review of a hospital Discharge summary dated [DATE] indicated Resident #75 had a diagnosis which included schizophrenia. Record review of the facility's physician's orders dated 05/29/2026 indicated Resident #75 had a diagnosis of schizophrenia and an order for Risperidone, an antipsychotic medication for the treatment of schizophrenia upon admission to the facility. Record review of an admission MDS assessment dated [DATE] reflected Resident #75 had a BIMS score of 12 indicating his cognition was moderately impaired. Further review of the admission MDS assessment indicated Resident #75 had a diagnosis of schizophrenia. Record review of Resident #75's PASRR Level 1 Screening completed by the hospital on [DATE] indicated in section C0100 there was no evidence of this individual having mental illness. During an interview on 06/29/2026 at 12:01 PM, the MDS Coordinator said he was responsible for tasks related to the PASRR and MDS processes. He said he was responsible for ensuring the PASRR Level I screening was accurate upon admission. He said he coded the admission MDS assessment for schizophrenia but did not catch that the PASRR Level 1 screening was incorrect. The MDS Coordinator said it was important to have correct PASRR Level I screenings to ensure residents were referred for PASRR Level II evaluations. He said the LA should have been made aware of the incorrect PASRR Level I screening. He said incorrect PASRR I screenings could result in a resident not receiving needed services. He said the facility used the RAI Version 3.0 Manual as the policy for completing PASRR tasks. A review of the October 2024 RAI 3.0 Manual: Chapter 3: Section A 1500 indicated the following:All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level I PASRR completed to screen for a possible mental illness (MI), intellectual disability (ID), developmental disability (DD), or related conditions.

Based on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS discharge in facility tracking record was electronically transmitted to the CMS System within 14 days after completion for 1 of 1 resident (Resident #85) reviewed for discharge MDS assessments. The facility failed to transmit a discharge MDS assessment for Resident #85. This failure could place residents at risk of not having records completed and submitted in a timely manner as required. Findings include: Record review of a face sheet dated 06/30/2026 indicated Resident #85 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included sepsis (a life-threatening complication of infection), acute respiratory failure with hypoxia (a condition where the respiratory system fails to maintain adequate blood oxygen levels), hypovolemic shock (a life-threatening medical emergency caused by severe blood or fluid loss), type 2 diabetes, Obstructive sleep apnea (a chronic disorder where the upper airway repeatedly collapses during sleep, blocking airflow), hypocalcemia (abnormally low levels of calcium in the blood), rheumatoid arthritis (a chronic autoimmune disease where the immune system mistakenly attacks the lining of your joints), depression, anxiety, and hypertension. The face sheet indicated Resident #85 had a date of discharge to home of 02/02/2026 with a discharge status of no return anticipated. Record review of Resident #85's electronic medical record indicated there was a discharge MDS assessment completed on 2/2/2026 on record. However, the discharge MDS assessment was not transmitted electronically to CMS. During an interview on 06/29/2026 at 02:50 P.M. with the MDS Coordinator, he said he was responsible for completing the discharge MDS assessments and transmitting the discharge MDS assessment to CMS. He said the resident's discharge MDS assessment had been completed. However, he acknowledged he forgot to transmit the assessment to CMS and that it was missed. MDS Coordinator said it was important to complete and transmit the MDS assessments timely because they affect quality of care measures and payments. He said failure to complete and transmit discharge MDS assessments could result in inaccurate Quality Measures. During an interview on 06/29/2026 at 03:15 P.M., with the DON, she said admissions and discharges were discussed in the daily morning team meetings. She said they used the RAI Manual's schedule for completing and transmitting all MDS assessments. During an interview on 06/29/2026 at 03:22 P.M., the Admin., said the MDS LVN were responsible for completing the discharge MDS assessments. The Admin. said he expected the MDS Coordinators to complete and transmit the MDS assessments as scheduled and required by state and federal governing agencies. Record review of the CMS's RAI Version 3.0 Manual dated October 2023, Chapter 2:2-17, 2-37, and 2-44 indicated the following under required assessment summary: MDS Completion Date No Later Than discharge date +7 Calendar days.Transmission Date No Later Than discharge date +14 Calendar days.

Based on observation, interview, and record review, the facility failed to post their most recent survey of the facility in an area of the facility accessible to residents, and family members and legal representatives of residents. The facility also failed to have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request, in 1 of 1 facility reviewed for resident rights. 1. The facility failed to maintain the most recent standard survey results dated 4/4/2026 and 4/22/2026 inside the public survey binder.2. The facility failed to post the results of the most recent survey in a place readily accessible to residents, family members, and legal representatives. These failures could place residents at risk for not having access to current information regarding the facility's compliance with federal and state regulations, limiting their ability to make informed decisions and exercise their rights.The findings included: An observation on 06/29/2026 at 10:48 AM revealed the survey binder was located within the facility behind receptionist desk. Review of the binder indicated it did not include the results from the most recent standard surveys completed 04/4/2026 and 04/22/2026. During an interview on 06/30/2026 at 10:02 AM, the ADM indicated he was responsible for ensuring the survey binder was up to date. The ADM indicated he believed the most recent standard survey to be located within the binder. The ADM reviewed the survey binder and recognized the most recent standard survey was not located inside. When asked the ADM did not indicate any potential risk to residents if residents requested to review the survey results. The ADM indicated he understood it was a resident's right to review the most standard survey results without having to ask for them. During a confidential group interview at an undisclosed date and time, 2 confidential residents indicated they did not have access to the most recent standard survey results without asking receptionist. Record review of the facility's policy entitled Survey Results, Examination stated a copy of the most recent standard survey, including any subsequent extended surveys, follow-up revisits reports, etc., along with state approved plans of correction of noted deficiencies, is maintained in a 3-ring binder located in an area frequented by most residents, such as the main lobby or resident activity room.

Based on observation and interview, the facility failed to post the daily nurse staffing data at the beginning of the shift, in a prominent place, and readily accessible to residents and visitors that included the facility name and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care for 12 of 14 days reviewed for nurse staffing data. The facility did not post the daily staffing on 06/17/2026, 06/18/2026, 06/19/2026, 06/20/2026, 06/21/2026, 06/22/2026, 06/23/2026, 06/24/2026, 06/25/2026, 06/26/2026, 06/27/2026, or 06/28/2026. This failure could place residents, their families, and facility visitors at risk of not having access to information regarding staffing data and facility census. The findings included: During an observation on 06/28/2026 at 7:53 AM, the staffing sheet located in the front lobby of the facility was dated 06/16/2026. During an observation on 06/28/2026 at 1:00 PM, the staffing sheet located in the front lobby of the facility was dated 06/28/2026. During a telephone interview on 06/30/2026 at 8:27 AM, RN C stated she was the RN in charge on 06/28/2026. RN C stated she had never been instructed to update posted nurse staffing information. RN C stated she had seen ADON D update the posted nurse staffing information in the past, but was not aware of any other staff member assigned to update this information on the weekends. During an interview on 06/30/2026 at 9:25 AM, ADON D stated she typically updated the posted nurse staffing information. ADON D stated she was off work the week prior and did not assign anybody to update the staffing information. ADON D stated in her absence the Staffing Coordinator would update the posted nurse staffing information, but she was also off work. ADON D stated the nurse staffing information is required to be posted daily. During a telephone interview on 06/30/2026 at 9:53 AM, RN G stated she was the weekend supervisor on 06/27/2026. RN G stated she was aware of the posted nurse staffing information but had never been instructed to update it. During an interview on 06/30/2026 at 10:12 AM, the DON stated the staffing coordinator usually updated the posted nurse staffing information. The DON stated on the weekends the weekend supervisor was responsible for ensuring the posted nurse staffing information is updated. The DON stated the weekend supervisors may not have been aware they should have been updating the posted nurse staffing information. The DON stated the information should be posted and residents should be able to know what staff are available for them. During an interview on 06/30/2026 at 10:25 AM, the Staffing Coordinator stated ADON D usually completed the nurse staffing information and she would ensure it was posted. The Staffing Coordinator stated she did not assign anybody to post the nurse staffing information in her absence. The Staffing Coordinator stated she thought the weekend supervisor was assigned to update the posted nurse staffing information on the weekend, but she was unsure if they had been told they were supposed to. The Staffing Coordinator stated the posted nurse staffing information should have been updated . During an interview on 06/30/2026 at 11:00 AM, the ADM stated he was not aware the posted nurse staffing information was not updated. The ADM stated the Staffing Coordinator usually posted the information, but she was off work that week. The ADM stated on the weekend the Staffing Coordinator would post those days and if anything changed the receptionist would update the posting. The ADM stated the posted nurse staffing information should have been updated. A record review of an undated facility policy titled Policy on Staffing Sheet Posting indicated the following: In nursing home and long-term care facilities, staffing sheet posting is a regulatory requirement under the federal F732 - Posted Nurse Staffing Information rule (483.35(i)). The policy ensures that residents, staff, and visitors can see up-to-date staffing data at all times.Required Information to PostEach day, the facility must post:Facility nameCurrent dateMidnight censusTotal number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:Registered nurses (RNs)Licensed practical/vocational nurses (LPNs/LVNs)Certified nurse aides (CNAs).

Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than two hours after the allegations were made, if the events that caused the allegation involved abuse or resulted in serious bodily injury to the administrator of the facility and to other officials, including to the State Survey Agency, in accordance with State law through established procedures for one of five residents (Resident #1) reviewed for injury of unknown origin. The facility failed to report an injury of unknown origin until 6 hours after the incident occurred. This failure could place residents at risk of not receiving timely investigation into allegations of injury of unknown origin. The findings included: A record review of TULIP case details on 04/20/2026 at 3:32 PM indicated the report of injury of unknown origin was received by HHSC on 04/10/2026 at 10:30 PM. A record review of Resident #1's face sheet dated 04/22/2026 indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included metabolic encephalopathy (a condition that could lead to confusion, memory loss, personality differences, and drowsiness), generalized muscle weakness, and cognitive communication deficit (a condition that could disrupt a person's ability to communicate effectively). A record review of Resident #1's admission MDS dated [DATE] indicated BIMS of 4, which indicated severe cognitive impairment. Section GG of Resident #1's MDS indicated Resident #1 required partial/moderate assistance in which the helper provided less than half the effort for most functional abilities. A record review of a nurses note dated 04/10/2026 at 4:30 PM indicated Resident #1 was heard calling for help from her room and was found by staff on the floor laying on her back with a deep laceration to the palm of her left hand that was actively bleeding. The note indicated Resident #1 was crying out and stated it hurt while her left arm was being assessed for injury. The note indicated Resident #1's laceration was cleaned and covered with a dry dressing and the bleeding was controlled. The note indicated the physician, the ADON, DON, and Resident #1's family member were notified of the incident. The note indicated 911 was called and Resident #1 was transferred to the hospital for further care. A record review of hospital records dated 04/10/2026 at 6:25 PM indicated an x-ray of Resident #1's left humerus (the bone of the upper arm) revealed a fracture. Hospital records indicated Resident #1 received sutures to the laceration on her left palm. An observation on 04/22/2026 at 9:15 AM indicated Resident #1's left arm was swollen, bruised, and she had sutures to her left palm. Resident #1 did not have any facial grimacing, groaning, or other indicators she was experiencing pain and stated her left hand only hurt if she messed with it. Resident #1's bedroom and bathroom did not have any observable tripping hazards or sharp objects. An attempt was made to interview Resident #1, but she was unable to appropriately answer questions and repeated I don't know. During a telephone interview on 04/22/2026 at 10:30 AM, LVN A indicated she was the nurse who assessed Resident #1 after a CNA notified her Resident #1 was on the floor. LVN A indicated she was unsure how the laceration on Resident #1's hand was obtained as there was nothing in the surrounding area she believed sharp enough to cause the laceration. LVN A indicated she assessed and provided care for Resident #1 and then contacted the physician, ADON A, the DON, and Resident #1's family member. During a telephone interview on 04/22/2026 at 1:40 PM, CNA B indicated she heard Resident #1 call for help from her room, saw her on the floor, and immediately notified the nurse. CNA B indicated Resident #1 was crying and her left hand was bleeding. CNA B indicated she did not observe blood anywhere in the room other than on Resident #1's hand and Resident #1 had fragile skin. During an interview on 04/22/2026 at 2:50 PM, ADON A indicated she was contacted shortly after the incident occurred and notified Resident #1 had fallen and was being sent to the hospital due to the laceration on her left hand and the inability to move her left arm without showing signs of pain. ADON A indicated she was able to monitor when x-rays were completed through her computer at home. ADON A indicated she notified the DON at 7:08 PM on 04/10/2026 x-rays were completed and Resident #1 had a fracture to her left arm. ADON A indicated the DON relayed this information to the ADM who would complete a self-report to HHSC. ADON A indicated she was aware of the 2-hour time frame to notify HHSC of an injury of unknown origin. ADON A indicated she did not feel there was a risk to residents for not reporting timely in this instance as Resident #1 was receiving care at the hospital and upon her return to the facility. During an interview on 04/22/2026 at 3:03 PM, the DON indicated she was made aware of the incident immediately and she believed the ADM was notified when Resident #1 was sent to the hospital. The DON indicated she instructed ADON A to notify her when x-ray results were obtained and she believed it was at 6:06 PM on 04/10/2026 she was made aware of the fracture and notified the ADM in Training who was to let the ADM know so he could report it to HHSC. The DON indicated she was aware injury of unknown origin must be reported within 2 hours to HHSC. The DON indicated she did not know why the ADM would not report the injury of unknown origin outside of the 2-hour window. The DON indicated the facility utilized Provider Letter 2024-14 as their policy for reporting timelines. During a joint interview with the ADM and the ADM in Training on 04/22/2026 at 3:38 PM, the ADM indicated he was notified by the ADM in Training of Resident #1's fracture but could not recall at what time. The ADM indicated he was unsure of the timeframe in which injury of unknown origin was to be reported to HHSC. The ADM in Training indicated it was approximately 7:15 PM on 04/10/2026 when she received a call from the DON regarding the fracture and she immediately contacted the ADM. The ADM indicated he recalled the phone call, but he was doing yard work, showered, and then fell asleep. The ADM indicated he woke up later in the evening and remembered to report the injury of unknown origin to HHSC. Record review of the facility's policy titled Assessing Falls and Their Causes, last revised March 2018, indicated the following: Reporting:2. Report other information in accordance with facility policy and professional standards of practice. Record review of Provider Letter 2024-14 titled Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility (NF) Must Report to the Health and Human Services Commission (HHSC) dated 08/29/2024 indicated the following: Type of Incident Do Report:Abuse (with or without serious bodily injury)An incident that results in serious bodily injury and that involves any of the following:NeglectExploitationMistreatmentInjuries of unknown sourceMisappropriation of resident propertyWhen to ReportImmediately, but not later than two hours after the incident occurs or is suspected.

Based on interview, and record review, the facility failed to provide or obtain necessary emergency dental services for 1 of 9 residents reviewed for dental services (Resident #1).The facility failed to timely complete and follow up on a dental referral after becoming aware of Resident #1's dental concerns on 3/3/26. The referral was not submitted until 3/12/26, resulting in the resident developing right-sided facial swelling, pain, and infection, requiring transfer to the emergency room on 3/12/26.This failure placed residents at risk for delayed dental treatment, increased pain, infection, and decline in condition.Findings included:Record review of an admission record dated 04/03/26 indicated Resident #1 was a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE] with a cellulitis and abscess of mouth (serious, often interconnected dental emergencies resulting from bacterial infections, typically arising from untreated tooth decay or gum disease. Dental Abscess: A pocket of pus at the root of a tooth, causing sharp pain, heat sensitivity, and localized swelling. Facial Cellulitis: Spreads from an abscess, causing widespread facial swelling, redness, high fever, chills, and intense pain.) with new onset date of 3/3/26.Record review of quarterly MDS assessment dated [DATE] indicated Resident #1 had clear speech, was able to make self-understood and had the ability to understand others. He had BIMS score of 14 out of 15 indicating he was cognitively intact. The MDS assessment indicated Resident #1 did not exhibit rejection of care. The MDS assessment indicated Resident #1 was independent with ADLs. The MDS assessment indicated Resident #1 had no mouth or facial pain, discomfort and no oral or dental problems.Record review of Resident #1's nursing progress notes from March 2026 indicated the following:-3/3/26 at 9:56am completed by DON - Spoke to [Resident #1's family member] regarding [Resident #1] inquiring about dental concerns. SW consulted and will follow up for dental referral.-3/3/26 at 12:55pm completed by LVN B - [Resident #1] c/o tooth pain with blood and puss coming from back of right mouth. NP notified. N.O. Amoxicillin 1g today then Amoxicillin 500mg TID x 3 days.-3/12/26 at 1:40pm completed by LVN C - [Resident #1] that shift present with swelling to right side of face. [Resident #1] report pain 8/10, constant and aching, afebrile, vs stable WNL, notified MD, ordered to transfer [Resident #1] to local ER for evaluation and treatment.-3/12/26 at 7:09pm completed by LVN C - [Resident #1] returned from the local ER at 5:00pm via facility van transport. Discharge orders are as followed from the local ER: 1. AUGMENTIN 875-125 MG - ONE TAB PO BID X 7 DAYS. 2. PERIDEX 0.12% - ADMINISTER 15 ML PO ( SWISH AND SPIT ) PO BID X 14 DAYS. Facial swelling had decreased and not warm to the touch.Record review of an emailed dental referral dated 3/12/26 at 11:33 a.m. from SW to the [Name of in house Dental provider] indicted SW initiated a new patient dental referral for Resident #1.Record review of Resident #1's social service progress note indicated the following:-3/12/26 at 12:21pm completed by SW - SW sent Dental referral.Record review of after visit summary dated 3/12/26 indicated Resident #1 was in the ER for dental pain due to toothache. Resident #1 was discharged with new two new medications: amoxicillin 875-125mg (take 1 tablet by my mouth every 12 hours for 7 days); and chlorhexidine 0.12% solution (apply 15 mL to the mouth or throat two times per day for 14 days). Also, instructed to follow up with a dentist for re-evaluation. Unable to interview or observe Resident #1 during the visit as the resident was out on pass for the holidays.During a telephone interview on 4/3/26 at 4:46 p.m., the dental office representative stated that Resident #1's dental referral was received on 3/12/26 and Resident #1 was seen by the facility's dentist on 3/17/26. The representative reported that the new patient referral packet included a face sheet, medication list, and financial status form, along with a physician-signed form; however, the attending physician signed Resident #1's paperwork on 3/3/26, while SW submitted Resident #1's dental referral on 3/12/26.During an interview on 4/4/26 at 1:12 p.m., the DON stated that Resident #1's family member notified her on 3/3/26 of the need for a dental referral. The DON reported she initiated the dental consult for SW to follow up and expected timely follow-up, although no specific timeframe was provided. The DON stated she was unaware Resident#1's dental referral had not been completed until 3/12/26. She further reported that Resident #1 had been receiving antibiotics during that time and, although the Resident#1's room was near her office, Resident #1 did not report any mouth-related concerns to her. The DON said they did not have a dental policy.During an interview on 4/4/26 at 1:20 p.m., SW stated she was hired in January 2026 as the facility's SW and, shortly after starting, identified multiple residents in need of dental referrals. SW reported she was responsible for completing new patient referrals for the in-house dental provider. SW stated Resident #1 had a dental consult dated 3/3/26; however, she delayed submitting the referral and sent it on 3/12/26 with other new patient referrals. SW said she did not follow up on the 3/3/26 consult until 3/12/26, because she did not believe it would be an issue due to the resident being prescribed three days of antibiotics. SW reported the in-house dental provider evaluated Resident #1 on 3/17/26.During an interview on 4/4/26 at 2:13 p.m., LVN C stated she was the charge nurse on the right side of North Hall during the 6 a.m. to 2 p.m. shift. She reported that on 3/12/26, Resident #1 complained of mouth pain and right-sided facial swelling. The nurse stated the resident reported no swelling the night prior; however, upon waking the morning of 3/12/26, the right side of his face was swollen, and he was experiencing toothache-related pain and Resident #1 was sent to the ER for evaluation.During a telephone interview on 4/4/26 at 3:32 p.m., LVN B stated she was the charge nurse for the right side of North Hall during the 6 a.m. to 2 p.m. shift and that Resident #1 was assigned to her hall. She reported that on 3/3/26, Resident #1 complained of right-sided mouth pain and stated he had to gargle his mouth prior to her assessment. The nurse stated she assessed the resident's mouth and did not observe or feel swelling or drainage at that time; however, she notified the physician, who ordered a three-day course of antibiotics. She further reported that during the 3/3/26 morning meeting, she notified the DON and SW of Resident #1's condition, and SW indicated awareness and reported awaiting completion of the dental referral process. The nurse stated she did not follow up further after being informed that SW was completing the referral.Record review of SW job description signed 12/12/25 indicated, .Position Summary: The purpose of the Director of Social Services position was to enable the community to identify the personnel and medically related psycho-social, socio-economic and emotional needs of the residents. To act to meet those needs through individual and family assessments and counselling as well as other social services interventions. This position also promotes residents' potential, rights and quality of care during their stay.Record review of undated Quality Assessment and Assurance Committee: Social Services policy and procedure indicated: Duties and responsibilities.4. Referring residents/families to appropriate social services agencies when the facility does not provide the services or needs of the resident.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 residents (Resident #1, Resident #2, and Resident #3) reviewed for infection control. The facility failed to ensure CNAs A and C wore PPE when providing ADL care to Residents #1 and 3 both were labeled for EBP with Blue name tagThe facility failed to ensure LVN D wore PPE when providing enteral feeding to Resident #2 had a blue name tag indicating EBP.These failures could place residents at risk for cross contamination, spread of infection and sepsis, in violation of infection prevention and control requirementsFindings included:In an observation on 1/21/2026 at approximately 9:35 AM, Residents #1, #2, and #3 had EBP signage in place which was indicated by a blue name tag on the resident's door with their name and PPE (Personal protective equipment) was noted at the entrance to the resident room. Record Review on 1/21/2026, Residents #1 had a physician's order dated 8/7/2025 (Enhanced Barrier Precautions (EBP) R/T widespread rash and other skin conditions) Record Review on 1/21/2026 Resident #2 had a physician's order dated 1/7/26 (Enhanced Barrier Precautions every shift Dx: peg-tub) Record Review on 1/21/2026 of Resident #3 had a physician's order dated 7/31/2025 Enhanced Barrier Precautions (EBP) related to other skin changes.During an observation on 1/21/2026, of EBP signage (Enhanced Barrier Precautions) stated: everyone MUST clean hands before and after leaving room, wear gloves and gown for the following residents: dressing, bathing/showering, transferring, changing linen, providing hygiene, changing briefs or assisting with toileting device care central line, urinary catheter, feeding tube, tracheostomy, and wound care: any skin opening requiring a dressing) In an observation on 1/21/2026 at approximately 9:45 AM CNA A entered Resident #1's room to perform ADL care and did not sanitize her hands before entering and did not don (put on) a gown to perform the ADLs (doing a bed bath).In an observation on 1/21/2026 at approximately 10:00 AM CNA C entered Resident #3's room to perform ADL care and did not sanitize her hands before entering and did not don (put on) a gown to perform the ADLs (peri care)During an interview on 1/21/2026 at approximately 10:30 AM with CNA's A and C both stated they both failed to put on a gown to do ADLs with Residents. Both CNAs stated they had been trained on hire on- Enhanced Barrier Precautions. Both stated, I just forgot to put on PPE on while doing ADL care.During an interview on 1/21/2026 at 10:35 AM with the DON (who also observed CNA A and C, doing ADL care), admitted she will take care of this. She said, this was not ok and both CNAs should have PPE on as this could cause spread of infection.In an observation on 1/21/2026 at 12:00PM LVN D was observed in Resident #2's room doing an enteral feeding and not wearing a mask or gown. There was signage indicating EBP was to be used, and PPE was present at the room entrance area.In an interview on 1/21/2026 at 12:15 PM with LVN D she said, she did not notice that she had not put on a gown for Resident #2 but was aware of the EBP and what she should have done when doing care for the residents, she stated, The EBP signage stated: When providing care for Dressing, bathing/Showering, transferring, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, wound care any skin opening requiring a dressing.In an interview on 1/21/2026 at 12:30PM with the DON who was the IP (Infection Preventionist Nurse), she was able to state a potential negative outcome for failure to observe EBP on at-risk residents. She said, These failures could place residents at risk for cross contamination, spread of infection and sepsis, in violation of infection prevention and control requirements.In an interview on 1/21/2026 at 12:45 PM with the Administrator, DON and AIT, the DON said, All the staff in the building all been trained and retrained on EBP. All three were able to state a potential negative outcome for failure to observe EBP on at-risk residents. These failures could place residents at risk for cross contamination, spread of infection and sepsis, in violation of infection prevention and control requirementsRecord Review of the EBP Enhanced Barrier Precautions Policy dated 4/1/2024 indicated, EBP employs targeted gown, and gloves use in addition to standard precaution during high contact residents care activities when contact precautions do not otherwise apply .

Based on interviews and record reviews, the facility failed to implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the residents' practicable physical, mental, and psychosocial well-being for 3 (Resident #1, Resident #2, and Resident #3) of 6 residents reviewed for care plans. The facility failed to implement person-centered care plans for areas triggered on the CAA (Care Area Assessment) with interventions within 21 days of admission for Resident #1, Resident #2 and Resident #3 to meet medical, nursing, mental and psychosocial needs. This failure could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services.Findings included: Record review of an undated face sheet revealed Resident #1 was an [AGE] year-old female admitted on [DATE] with the diagnoses of rheumatic mitral stenosis (the narrowing and stiffening of the heart's mitral valve, usually caused by damage from rheumatic fever), bipolar disorder ( serious mental illness causing extreme shifts in mood, energy, and activity levels, from highs (mania/hypomania) to lows (depression), significantly affecting daily functioning, sleep, and thinking, and chronic kidney disease stage 4 (severe kidney damage, with kidneys functioning at only 15-29%). Record review of an admission MDS assessment dated [DATE] revealed Resident #1 had a BIMS of 10, which indicated moderate cognitive impairment. She required substantial assistance (helper provides over half the help) with ADLs. The MDS revealed the triggered care areas of cognitive loss/dementia, visual function, communication, ADLs function/rehab potential, urinary incontinence/indwelling catheter, psychological well-being, falls, nutritional status, dehydration fluid maintenance, pressure ulcer, psychotropic drug use and pain. Record review of the EHR on 12/30/2025 at 10:00 a.m. revealed no care plan was implemented for Resident #1. Record review of an undated face sheet revealed Resident #2 was a [AGE] year-old male admitted on [DATE] with the diagnoses of diabetes mellitus type 2 (a chronic condition where the body either doesn't make enough insulin or doesn't use insulin effectively (insulin resistance), leading to high blood sugar levels as glucose can't enter cells for energy), atrial fibrillation (the most common type of heart arrhythmia, an irregular heartbeat where the upper chambers quiver chaotically, causing the heart to beat too fast and irregularly, which can lead to fatigue, palpitations, dizziness, and significantly increases stroke risk), and chronic kidney disease (a progressive condition where kidneys gradually lose their ability to filter waste and fluids from the blood). Record review of an admission MDS assessment dated [DATE] revealed Resident #2 had a BIMS of 10, which indicated no cognitive impairment. Resident #2 required substantial assistance (helper provides over half the help) with ADLs. The MDS revealed the triggered care areas of ADLs function/rehab potential, urinary incontinence/indwelling catheter, psychological well-being, falls, nutritional status, pressure ulcer, and pain. Record review of the EHR on 12/30/2025 at 10:15 a.m. revealed no care plan was implemented for Resident #2. Record review of an undated face sheet revealed Resident #3 was a [AGE] year-old male admitted on [DATE] with the diagnoses of fractured femur (a break in the thighbone, the body's longest and strongest bone, typically caused by severe trauma like car accidents or falls), hypertension (high blood pressure), obesity (a complex disease defined as having excessive body fat). Record review of an admission MDS assessment dated [DATE] revealed Resident #3 had a BIMS of 07, which indicated moderate cognitive impairment. Resident #3 required supervision and set up for ADLs. The MDS revealed the triggered care areas of cognitive loss/dementia, ADLs function/rehab potential, urinary incontinence/indwelling catheter, psychological well-being, falls, nutritional status, pressure ulcer, pain, and return to community. Record review of the EHR on 12/30/2025 at 10:30 a.m. revealed no care plan was implemented for Resident #2. During an interview on 12/30/2025 at 1:00 p.m., the MDS Coordinator stated about 3 weeks prior there were two MDS nurses. One MDS nurse was responsible for the residents on the bottom floor and the skilled residents. He was responsible for the rest of the residents. He stated he was unsure why the previous MDS nurse had not completed the care plans for Resident #1, Resident #2, and Resident # 3. He stated the guidelines in the RAI manual stated 14 calendar days to complete the admission MDS and 21 calendar days to complete the comprehensive care plan. He stated the care plan was important because if it were read by everyone, they would have a blueprint to resident centered care. During an interview on 12/30/2025 at 2:00 p.m., the DON stated it was important for all residents to have a care plan. She stated the care plan provided an individualized guide to resident care. She stated that without the care plan everyone received generalized care. Record review of an undated facility policy titled 'Comprehensive Care Planning revealed The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility will establish, document, and implement the care and services to be provided for each resident to assist in attaining or maintaining his or her highest practical quality of life.

Based on interviews and record review, the facility failed to ensure in accordance with professional standards of practices, the medical records on each resident were accurately documented for 1 of 4 residents (Resident #1) reviewed for accurate medical records. The facility failed to ensure as of 10/20/25 Resident #1's WAR had been completed to reflect she had been receiving wound care to her BLE as ordered in October 2025. The facility failed to be able to identify the staff member who's initial in the EMR system were MP1 on Resident #1's WAR after it had been filled out for October 2025. These failures could place residents receiving wound care at risk for wound care to be done more often than ordered by the physician, for staff not being able to question or collaborate with the unidentified staff member, or for receiving inaccurate care or diagnoses due to lack of documentation.Findings included:Record review of the face sheet dated 10/20/25 indicated Resident #1 was a [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses including diabetes, non-pressure chronic ulcers (persistent open wounds that do not heal within 6 weeks and are not caused by pressure) of the right and left lower legs, congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), hypertension (elevated blood pressure), and atrial fibrillation (a condition where the upper chambers of the hear beat irregularly and rapidly). Record review of the Quarterly MDS dated [DATE] indicated Resident #1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS of 10 and was moderately cognitively impaired. The MDS indicated Resident #1 had open lesion(s) other than ulcer, rashes, or cuts with treatment in place of non-surgical dressing and application ointments/medications. Record review of the care plan last revised 9/5/25 indicated Resident #1 had actual impairment of skin integrity related to wound to the lower leg. Record review of the physician orders indicated Resident #1 had orders to cleanse BLE with normal saline or wound cleanser, apply Xeroform (petroleum wound dressing) to open areas, apply ABD pads to the sites, wrap with rolled gauze, and secure with tape starting 9/6/25. Record review of the WAR dated 10/20/25 indicated it was not signed off that Resident #1 had received her wound cared to her BLE on 10/1/25, 10/2/25, 10/3/25, 10/4/25, 10/6/25, 10/7/25, 10/8/25, 10/9/25, 10/10/25, 10/11/25, 10/12/25, 10/13/25, 10/14/24, 10/16/25, and 10/17/25. Record review of the WAR dated 10/21/25 indicated it was signed off that Resident #1 had received wound care by a staff member with the assigned initials MP1 on 10/1/25, 10/2/25, 10/3/25, 10/4/25, 10/13/25, 10/14/25, 10/16/25, and 10/17/25 and by at staff member with the assigned initials kb25 on 10/6/25, 10/7/25, 10/8/25, 10/9/25, 10/10/25, 10/11/25, and 10/12/25. During an interview on 10/21/25 at 11:46 a.m. the DON said the floor nurses, herself and the ADON performed wound care on the residents since the Treatment Nurse's status changed to PRN. The DON said she did not know who went back in and documented wound care being performed daily in October after the previous surveyor had printed the WAR on 10/20/25. The DON said it could not be proved the wound care was performed on the days not documented other than the nurse saying she worked that day. The DON said LVN A had come to her the other day (date not specified) asking for bigger xeroform as she was using approximately 9 xeroform per leg on Resident #1's legs. The DON said she would ask who documented on the WAR for Resident #1's wound care and how they were able to prove the wound care was performed. During an interview on 10/21/25 at 12:09 p.m. the DON said kb25 was LVN A. The DON said she spoke with LVN A who said she went back in Resident #1's chart this morning (10/21/25) and documented wound care being performed. The DON said that LVN A said she had to go back in to document the wound care because she forgot to go to the WAR and check it off. The DON said she did not know who the assigned initials MP1 belonged to. The DON said her assigned initials in the EMR were MP25. The DON said she pulled the facility staff list for the EMR and could not find any staff member with the initials MP1 assigned to them. During an interview on 10/21/25 at 1:26 p.m. LVN A said she floated between sides upstairs depending on who was off work. LVN A said the nurses were responsible for performing wound care. LVN A said she worked out of the TAR in the EMR and did not check the WAR. LVN A said she did go in this morning and checked off in the WAR that wound care was performed on Resident #1 on the days she had worked. LVN A said she normally documented performing wound care on the 24hr report. During an interview on 10/22/25 at 9:52 a.m. Resident #1 said she was treated good at the facility. Resident #1 said her legs had to be wrapped today. Resident #1 said staff at the facility performed wound care on her daily. Resident #1 said she did not have any concerns at the facility. During an interview on 10/22/25 at 10:21 a.m. LVN B said to know if a resident had orders for wound care she would look in the WAR. LVN B said once wound care was completed it was checked off on the WAR. LVN B said most of the time the morning shift performed wound care on residents in even numbered rooms and the evening shift performed wound care on the odd numbered rooms. LVN B said she had performed wound care on Resident #1. LVN B said she would forget to sign out on the WAR when she completed wound care. LVN B said the importance of accurate documentation was to ensure it could be proved a resident was receiving their ordered care and so other nurses could determine what care had been provided for a resident. During an interview on 10/22/25 at 12:35 p.m. the DON said the facility's Electronic Medical Records policy was the only policy they had regarding medical or clinical records. During an interview on 10/22/25 at 12:54 p.m. the DON said she was never able to determine what staff member had been assigned initials MP1. The DON said she expected documentation to be done daily and as care was provided, or when medications were administered. The DON said the importance of accurate documentation was to prove care was provided and what was going on with the residents. Record review of the facility's Electronic Medical Records policy last revised March 2014 indicated, .Only authorized persons who have been issued a password and user ID code will be permitted access to the electronic medical records system.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 staff (LVN B) viewed for infection control. The facility failed to ensure LVN B performed hand hygiene between glove changes while performing wound care on 10/22/25. These failures could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. These failures could place residents receiving wound care at risk for wound care to be done more often than ordered by the physician, for staff not being able to question or collaborate with the unidentified staff member, or for receiving inaccurate care or diagnoses due to lack of documentation.Findings Include:1. During an observation on 10/22/25 at 10:35 am LVN B performed wound care on Resident #1. Prior to starting wound care LVN B washed her hands, disinfected her workspace, and gathered all wound care supplies. LVN B washed her hands, put on clean gloves, and removed the dressing from Resident #1's RLE. LVN B removed her gloves, washed her hands, put on clean gloves, and then cleansed Resident #1's RLE with normal saline. LVN B removed her gloves, did not perform hand hygiene, put on clean gloves, applied cream to Resident #1's RLE, and then applied Xeroform (petroleum-based dressing) to the open areas on Resident #1's RLE. LVN B removed her gloves, did not perform hand hygiene, put on clean gloves, applied ABD pads, and wrapped Resident #1's RLE with rolled gauze. LVN B washed her hands, put on clean gloves, and removed the dressing from Resident #1's LLE. LVN B removed her gloves, washed her hands, put on clean gloves, and then cleaned Resident #1's LLE. LVN B removed her gloves, did not perform hand hygiene, put on clean gloves, and then applied cream to Resident #1's LLE. LVN B removed her gloves, did not perform hand hygiene, put on clean gloves, and applied Xeroform to Resident #1's LLE. LVN B removed her gloves, washed her hands, put on clean gloves, and applied ABD pads secured with rolled gauze to Resident #1's LLE. During an interview on 10/22/25 at 11:20 a.m. LVN B said hand hygiene should be performed prior to starting care, after removing soiled dressing (during wound care), and when wound care was completed. LVN B said, It just depends (she did not give specifics on what it depended on) if hand hygiene should be done with glove changes. LVN B said the importance of hand hygiene was infection control. During an interview on 10/22/25 at 12:54 p.m. the DON said she expected staff to perform hand hygiene before providing care, any time gloves were changed, and when hands were visibly soiled. The DON said the importance of proper hand hygiene was to prevent infection. Record review of the facility's Handwashing/Hand Hygiene policy last revised October 2023 indicated, This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.Hand hygiene is indicate: immediately before touching a resident.after contact with blood, body fluids, or contaminated surfaces.before moving from work on a soiled body site to a clean body site on the same resident; and immediately after glove removal. Record review of the facility's Standard Precautions policy last revised September 2022 indicated, Standard precautions are used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard precautions presume all blood, body fluids secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents.Standard precautions include the following practices: 1. Hand Hygiene.b. Hand hygiene is performed with ABHR or soap and water. (1) before and after contact with the resident. (3) before moving from work on a soiled body sire to a clean body site on the same resident. (5) after removing gloves.

Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical abuse for 1 of 4 residents reviewed for abuse. (Residents #1)The facility failed to ensure Resident #1 was free from physical abuse when on 05/02/25 Resident #2 grabbed Resident #1's shirt around the neck, stretching the fabric, and bit her hand. Resident #1 had a visible bite mark to the back of the left hand and redness to the chest. This failure could place residents at risk for emotional distress, fear, decreased quality of life, and further abuse.Findings included:Record review of a face sheet dated 11/20/25 indicated Resident #1 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia (loss of cognitive functioning), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), depression (mental illness that negatively affects how you feel, the way you think and how you act), anxiety disorder (persistent and excessive worry that interferes with daily activities), and Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). Record review of the MDS dated [DATE] indicated Resident #1 had clear speech, was able to make herself understood, could understand others, she had a BIMS of 9 out of 15 indicating she had moderately impaired cognition, and she had no behaviors. Record review of the MDS dated [DATE] indicated Resident #1 had clear speech, was able to make herself understood, could understand others, she had a BIMS of 8 out of 15 indicating she had moderately impaired cognition, and she had no behaviors.Record review of the care plan revised on 09/08/25 indicated Resident #1 had no indication of behaviors. Record review of Nurse Notes for Resident #1 indicated on 05/02/25 Incident Report:Date/Time of Incident: 05/02/2025 at 06:30pmLocation: 1st Floor Front Doorway near LobbyDetails of Incident:Patient sustained a visible bite mark measuring 4cm x 3.5cm on the posterior lateral (outside of the back side) aspect of the left hand, without skin break,during an incident involving physical and verbal aggression by another resident. The patient also presents with redness to the chest,with no visible scratches noted. The patient reports that the aggressor grabbed her shirt around the neck, visibly stretching thefabric, and would not release it before biting her hand. Immediately following the incident, the patient was visibly shaken, anxious,and tearful, reporting 5/10 pain to the chest and neck. PRN tramadol was administered for pain management, and the patientexpressed that the tramadol had a good effect, with her pain now rated at 1/10.Vital Signs: BP: 130/72 Pulse: 80 bpm Respirations: 20/min SpO2: 99% Temperature: 98 FPost-Incident Actions:The on-call supervisor and ADON were notified immediately. The patient was removed from the area, and breathing exercises wereencouraged to reduce anxiety. Staff and a resident friend provided emotional support by sitting with the patient. The patient's nextof kin (daughter) was notified by this nurse at approximately 8:00 PM; however, the phone call went unanswered, and a voicemailwas left. At 8:00 PM, I spoke with [name] NP, who gave a verbal order for 50mg hydroxyzine PRN every 8 hours for anxiety. Thepatient received her first dose at 8:00 PM. Following this, the patient is now sitting in the dining room with two friends, andadditional ice was provided to the left hand to apply for 5-10 minutes to reduce swelling and discomfort. Notably, bruises arebeginning to form on the posterior side of the left hand. Resident friends continue to offer the patient support.Ongoing Monitoring:Frequent checks are being conducted on the patient, and she appears to be doing better emotionally but remains somewhat anxious.This nurse will continue to monitor the patient with checks every 15 minutes to assess her emotional state and pain levels. Thecurrent pain level remains at 1/10, and the patient continues to express relief following the tramadol.Documentation and Handoff:The ADON and on-call supervisor are aware of the situation and subsequent actions taken. This information will be passed on duringthe next shift handoff for continued monitoring and care.Conclusion:This nurse will continue to provide support, monitor the patient's condition, and document any changes. The situation will be closelymonitored, and further updates will be provided as necessary.The note was signed by LVN A.Record review of an Incident/Accident Report dated 05/02/25 indicated Resident #1 .sustained a visible bite mark measuring 4cm x 3.5cm on the posterior lateral aspect of the left hand, without skin break, during an incident involving physical and verbal aggression by another resident. [Resident #1] also presents with redness to the chest, with no visible scratches noted. [Resident #1] reports that the aggressor grabbed her shirt around the neck, visibly stretching the fabric, and would not release it before biting her hand.Following the incident, [Resident #1] was visibly shaken, anxious, and tearful, reporting 5/10 pain to the chest and neck. PRN tramadol was administered for pain management, and [Resident #1] expressed that the tramadol had a good effect, with her pain now rated at 1/10.[Resident #1] was removed from the area, and breathing exercises were encouraged to reduce anxiety. Staff and a resident friend provided emotional support by sitting with [Resident #1]. Following this, [Resident #1] is now sitting in the dining room with two friends, and additional ice was provided to the left hand to apply for 5-10 minutes to reduce swelling and discomfort. Notably, bruises are beginning to form on the posterior side of the left hand.During an observation and interview on 11/19/25 at 10:45 a.m. Resident #1 was in main dining room for activity. She indicated she was doing good. She indicated she had no issues. She said there was an incident involving Resident #2. She said he grabbed her shirt she was wearing and caused red areas on her chest. She said he also bit her on her hand. She said after the incident she would not sit at the table with him anymore and would stay away from him when she came downstairs. She said she had had no further issues with Resident #2. There was no observed visible redness or bruising on her chest or hand.During an interview on 11/19/25 at 02:48 p.m. LVN A said Resident #1 would go down to the dining room and she sat at the same table as Resident #2. She said since the Resident #2 grabbed and bit Resident #1 back in May, she no longer sat at the table with Resident #2. She said Resident #1 told her she was going to stay away from Resident #2. Record review of a face sheet dated 11/20/25 indicated Resident #2 was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included epilepsy (neurological disorder that causes seizures or unusual sensations and behaviors), attention deficit hyperactive disorder (a neurodevelopmental disorder that affects attention, impulse control, and activity levels), spastic cerebral palsy (a movement and neurological disorder that causes muscles to be overly toned), phonological disorder (a type of speech sound disorder condition where a person knows what they want to say but have difficulty organizing sound patterns to create words).Record review of the MDS dated [DATE] indicated Resident #2 had unclear speech, was usually able to make himself understood, sometimes understood others, he had a BIMS of 2 out of 15 indicating he had severely impaired cognition, and he had no behaviors.Record review of the MDS dated [DATE] indicated Resident #2 had unclear speech, was usually able to make himself understood, usually understood others, he had a BIMS of 2 out of 15 indicating he had severely impaired cognition, and he had no behaviors.Record review of the care plan revised on 08/12/25 indicated Resident #2 had no indication of behaviors.Record review of Nurse Notes for Resident #2 indicated on 05/02/25 [Resident #2] was sitting at the front door when another resident attempted to help him to the dining room for dinner. [Resident #2] then scratched and bit the female resident attempting to help him. received orders to send the resident to the emergency room due to him being a harm to others. The resident's mother was notified. EMS notified. [Resident #2] left the facility via EMS stretcher. The note was signed by RN Record review of an Incident/Accident Report dated 05/02/25 indicated Resident #2 .[Resident #2] was sitting at the front door when another resident attempted to help him to the dining room for dinner. [Resident #2] then scratched and bit the female resident attempting to help him. This RN notified NP and received orders to send the resident to the emergency room due to him being a harm to others. The resident's mother was notified. EMS notified. Resident left the facility via EMS stretcher.[Resident #2] was transferred to the ER for evaluation due to behaviors and change in baseline; returned with new orders for [antibiotic] related to positive urine culture.During an observation and interview on 11/19/25 at 10:45 a.m. Resident #2 was in propelling himself in the main area of the facility. Interactions with other residents were appropriate. Resident #2 indicated he was doing okay and had no issues with anyone. During an interview on 11/20/25 at 07:30 a.m. RN B said Resident #2 would have times he refused care, but he had not attacked another resident like he did Resident #1. She said she had no issues with him behaving like that again. She said Resident #1 and Resident #2 used to sit at the same table in the dining room but they don't since he grabbed her by the shirt and bit her back in May. She said they avoid each other. During an interview on 11/19/2025 at 3:30 p.m., the DON said Resident #2 had not had behaviors of grabbing or biting other residents. He was known to bite himself at times. She said Resident #1 and Resident #2 were separated immediately after he grabbed her shirt and bit her hand. She said assessments were done on both residents which indicated Resident #1 had red areas to her chest and a bite mark on the back side of her left hand and Resident #2 had no injuries. Resident #2 was sent out to the hospital for evaluation of his aggressive behavior. Record review of a Provider Investigation Report dated 05/07/25 indicated an incident categorized as Other: Resident to Resident Altercation occurred on 05/02/25. The incident involved Resident #1 and Resident #2. At approximately 6:05 a disturbance was heard coming from the entrance/lobby area of the facility by staff serving dinner in the main dining room. Upon arrival staff found Resident #1 was pressing her hand against her chest and standing a few feet away from Resident #2 who was seated in his wheelchair. Staff immediately separated the Residents and initiated assessments to determine if either of them were injured from the altercation. Resident #2 was transported to the hospital for evaluation of aggressive behavior and potential underlying medical conditions. An assessment conducted by RN B determined Resident #2 had no injuries from the altercation. He left the facility via EMS transport. RN B assessed Resident #1 and noted red areas to her chest and the left hand and area above left thumb were noted to be red without any broken skin.Record review of the Abuse, Neglect, Exploitation, and Misappropriation of Property policy revised February 12, 2020 indicated the following: .Policy 1. Resident Rights. Each resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse, neglect, exploitation, misappropriation of resident's property by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, resident representative, friends, or other individuals.

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care within 48 hours of a resident's admission and provide the resident and their representative with a summary of the baseline care plan for 4 of 21 residents (Resident #4, #5, #12 and #15) reviewed for new admissions. 1. The facility did not provide a copy of the baseline care plan to Resident #4 or their representative. 2. The facility to develop and accurately complete a baseline care plan within 48 hours of admission for Resident #5, #12, and #15. This failure could lead to residents not receiving necessary care and decreased quality of life.1. Record review of a face sheet dated [DATE] indicated Resident #4 was a [AGE] year-old male admitted on [DATE]. His diagnoses included respiratory failure (a serious condition that makes it difficult to breathe on your own), depression (mental illness that negatively affects how you feel, the way you think and how you act), post-traumatic stress disorder (mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it), hypertension (a condition in which the force of the blood against the artery walls is too high), heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs), chronic obstructive pulmonary disease (lung disease that blocks airflow making it difficult to breathe), benign prostatic hyperplasia (noncancerous enlargement of the prostate gland), and obstructive uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional). Resident #4 expired on [DATE]. Record review of a Baseline Care Plan dated [DATE] reflected it had no indication it was provided to Resident #4 or the RP.During an interview on [DATE] at 10:39 a.m. the DON said she did not see where the BLCP was provided to Resident #4 or the RP after reviewing the previous EMR system. She said he expired before the new EMR system was put into place on [DATE] so it would not be in the new EMR system. 2. Record review of a face sheet dated [DATE] indicated Resident #5 was a [AGE] year-old male admitted on [DATE]. His diagnoses included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), sepsis (potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), neoplasm of the prostate (non-cancerous enlargement of the prostate gland that commonly occurs in older men), atrial flutter (upper chambers of the heart beat faster than normal and are coordinated), anxiety disorder (persistent and excessive worry that interferes with daily activities), depression (mental illness that negatively affects how you feel, the way you think and how you act), and hypertension (condition in which the force of the blood against the artery walls is too high).Record review of a Baseline Care Plan for Resident #5 indicated the following: .B. Signature of Resident and Representative1. Resident signature and dateResident #5 [DATE]. C. Signatures of Staff Completing the Baseline Care Plan1. Signature of staff completing plan, title and dateLVN D [DATE].Record review of a Baseline Care Plan Acknowledgement for Resident #5 indicated a copy of the BLCP was provided to Resident #5 and to the RP on [DATE].Record review of a face sheet dated [DATE] indicated Resident #12 was a [AGE] year old female admitted on [DATE], and her diagnoses included mood disorder (mental disorders that primarily affect a person's emotional state), schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), morbid (severe) obesity due to excess calories, diabetes (a chronic condition that affects the way the body processes blood sugar), general anxiety (persistent and excessive worry that interferes with daily activities), vascular dementia (a type of loss of cognitive functioning caused by conditions that damage blood vessels and block blood flow to your brain) and depression (mental illness that negatively affects how you feel, the way you think and how you act). Record review of admission MDS assessment dated [DATE] for Resident #12 indicated she was able to make herself understood and understood others, she was cognitively intact (BIMS score 13), she was at risk for developing pressure ulcers and was utilizing pressure reducing devices for bed and chair for skin ulcer and injury prevention. She was frequently incontinent with bowel and bladder. Record review of a base line care plan dated [DATE] for Resident #12 reflected it did not contain the following CMS guideline required information:*Precautionary plan for fall risk;*Dietary instructions for Diabetic diet;*Prescribed PRN (as needed) medications;*Prescribed routine medications;*Prescribed therapy services; and*Failed to provide Resident #12 with a summary of the baseline care plan.During an interview on [DATE] at 2:15 p.m., LVN H said she completed the admission on Resident #12 on [DATE] but did not have time to complete the nursing section of the baseline care plan. She said that during shift report she told the oncoming nurse that the baseline care plan nursing section needed to be completed. Record review of a face sheet dated [DATE] indicated Resident #15 as [AGE] year old female admitted on [DATE], and her diagnoses included femur fracture (broken upper leg bone), delirium due to known physiological condition (serious disturbance in mental abilities that results in confused thinking and reduced awareness of the environment) and hypertension (condition in which the force of the blood against the artery walls is too high).Record review of a base line care plan dated [DATE] for Resident #15 reflected it did not contain the following CMS guideline required information:*Dietary instructions for Regular diet;*Prescribed social services; and*Prescribed therapy services; and*Failed to provide Resident #15 and/or her representative with a summary of the baseline care plan.During an interview on [DATE] at 4:15 p.m., SW said that she was unsure why Resident #15's social service base line care plan section (social services provided, mental health needs, behavioral concerns, PASARR Level recommendations, social service goals, and depression screening) was not completed. She said that as soon as she realized a new resident was admitted she completed the social service baseline this baseline care plan must have been missed.During an interview on [DATE] at 10:39 a.m. the DON said the base line care plan was to be completed within 48 hours of admission and acknowledged by the resident or resident representative. She said she did not know why Resident #5, #12, and #15's baseline care plans were not completed on time. She said the admitting charge nurse was responsible for completing the nursing and diet information, social workers and therapy staff were responsible for their sections. She said the completed baseline care plan should be acknowledged by the resident or resident representative. She said not completing the baseline care plans within 48 hours could delay the residents immediately health and safety needs. Record review of a facility's Care Plans - Baseline policy revised on [DATE] indicated .a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission .1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimal health care information necessary to properly care for their residents including but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b. physician orders c. dietary orders; d. therapy services; e. social services; and f. PASARR recommendations, if applicable.

Based on observation, interview, and record review, the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers based on the comprehensive assessment for 7 of 21 residents (Resident #s 1, 8, 9, 10, 11, 12, and 14) reviewed for skin assessments. The facility failed to ensure Residents #1, #8, #9, #10, #11, #12, and #14 received a weekly skin assessment to identify risk of pressure injuries or existing pressure injuries.This failure could place residents at risk for developing unidentified pressure ulcers, could contribute to developing avoidable pressure ulcers and of not receiving adequate care and medical treatments to maintain skin integrity.Findings include:Record review of a face sheet dated 11/20/25 indicated Resident #1 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia (loss of cognitive functioning), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), depression (mental illness that negatively affects how you feel, the way you think and how you act), anxiety disorder (persistent and excessive worry that interferes with daily activities), and Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). Record review of the MDS dated [DATE] indicated Resident #1 had clear speech, was able to make herself understood, could understand others, she had a BIMS of 9 out of 15 indicating she had moderately impaired cognition, and she had no behaviors. Record review of the MDS dated [DATE] indicated Resident #1 had clear speech, was able to make herself understood, could understand others, she had a BIMS of 8 out of 15 indicating she had moderately impaired cognition, and she had no behaviors.Record review of the care plan revised on 11/22/2024 indicated Resident #1 was at risk for skin breakdown due to impaired mobility, incontinent of bowel and bladder and impaired skin. Record review of Resident #1's EMR reflected he did not have a skin assessment for the weeks of 11/03/2025 and 11/10/2025.Record review of Resident #8's face sheet dated 11/18/2025 indicated he was [AGE] years old, initially admitted on [DATE] and readmitted on [DATE], and his diagnoses included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), Alzheimer's disease (progressive disease that destroys memory and other important mental functions), and cognitive communication deficit.Record review of Resident #8's quarterly MDS assessment dated [DATE] indicated he sometimes was able to make himself understood and usually understood others, had severe cognitive impairment (BIMS score 03), was utilizing pressure reducing device for bed and chair for skin ulcer and injury prevention. He was frequently incontinent with bowel and bladder.Record review of Resident #8's care plan dated 09/29/2025 indicated Resident #8 was at risk for pressure ulcers related to poor nutrition, and impaired skin integrity related to bowel/bladder incontinence and limited mobility related to dementia. Interventions included following facility policies/protocols for the prevention/treatment of skin breakdown, incontinent care after each episode and apply moisture barrier and notify nurse immediately of new skin breakdowns. Record review of Resident #8's EMR reflected he did not have a skin assessment for the weeks of 10/27/2025, 11/03/2025, and 11/10/2025.During an observation of Resident #8's skin assessment provided by WCN on 11/19/2025 at 4:15 p.m., skin color was normal, temperature of skin was warm, and no bruises, skin tears, abrasion, laceration, surgical incision, rash, moisture associated skin damage, pressure, venous, arterial or diabetic ulcer identified. Record review of Resident #9's face sheet dated 11/18/2025 indicated he was [AGE] years old, initially admitted on [DATE] and readmitted on [DATE], and his diagnoses included myocardial infarction (blood flow decreases or stops in one of the blood vessels of the heart causing tissue death), diabetes (a chronic condition that affects the way the body processes blood sugar) with neuropathy (type of nerve damage that can happen with diabetes), combined systolic (a condition in which the heart's main pumping chamber (left ventricle) is weak). and diastolic (a condition in which the heart's main pumping chamber (left ventricle) becomes stiff and unable to fill properly) heart failure, and cognitive communication deficit.Record review of Resident #9's significant change MDS assessment dated [DATE] indicated he usually was able to make himself understood and usually understood others, he was cognitively intact (BIMS score 14), he was at risk for developing pressure ulcers and was utilizing pressure reducing devices for bed and chair for skin ulcer and injury prevention. He was frequently incontinent with bowel and bladder.Record review of Resident #9's care plan dated 09/26/2025 indicated Resident #9 was at risk for impaired skin integrity related to bowel/bladder incontinence. Interventions included following facility policies/protocols for the prevention/treatment of skin breakdown, incontinent care after each episode and apply moisture barrier and notify nurse immediately of new skin breakdowns. Record review of Resident #9's EMR reflected he did not have a skin assessment for the weeks of 10/20/2025, 10/27/2025, 11/03/2025, and 11/10/2025.During an observation of Resident #9's skin assessment provided by WCN on 11/20/2025 at 7:45 a.m., skin color was normal, temperature of skin was warm, old fading bruise to right thigh, and no skin tears, abrasion, laceration, surgical incision, rash, moisture associated skin damage, pressure, venous, arterial or diabetic ulcer identified.Record review of Resident #10's face sheet dated 11/18/2025 indicated she was [AGE] years old, initially admitted on [DATE] and readmitted on [DATE], and her diagnoses included cellulitis (spreading skin infection, most commonly of the lower leg. It's caused by bacteria entering through a break in the skin), non-chronic ulcer to lower legs (leg ulcers or sores that take a long time to heal caused by poor circulation, diabetes or other health conditions), diabetes (a chronic condition that affects the way the body processes blood sugar), chronic obstructive pulmonary disease (COPD - a lung disease that blocks airflow making it difficult to breathe) and dementia (loss of cognitive functioning). Record review of Resident #10's significant change MDS assessment dated [DATE] indicated she usually was able to make herself understood and usually understood others, she was moderated impaired cognitively (BIMS score 09), she was at risk for developing pressure ulcers and was utilizing pressure reducing devices for bed for skin ulcer and injury prevention. She was always incontinent with bowel and bladder.Record review of Resident #10's care plan dated 09/05/2025 indicated Resident #10 was at risk for impaired skin integrity related to bowel/bladder incontinence and she had skin impairment to lower legs. Interventions included following facility policies/protocols for the prevention/treatment of skin breakdown and wound care, incontinent care after each episode and apply moisture barrier and notify nurse immediately of new skin breakdowns. Record review of Resident #10's EMR reflected he did not have a skin assessment for the weeks of 10/20/2025, 10/27/2025, 11/03/2025, and 11/10/2025.During an observation of Resident #10's skin assessment provided by WCN on 11/20/2025 at 7:30 a.m., skin color was normal, temperature of skin was warm, and no skin tears, abrasion, laceration, surgical incision, rash, moisture associated skin damage, pressure, venous, arterial or diabetic ulcer identified.Record review of Resident #11's face sheet dated 11/19/2025 indicated she was [AGE] years old, initially admitted on [DATE] and readmitted on [DATE], and her diagnoses included diabetes (a chronic condition that affects the way the body processes blood sugar), polyneuropathy (a nerve disease caused by damage to many nerves, often due to conditions like diabetes or alcohol overuse), general anxiety (persistent and excessive worry that interferes with daily activities), vascular dementia (a type of loss of cognitive functioning caused by conditions that damage blood vessels and block blood flow to your brain) and depression (mental illness that negatively affects how you feel, the way you think and how you act). Record review of Resident #11's quarterly MDS assessment dated [DATE] indicated she usually was able to make herself understood and usually understood others, she was severely impaired cognitively (BIMS score 03), she was at risk for developing pressure ulcers and was utilizing pressure reducing devices for bed and chair for skin ulcer and injury prevention. She was always incontinent with bowel and bladder. She had skin issues identified as MASD (moisture associated skin damage).Record review of Resident #11's care plan dated 09/16/2025 indicated Resident #11 was at risk for impaired skin integrity related to bowel/bladder incontinence. Interventions included following facility policies/protocols for the prevention/treatment of skin breakdown, incontinent care after each episode and apply moisture barrier and notify nurse immediately of new skin breakdowns.Record review of Resident #11's EMR reflected he did not have a skin assessment for the weeks of 10/13/2025, 10/20/2025, 10/27/2025, and 11/03/2025.Record review of Resident #11's wound evaluation and management summary dated 11/11/2025 authored by wound care physician indicated that Resident #11 had a skin tear wound of the left buttock and receiving treatment of house barrier cream to be applied once daily and as needed: if saturated, soiled or dislodged for 30 days. Record review of Resident #11's wound evaluation and management summary dated 11/18/2025 authored by wound care physician indicated that Resident #11's wound had healed. During an observation of Resident #11's skin assessment provided by MDS Nurse on 11/20/2025 at 7:00 a.m., skin color was normal, temperature of skin was warm, and no skin tears, abrasion, surgical incision, rash, moisture associated skin damage, pressure, venous, arterial or diabetic ulcer identified. Resident #11 had a red dime sized area to the coccyx/tailbone area. Record review of Resident #12's face sheet dated 11/18/2025 indicated she was [AGE] years old, admitted on [DATE], and her diagnoses included mood disorder (mental disorders that primarily affect a person's emotional state), schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), morbid (severe) obesity due to excess calories, diabetes (a chronic condition that affects the way the body processes blood sugar), general anxiety (persistent and excessive worry that interferes with daily activities), vascular dementia (a type of loss of cognitive functioning caused by conditions that damage blood vessels and block blood flow to your brain) and depression (mental illness that negatively affects how you feel, the way you think and how you act). Record review of Resident #12's admission MDS assessment dated [DATE] indicated she was able to make herself understood and understood others, she was cognitively intact (BIMS score 13), she was at risk for developing pressure ulcers and was utilizing pressure reducing devices for bed and chair for skin ulcer and injury prevention. She was frequently incontinent with bowel and bladder. Record review of Resident #12's care plan dated 11/13/2025 indicated Resident #12 was at high risk for pressure ulcer and risk for impaired skin integrity related to bowel/bladder incontinence. Interventions included following facility policies/protocols for the prevention/treatment of skin breakdown, incontinent care after each episode and apply moisture barrier and notify nurse immediately of new skin breakdowns.Record review of Resident #12's EMR weekly skin assessments indicated the last skin assessment done was an initial skin assessment on 10/31/2025.During an observation of Resident #12's skin assessment provided by WCN on 11/19/2025 at 2:30 p.m., skin color was normal, temperature of skin was warm, and no skin tears, abrasion, lacerations, surgical incision, rash, moisture associated skin damage, pressure, venous, arterial or diabetic ulcer identified. Record review of Resident #14's face sheet dated 11/19/2025 indicated he was [AGE] years old, admitted on [DATE], and his diagnoses included acute kidney failure (kidneys suddenly stop working), chronic kidney disease stage 5 (kidneys are working less than 15%; people with stage 5 CKD will need dialysis or a kidney transplant to survive), systolic heart failure (a condition in which the heart's main pumping chamber (left ventricle) is weak), and malignant neoplasm (cancerous tumor) of unspecified part of the lung.Record review of Resident #14's quarterly MDS assessment dated [DATE] indicated he was able to make himself understood and understood others, he was cognitively intact (BIMS score 14), he was not a risk for developing pressure ulcers but utilizing pressure reducing devices for bed for skin ulcer and injury prevention. He was occasionally incontinent with bladder and always continent of bowel. Record review of Resident #14's care plan dated 09/30/2025 indicated Resident #14 had actual impairment to skin integrity at potential for pressure ulcer development. Interventions included following facility policies/protocols for the prevention/treatment of skin breakdown, incontinent care after each episode and apply moisture barrier and notify nurse immediately of new skin breakdowns.Record review of Resident #14's EMR reflected he did not have a skin assessment for the weeks of 10/13/2025, 10/20/2025, 10/27/2025, 11/03/2025, and 11/10/2025.During an observation of Resident #14's skin assessment provided by WCN on 11/19/2025 at 5:00 p.m., skin color was normal, temperature of skin was warm, and no skin tears, abrasion, surgical incision, rash, moisture associated skin damage, pressure, venous, arterial or diabetic ulcer identified. Resident #14 had a bandage to left antecubital (front of elbow) area with a 11/18/2025 date. Bruising noted to left antecubital, elbow and down arm and hand. During an interview on 11/20/2025 at 9:00 a.m., WCN said she had only been employed at the facility for 1.5 weeks. She said she makes rounds with the wound care physician weekly and assists with wound care treatment and completes skin assessments at that time. She said that she was responsible for providing wound care and completing skin assessment for the residents requiring wound care. She said that the charge nurses were responsible for completing the weekly skin assessment for the residents that are not being seen by the wound care physician. She said Resident #10 was being seen by the wound care physician and receiving treatment to BLE for a rare skin disorder. She said she provides wound care daily to Resident #10's LE's and she performs her skin assessments weekly. She said that Resident #11 was being seen by the wound care physician for a skin laceration to coccyx/buttock and had recently been discharged from his care due to the wound progressing and only requiring barrier cream for protectant. She said Resident #14 was receiving dialysis and recently received a new dialysis graft to his left arm and that is why his left arm was so bruised. She said Resident #14's new dialysis graft site was being treated and monitored by the dialysis center and that the facility was to assess the site and report any abnormal findings to the dialysis center. She said that it was important for the impaired and limited residents to have weekly skin assessments to identify any skin breakdown and provide treatment promptly. During an interview on 11/19/2025 at 3:00 p.m., LVN A said she would complete weekly skin assessment if they were assigned or flagged in the resident's electronic record. She said she would print out a list of required assessments needed to complete for her shift from the EMR and she would complete the assigned assessments in the EMR. She said the residents were at risk of not receiving care as necessary without assessments.During an interview on 11/19/2025 at 1:10 p.m., LVN D said all residents were assigned on a schedule for skin assessments. She said the resident weekly skin assessment was usually triggered in the EMR and indicated the assessment is due. She said the residents were at risk of not receiving care as necessary without assessments.During an interview on 11/19/2025 at 1:40 p.m., RN B said all residents were assigned on a schedule for weekly skin assessments. She said the resident weekly skin assessment was usually triggered in the EMR and indicated the assessment is due. She said that prior to the current EMR that was new as of 08/01/2025 the nurses had a list of skin assessments and when each should be done. She said since the new system was initiated that the system should generate weekly skin assessments. She said the facility recently learned that if the skin assessment is not completed the system will not generate the next due assessment. She said the residents were at risk of skin breakdowns or not receiving care as necessary without assessments. She said that the CNAs usually report to charge nurses if they identify any new skin issues during personal care or bath/showers. During an interview on 11/19/2025 at 5:15 p.m., the DON indicated that the charge nurses were responsible for completing the weekly skin assessments unless the resident was being seen by the wound care nurse and wound care physician. The DON said the nurses were trained in how to document the weekly skin assessments in the new EMR. The DON said she had just learned from the facility staff that the EMR was not automatically generating some of the weekly skin assessments as required. She said that RN B told her that the weekly skin assessment was not generating weekly in the EMR if the previous weekly skin assessment was not completed. She said she had contacted the EMR representative and submitted a ticket to attempt to alleviate this issue. She said the EMR should generate a weekly skin assessment weekly until the resident is discharged . She said that she will have staff do a sweep of all residents and conduct a skin assessment. She said she would start tracking the weekly skin assessments as facility had done previously by paper copy of list skin assessments required weekly assigned to charge nurse for each shift with room number and bed location. She said once the new WCN becomes more familiar with the facility and residents she will be assigned to complete the weekly skin assessments on the residents. The DON said skin assessments not being completed could cause residents to have skin impairment which may go untreated. The DON said that the CNAs are responsible for reporting any skin impairment identified while providing personal care and baths, so she would hope that no skin impairments go unidentified or untreated. Record review of the facility's Prevention of Pressure Injuries policy revised April 2020 indicated Purpose: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors . Risk Assessment. 1. Assess the resident on admission (within 8 hours) for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. Skin Assessment. 1. Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment as indicated according to the resident's risk factor and prior to discharge. 2. During a skin assessment inspect. Presence of a. erythema (redness) b. temperature of skin and soft tissue; and c. edema (swelling) .

Based on observation, interview and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 3 of 3 medication carts (1st Floor North/East Medication Aide Cart, 1st Floor North (even)/East Nurse Cart, and 1st Floor North (odd)/West Nurse Cart) and 1 of 3 residents (Resident #3) reviewed for controlled medications.* LVN C did not sign out on Resident #3's narcotic count sheet for the hydrocodone/acetaminophen 5mg/325mg (narcotic pain medication) when she administered the medication on 11/19/25 or 11/20/25 during the night shift.* LVN C, RN B, and LVN D did not count the narcotics on the 1st Floor North/East Medication Aide Cart with during the shift change on 11/20/25 to ensure the count was correct.* LVN C and RN B did not count the narcotics on the 1st Floor North (even)/East Nurse Cart during the shift change on 11/20/25 to ensure the count was correct.* LVN C and LVN D did not count the narcotics on the 1st Floor North (odd)/West Nurse Cart during the shift change on 11/20/25 to ensure the count was correct.This failure could place residents at risk for medication overdose, medication under-dose, ineffective therapeutic outcomes, and drug diversion. Findings included: During an observation and interview on 11/20/25 at 06:43 a.m. MA E asked RN B to count Resident #3's bottle of hydrocodone/acetaminophen 5mg/325mg because the count was off by 1 tablet. When RN B counted the medication, it was one 1 tablet short. RN B said LVN C had told her she had given Resident #3 a hydrocodone/acetaminophen 5mg/325mg tablet on the 11/19/25 6p-6a shift. Record review of the narcotic count sheet for Resident #3 indicated there was no medication signed out for 11/19/25 or 11/20/25 by LVN C. During an interview on 11/20/25 at 06:45 a.m. MA E said she was late this morning and LVN C was already gone when she arrived, so she did not count the medication cart with her. RN B said she and LVN C did not count the Medication Aide cart before LVN C left. She said if the MA was not at work yet then the nurse should count with one of the other nurses. MA E said she counted the cart when she arrived and noticed the one medication was off by one tablet so she had RN B recount with her. During an interview on 11/20/25 at 07:22 a.m. LVN D said LVN C did not count the medication aide cart or her cart with her. She said they were supposed to count the narcotics when she comes on and before the night shift leaves. During an interview on 11/20/25 at 07:23 a.m. RN B said LVN C did not count her cart with her. She said she signed the shift count sheet because she counted her cart to ensure the count was correct. During an interview on 11/20/25 at 07:25 a.m. the ADON said the nurses and medication aides were expected to count narcotic medications during shift change. Record review of the Narcotic Drug Shift Count Sheets for November 2025 for the 1st Floor North/East Medication Aide Cart indicated there was no signature for:-10p-6a off going shift on1st through 6th, 9th through 15th, and 19th through 20th;- 6a-2p off going shift on 5th, 17th, and 18th;- 2p-10p off going shift on 14th and 16th; and- 10p-6a on coming shift on 1st through 5th, 8th through 14th, and 17th through 20th. Record review of the Narcotic Drug Shift Count Sheets for November 2025 for the 1st Floor North (even)/East Nurse Cart indicated there was no signature for:- 6p-6a off going shift on 8th, 12th, and 15th;- 6a-6p on coming shift on 17th and 18th;- 6a-6p off going shift on 10th, 17th, and 18th; and- 6p-6a on coming shift on 16th. Record review of the Narcotic Drug Shift Count Sheets for November 2025 for the 1st Floor North (odd)/West Nurse Cart indicated there was no signature for:- 6p-6a off going shift on 3rd, 8th, 16th, 17th, and 18th; - 6a-6p on coming shift on 3rd, 9th, 12th, 13th, 17th, 18th, and 20th;- 6a-6p off going shift on 3rd, 9th, 12th, 13th, 17th, and 18th; and- 6p-6a on coming shift on 1st, 2nd,7th, 14th, and 15th. During an interview on 11/20/25 at 09:56 a.m. the DON said she expected nurses and medication aides to count the narcotics at shift change. She said she was not aware of all the missing signatures from the shift count sheets. She said they figured out where Resident #3's hydrocodone/acetaminophen 5mg/325mg missing tablet went. She said she spoke with Resident #3 and she said she had received the medication when she requested it. She said LVN C was not able to be contacted at this time because she was asleep. During an interview on 11/20/25 at 10:28 a.m. the Administrator said staff were expected to count the narcotics at shift change. He said if they were not counted staff would be counseled and re-educated. He said there was the risk of drug diversion if not counted. Record review of a Controlled Substances policy dated 2001 indicated the following: Policy StatementThe facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule 11-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976).Policy Interpretation and Implementation Handling Controlled Substances.4. If the count is correct an individual resident controlled substance record is made for each resident who will be receiving a controlled substance. Do not enter more than one (1) prescription per page. This record contains:. l. signature of nurse administering medication.Dispensing and Reconciling Controlled Substances.3. Nursing staff count controlled medication inventory at the end of each shift using these records to reconcile the inventory count.4. The nursing coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the State Survey Agency, for 1 (Resident #6) of 4 residents reviewed for reporting allegations of abuse. The facility failed to report an allegation of abuse within 2 hours to the State Agency when Resident #6 reported to PTA J he was left on the bedpan too long and felt like he was abused. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.Findings included: Record review of a face sheet dated 11/20/2025 indicated Resident #6 was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included unspecified atrial fibrillation (a type of irregular heartbeat), cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump), muscle weakness, peripheral disease (a blood circulation disorder that causes the blood vessels outside of the heart and brain to narrow, block, or spasm) extended spectrum beta lactamase (ESBL) resistance (enterobacterales are a group of bacteria that cause infections in healthcare settings and communities) and pneumonitis due to inhalation of food and vomit (a condition that occurs when foreign substances such as food, liquids, or stomach contents are inhaled into the lungs. This can lead to inflammation and irritation in the lungs, affecting the ability to breathe properly). Record review of a MDS admission assessment dated [DATE] indicated Resident #6 was able to make himself understood and understood others. He had a BIMS of 15 (intact cognitively). He had no behaviors identified. He required maximum assistance for toileting hygiene, shower/bathing and lower body dressing and moderate assistance with upper body dressing, and personal hygiene. He was always incontinent of bowel and bladder. Record review of Resident #6's care plan dated 10/13/2025 indicated Resident #6 had limited mobility, bowel/bladder incontinence and he required the support of one-person physical assist for toilet use. Record review of Resident #6's grievance form dated 11/13/2025 at 3:28 p.m. authored by PTA J reflected Resident #6 stated he is often left on his bedpan for long periods of time and reports it was 90 minutes yesterday and states this is abuse. Record review of TULIP (online system for submitting long-term care incidents and complaints) indicated the facility did not report the allegation of abuse on 11/13/2025.During an interview on 11/19/2025 at 2:00 p.m., PTA J said during Resident #6's therapy session on 11/13/2025 he reported to him that he felt like he was abused because he was left on his bedpan for long periods of time on 11/12/2025. He said Resident #6 said the incident occurred 11/12/2025 but he did not inform anyone until telling him on 11/13/2025. He said that he sent an electronic message to the management team and notified the Administrator of the report immediately.During an interview on 11/19/2025 at 2:15 p.m., CNA G said he does not recall Resident #6 but if a resident is placed on the bedpan around shift change or last rounds that he checks with the resident before leaving the hall or notifies the oncoming shift that the resident is on the bedpan. He said he would leave the call light nearby and tell the residents to call when they needed to be removed or assistance. He said he has been trained on abuse and neglect and was aware of reporting any allegations of abuse to the Administrator/Abuse Prevention Coordinator immediately.During an interview on 11/19/2025 at 3:30 p.m., the DON said that she received an electronic message from PTA J reporting that Resident #6 had stated to him that he felt like he had been abused by facility staff because he was left on the bedpan too long 11/12/2025. She said she and the Administrator immediately went and interviewed Resident #6. She said that Resident #6 declined being abused and acknowledged he was frustrated because of loss of independence. She said Resident #6 said he had requested the bedpan at shift change and the outgoing staff checked on him prior to leaving the shift but he was not finished, so he had to wait a little longer for oncoming staff to remove him from the bedpan. She said he denied abuse and said he felt safe at the facility. She said he was apprehensive about his upcoming discharge and providing self-care at home. She said allegations of abuse should be reported to the Administrator/abuse coordinator immediately, so the appropriate authorities (local police, state agencies, ombudsman, family) could be notified during the required timeframe. During an interview on 11/19/2025 at 4:00 p.m., the Administrator said that he received an electronic message from PTA J that Resident #6 had made a statement regarding being abused. He said he and the DON immediately went to interview Resident #6. He said that Resident #6 declined being abused and acknowledged he was frustrated because of loss of independence. He said Resident #6 said he had requested the bedpan at shift change and the outgoing staff checked on him prior to leaving the shift but he was not finished, so he had to wait a little longer for oncoming staff to remove him from the bedpan. He said Resident #6 denied abuse and said he felt safe at the facility. He said he did not report the allegation of abuse because during his 2-hour window he spoke with the resident, and he denied the allegation. He said if abuse occurred that he would have reported it to the appropriate authorities (local police, state agencies, ombudsman, family) during the required timeframe. He acknowledged that his policy does say that alleged abuse should be reported to the state agency within 2 hours and he should have reported the allegation to the state agency within 2 hours. Record review of the facility's Abuse investigating and reporting policy revised July 2017 indicated . Reporting: 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation of property will be reported by the facility administrator or his or her designee to the following persons or agencies: a. The state licensing certification agency responsible for surveying licensing the facility. 2. An alleged violation of abuse neglect exploitation OR mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately but no later than: a. Two hours if the alleged violation involves abuse or has resulted in serious bodily injury.

Based on interview and record review, the facility failed to ensure that residents received care and services in accordance with professional standards of practice for 1 of 9 residents (Resident #1) reviewed for quality of care. 1. The facility failed to follow up with a cardiologist appointment on 2/25/25 for Resident #1 for 36 days, from 2/25/25 to 4/1/25. 2. The facility failed to ensure Resident #1 received a vascular surgeon referral when the order was given on 02/12/25, which resulted in the development of gas gangrene (rare but highly lethal and potentially life-threatening bacterial infection that destroys muscle tissue, blood cells, and blood vessels producing a gas that causes tissue death and a foul smell) and an above-the-knee amputation (surgical removal) of his right leg on 04/02/25. An immediate jeopardy (IJ) was identified on 05/04/25 at 11:00 AM. The IJ template was provided to the facility on [DATE] at 11:15 AM. While the IJ was removed on 05/05/25 at 5:32 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems on entering physician orders, scheduling appointments or referrals, and ensuring documentation of missed appointments. These failures could place residents at risk of receiving a delay in treatment or services, serious injury, harm, disfigurement, or death. The findings included: Resident review of Resident #1's face sheet printed on 4/11/25 indicated Resident #1 was an [AGE] year-old male who admitted on [DATE] and discharged on [DATE] and did not return. Record review of Admission MDS assessment dated [DATE] indicated Resident #1 had clear speech, was able to make self-understood and had the ability to understand others. He had BIMS score of 12 out of 15 indicating he was moderately impaired cognitively. The MDS assessment indicated Resident #1 did not exhibit rejection of care. The MDS assessment indicated Resident #1 required substantial to moderate assist with most ADLs. The MDS assessment indicated Resident #1 had no unhealed pressure ulcer/injuries, no venous and arterial ulcers present and no foot problems. Record review of Resident #1's revised care plan dated 01/31/25 revealed that the Resident #1 as being care planned for skin breakdown: At risk/actual. Related to: History of Cardiovascular Disease. Evidence By: Severe score 6-9 for Pressure Ulcer risk, Confined to bed and/or chair most of the time, extensive bed mobility and total transfer assist. Goal: Resident #1 would maintain clean and intact skin for the next 90 days. - Measures would be taken to prevent skin breakdown over the next 90 days and open area will be healed over the next 90 days. Interventions: -Assist Resident #1 to turn and reposition frequently. - Inspect skin daily with care and bathing and report any changes to charge nurse. - Keep skin clean, dry, and free of irritants. - Treatments and dressings as ordered per physician. Record review of after visit summary also known as the admitting orders printed on 1/24/25 indicated Resident #1 was in the hospital from 1/14/25 to 1/24/25 due to malignant hypertensive urgency (high blood pressure that requires treatment to bring it down). Follow up appointment with Cardiologist on Tuesday February 25, 2025, at 10:40am (arrive by 10:25am). Record review of an undated physician's orders report printed on 4/11/25 indicated Resident #1 had diagnoses including hypertensive urgency (a clinical situation in which blood pressure is very high with minimal or no symptoms, and no signs or symptoms indicating acute organ damage), unspecified skin changes, muscle weakness (generalized), unspecified diastolic (congestive) heart failure, and essential (primary) hypertension. The physician order's report further revealed the following treatment orders: 1. Dated: 02/06/25 to 02/25/25 - Cleanse right heel with normal saline, pat dry, apply xeroform, apply dry protective dressing, and wrap with Kerlex daily on the 6 AM - 2 PM shift. 2. Dated: 02/06/25 to 02/25/25 - Cleanse right great toe with normal saline, pat dry, apply xeroform, apply dry protective dressing, and wrap with Kerlex daily on the 6 AM - 2 PM shift. 3. Dated: 02/06/25 to 04/05/25 - Skin prep wipes twice daily to the right lateral ankle. 4. Dated 02/06/25 to 04/05/25 - Skin prep wipes twice daily to the right second toe. 5. Dated 02/06/25 to 04/05/25 - Skin prep wipes twice daily to the right lateral foot. 6. Dated 02/25/25 to 04/05/25 - Skin prep wipes twice daily to the right first toe. 7. Dated 02/25/25 to 04/05/25 - Skin prep wipes twice daily to the right heel. Record review of the wound care note, dated 02/06/25, reflected Resident #1 presented with wounds on his right heel, right distal lateral foot, right first toe, right second toe, and right proximal lateral foot. The exam portion reflected the wound care physician was unable to palpate the right pedal (foot) pulses. The recommendations included a right lower extremity arterial doppler. Record review of Resident #1's radiology report from a doppler scan, completed on 02/10/25, reflected The blood flow velocity (movement) is decreased in the arteries of the right lower extremity with a monophasic flow (decreased blood flow), likely moderate inflow disease (type of peripheral artery disease that refers to blockage in the arteries), outflow disease (refers to blockage in the lower extremity affecting the femoral artery and pedal (foot) vessels), and severe arterial disease (a vascular disorder that causes abnormal narrowing of arteries other than those that supply the heart or brain). Record review of the physician progress note, dated 02/12/25, reflected Resident #1 was seen in the facility. The progress note reflected Resident #1 had possible peripheral vascular disease (a vascular disorder that causes abnormal narrowing of arteries other than those that supply the heart or brain) and lower extremity wounds. The plan included Vascular Surgery referral. Record review of the wound care note, dated and signed by the Wound Care Doctor on 02/17/25, reflected Resident #1 had a total of 5 wounds to his right foot. A deterioration of the arterial wound to his right first toe was documented. A Vascular Surgeon referral was recommended. The wounds and measurements as follows: 1. right heel measured 2 cm x 2.5 cm x not measurable due to the presence of dried fibrinous exudate. 2. right first toe measured 4 cm x 2 cm x not measurable due to the presence of nonviable tissues and necrosis. 3. right second toe measured 1 cm x 0.4 cm x not measurable due to the presence of nonviable tissue and necrosis. 4. right distal, lateral foot measured 1.7 cm x 1.5 cm x not measurable due to the presence of nonviable tissues and necrosis. 5. right proximal, lateral foot measured 0.5 cm x 0.5 cm x not measurable due to the presence of nonviable tissue and necrosis. Record review of the wound care note, dated and signed by the Wound Care Doctor on 02/24/25, reflected Resident #1 had a total of 5 wounds to his right foot and was awaiting vascular referral for pad with dry gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection). The wounds and measurements as follows: 1. right heel measured 2 cm x 2.5 cm x not measurable due to the presence of dried fibrinous exudate. 2. right first toe measured 4 cm x 2 cm x not measurable due to the presence of nonviable tissues and necrosis. 3. right second toe measured 1 cm x 0.4 cm x not measurable due to the presence of nonviable tissue and necrosis. 4. right distal, lateral foot measured 1.5 cm x 1.5 cm x not measurable due to the presence of nonviable tissues and necrosis. 5. right proximal, lateral foot measured 0.5 cm x 0.5 cm x not measurable due to the presence of nonviable tissue and necrosis. Record review of the wound care note, dated and signed by the Wound Care Doctor on 03/03/25, reflected Resident #1 had a total of 5 wounds to his right foot. The not reflected Resident #1's wound to his right distal lateral foot was not at goal. The note reflected Resident #1 was awaiting a vascular referral. The wounds and measurements as follows: 1. right heel measured 2 cm x 2.5 cm x not measurable due to the presence of dried fibrinous exudate. 2. right first toe measured 4 cm x 2 cm x not measurable due to the presence of nonviable tissues and necrosis. 3. right second toe measured 0.8 cm x 0.4 cm x not measurable due to the presence of nonviable tissue and necrosis. 4. right distal, lateral foot measured 2 cm x 1.5 cm x not measurable due to the presence of nonviable tissues and necrosis. 5. right proximal, lateral foot measured 0.5 cm x 0.5 cm x not measurable due to the presence of nonviable tissue and necrosis. Record review of Resident #1's physician's telephone order dated 3/6/25 indicated an order for vascular consult referral for previous vascular issues. Diagnosis: Unspecified skin changes. Record review of the wound care note, dated and signed by the Wound Care Doctor on 03/10/25, reflected Resident #1 had a total of 4 wounds to his right foot. The note reflected Resident #1's wound to his right heel was not at goal. The note reflected Resident #1's wound to the right lateral distal foot was worsening. The note reflected Resident #1 was awaiting a vascular referral. The wounds and measurements as follows: 1. right heel measured 3 cm x 2.5 cm x not measurable due to the presence of dried fibrinous exudate. 2. right first toe measured 4 cm x 2 cm x not measurable due to the presence of nonviable tissues and necrosis. 3. right second toe was resolved. 4. right distal, lateral foot measured 4 cm x 1.5 cm x not measurable due to the presence of nonviable tissues and necrosis. 5. right proximal, lateral foot measured 0.5 cm x 0.5 cm x not measurable due to the presence of nonviable tissue and necrosis. Record review of the wound care note, dated and signed by the Wound Care Doctor on 03/17/25, reflected Resident #1 had a total of 4 wounds to his right foot. The note reflected Resident #1's wound to the right lateral distal foot and the right proximal lateral foot were worsening. The note reflected Per patient, saw vascular last week. Will check on note. The wounds and measurement as follows: 1. right heel measured 3 cm x 2.5 cm x not measurable due to the presence of dried fibrinous exudate. 2. right first toe measured 4 cm x 2 cm x not measurable due to the presence of nonviable tissues and necrosis. 3. right distal, lateral foot measured 6 cm x 4 cm x not measurable due to the presence of nonviable tissues and necrosis. 4. right proximal, lateral foot measured 1 cm x 1 cm x not measurable due to the presence of nonviable tissue and necrosis. Record review of the wound care note, dated and signed by the Wound Care Doctor on 03/24/25, reflected Resident #1 had a total of 4 wounds. The note reflected Resident #1's wound to the right first toe was worsening. The note reflected Resident #1 was to see vascular next week. The wounds and measurements as follows: 1. right heel measured 3 cm x 2.5 cm x not measurable due to the presence of dried fibrinous exudate. 2. right first toe measured 6 cm x 4 cm x not measurable due to the presence of nonviable tissues and necrosis. 3. right distal, lateral foot measured 6 cm x 4 cm x not measurable due to the presence of nonviable tissues and necrosis. 4. right proximal, lateral foot measured 1 cm x 1 cm x not measurable due to the presence of nonviable tissue and necrosis. Record review of the wound care note, dated and signed by the Wound Care Doctor on 03/31/25, reflected Resident #1 had a total of 4 wounds. The note reflected Resident #1 was awaiting a vascular referral. The wounds and measurements as follows: 1. right heel measured 3 cm x 2.5 cm x not measurable due to the presence of dried fibrinous exudate. 2. right first toe measured 6 cm x 4 cm x not measurable due to the presence of nonviable tissues and necrosis. 3. right distal, lateral foot measured 6 cm x 4 cm x not measurable due to the presence of nonviable tissues and necrosis. 4. right proximal, lateral foot measured 1 cm x 1 cm x not measurable due to the presence of nonviable tissue and necrosis. Record review of Resident #1's weekly wound report from 1/24/2025 to 4/11/2025 indicated he was treated by the treatment nurse on the following dates: 2/6/25, 2/10/25, 2/17/25, 2/14/25, and on 3/3/25. Record review of Resident #1's treatment administration records dated March 2025 and April 2025 indicated wound care to Resident #1's right first toe, right second toe, right heel, right lateral ankle, right lateral foot was last completed on 03/31/25. Record review of Resident #1 transfer form dated 4/1/25 indicated he was transferred to a local hospital for signs and symptoms of infections/fever and wound deterioration/treatment. Record review of Resident #1 hospitalist admission note dated 4/1/25 indicated Resident #1 was sent from local nursing home for gangrene foot. Also, indicated Resident #1 was very unkempt and very odorous smelling in general and had a very gangrenous mummified right foot. Record review of Resident #1 hospital vascular surgery note dated 4/2/25 indicated the following: Reason for Consultation: Right foot gangrene; History of present illness: [Resident #1] was an [AGE] year-old male with history of atrial fibrillation, hyperlipidemia, and hypertension who presented to the emergency department yesterday via ambulance from nursing home for right lower extremity wounds. It appeared that the wounds had been there for some time with extensive gangrene to right foot and lower leg . Vascular surgery was consulted for major amputation as right foot was not salvageable. [Resident #1] did not take any blood thinning medications. Record review of after visit summary printed on 4/8/25 indicated Resident #1 was in the hospital from 4/1/25 to 4/8/25 for above the knee amputation due to gangrene of the right foot. During an interview on 4/11/25 at 3:27pm, LVN L said that she was the admitting nurse for Resident #1 and responsible for entering his orders. She said that she had finished the new admission paperwork and entered the orders and appointments as outlined in the after-visit summary from the admitting hospitals. LVN L said that she was not very proficient with the new admission process and could not remember the admission paperwork for Resident #1. However, she said that if a cardiologist appointment was listed in the after-visit summary for Resident #1, it should have been recorded in the scheduler for the transportation driver. She indicated that the ADONs were responsible for reviewing the new admission orders and paperwork after the admission to ensure their accuracy. LVN L also said that the ADON on the second floor at that time was no longer employed there. During an interview on 4/14/25 at 3:34pm and at 5:54pm, DON O said she was unaware that Resident #1 had missed his cardiology appointment on 02/25/25, as well as the vascular appointment on 03/26/25, until the information was brought to her attention on 04/11/25. DON O stated the charge nurse assigned to the admitting resident's hall was responsible for entering the admission orders and scheduling the appointments in their system. During the morning meetings, department heads reviewed all new admissions from the previous day, and she did not know how the ball got dropped with Resident #1. DON O said she had access to the cardiologist's company system and was able to verify that Resident #1 indeed missed the appointment on 02/25/25, which was not rescheduled due to the failure to enter it at the time of admission, and the oversight was not identified until it was too late. DON O indicated Resident #1 maintained stable vital signs with no acute cardiac events of record and was followed by [their] in-house physician, NP and wound care doctor. She expressed her expectation was the Transportation Driver would have taken Resident #1 to the appointment on 03/26/25, as he was not a nursing staff member and was not qualified to make that decision. Additionally, she expected the nurse to document any missed appointments, reschedule them, and notify her, which had not occurred. DON O said she expected for the Treatment nurse to follow up on all orders given by the wound doctor because she was the only staff who had access to the wound doctor's notes. She said the Treatment nurse should be documenting on Resident #1's chart and followed up with Resident #1's vascular consult. During an interview on 4/11/25 at 1:28pm, LVN L said that she was the charge nurse for [NAME] Hall and the left side of North Hall during the 6am-2pm shift. She indicated that Resident #1 was located on her hall and had a scheduled vascular surgeon appointment on an unspecified date in March 2025, which was missed because Transportation Driver P was impatient and refused to wait for CNA M to wash and clean Resident #1's face. LVN L said Resident #1 was positioned in a wheelchair near the nurse station, and when Transportation Driver P arrived to pick up Resident #1, CNA M was in the process of preparing to clean his face. At that moment, Transportation Driver P informed both her and CNA M that he did not have time to wait for the cleaning and subsequently decided it was too late to take Resident #1 to the appointment. LVN L attempted to explain to Transportation Driver P that most appointments typically allow a 15-minute grace period and expressed her belief that Resident #1 could have arrived on time since the appointment location was not far from the facility. However, Transportation Driver P dismissed her comments and left without taking Resident #1. LVN L mentioned she called to reschedule the appointment but was unable to provide a new date nor confirm the rescheduling had occurred, and she stated she did not document this information in Resident #1's chart. LVN L stated she did not remember informing anyone about Resident #1 missing the scheduled appointment and she should have documented it but failed to do so. During an interview on 4/11/25 at 1:35pm, CNA M said she worked as the NA for [NAME] Hall during the 6 am to 2 pm shift. She said Resident #1 resided on her hall and had a scheduled appointment on an unspecified date in March 2025. Resident #1 was unable to attend because Transportation Driver P refused to wait for her to clean Resident #1's face prior to the appointment. CNA M asserted the cleaning would not take long and communicated this to Transportation Driver P but, he determined it was too late to transport Resident #1 to the appointment. LVN L informed the driver Resident #1 still had sufficient time to arrive, but Transportation Driver P chose to walk away and instructed them to reschedule the appointment. CNA M stated she was unaware if Resident #1's appointment had been rescheduled. During an interview on 4/14/25 at 2:49pm, Transportation Driver P said he worked Monday-Friday from 7am to 3pm and rotated weekends since November 2024.He stated he received minimal on-the-job training when he first began his role. The limited training he did receive was from the previous driver he replaced, who provided instruction for approximately four days, after which he learned independently. Transportation Driver P recalled the incident involving Resident #1, LVN L, and CNA M. He stated on that morning, he had several back-to-back appointments. Due to the type of van, he operated, he could only transport one resident at a time if they were in a wheelchair, as that was the maximum capacity. He informed an unidentified nurse to ensure that Resident #1 was prepared for his appointment, given his busy schedule. Transportation Driver P could not recall the exact time, he attempted to pick up Resident #1 twice, but on both occasions, the resident was not ready. During the first attempt, Resident #1 was still in bed in his room, prompting him to notify the nurse to have the resident prepared for his return. After taking another resident to an appointment, he returned to the facility for Resident #1, only to find that CNA M had still not prepared him. He was informed they needed a few more minutes to clean Resident #1's face, but the process was taking longer than anticipated. When he returned to check on Resident #1 again, he found that the resident was still not ready. He then informed LVN L that Resident #1 would not make it to his appointment on time, as the time required to prepare the resident, transport him down the elevators, and secure him in the van would exceed the 15-minute grace period. Transportation Driver P stated that LVN L was responsible for rescheduling Resident #1's missed appointment, but he did not recall seeing a new appointment scheduled for the resident. He expressed that he did not believe the situation was his fault. During an interview on 4/14/25 at 6:21pm, the Treatment Nurse said that the wound doctor had instructed her to arrange an appointment for Resident #1 with the vascular specialist, which was her duty. She said the Vascular Consult was recorded on 3/6/25, and although she attempted to schedule the vascular appointments for Resident #1, her efforts were unsuccessful, and she failed to document those attempts in Resident #1's medical record. The Treatment Nurse could not clarify the reason for the 14-day delay between 3/6/25 and 3/20/25 in scheduling the vascular appointment. She said her last assessment of the Resident #1's wound occurred on Friday, 03/28/25, at which point there was no odor present, and Resident #1 had wounds located only on the right foot's side and heel, with indications that healing was taking place. Treatment nurse said herself and the wound doctor examined Resident #1's right foot the following Monday, 03/31/25, they detected an odor and noted a deterioration in the condition of the resident's wounds, which had begun to spread to the toes. She stated she only became aware of the situation on 3/31/25 when the Wound Doctor inquired about the outcome of Resident #1's vascular appointment scheduled for 3/26/25. Upon reviewing Resident #1's chart, she learned from an unidentified nurse that Resident #1 had missed the appointment due to transportation issues. The Treatment Nurse stated her responsibility to follow up on the wound doctor's orders, which she failed to do in this case. She did not reschedule the missed appointment because she was unaware of it until after the fact, and by the time she realized the oversight, Resident #1 was sent to the hospital the following day, 4/1/25. During an interview on 4/14/25 at 12:46pm, the Wound Care Doctor said Resident #1 had significantly inadequate blood flow, and the poor blood flow affected the healing, and the outcome of amputation might not have changed even with going to the appointment. During an observation and interview on 4/12/25 at 1:56pm, Resident #1 was at a different facility with an above-the-knee amputation on the right leg, accompanied by approximately 22 to 24 staples. He expressed no complaints or concerns regarding the previous facility. He mentioned feeling somewhat anxious at the hospital when informed about the impending loss of his leg, but he desired relief from pain and instructed the medical team to proceed with necessary actions. Resident #1 reported that he was free from pain. During an interview on 05/03/25 at 10:02 AM, CNA M stated she worked with Resident #1 regularly. CNA M stated Resident #1's wounds developed an odor prior to being sent to the hospital. CNA M stated she never saw the wounds because they were wrapped up most of the time. CNA M stated she had reported Resident #1's wound odor to multiple charge nurses and they handled it. CNA M was unable to remember when the odor started but stated it was approximately 1 week before he was sent to the hospital. During an interview on 05/03/25 at 10:22 AM, LVN L stated she did not recall any discoloration, edema, or wounds to Resident #1's legs when he admitted to the facility. LVN L stated she remembered Resident #1 developing a wound on his heel but was unable to remember the wound. LVN L stated on 04/01/25 CNA M reported that Resident #1 had an odor to his wounds. LVN L stated CNA M had reported she had told other nurses about the odor. LVN L stated Resident #1 was in therapy when CNA M reported the odor, so she requested Resident #1 be laid down after lunch so she could assess the wound. LVN L stated before she was able to assess Resident #1's wounds, LVN J and ADON D had assessed Resident #1 and sent him to the hospital for evaluation. LVN L stated she had not seen Resident #1's foot wounds for a couple of weeks because the Treatment Nurse was completing the treatments. During an interview on 05/03/25 at 11:01 AM, LVN J stated she was the treatment nurse at the facility. LVN J stated she completed treatments Monday through Friday unless she was working the floor. LVN J stated on the weekends and when she worked the floor the charge nurses were responsible for completing the treatments. LVN J stated on 02/06/25 she was alerted by therapy via a communication app that Resident #1 had some blisters to his right foot. LVN J stated the wound care doctor was in the facility, so she had him assess the wounds. LVN J stated the wound care doctor looked at the wounds, ordered treatments and an arterial doppler study. LVN J stated the wounds started off as fluid filled blisters than with treatment initiated, they started to dry out. LVN J stated the wounds appeared arterial or vascular from the beginning, which was why a doppler study was ordered. LVN J stated Resident #1 had no discoloration to his foot in the beginning. LVN J stated she was unaware Resident #1 had no palpable pedal pulses to his right foot, until she read the wound care doctors notes. LVN J stated she communicated the results of the doppler to the wound care doctor and he ordered a vascular surgeon referral. LVN J stated the DON had asked ADON Q to make the appointment, but he did not. LVN J stated after a few weeks had passed it was discovered that ADON Q had not made the appointment. LVN J stated she had made a few calls to attempt to schedule the appointment, but they had not gotten back to her, and she did not follow up. LVN J stated Resident #1's wounds started off as fluid-filled blisters, then dried and became black. LVN J stated Resident #1's feet were normal color and had no problems when he first admitted . LVN J stated LVN R reported Resident #1 had a deterioration of his wounds the day before he was sent to the hospital, but she was off and told her she would handle it tomorrow. LVN J stated pedal pulses were assessed each time the wound care doctor was at the facility. LVN J stated no pedal pulses to his right foot were able to be felt. LVN J stated the wound care doctor followed up with her every week regarding the vascular referral appointment and she would follow up with nursing management. LVN J stated Resident #1's right foot have no palpable pedal pulses, indicated there was no blood flow to that foot. LVN J stated when there was no blood flow, there was no blood circulation. LVN J stated complications of no blood flow to the foot or tissues included: hardening of the foot, increased risk of infection, and loss of limb. LVN J stated the vascular appointment and cardiologist appointment could have prevented the loss of his leg. LVN J stated she was responsible for following up with the wound care doctors' orders. LVN J stated she pulled an order report every day to review order changes for wounds. During an interview on 05/03/25 at 12:21 PM, the Wound Care Doctor stated Resident #1 presented with fluid-filled blisters to his right foot and there was no pulses present to the right foot. The Wound Care Doctor stated he believed it could have been arterial, so he ordered a doppler study. When the doppler study results were received he then ordered a vascular referral. The Wound Care Doctor stated he followed up with the referral status each time he was at the facility. The Wound Care Doctor stated the facility reported multiple issues which caused a delay in the appointment. The Wound Care Doctor stated Resident #1 had poor circulation from the first day he was treated, which was why the priority for his treatment was getting the Vascular Surgeon referral. The Wound Care Doctor stated his main goals for his wound care was to prevent infection and keep it dry and scabbed over. The Wound Care Doctor stated complication of residents with vascular disease and wounds included: the wounds would not heal, the wounds were more prone to infection, and the wounds would have progressively worsened, which could lead to gangrene. During an interview on 05/03/25 at 1:01 PM, ADON Q stated he worked at the facility until March 2025. ADON Q stated he was the ADON at the facility. ADON Q stated he was unable to remember Resident #1 or anything to do with his care. ADON Q stated if a new admission arrived at the facility with a referral or an appointment the charge nurse would have looked at the paperwork and then placed it in the DON's box for review. ADON Q stated the Treatment Nurse was responsible for making the appointments or referrals requested from the Wound Care Doctor. ADON Q stated he was not involved in the wound care processes. ADON Q stated if a referral or specialist appointment was wound related LVN J would have made the appointment. During an interview on 05/03/25 at 2:12 PM, LVN R stated she had noticed a decline in Resident #1's wounds the day before he was sent to the hospital, which was a weekend. LVN R stated LVN J was at the facility brining some treatment supplies, when she notified her that Resident #1's wound looked worse and had an odor. LVN R stated LVN J stated she would assess the wound tomorrow during her normal working hours. LVN R stated she did not report the wound decline or odor to the doctor but thought the treatment nurse would have handled it. Record review of revised physician order policy dated 1/12/20 indicated, Policy: 1. The licensed nurse will receive and transcribe the physician's orders according to Practice Guidelines. 2. The licensed nursing staff will provide residents with medications and treatments as ordered by his/her physician . Record review of an undated DON O job description indicated, .Job Summary: The Director of Nursing position is to direct the provision of nursing services to facility residents. DON O will oversee the development and implementation of resident care plans and assure the provision of the best available quality of care for facility residents. Key Responsibilities (list specific job duties): A. Maintains appropriate nursing service obligations, goals, and standards of nursing practices consistent with licensure requirements and the Nurse Practice Act. B. Oversees, directs, and coordinates nursing staff to provide proper resident care consistent with standard nursing practices. C. Participates in screening prospective residents as well as ongoing assessment of resident needs . Record review of an undated charge nurse job description indicated, .Job Summary: The Charge Nurse position participates in and oversees the assurance of the provision of resident care services consistent with accepted standards of care and as prescribed by the attending physician. This position also provides direct resident care and assigns duties to LVN's and/or Nursing Assistant as appropriate. Key Responsibilities (list specific job duties): A. Assure resident care according to accepted standards. B. Observes, assesses, and reports resident condition/changes and documents. C. Administers medication/treatments as prescribed. D. Receive, transcribe, implement physician's orders . This was determined to be an Immediate Jeopardy (IJ) on 05/04/25 at 11:00 AM. The Administrator and DON were notified. The Administrator was provided the IJ template on 05/04/25 at 11:15 AM. The following plan of removal submitted by the facility was accepted on 05/04/25 at 3:47 PM and includ[TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance to prevent injury for 1 of 6 residents reviewed for accidents. (Resident #1) The facility did not provide adequate supervision for Resident #1 who was a 2-person transfer during a Hoyer lift transfer. CNA D transferred Resident #1 by herself using a Hoyer lift. Resident #1 fell which resulted in a fractured ankle/leg. This failure could place 22 residents who required a 2-person assistance with transfers at risk for injury, discomfort, and decreased quality of care. Findings included: Physician orders [REDACTED].#1 was a [AGE] years old female, admitted [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 made herself understood and understood others and she had moderately impaired cognition. She required extensive assistance of 2-person physical assist with performing bed mobility and transfers. She was always incontinent to bowel and bladder. A fall risk assessment dated [DATE] and last updated 04/11/18 was a high risk for falls. A care plan dated 08/08/17 and updated 05/07/18 indicated Resident #1 was a high fall risk and required total assistance with bed mobility and transfers. A care plan dated 05/07/18 did not indicate how Resident #1 was to be transferred. A nursing note dated 06/06/18 at 5:50 a.m. by LVN C indicated it was reported to her staff dropped Resident #1 while transferring her with the Hoyer Lift. Resident #1 complained of left leg pain and was given prn (as needed) pain medication for comfort. A witness statement dated 06/06/18 by LVN C indicated CNA D notified her (LVN C) that Resident #1 had fallen during a Hoyer Lift transfer and was complaining of left leg pain. The note indicated LVN C found Resident #1 on the floor in her room. LVN C assessed Resident #1 and found her to have painful limited range of motion to her left leg. A witness statement dated 06/06/18 indicated CNA D got Resident #1 up for [MEDICAL TREATMENT] with the Hoyer Lift by herself and Resident #1 slipped on the floor as she was trying to transfer her to the wheelchair. CNA D said Resident #1 complained of her left leg hurting and she went and notified LVN C of the incident. A nursing note dated 06/06/18 at 11:59 a.m., by LVN G indicated a report was received from the local hospital RN that Resident #1 had a comminuted fracture of her distal tibia and fibula diaphysis (fractured ankle). The note indicated LVN G notified Resident #1's family and physician and the DON. During an observation and interview on 06/14/18 at 11:40 a.m., Resident #1 said she fell out of the Hoyer Lift when CNA D was trying to transfer her to her wheelchair. She said CNA D was the only CNA in the room. She said normally two CNAs transferred her. Resident #1 had a cast on her leg. During an interview on 06/14/18 at 1:30 p.m., CNA E said she cared for Resident #1 multiple times. She said Resident #1 was dependent on staff for bed mobility and transfers and required a 2- person assist to transfer with the Hoyer Lift. She said she was last in-serviced on Hoyer Lift on 06/06/18 following the incident with Resident #1. During an interview on 06/14/18 at 3:45 p.m., CNA F said she sometimes cared for Resident #1. She said Resident # 1 required the Hoyer Lift for transfers. She said the DON in-serviced staff on proper usage of the Hoyer Lift and Abuse/Neglect on 06/06/18 following the incident. She said all CNAs were required to demonstrate competencies on 2- person Hoyer Lift and they were observed doing so by the DON. During an interview on 06/14/18 at 4:50 p.m., LVN A said Resident #1 was alert and oriented. She said Resident #1 was able to make her needs known and was compliant with care. She said Resident #1 required a 2-person Hoyer Lift for transfers. During an interview on 06/14/18 at 5:45 p.m., the DON said she had completed in-service training and competencies for all CNAs (on 06/07/18) on how to transfer a resident using two staff and a Hoyer lift. She said that she ensured all care plans and ADL instructions specified 2-person transfer for Hoyer lift after the incident involving Resident #1 had occurred. An undated policy for Using a Portable Lift Machine (Hoyer lift) indicted the portable lift should be used by two (2) nursing assistants if the resident was not able to participate in the lifting procedure. The CMS 672 dated 6/14/18 indicated 22 residents were dependent on two staff for transfers.

Based on observation, interview and record review, the facility failed to implement interventions to prevent development and worsening of pressure sores for 2 of 4 residents sampled for pressure sores. (Resident #s 1, 3) Resident #3 was admitted [DATE] with a "full thickness Stage II-III" pressure sore to her coccyx that deteriorated to an unstageable, draining sore with a foul odor in one month. The facility did not complete accurate skin assessments on admission and did not consult with the physician when the pressure sore worsened. Dietary interventions were not initiated until 9/13/11. Resident #1 had a history of [REDACTED]. She developed a deep tissue injury which deteriorated to a Stage IV pressure sore with slough on the wound bed. The facility did not complete a skin assessment for 13 days and did not provide the correct treatment. This failure contributed to the deterioration of Resident #3's pressure sore from a "Stage II-III" to unstageable, with drainage and a foul odor. Resident #1 developed a DTI that deteriorated to a Stage IV pressure sore. This failure could place 3 residents with pressure sores and 95 residents who received preventative skin treatments at risk for developing new pressure sores and decline in existing pressure sores. Findings included: 1. Physician orders [REDACTED]. An admission skin assessment dated [DATE] indicated Resident #3 had a "full thickness Stage II-III" pressure coccyx-sacrageal pressure sore which measured 4.5 x 6 cm. There was no description of the wound. A pressure sore care plan for Resident #3 dated 08/26/11 indicated staff were to document assessments at least weekly, notify the physician of signs/symptoms of infections, consult with the RD as needed, and encourage the resident to allow treatment to be completed. The most recent MDS dated [DATE] indicated Resident #3 had [DIAGNOSES REDACTED]. The resident required extensive assistance with bed mobility and toilet use, had a catheter and was continent of bowel. The resident had minimal problems in the area of mental status and no behavior problems. There was a "Stage III-IV" pressure sore which was 4.0 x 9.0 cm with yellow slough or white tissue. An undated Braden scale assessment indicated Resident #3 was at moderate risk for skin breakdown. Skin assessment tools provided the following information regarding Resident #3's coccyx pressure sore: *08/31/11 and 09/07/11, the pressure sore measured 4 x 9 cm, black necrotic tissue measured 3 x 5 cm, with a moderate amount of clear, serosanguinous exudate with no odor. No pain was present. *09/14/11, necrotic pressure sore measured 4 x 7 cm with a moderate amount of clear, serosanguinous exudate. There was pain on touch. There was no other description of the wound or if there was odor. *09/22/11, pressure sore increased to 5 x 8 cm, had an odor and yellow slough. There was a moderate amount of cloudy serosanguinous exudate and pain on touch. During an interview on 10/04/11 at 4:05 p.m., LVN A said she admitted Resident #3 on 8/25/11. The pressure sore to the coccyx had a grayish-black color, but she had not documented this on the assessment sheet. laboratory results dated [DATE] indicated Resident #3 had a low [MEDICATION NAME] of 2.9 (reference range 3.5-5.0) and a low total protein of 5.6 (reference range of 6.4-8.3). The website <http://www.webmd.com/hw-popup/dehydration, viewed 10/18/11, noted, "low [MEDICATION NAME] levels may be caused by a poor diet ([MEDICAL CONDITION])." The website http://www.labtestsonline.org/understanding,viewed 10/18/11, noted, "total protein level may be ordered to provide general information about nutritional status, such as a recent weight loss." A physician order [REDACTED]. * [MEDICATION NAME] 15 mg tablet one by mouth every night for appetite. * Vitamin C 500 mg twice a day for wound healing. * Zinc 220 mg tablet one by mouth twice a day for 30 days for wound healing. * [MEDICATION NAME] one packet twice a day for 30 days During an interview on 10/04/11 at 9:47 a.m., the ADON said she was the treatment nurse and was responsible for weekly assessments. During an interview on 10/04/11 at 4:08 p.m., the ADON said Resident #3's pressure sore had a strong "dead tissue" smell on 09/22/11 and this was a change in condition. She said no physician notification was made regarding the change. The ADON said she requested the 9/13/11 dietary interventions because Resident #3's wound was not getting better, the resident was not eating and was depressed. A dietary assessment dated [DATE] indicated Resident #3 had a weight loss and was eating less that 50 percent of meals. The RD recommended Resident #3's vitamin D and iron levels be checked and to start the appetite stimulant [MEDICATION NAME], Vitamin B12 and iron supplement Ferritin. During an interview on 10/04/11 at 11:38 a.m., the RD said the only time she assessed Resident #3 was on 09/21/11. She found out about the pressure sore on 09/21/11. The RD said Resident #3's assessment "fell through the cracks." There was no set system for her receiving notification regarding new admissions. An undated weight log indicated Resident #3 lost 29 pounds from 08/26/11 to 09/21/11. She had a severe weight loss of 22.3 percent in 24 days. Nursing notes dated 09/26/11 at 4:30 p.m. indicated Resident #3 was unresponsive with a blood sugar of 572 and was sent for emergency care. Hospital emergency room notes dated 09/26/11 at 5:17 p.m. indicated Resident #3 had a Stage III pressure sore to the coccyx. with dried feces on her buttock and inside the coccyx wound. Hospital skin progress notes dated 09/26/11 at 11:45 p.m. indicated the coccyx pressure sore was 15 x 7.5 x 2 cm, with tunneling/undermining, wound bed gray and yellow, and drainage milky yellow. A wound culture collected 09/26/11 and with final results dated 10/01/11 indicated the bacteria that grew from the wound was [MEDICATION NAME] resistant. A hospital skin assessment dated [DATE] indicated the coccyx pressure sore was 22 x 6 cm and unstageable. A hospital critical care note dated 09/29/11 indicated Resident #3 had [MEDICAL CONDITION] from urine, wound and blood. During an observation at another facility on 10/04/11 at 2:26 p.m., Resident #3 had a foul smelling, black necrotic pressure sore that almost covered the buttocks. During an interview on 10/05/11 at 11:13 a.m., LVN C said she provided Resident #3's treatment between 12-1 p.m. on 9/26/11 before the resident was transferred to the hospital. The wound bed looked grayish in color and was soft. The resident had a foul odor since "maybe" 09/22/11. She said she "may have told" the physician about the odor in passing, but nothing was documented. During an interview on 10/05/11 at 1:18 p.m., the NP said she "assumed" Resident #3's pressure sore on the coccyx was a Stage II. No one told her the pressure sore had drainage and a foul odor. 2. Physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 required total staff assistance with bed mobility, toilet use, and was incontinent of bowel and bladder. Resident #1 had pressure sores. A Braden scale dated 08/08/11 indicated Resident #1 was at high risk for skin breakdown. A "potential for pressure sore care plan" dated 08/08/11 indicated staff were to complete weekly skin assessments and place pressure relieving devices as warranted. A physician order [REDACTED]. The dressing was to be changed every day and as needed. A physician order [REDACTED]. Staff were to cleanse the area to the coccyx with normal saline, apply Santyl, cover with gauze and bordered foam dressing. Staff were to cleanse the area to the sacrum with normal saline, apply Silver Hydrogel, cover with gauze and bordered foam dressing. Skin assessment sheets for Resident #1 indicated the following: Coccyx Pressure Sore 09/14/11, coccyx pressure sore resolved this day. Sacrum Pressure Sore *08/11/11, onset of a DTI which measured 0.5 x 0.4 x less than 0.2 cm. Necrotic tissue was present, purple and measured 0.8 x 0.6 cm. *08/18/11, the pressure sore was 2.5 x 2.0 x less than 0.2 cm, unstageable with eschar. *08/25/11, 4 x 4 cm, unstageable with brown necrotic tissue. *08/31/11, 3 x 2 cm, unstageable with necrotic tissue. *09/07/11, 4 x 3 cm, unstageable with yellow slough. *09/14/11, 3 x 2 x 0.3 cm, unstageable with grey necrotic tissue. *09/21/11, 3 x 2 x 1 cm, unstageable with necrotic tissue. *09/28/11, no assessment documented. During a treatment observation with LVN C and the ADON on 10/04/11 at 10:20 a.m., Resident #1 had an open Stage IV pressure sore to the sacrum which had pink tissue to the wound bed and yellow slough. The pressure sore measured 2 x 1.5 x 0.5 cm and the slough was measured as 0.5 x 0.8 cm. LVN C cleaned the pressure sore and applied Santyl to the wound bed and covered with a gel product in a cup identified as collagen. A foam dressing was placed over the pressure sore. During an interview on 10/05/11 at 12:30 p.m., the ADON said the sacral pressure sore started on 08/11/11 as a DTI and was 0.5 x 0.4 x less than .2 cm. She received an order to put Hydrogel on the pressure sore and cover it with a bordered dressing. They were using [MEDICATION NAME] (Silver Hydrogel) on the sacrum. On 08/22/11 they did a treatment change from the [MEDICATION NAME] to Santyl because the pressure sore was larger. The ADON said she wrote the 08/22/11 order wrong and staff were supposed to be using Santyl only for the sacral pressure sore. The ADON said she thought Resident #1's pressure sore developed because the air mattress was not holding air in the center. She discovered the problem with the air bed a week after the sore on the sacrum developed. During an interview on 10/05/11 at 1:11 p.m., the ADON said an assessment was due 09/28/11. The ADON said she was out this week and the DON was to complete the assessment. During an interview on 10/05/11 at 10:00 a.m., the DON said she did not complete a skin assessment for Resident #1 for 09/28/11. The National Pressure Ulcer Advisory Panel at <http://www.npuap.org/pr2.htm>, accessed 10/06/11, noted the following pressure ulcer definitions: "A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Pressure Ulcer StagesSuspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Further description:Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.Further description:The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate "at risk" persons (a heralding sign of risk)Stage II: 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. Further description:Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal [MEDICAL CONDITION], maceration or excoriation. *Bruising indicates suspected deep tissue injuryStage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Further description: The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.Stage IV: Full thickness tissue 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.Further description: The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] possible. Exposed bone/tendon is visible or directly palpable.Unstageable:Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.Further description:Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed." The facility prevention of pressure ulcer policy dated January 2002 indicated staff were to " assess the pressure ulcer for location, size (measure length, width, and depth), sinus tracts, undermining, tunneling, exudate, necrotic tissue, and the presence of absence of granulation tissue and [MEDICATION NAME]." "Staff were to monitor nutrition and hydration status. Encourage proper dietary and fluid intake. If a normal diet is not possible, talk to physician about supplements." "Signs of healing (i.e., decreased size and depth of the ulcer, decreased drainage) should be evident after 2 to 4 weeks of treatment. Notify physician if any evidence of deterioration is noted." The CMS Form 672 dated 10/4/11 indicated there were 4 residents with pressure sores and 95 receiving preventative skin care.

Based on observation, interview and record review, the facility failed to implement interventions to prevent significant weight loss for 1 of 4 residents sampled for nutrition. (Resident #3) Resident #3 was admitted [DATE] with a Stage II-III pressure sore and was in the facility 25 days before a nutritional assessment was completed. Resident #3 lost 29 pounds from 08/26/11 to 09/21/11. She had a severe weight loss of 22.3 percent in 24 days. The facility did not develop and implement nutritional interventions until 9/13/11 or consistently monitor the resident's meal intake as care planned. Resident #3's pressure sore to her coccyx declined to unstageable in a one month time frame. This failure contributed to Resident #3's severe weight loss and could place 5 residents with weight loss at risk for serious health complications. Findings included: Physician orders [REDACTED]. Resident #3 had an order for [REDACTED]. An admission skin assessment dated [DATE] indicated Resident #3 had a full thickness Stage II-III pressure coccyx-sacrageal pressure sore which measured 4.5 x 6 cm. The most recent MDS dated [DATE] indicated Resident #3 had [DIAGNOSES REDACTED]. The resident required extensive assistance with bed mobility and toilet use, had a catheter and was continent of bowel. The resident had minimal problems in the area of mental status and no behavior problems. Resident #3 required supervision with eating. The resident had a weight of 121 pounds and a height of 60 inches. A potential for nutritional deficit care plan dated 08/25/11 indicated staff were to assess Resident #3 for food preference (likes/dislikes) and monitor and record meal intake. A weight log indicated Resident #3's weights as follows: 08/26/11 -130 lbs 09/02/11- 121 lbs 09/21/11- 101 lbs laboratory results dated [DATE] indicated Resident #3 had a low [MEDICATION NAME] of 2.9 (reference range 3.5-5.0) and a low total protein of 5.6 (reference range of 6.4-8.3). The website <http://www.webmd.com/hw-popup/dehydration, viewed 10/18/11, noted, "low [MEDICATION NAME] levels may be caused by a poor diet ([MEDICAL CONDITION])." The website http://www.labtestsonline.org/understanding,viewed 10/18/11, noted, "total protein level may be ordered to provide general information about nutritional status, such as a recent weight loss." A physician order [REDACTED].#3: * [MEDICATION NAME] 15 mg tablet one by mouth every night for appetite. * Vitamin C 500 mg twice a day for wound healing. * Zinc 220 mg tablet one by mouth twice a day for 30 days for wound healing. * [MEDICATION NAME] one packet twice a day for 30 days During an interview on 10/05/11 at 1:18 p.m., NP B said she knew the resident was eating well and that was why the interventions were started on 09/13/11. The assessment from the dietitian was missed because she was coming after hours to see residents. During an interview on 10/4/11 at 4:08 p.m., the ADON said she had requested the 9/13/11 dietary interventions because Resident #3's wound was not getting better, and the resident was depressed and not eating A weight loss care plan for Resident #3 dated 09/14/11 indicated staff were to notify the physician/family of significant changes and monitor percent meals consumed. The September 2011 dietary log did not have documentation of Resident #3's food intake for 10 of 27 days. During an observation at another facility on 10/04/11 at 2:26 p.m., Resident #3 had a thin frame and a foul smelling, black necrotic pressure sore which almost covered her buttocks. A dietary assessment dated [DATE] indicated Resident #3 had a weight loss from 130 lb to 121 lb (usual weight range 125-131) and was eating less than 50 percent of her meals. The RD recommended Resident #3's vitamin D and iron levels be checked and to start the appetite stimulant [MEDICATION NAME], vitamin B12 and and iron supplement Ferritin. During an interview on 10/04/11 at 11:38 a.m., the dietitian said she completed her initial assessment of Resident #3 on 9/21/11. She found out about the resident's pressure sores on 09/21/11. The dietitian said Resident #3's assessment "fell through the cracks." There was no set system for her receiving notification regarding new admissions. The dietitian indicated she used the resident's 9/2/11 weight of 121 lbs on her assessment. Nursing notes dated 09/26/11 at 4:30 p.m. indicated Resident #3 was unresponsive with a blood sugar of 572 and was sent for emergency care. Hospital emergency room notes dated 09/26/11 at 5:17 p.m. noted Resident #3 was received with a Stage III pressure sore. A hospital laboratory report dated 09/26/11 indicated Resident #3 had a total protein of 5.3 with reference ranges of 6.4-8.3 and her [MEDICATION NAME] was 2.2 with reference ranges of 3.5-5.0. A hospital history and physical dated 09/26/11 indicated Resident #3's [DIAGNOSES REDACTED]. During an interview on 10/05/11 at 10:00 a.m., the DON said no current training was done on skin assessment, notification and weight loss. The pressure ulcer policy dated January 2002 indicated the following interventions: *monitor nutrition and hydration status *encourage proper dietary and fluid intake *If a normal diet is not possible, talk to physician about supplements. The CMS Form 672 dated 10/04/11 indicated there were 5 residents with weight loss.