Every finding on record at Regency Village

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures to ensure the accurate acquiring, receiving, dispensing, and administering of medications, to meet the needs of residents for 3 of 8 residents (Resident #1, CR #2, and CR #3) reviewed for pharmaceutical services. The facility failed to provide Resident #1 with Apixaban (anticoagulant) on 7/1/2026 and 7/2/2026, resulting in 4 missed doses. The facility failed to provide CR #2 with the following prescribed medications:Atorvastatin from 6/2/2026-6/6/2026 (6 missed doses);Flomax from 6/2/2026-6/6/2026 (6 missed doses);Pregabalin from 6/2/2026-6/6/2026 and 6/13/2026-6/19/2026 (23 missed doses);Methocarbamol from 6/11/2026-6/19/2026 (24 missed doses); andMidodrine from 6/2/2026-6/7/2026 (16 missed doses). The facility failed to provide CR #3 with prescribed Vigamox ophthalmic antibiotic drops for treatment of an eye infection from 6/27/2026-6/30/2026, resulting in 10 missed administrations. These failures could place residents at risk for untreated medical conditions, worsening symptoms or infection, hospitalization, and a decline in their overall health and well-being. Findings included: Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Nonrheumatic Aortic (Valve) Stenosis (when the heart's aortic valve narrows due to age-related calcium buildup or congenital defects, this restricts blood flow from the heart to the body), Chronic Atrial Fibrillation (a constant, ongoing irregular heartbeat that lasts longer than 12 months), and Cardiac Arrhythmia (an irregular, too-fast, or too-slow heartbeat caused by faulty electrical signals in the heart). Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS score of 5 out of 15 indicating severe cognitive impairment. Further review of the MDS revealed Resident was not taking an anticoagulant (known as blood thinners, are a class of medications that prevent blood clots from forming or stop existing clots from getting larger) but was taking an antiplatelet (medications that prevent blood cells, called platelets, from clumping together to form unwanted blood clots). Record review of Resident #1's care plan initiated on 6/25/2026 revealed a focus area of Resident is currently taking ananticoagulant related to atrial fibrillation, cardiac arrhythmia, the interventions included: Labs as ordered. Report abnormal lab results to the Physician. Resident/family/caregiver teaching to include the following: Take/give medication at the same time each day, Use soft toothbrush, Use electric razor, Avoid activities that could result in injury, Take precautions to avoid falls, Signs/symptoms of bleeding, Avoid foods high in Vitamin K. These include greens such as spinach and turnips, asparagus, broccoli, cabbage, Brussels sprouts, milk and cheese. Record review of Resident #1's physician orders revealed an order started on 6/4/2026 for Apixaban Oral Tablet 5 MG, give 1 tablet by mouth two times a day for Anticoagulant. Record review of Resident #1's July 2026 MAR revealed Apixaban Oral Tablet 5 MG, give 1 tablet by mouth two times a day for Anticoagulant was not administered on 7/1/2026 and 7/2/2026 indicating 4 missed administrations. The Apixaban was marked with a 9 indicating to see nurses notes. Further review of the MAR revealed Apixaban was administered on 7/3/2026 morning dose (9:00am), not administered 7/3/2026 evening (5:00pm) because resident was sleeping, and administered 7/4/2026 morning (9:00am). Record review of Resident #1's progress notes dated 7/1/2026 at 10:004am by MA A revealed, Apixaban Oral Tablet 5 MGGive 1 tablet by mouth two times a day for Anticoagulant on order. Record review of Resident #1's progress notes dated 7/1/2026 at 5:00pm by MA A revealed, Apixaban Oral Tablet 5 MGGive 1 tablet by mouth two times a day for Anticoagulant on order. Record review of Resident #1's progress notes dated 7/2/2026 at 9:48am by MA A revealed, Apixaban Oral Tablet 5 MGGive 1 tablet by mouth two times a day for Anticoagulant on order. Record review of Resident #1's progress notes dated 7/2/2026 at 5:01pm by MA A revealed, Apixaban Oral Tablet 5 MGGive 1 tablet by mouth two times a day for Anticoagulant on order. Record review of the facility work schedule dated 7/1/2026 revealed LVN B worked was assigned to Resident #1 and review of schedule dated 7/2/2026 revealed LVN A was assigned to work with Resident #1. Record review of Resident #1's progress notes dated 7/4/2026 at 3:50pm by DON revealed, Apixaban 5mg removed from the E-kit for Med Aid to administer, call placed to pharmacy regarding medication. Will be delivered today. Notified NP. Interview on 7/3/2026 at 9:30am, the Administrator and DON both stated they were new to the facility, the Administrator said he started on or around 6/10/2026 and the DON started on or around 6/15/2026. They stated prior to them starting the facility was taken over by new owners which caused the facility to change pharmacies on 6/1/2026 which did cause some complications. They stated the previous DON received training on the new pharmacy system prior to it going into effect on 6/1/2026, however, the previous DON quit right before the switch which also added to the rough transition in pharmacies. They stated the ADON had also received the training on the new pharmacy processes and was one of few management staff that remained working in the facility prior to the transition, however, she was currently out and not available. The DON said prior to her starting there was a liaison from the new pharmacy that was providing training to her and the staff and helping them with the transition. The DON said there were lots of challenges in getting staff to understand the new system and she was also getting fully trained on how the new pharmacy worked. The DON said there was a time period after 6/1/2026 where they did not have a pyxis machine (an automated, secure medication dispensing cabinet used to store, track, and dispense drugs) but there was emergency kits that were provided by the pharmacy during that time. The DON said there had been a few residents affected by the pharmacy transition but now that they have the pyxis they are able to provide residents with their medications from the pyxis until they can get them in from the pharmacy. Observation and interview on 7/3/2026 at 1:03pm, Resident #1 was sitting in her room in her wheelchair next to her bed. Resident #1 denied knowing about any issues with her medications and said she was not experiencing any type of discomfort. A telephone interview attempted on 7/4/2026 at 4:23pm with LVN A, no answer and voicemail was left requesting a return phone call. Aa telephone interview attempted on 7/4/2026 at 4:33pm with MA A, no answer and voicemail was left requesting a return phone call. Telephone interview on 7/4/2026 at 4:29pm, LVN B stated she was an agency nurse and 7/1/2026 was her first time working at the facility. LVN B stated if medication was not available for the med aides, they are supposed to let the nurse know. LVN B said no one notified her Resident #1's Apixaban was not available on 7/1/2026. LVN B said if she was notified, she would of asked the DON to retrieve it from the pyxis for her because as an agency staff she did not have access, but the DON was able to access it for her if she needed medication from it. LVN B added there was two other medications that day she had to get out of the pyxis for a different resident so if she was notified by the med aide, she did know what to do to get the resident some medication. LVN B said in addition to retrieving the medication from the pyxis so the resident would not miss a dose, she would contact the pharmacy to check on the status of the resident's medication being delivered and ensure the refill had been ordered. Interview on 7/4/2026 at 4:50pm, the DON said if there was a medication not available on the med aide carts, the med aides are expected to notify their nurse and the nurse should get the medication from the pyxis if it was a medication available in the pyxis. The DON stated that Apixaban was a medication available in the pyxis and stated she had just retrieved herself for Resident #1 earlier because they are waiting on her medications to be delivered. The DON said the med aides had been in-serviced on not putting on order when something was not available and how they should notify the nurse first. The DON said MA A was in-serviced over this and had previously voiced understanding on the procedure when medication was not available. The DON said she would speak with MA A one on one later to provide additional training but also voiced maybe taking further action because she had been previously trained on the process. The DON stated she could not be certain without looking at Resident #1's chart but stated she was likely taking Apixaban for her diagnosis of Atrial Fibrillation. The DON said the medication Apixaban helped to thin the residents blood and it helped to keep the blood flowing through her heart. The DON said Resident #1 was also taking Aspirin that helped to keep her blood flowing as well, and she had not missed any doses of the Aspirin. Record review of In-Service Training Report dated 6/24/2026 revealed topics of HIPAA, Privacy, Medication Administration, Medication Ordering, and Missing Med policy. MA A named was signed on the in-service log. CR #2 Record review of CR #2's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and discharged home on 6/19/2026. His diagnoses included: Spinal Stenosis (occurs when the spinal canal narrows, putting pressure on the spinal cord and nerves), Uninhibited Neuropathic Bladder (a condition where nerve damage causes your bladder to spasm and empty involuntarily), Pure Hypercholesterolemia (a genetic disorder that impairs the body's ability to remove bad cholesterol from the blood), and Essential (Primary) Hypertension (high blood pressure with no identifiable secondary medical cause). Record review of CR #2's admission MDS dated [DATE] revealed a BIMS score of 13 out of 15 indicating his cognition was intact. Further review of the MDS revealed in the bowel and bladder section he had an indwelling catheter. The pain section of the MDS indicated he received a scheduled pain medication regimen and he had occasional pain that rarely affected him or interfered with his day-to-day activities. Record review of CR #2's physician orders revealed an order started on 6/2/2026 and discontinued on 6/19/2026 for Atorvastatin Calcium Oral Tablet 20 MG, give 1 tablet by mouth one time a day for cholesterol. Record review of CR #2's June 2026 MAR revealed Atorvastatin Calcium Oral Tablet 20 MG, give 1 tablet by mouth one time a day for cholesterol was not administered from 6/2/2026 - 6/6/2026, indicating 6 missed administrations and noted to see nurses notes. Record review of CR #2's physician orders revealed an order started on 6/2/2026 and discontinued on 6/19/2026 for Flomax Capsule 0.4 MG (Tamsulosin HCl), give 1 capsule by mouth one time a day for benign prostatic hyperplasia. Record review of CR #2's June 2026 MAR revealed Flomax Capsule 0.4 MG (Tamsulosin HCl), give 1 capsule by mouth one time a day for benign prostatic hyperplasia was not administered from 6/2/2026 - 6/6/2026, indicating 6 missed administrations and noted to see nurse's notes. Record review of CR #2's physician orders revealed an order started on 6/2/2026 and discontinued on 6/19/2026 for Pregabalin Oral Capsule 75 MG, give 1 capsule by mouth two times a day for pain. Record review of CR #2's June 2026 MAR revealed Pregabalin Oral Capsule 75 MG, give 1 capsule by mouth two times a day for pain was not administered from 6/2/2026 - 6/6/2026 and from 6/13/2026 - 6/19/2026, indicating 23 missed administrations and noted to see nurse's notes. Record review of CR #2's physician orders revealed an order started on 6/2/2026 and discontinued on 6/19/2026 for Midodrine HCl Oral Tablet 10 MG, give 1 tablet by mouth three times a day for hypotension. Record review of CR #2's June 2026 MAR revealed Midodrine HCl Oral Tablet 10 MG, give 1 tablet by mouth three times a day for hypotension was not administered from 6/2/2026 - 6/6/2026 afternoon (1:00pm), medication was marked administered on 6/4/2026 afternoon dose (1:00pm) indicating 16 missed administrations and noted to see nurse's notes. Record review of CR #2's physician orders revealed an order started on 6/11/2026 and discontinued on 6/19/2026 for Methocarbamol Oral Tablet 500 MG, give 1 tablet by mouth three times a day for muscle spasm. Record review of CR #2's June 2026 MAR revealed Methocarbamol Oral Tablet 500 MG, give 1 tablet by mouth three times a day for muscle spasm was not administered from 6/11/2026 - 6/19/2026, medication was marked administered on 6/15/2026 morning dose (9:00am) indicating 24 missed administrations and noted to see nurse's notes. Record review of CR #2's progress notes dated 6/3/2026 - 6/6/2026 revealed Flomax, Atorvastatin, Midodrine, and Pregabalin were awaiting delivery or on order. Record review of CR #2's Progress note dated 6/4/2026 at 2:27pm by LVN C revealed in part, .Medications remains on order at this time, Midodrine is given during the shift due to availability in the E kit. Record review of CR #2's Progress note dated 6/5/2026 at 12:35pm by LVN D revealed, Resident Lyrica has not come in yet. Need a script for new resident. Let ADON know, it should be coming in this afternoon. Still waiting for pharmacy. Record review of CR #2's progress notes from 6/11/2026 - 6/18/2026 revealed Methocarbamol Oral Tablet 500 MG, give 1 tablet by mouth three times a day for muscle spasm was on order and from 6/13/2026 - 6/18/2026 Pregabalin Oral Capsule 75 MG Give 1 capsule by mouth two times a day for pain was on order. Record review of CR #2's progress notes dated 6/19/2026 at 11:50am revealed resident was discharged home. Interview on 7/3/2026 at 1:51pm, the pharmacy Client Service Manager said the facility started using the pharmacy on 6/1/2026 but prior to that she had been on site conducting trainings with the DON and ADON to prepare for the transition. The Client Services Manager stated right as they were set to go live the previous DON quit and it did cause issues with the start of the new pharmacy. She said the DON was tasked with getting triplicate prescription (a special three-page form doctors use to prescribe highly regulated medicines) but she left without completing them. The Client Service Manager said she was onsite everyday at the facility for the first few weeks helping with the transition because there was so many issues and changes with management during the time of the pharmacy switch. She started training floor staff on 6/1/2026 in person daily and could be reached in the pharmacy app (electronic application) as well if there were any pharmacy questions. She said she trained staff on how to use the pharmacy dashboard, how to use the fax machine regarding reorders, and how to access the emergency kits. She had also trained the interim DON they had as well as the current DON. She said the ADON was the only management staff that was there before the pharmacy transition and was a help in training the other staff as well. The Client Service Manager said the facility was provided with emergency kits (a locked bag of essential, fast-acting medicines) on 6/3/2026 and they were able to exchange them as needed. The Client Service Manager said the facility was provided with a pyxis the week of 6/15/2026 and said it was maybe on the 6/19/2026 it was delivered. The Client Service Manager said she did recall being asked about CR #2's medications but stated there was a lot of issues with getting residents face sheet and required information submitted so medications could fill, and she also relayed this to being one of the complications she felt came from the changes in management. Interview on 7/3/2026 at 4:35pm, MA B said she had been working at the facility since March 2026 and became full time in May 2026. MA B stated the facility changed pharmacies on 6/1/2026 and it caused a lot of issues. MA B said there was a period where medication aides were not able to reorder medications and the nurses had to reorder the medications and even then there was issues with getting the medications delivered. MA B said she remembered CR #2 and said he was a pleasant man and the facility did not have his medications when he first admitted . She recalled he took Flomax, Lyrica, Midodrine, and methocarbamol and for his first few days in the facility he was not getting any of the medications and she did not think he ever got the muscle relaxer (methocarbamol). MA B said she would always let the nurse know each day that the medication was not there and said for a while the nurses were not able to get into the emergency kit either but the ADON could access it. MA B said she never saw CR #2 complain of pain and said she would ask him and he denied any pain. MA B said the resident did voice frustrations about not getting his medication and said he was more upset about not getting his maintenance medications such as his Flomax. MA B denied knowing of any adverse effects of the missed medications and said to her knowledge the resident left the facility happy and in good health. Interview on 7/3/2026 at 5:35pm, CNA A said he remembered CR #2 and said overall the resident was doing well and was a nice guy. CNA A said CR #2 he never had any complaints of pain but stated he did voice frustration with the service and said he was upset about not getting all his medications. CNA A said he does not deal with medication administration but was aware there was some issues with the pharmacy change and CR #2 was one of the residents who had issues with their medications. Interview on 7/3/2026 at 6:17pm, LVN D said she recalled them having issues with CR #2's medications when he admitted , she said the resident came just as the pharmacy switch happened. LVN D said the med aide did let her know later on that CR #2 was not getting his medications. She did try contacting the pharmacy about his medications and would get the run around, LVN D said eventually they involved the pharmacy Client Service Manager who assisted in getting CR #2's medications. LVN D said they were unable to access the emergency kit for the Lyrica or Methocarbamol and said she thinks the resident may have discharged by the time they got the pyxis. LVN D said she assessed CR 2 for pain and he always denied being in any pain or discomfort, but he did express frustrations about the facility not having his medications. Interview on 7/3/2026 at 7:45pm, the DON said she did remember meeting CR #2 but did not get to work with him much due to him discharging right around the time she was started working at the facility. She did not know much about his missing medications due to it being before she started but reiterated the facility went through a lot of challenges at the start of the pharmacy switch. The DON stated given that CR #2 admitted at the time of the change his pharmacy issues were most likely due to the transition struggles. The DON said as of now residents should not be going without medications because they have a pyxis, the pharmacy is now integrated with their electronic records systems so the medication aides and nurses are now able to easily reorder medications, and she and the ADON are learning how to monitor the pharmacy dashboard to see why medications are not being delivered and to try and fix the issue. The DON added that LVN C no longer worked at the facility and they did not have contact information for her. Interview on 7/4/2026 at 3:00pm, the DON said she could not say how CR #2 missing medication could affect him because it depended on the medication and why the resident was using them. The DON said missing maintenance medications could potentially cause some adverse effects of their condition not being managed. Telephone interview on 7/4/2026 at 3:11pm, CR #2's RP said CR #2 was now at home and doing well. He said he and CR #2 were both concerned about the facility not having the majority of his medications when he admitted . The RP said CR #2 did get some of his medications here and there but it was a huge concern he was not getting all his medications for several days in the facility and felt it was not professional. The RP said he was told there was issues with the pharmacy which was the reason behind CR #2 not getting his medication but felt it was not an excuse to not provide residents with their medications. The RP denied CR #2 having any adverse effects from not getting his medications and said after he left hospital and was admitted to the facility his pain had subsided, so luckily he was okay with not getting his pain medications and was not in pain. CR #3 Record review of CR #3's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and discharged to the hospital on 6/30/2026. His diagnoses included: End Stage Renal Disease (the final, irreversible stage of chronic kidney disease), Type 2 Diabetes Mellitus (a chronic metabolic condition where the body's cells become resistant to insulin or the pancreas doesn't make enough of it), Peripheral Vascular Disease (a slow, progressive disorder of the blood vessels outside the heart and brain, often affecting the legs), and Dependence On Renal Dialysis (describes the need for regular, life-sustaining blood-filtering treatments). Record review of CR #3's quarterly MDS dated [DATE] revealed a BIMS score of 13 out of 15 indicating his cognition was intact. Record review of CR #3's care plan initiated on 6/29/2026 revealed a focus of, The resident has an Eye Infection,Conjunctivitis of the right eye and is being treated with Vigamox eye drop. The interventions included: Give therapeutic ointments, drops as ordered by physician; Instruct resident not to rub eyes; Monitor/document/report to MD PRN the following signs and symptoms: redness of the eye, pain, swelling, tearing of the eye, discharge, change in conjunctiva; Prevent spread of infection by good hand washing before and after treating eye; Use washcloth or towel on the affected eye only once then discard in order toprevent spread of infection; Wash eye to remove crust and discharge PRN. Record review of CR #3's progress note dated 6/26/2026 at 6:10pm by RN A revealed in part, .Resident arrived to facility via stretcher at this time with EMS from hospital. Resident placed in bed at this time and handoff report received. Yellow drainage noted to Right eye at this time and mild irritation present as stated by resident. MD notified at this of residents return to facility and Right eye findings. Vigamox 0.5% TID ordered per MD until cleared and continue order in Left eye if needed. No further complaints from resident at this time. Family member notified of residents return at this time and new orders started for eye findings. Resident educated on washing hands thoroughly and avoiding touching eye with fingers, education understood . Record review of CR #3's physician orders revealed an order started on 6/27/2026 for Vigamox Ophthalmic Solution 0.5 % (a prescription antibiotic eye drop used to treat bacterial conjunctivitis) (Moxifloxacin HCl (Ophth)), Instill 1 drop in right eye three times a day for Conjunctivitis. Record review of CR #3 June MAR revealed Vigamox Ophthalmic Solution 0.5 % (Moxifloxacin HCl (Ophth)), Instill 1 drop in right eye three times a day for Conjunctivitis was not administered from 6/27/2026 - 6/30/2026 indicating 10 missed administrations. Record review of CR #3's progress note dated 6/29/2026 at 10:55am and 6:01pm by LVN E revealed Vigamox Ophthalmic Solution 0.5 % Instill 1 drop in both eyes three times a day for Conjunctivitis for 7 Days was on order. Record review of CR #3's progress note dated 6/30/2026 at 9:32am by LVN D revealed Vigamox Ophthalmic Solution 0.5 %Instill 1 drop in both eyes three times a day for Conjunctivitis for 7 Days was not available. Record review of CR #3's progress note dated 6/30/2026 at 11:54am by LVN D revealed he was transferred to the hospital for altered mental status. Interview on 7/3/2026 at 1:51pm, the Client Services Manager from the pharmacy said the facility reached out to her on 6/29/2026 regarding the status of CR #3's eye drops. She said the dashboard showed the order needed clarification of a stop date in order for the pharmacy to fill it and that was why the medication had not been sent out. The Client Services Manager said the information was provided by the facility and was supposed to come out on the next run on 6/30/2026. The Client Services Manager said the staff are able to see why a medication has not been sent by looking at the dashboard but she does not feel all staff are comfortable just yet with utilizing the pharmacy dashboard and she said if that was the case they could always reach out to her and she could look into it for them. Interview on 7/3/2026 at 4:00pm, the DON said she was made aware of CR #3's missing eye drops from the pharmacy. She looked and was able to see the medication needed clarification of a stop date in order to fill. The DON said she provided the information and the medication was sent but the resident went out to the hospital before they arrived. The DON said they are used to being called or notified by the pharmacy if something is not being filled or clarification is needed but stated the new pharmacy does not do that and they have to check the dashboard to see if something is not being sent and why which is a new process for them and she and the ADON are no getting into the habit of checking the dashboard daily to see if any medications are being held up. They are now also ensuring stop dates are being placed on orders since they now this is something pharmacy wants done. Interview on 7/3/2026 at 4:35pm, MA B said CR #3's eye drops never came in before he discharged to the hospital. She said CR #3 eye was swollen and had lots of crust built up in it. MA B said she recalled on maybe 2 occasions where CR #3 asked her about his eye drops and if they were in yet and she had to tell him they were still waiting for them to be delivered from the pharmacy. MA B said she did tell the nurses that CR #3 eye drops were not there and it was not a medication available in the pyxis to her knowledge. MA B said the risk of CR #3 not getting his antibiotic eye drops was it could have gotten worse. MA B said she felt CR #3's eye looked the same from when she first saw it was infected, but she did say he complained of discomfort to the eye and it looked severely irritated. Interview on 7/3/2026 at 5:24pm, CNA B said when CR #3 returned from the hospital on 6/27/2026 his eye was almost swollen shut and had drainage and crust in it. She does not recall seeing it get any better and it remained almost swollen shut. She does not know anything about medications the resident was getting or not getting to treat his eye. Interview on 7/3/2026 at 5:35pm, CNA A said he did see CR #3 in passing in the hall and he would stop him and ask for a towel for his eye. He would get him a hot towel for his eye and let the nurse know he asked for it. CNA A said he remembered seeing CR #3's eye swollen and draining. He stated he last saw him on 6/29/2026 and the condition of his eye had not changed. He denied knowing anything about CR #1 not receiving eye drops and said he would just supply the resident with hotel towels to hold on his eye. Interview on 7/3/2026 at 6:17pm, LVN D said she worked on 6/30/2026 with CR #3 and said that morning they were still waiting on his antibiotic eye drops to be delivered. She told the DON about the medication still not being delivered and she also tried contacting the pharmacy but said she was on hold for a long time and she kept getting disconnected. LVN D said CR #3 eye looked bad and said it was full of eye boogers and crust. LVN D said CR #3 could barely open his eye and stated she would clean his eye out but the crust would come right back shortly after cleaning it. LVN D said he complained of irritation to the eye. LVN D said the eye drops were not available in the pyxis and said if there was medication not being delivered they should contact the pharmacy and let the ADON or DON which was what she did. LVN D said the risk of CR #3 not getting his antibiotic eye drops was the infection could get worse. Interview on 7/3/2026 at 7:25pm, LVN E said she worked with CR #3 on 6/29/2026 and said it was her first time observing his eye with crust in it. LVN E said prior to her working on 6/29/2026 an order had already been placed for his antibiotic eye drops on 6/27/2026 and still had not come in. LVN E said she checked through the pharmacy app for the status of the medication, and it sent a message saying the medication was on the way and would be delivered that afternoon. LVN E stated to her knowledge the medication never came. LVN E said everyone was aware they were still waiting on the medication to be delivered because it was discussed in their morning meeting. LVN E said she would put a warm compress on CR #3's eye and said she observed his eye having lots of crust built up in it but stated the resident did not grimace or voice any pain when she cleaned it. Interview on 7/3/2026 at 8:52pm, RN A said he was the admitting nurse for CR #3 when he returned from the hospital on 6/27/2026 and he noticed his eye was swollen with drainage in it. He said the resident complained that his eye was killing him. RN A said he notified the doctor and got orders for the Vigamox eye drops and he put the order into the pharmacy right away. RN A did not know if his eye worsened and stated the resident was usually sleep by his shift especially if it was a day he went to dialysis. Observation and interview on 7/4/2026 at 1:00pm, CR #3 was observed in the hospital sitting in bed. CR #3 said he was feeling okay and said he thinks his eye was looking better. CR #3 was unable to provide details about how his eye looked before or if he received medication in the facility for his eye. Observation of CR #3 right eye revealed his eye was open and was slightly pink in his eye and top eye lid. No drainage or swelling observed. Interview on 7/4/2026 at 1:10pm, the hospital nurse said CR #3 was admitted to hospital for reasons unrelated to his eye infection but stated he did have an eye infection upon admission. The hospital nurse said the hospital was treating his eye infection with antibiotic eye drops and said it was getting better. Interview on 7/4/2026 at 3:00pm, the DON stated she has started doing chart audits to check for any missing medications and they have also started new in-services with the staff regarding pharmacy procedures. The DON said she will now get directly involved if there was a missing medication and staff should let her know immediately if a medication has been ordered and not available. The DON said if a medication is not available they will contact the doctor who will either let them know if it is okay to hold the medication until it arrives or get an order for something comparable that is available in the emergency kit until the other medication comes available. The DON said the nurses should be contacting the pharmacy themselves first if a medication is missing to check the status and still letting her know as well. The DON stated efforts to obtain the medication should be documented. Record review of the facility Pharmacy Services overview policy revised April 2019 revealed in part, .The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals. Pharmaceutical services consists of: a. The processes of receiving and interpreting prescriber's orders; acquiring, receiving, storing, control-ling, reconciling, compounding (e.g., intravenous antibiotics), dispensing, packaging, labeling, dis-tributing, administering, monitoring responses to, using and/or disposing of all medications, biologicals, chemicals. 4. Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner.5. Nursing staff communicate prescriber orders to the pharmacy and are responsible fo

Based on interviews and record review, the facility failed to report and investigate an incident for 1 resident of 5 residents (Resident #1) reviewed for abuse/neglect in that: The facility failed to report an allegation of staff abuse made by Resident #1 of an incident that occurred on 11/8/25 at an unknown time, to the State Agency. This failure could place residents at risk of abuse of residents.Record review of the admission record dated 1/12/26, revealed that Resident #1 was a [AGE] year-old male who was originally admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included Amyotrophic Lateral Sclerosis (also known as ALS, is a nervous system disease that affects nerve cells in the brain and spinal cord. ALS causes loss of muscle control. The disease gets worse over time), muscle wasting atrophy on the right lower leg (the presence of both low muscle mass and low muscle function (strength or performance), and need for assistance with personal care (anything that a client needs to maintain hygiene, well-being, self-esteem, and dignity). Record review of Resident #1's Significant Change MDS assessment dated [DATE] reflected a BIMS score of 15 out of 15 indicating his cognition was intact. He had upper limited range of motion on one side and lower extremity impairment on both sides. Resident #1 required total to substantial to maximal assistance with bathing/showering, toileting, lower body dressing. Record review of Resident #1's care plan, date Initiated: 09/3/2025 revealed the following: A care plan to address: ADL Self Care Performance Deficit r/t Musculoskeletal impairment R/T ALS Date Initiated: 09/03/2025. Revision on 09/03/2025, which included goals and interventions. Read in part. [Resident #1] will maintain current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene; ADL Score) through the review date. Date Initiated: 09/03/2025. Revision on: 1/2/26. Target Date: 3/5/26 BATHING: the resident is EXTENSIVE PER 1 STAFF Date Initiated: 9/3/.25 Revision on: 9/3/25. BED MOBILITY: The resident is EXTENSIVE PER 1 STAFF, Date Initiated: 9/3/2025.Revision on: 9/3/25. PERSONAL HYGIENE/ORAL CARE: The resident is EXTENSIVE PER 1 STAFF, Date Initiated: 9/3/25. Revision on: 9/3/25. DRESSING: Resident is EXTENSIVE PER 1 STAFF. Date Initiated: 9/3/25. Revision on: 9/3/25. EATING: The resident is able to FEED SELF WITH ASSIST AS NEEDED. Date Initiated: 9/3/25. Revision on: 9/3/25. Transfers: The resident is TOTAL PER 2 STAFF. Date Initiated: 9/3/25. Revision on: 9/3/25. TOILET USE: The resident is EXTENSIVE PER 1 STAFF. Date Initiated: 9/3/25. Revision on: 9/3/25. Record review of the facility's incident/accident reports between 11/1/25 and 1/14/26 revealed there was no incident documented for Resident #1. Record review of the complaint intake #: 1053184 read in part. perpetrator was changing [Resident #1], unable to get the resident's arm to go through his sleeve. So, she had wrenched the resident's left arm behind him like the cops do to suspects, per the resident. The resident further reported that his arm had been hurting since the incident. The resident also reported that the incident was reported to the facility. Record review of Resident #1's pain assessment dated [DATE] revealed that Resident #1 complained of pain on the left shoulder at a pain level of 10 out 10 . Verbally complaining that he felt that his arm was being pulled out of its socket. Interventions that were attempted were pain medication which was denied. Signed by LVN S Record review of Resident #1's Radiology Reports dated 11/8/25 read in part. PROCEDURE: SHOULDER LT 2V Status: Final LEFT SHOULDER LT 2V: Findings: There is no shoulder separation, fracture or dislocation. Record review of a statement dated 11/8/25 written by CNA A revealed no issues with Resident #1 complaining of pain or injury. Record review of a statement dated 11/8/25 written by CNA B A revealed no issues with Resident #1 complaining of pain or injury. (Attempted to reach via telephone/number disconnected or no longer in services Record review of a statement dated 11/8/25 written by LVN S revealed that her statement described Resident #1's care received by CNA A and CNA B, per Resident #1, he, described his treatment received by CNA A, Resident #1and said he felt like a Rag Doll. An observation and interview on 1/14/26 at 10:00 AM of Resident #1 revealed he was sitting up in his bed, with the call-light within reach. He said that in November 2025, CNA A handled him like a rag doll while providing care, attempting to remove his shirt. He added that he had pain in his left shoulder after the incident. He said that he shared the information with (former) Administrator B. He stated the information was also shared during his most recent care plan meeting (date unknown). He said that this was never addressed and was swept under the rug. In an observation and interview on 1/14/25 at 10:19 AM with CNA A, regarding Resident #1, she said that she remembered the incident and the allegation made by Resident #1, but she could not remember the exact date. She stated she did not hear about the allegation until the next day, after the allegation was made and when she and other staff were required to write witness statements by the DON. She said that former Administrator B and the DON were aware, and her statement was provided, she said that she denied the allegation of handling Resident #1 rough. CNA A demonstrated with her arm how she removed the resident's shirt (holding her arm straight out). She denied pinning the resident's arm behind his back. She said she received training on Abuse/Neglect and Exploitation. An interview was conducted on 1/14/26 at 10:31 AM with the DON, she said that in reviewing her records, she vaguely remembered an issue with Resident #1 because in her records he had an X-Ray on 11/8/26. She said that former Administrator B, may have reported the incident, but she was not sure. When the surveyor shared the concern of an allegation of resident abuse from Resident #1 and asked the DON in the case where a resident alleged that he felt a staff member handled him like a rag doll would be considered abuse.? She said she would have to have additional information. When asked about a possible negative outcome for the resident if the allegation of abuse was not reported, she said that the abuse could continue, and no one would know anything about it. She said that the reason she felt that former Administrator B would not have reported the allegation would be that there were witnesses, abuse was not alleged, and there were no injuries. In an interview on 1/14/26 at 10:44 AM with Administrator A, he said that he was not the Administrator in November of 2025 but would begin an investigation into Resident #1's allegations of resident abuse. When asked in the case where a resident alleged that he felt a staff member handled him like a rag doll would be considered abuse? He said he would like to gather more information. On 1/15/26 at 10:00 AM attempted phone interview with CNA B, message that said phone is disconnected or is no lone=ger in service. On 1/15/26 at 12:26 PM, a telephone interview with LVN S regarding Resident #1, she said that she was not present in the room when Resident #1 received care by CNA A and CNA B, she came to assess and interview Resident #1 and said that Resident #1 said used the word Rag Doll to describe his treatment received by CNA A. She said that she did not see any injuries. She said that she documented her assessment in the electronic medical record and wrote her statement. A telephone interview was conducted on 1/15/26 at 12:38 PM with an anonymous complainant. The complainant said they were not present and did not witness the incident but called the complaint in when the resident said that a CNA was rough. During a telephone interview on 1/15/26 at 2:05 PM with former Administrator B, he said he did not recall an incident or allegation made by Resident #1 on 11/8/25. He said there were a lot of complaints, but he could not remember and no longer worked at the facility. Record review of the facility's policy and procedure entitled Abuse, Neglect and Exploitation and Misappropriation Prevention Program, dated revised April 2021 read in part.Residents have the right to be free from abuse, neglect, misappropriation and exploitation. This includes but is not limited to.verbal, mental, physical abuse.The resident abuse, neglect.prevention program consist of a facility-wide commitment and resource allocation to support the following objectives.protect residents from abuse including but not necessarily limited to facility staff, other residents, consultants .develop and implement policies and protocols to prevent and identify abuse and mistreatment of residents.

Based on interview and record review, the facility failed to ensure that a resident who entered the facility with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #1) of 5 residents reviewed for catheters.LVN S failed to change and/or irrigate Resident #1's foley catheter on 11/28/25 when it was leaking, not flowing correctly, and there was an order to change it and irrigate it PRN, causing Resident #1 to call 911 and go to the ER.This failure could place residents at risk of urinary tract infections, the bladder to burst, skin break down, embarrassment, and possible hospitalization.Findings included:Record review of Resident #1's undated face sheet revealed he was a [AGE] year old male originally admitted on [DATE], with diagnoses of neuromuscular dysfunction of the bladder (unable to control bladder), paraplegia (paralysis of lower half), osteomyelitis of thoracolumbar vertebra (infection of the vertebra in the mid back area), Type 2 diabetes (body does not produce insulin or resists it), and a right below the knee amputation.Record review of Resident #1's admission MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating normal cognition. The resident was dependent (helper does all of the effort and resident does none of the effort) with toileting hygiene. The MDS also revealed the resident had an indwelling catheter and was frequently incontinent of bowel. Resident #1 had a Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer that he admitted with.Record review of Resident #1's Care Plan dated 9/29/25, revealed a Focus: Resident had a foley catheter for neurogenic bladder (Initiated: 4/1/25, Revised: 4/1/25). The goal was to remain free from catheter-related trauma through the review date (Initiated: 4/1/25, Revised: 4/1/25, Target: 6/27/25). The interventions included check tubing for kinks every shift and maintain the drainage bag off of the floor, monitor/document for pain/discomfort due to catheter, monitor/record/report to MD for s/sx UTI: no output.Record review of Resident #1's Physician Orders revealed the following orders from MD M:- Foley Catheter 16Fr Dx: Neuromuscular Dysfunction of Bladder. Ordered 9/29/25.- Flush foley with 60cc NS every day, every shift and PRN. Ordered on 10/20/25.- May change foley catheter PRN leakage, blockage, and sedimentation. Ordered 10/17/25.- Cefpodoxime Proxetil Taoblet (antibiotic) 200mg, 1 PO BID for 10 days, for UTI. Ordered on 11/28/25.Record review of Resident #1's Progress Notes revealed a Nursing Note from 11/28/25 at 1:18pm from LVN S that read, Alerted by call light I entered patients room with patient advising me that he had notified EMS. Patient assessed A&O times 4 no pain, nonlabored respirations and able to verbalize. Patient stated that he would just like to be seen in the ER. Patient documentation was provided to EMS upon arrivale [arrival]. Patient transported to ER, facility supervisor notified. There was no documentation regarding the resident's catheter leaking or anything about the resident wanting to go to the ER for antibiotics.Record Review of Resident #1's hospital discharge paperwork from 11/28/25 revealed he was seen for a dislodged foley catheter and a UTI. He was prescribed Cefpodoxime (antibiotic) 200mg BID for 10 days, for UTI.In an interview on 11/30/25 at 11:35am, Resident #1 said on 11/28/25 his catheter was not draining, and he was soaked in urine. He said his shirt and his bed linen were soaked in urine. He said he had issues before with it not draining and the nurse would change out the catheter. Resident #1 said normally his foley bag was full in the morning and on 11/28/25 it was not. He said his pubic area was hard and tender, so he knew his bladder was full. He said he asked LVN S to change his foley and she told him his catheter was fine. Resident #1 then told LVN S if you don't help me, I'm calling 911. He said LVN S said, That's fine, do whatever you want. Resident #1 said since LVN S was not helping him, he called 911. He said once he got to the hospital they told him the foley catheter tube had a tear in it, the part that was in his urethra.In an interview on 12/1/25 at 11:50am, LVN R said the indications for changing a foley catheter were if it was occluded, leaking, or she could not irrigate it. She said she had changed Resident #1's catheter on 11/25/25 or 11/26/26 and that it had leaked before. She said if the catheter did not get changed it could cause a UTI, obstruction, or a full bladder. She said when Resident #1 came back from the hospital he was asking her if they were allowed to change and irrigate his foley, and he was telling her about his problems he had with LVN S not helping him when he was leaking everywhere. LVN R said Resident #1's foley catheter had to be changed in the ER when he went.In an interview on 12/1/25 at 12:10pm, EMS B said he observed Resident #1 covered in urine from his mid-chest down when he went to the facility to pick him up. EMS B said the resident told him that his catheter stopped working and he had told LVN S, and she told him not to worry about it. EMS B said the resident told LVN S if she did not help him he was going to call 911 and she told him to do whatever he wanted and walked out. EMS B said he saw the catheter leaking and saw it was not properly positioned. He said the tip of the catheter was in Resident #1's urethra instead of in the bladder. He said a CNA had gone in the room when he arrived and she attempted to put a clean brief on Resident #1, but as soon as they turned the resident he soiled it with more urine. He also said while the resident was turned he noticed a bandage on the resident's left buttocks and a reddened/darkened area to his lower back.In an interview on 12/1/25 at 1:15pm, the DON said Resident #1 filed a grievance yesterday (11/30/25) regarding LVN S not changing his catheter. The DON said that was the first time she heard about the incident. She said she was told by LVN S that Resident #1 wanted to go to the hospital to get antibiotics, but there was no documentation of that. The DON said if a resident had a leaking foley and had an order for it to be flushed and/or changed, she expected the nurse to flush the foley first to see if that took care of the leaking, and if that did not work, she expected the nurse to change the catheter. She said if the catheter did not get changed it could cause a urinary tract infection or a burst bladder.In an interview on 12/1/25 at 1:20pm, LVN S said she saw Resident #1's foley catheter leaking and saw that he was covered in urine. She said he asked her to change his catheter, but she wanted to call the MD to see what he wanted to do, even though there were orders to change it. She said she did not clean up Resident #1 or change his catheter because the resident did not want to wait for her to call the doctor and went ahead and called 911. She said she had not changed any catheter before in the facility and only worked at the facility PRN. She said indications for changing a foley were bleeding and discharge in the catheter. She also said she did not irrigate Resident #1's catheter at any time that day.Record review of the facility's policy and procedure on Catheter Care, Urinary (Revised September 2014) read in part: The purpose of this procedure is to prevent catheter-associated urinary tract infections. If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment, as ordered. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. Observe the resident for complications associated with urinary catheters. If the resident indicates that his or her bladder is full or that he or she needs to void (urinate), notify the physician or supervisor. Check the urine for unusual appearance (i.e., color, blood, etc.). Notify the physician or supervisor in the event of bleeding, or if the catheter is accidently removed. Report any complaints the resident may have of burning, tenderness, or pain in the urethral area. Observe for other signs and symptoms of urinary tract infection or urinary retention. Report findings to the physician or supervisor immediately. If the catheter material is contributing to obstruction, notify the physician and change the catheter if instructed to do so. Catheter irrigation may be ordered to prevent obstruction in residents at risk for obstruction.

Based on interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #1) of 5 residents reviewed for dignity.LVN S failed to change and/or irrigate Resident #1's foley catheter on 11/28/25 when it was leaking, not flowing correctly, and there was an order to change it and irrigate it PRN, causing Resident #1 to sit in urine soaked bed linen and t-shirt.This failure could place residents at risk for embarrassment, decrease in dignity, and a decrease in quality of life.Findings included:Record review of Resident #1's undated face sheet revealed he was a [AGE] year old male originally admitted on [DATE], with diagnoses of neuromuscular dysfunction of the bladder (unable to control bladder), paraplegia (paralysis of lower half), osteomyelitis of thoracolumbar vertebra (infection of the vertebra in the mid back area), Type 2 diabetes (body does not produce insulin or resists it), and a right below the knee amputation.Record review of Resident #1's admission MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating normal cognition. The resident was dependent (helper does all of the effort and resident does none of the effort) with toileting hygiene. The MDS also revealed the resident had an indwelling catheter and was frequently incontinent of bowel. Resident #1 had a Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer that he admitted with.Record review of Resident #1's Care Plan dated 9/29/25, revealed a Focus: Resident had a foley catheter for neurogenic bladder (Initiated: 4/1/25, Revised: 4/1/25). The goal was to remain free from catheter-related trauma through the review date (Initiated: 4/1/25, Revised: 4/1/25, Target: 6/27/25). The interventions included check tubing for kinks every shift and maintain the drainage bag off of the floor, monitor/document for pain/discomfort due to catheter, monitor/record/report to MD for s/sx UTI: no output.Record review of Resident #1's Physician Orders revealed the following orders from MD M:- Foley Catheter 16Fr Dx: Neuromuscular Dysfunction of Bladder. Ordered 9/29/25.- Flush foley with 60cc NS every day, every shift and PRN. Ordered on 10/20/25.- May change foley catheter PRN leakage, blockage, and sedimentation. Ordered 10/17/25.Record review of Resident #1's Progress Notes revealed a Nursing Note from 11/28/25 at 1:18pm from LVN S that read, Alerted by call light I entered patients room with patient advising me that he had notified EMS. Patient assessed A&O times 4 no pain, nonlabored respirations and able to verbalize. Patient stated that he would just like to be seen in the ER. Patient documentation was provided to EMS upon arrivale [arrival]. Patient transported to ER, facility supervisor notified.Record Review of Resident #1's hospital discharge paperwork from 11/28/25 revealed he was seen for a dislodged foley catheter and a UTI. He was prescribed Cefpodoxime (antibiotic) 200mg BID for 10 days, for UTI.In an interview on 11/30/25 at 11:35am, Resident #1 said on 11/28/25 his catheter was not draining, and he was soaked in urine. He said his shirt and his bed linen were soaked in urine. He said he asked LVN S to change his foley and she told him his catheter was fine. Resident #1 then told LVN S if you don't help me, I'm calling 911. He said LVN S said, That's fine, do whatever you want. Resident #1 said since LVN S was not helping him, he called 911. He said he did not want to be sitting in his urine.In an interview on 12/1/25 at 11:50am, LVN R said when Resident #1 came back from the hospital he was telling her about the problems he had with LVN S not helping him when he was leaking everywhere. She said if the catheter did not get changed it could cause a UTI, obstruction, or a full bladder. LVN R did not report the issue to anyone.In an interview on 12/1/25 at 12:10pm, EMS B said he observed Resident #1 covered in urine from his mid-chest down when he went to the facility to pick him up. EMS B said the resident told him that his catheter stopped working and he had told LVN S, and she told him not to worry about it. EMS B said the resident told LVN S if she did not help him he was going to call 911 and she told him to do whatever he wanted and walked out.In an interview on 12/1/25 at 1:15pm, the DON said Resident #1 filed a grievance yesterday (11/30/25) regarding LVN S not changing his catheter. The DON said that was the first time she heard about the incident. The DON said if a resident had a leaking foley and had an order for it to be flushed and/or changed, she expected the nurse to flush the foley first to see if that took care of the leaking, and if that did not work, she expected the nurse to change the catheter. She said if the catheter did not get changed it could cause a urinary tract infection or a burst bladder.In an interview on 12/1/25 at 1:20pm, LVN S said she saw Resident #1's foley catheter leaking and saw that he was covered in urine. She said he asked her to change his catheter, but she wanted to call the MD to see what he wanted to do, even though there were orders to change it. She said she did not clean up Resident #1 or change his catheter because the resident did not want to wait for her to call the doctor and ended up calling 911 himself. She also said she did not irrigate Resident #1's catheter at any time that day.Record review of the facility's policy and procedures on Resident Rights (Revised February 2021) read in part: Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence, be treated with respect, kindness, and dignity, to be free from abuse, neglect.be supported by the facility in exercising his or her rights.

Based on observation, interview, and record review, the facility failed to ensure the resident's right to be free from abuse for 1 of 7 residents (Resident #2) reviewed for abuse in that:The facility failed to ensure Resident #2 was free from abuse by Resident #1 on 07/25/2025 when Resident #1 hit Resident #2 in the face. This failure could place residents at risk of abuse and psychosocial harm. Findings included:Resident #1Record review of Resident #1's admission record, dated 11/20/2025, revealed a [AGE] year-old male who admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included unspecified dementia (loss of memory), schizoaffective disorder, bipolar type (a mental illness that combines symptoms of schizophrenia [chronic mental disorder affecting thoughts, perceptions, emotions, and social interactions] and a mood disorder but does not meet the criteria for either alone), and personal history of traumatic brain injury (damage to the brain caused by a head injury). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 14, indicating intact cognition. Further review of the MDS revealed no behavior exhibited for physical behavioral symptoms directed towards others; the resident's verbal behavior towards others and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) were coded 2 (Behavior of this type occurred 4 to 6days, but less than daily).Record review of Resident #1's care plan revealed the following:- Resident #1 requires psychotropic medications and antiseizure for Behavior management DX Schizoaffective and Bipolar and History of Traumatic Brain Injury. Date initiated 06/20/2025. - Resident #1 has potential to demonstrate physical behaviors hit another resident r/t Anger, Dementia. Date initiated 07/28/2025.Record review of Resident #1's nursing note, dated 07/25/2025 at 5:39 pm, revealed Received a phone call from [Name], NP with Dr. [name], requesting clarification regarding a recent incident involving the resident. Explained that this nurse was informed by staff that the resident was witnessed by dietary personnel physically assaulting another resident. According to the report, the resident appeared upset that the other resident was looking at him while he ate. He was initially seated one table away, then rolled over in his wheelchair and punched the other resident on the right side of the face without any verbal exchange. [Name], NP gave verbal orders to initiate a 1:1 sitter with 15-minute safety checks, to obtain an X-ray of the face if the resident complains of pain or discomfort, and to proceed with referral and transfer to an inpatient psychiatric facility as needed. Informed NP that [Facility Name] may have a potential bed available, and nursing staff will send documentation for possible admission. NP verbalized understanding and agreement. Also updated NP that the facility has been actively working on discharge placement, but efforts have been complicated by the resident's ongoing wound care needs. The assigned nurse was instructed to notify the resident's family regarding the incident and plan of care.Record review of Resident #1's nursing note, dated 07/25/2025 at 7:45 pm, revealed Resident physically assaulted another resident. He stated the other resident was taking food from a female in the dining room and he hit him. The two were immediately separated and all parties were notified of the assault.Record review of Resident #1's nursing note, dated 07/25/2025 at 9:40 pm, revealed pt. was relocated to the 500 hall currently has a 1:1 sitter. pt calm with no outward s/s of aggression or agitation.Record review of Resident #1's nursing note, dated 07/26/2025 at 8:16 am, revealed Patient continues to remains on 1:1 observation with dedicated staff per physician order and safety protocol. Throughout the shift, the patient has presented as calm, cooperative, and emotionally stable. No episodes of verbal or physical aggression have been observed or reported to writer. Patient is engaging appropriately with staff and peers and displays a mood congruent with affect. Notably, the patient has exhibited intermittent forgetfulness, including repeated questioning about whether pain medication was administered. Writer provided reassurance and clarification, and patient was redirected without resistance. No signs of distress, confusion, or agitation were noted following redirection.Record review of Resident #1's telehealth progress note, dated 07/28/2025 revealed .Other Symptoms: Highly irritable. Physical aggression towards others. Verbal aggression. [Name], LVN called to reported the patient is becoming verbally and physically aggressive. The nurse reported the patient assaulted another resident. No injuries reported. The facility attempted to send out the patient to an inpatient psych hospital but he was denied due to his wounds. The patient is currently on 1:1 observation with checks every 15 minutes. Plan: Continue 1 on 1 monitoring. Increase Depakote DR 1250mg QAM &QPM Continue 1000mg noon dose. Obtain CBC/VPA on 1 week send me results.Record review of Resident #1's nursing note, dated 07/28/2025 at 3:16 pm, revealed Tele health visit with [name] NP took place with resident. Resident was overheard stating that he did punch another resident in the face but it was self defense and provoked by the other resident. (Witness statement states otherwise) Resident was advised to seek assistance from staff members in the future, and not to take matters into his own hands. After visit was completed, [name] NP called back with new orders to increase Depakote, continue 1:1. (Will re evaluate on Wednesday) And labs in one week.Record review of Resident #1's psychiatric progress note, dated 07/30/2025 revealed Patient reveals: 'I'm all right'. Meeting with staff reveals: Meeting with facility staff indicates the patient has: Normal appetite. No anxiety and no irritability, and no hostility toward peer(s). No hostility toward caregivers. No depression and no sleep complaints. Energy level is normal. No physical aggression. No paranoid ideations and not resisting assistance with activities of daily living. No social isolation. Not refusing treatment. No verbal aggression. The patient verbalized to me if he becomes irritable and wants to become verbally or physically aggressive with anyone he would walk away and notify staff.Plan: Discontinue 1 on 1 observation at this time.Resident #2Record review of Resident #2's admission record, dated 11/20/2025, revealed a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included malnutrition (not getting the right amount of nutrients), myocardial infarction (heart attack), Type 2 Diabetes (a disease that occurs when the body does not respond properly to insulin leading to high blood sugar levels), unspecified dementia (loss of memory), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS score of 9, indicating moderate cognitive impairment. Further review of the MDS revealed no behaviors exhibited for the following: physical behavioral symptoms directed towards others; the resident's verbal behavior towards others and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds).Record review of Resident #2's care plan revealed the following: - The resident has a behavior problem (hitting, kicking, scratching staff) r/t dementia. I also smear BM on privacy curtain, date initiated 09/17/2024. - The resident has a psychosocial well-being problem actual r/t other resident hitting him, date initiated 07/28/2025. - Behavior: Verbal Threats dated initiated 08/07/2025. - The resident has a behavior problem r/t can be aggressive towards other residents and staff, date initiated 10/21/2025. Record review of Resident #2's nursing notes, dated 07/25/2025 7:41 pm, revealed Resident was physically attacked while in the dining room. He was punched in the face while sitting at a table. He and the aggressor were immediately separated. He was assessed and had no physical bruising and denied having pain. Resident stated he was fine. He returned to his room and got into his bed. All parties notified of the incident.Record review of Resident #2's nursing notes, dated 07/29/2025 2:16 am, revealed facial xray 2V results: No evidence of facial bone dislocation or fracture.Record review of Resident #2's skin assessment, dated 07/25/2025, revealed no changes to skin. Record review of Resident #2's post incident assessments, dated 07/25/2025 and 07/26/2025, revealed Resident #2 did not show any signs of emotional distress or changes to behavior. Record review of the facility's investigation report revealed On 7/25/2025 at 5:09, Resident stated that his roommate was trying to take food from a female resident in the dining room. Resident punched other resident in the rt. side of face without any words exchanged. Nurse assessed both residents, no injuries, no adverse effects. Witnessed by [Name], Cook. Emotional distress Q shift X 3 days, skin assessment, resident safety interviews initiated .Record review of the undated statement, written by [NAME] A revealed I [name] Dietary Cook, witnessed [Resident #1] punch [Resident #2] in the right side of face. [Resident #1] was upset because [Resident #2] was looking at him eat. [Resident #1] was 1 table away, he rolled over and punched him with no words.Observation on 11/19/2025 at 3:13 pm, Resident #1 was well groomed and dressed, sitting up in his w/c, appeared asleep. Interview was unsuccessful as Resident #1 did not wake up and answer surveyor questions. Observation on 11/19/2025 at 3:29 pm revealed Resident #2 was lying in bed, awake. Interview was unsuccessful as Resident #2 did not answer surveyor questions. Interview on 11/20/2025 at 9:55 am, the DON stated she did part of the investigation but did not witness this incident. She stated psych followed Resident #1, and staff managed his behaviors by redirection. The DON stated Resident #1 had anxiety, and some interventions included scheduling a day and time for when he could purchase items, scheduled days he received his money, talk with her or another staff member when feeling anxious, and monitoring Resident #1 in the dining room since most of his incidents happened in the dining area. The DON stated staff were in serviced on Abuse and Neglect by herself, the Administrator or the ADON and staff were taught to de-escalate resident behaviors and separate residents if an altercation occurred.Interview on 11/20/2025 at 2:02 pm with Resident #2 was unsuccessful, Resident #2 did not answer surveyor questions. Observation and interview on 11/20/2025 at 2:05 pm, revealed Resident #1 in his room, lying in bed. Resident #1 stated he had issues with his memory. When asked about the incident, Resident #1 stated he was in the dining room, and needed to get something so he went around to the line. He said he then told Resident #2 he was going to kick his ass because Resident #2 was sitting and eating his food. Resident #1 denied punching Resident #2 and said he knew better than to hit him because he was in a w/c, and elderly. Resident #1 stated if someone were to get ahold of him first, he would hit them. Interview on 11/20/2025 at 5:34 pm, the DON stated there was potential for residents who acted out to get hurt or potential for them to hurt other residents. She stated they tried to prevent instances of resident-to-resident abuse by providing a safe environment, monitoring any behaviors, and managing medications. The DON stated nurses were responsible for monitoring behaviors and meds, and to notify the MD with changes. She said the IDT team was responsible for coordinating with psych services, and discussing any changes. Interview on 11/20/2025 at 5:51 pm, the Administrator stated there was a risk to everybody and the problem was when they tried to send Resident #1 out for psych, he was denied due to his wound and there were not a lot of options. He stated Resident #1 was being seen by psych in house, but there were not other long term care psych facilities nearby. He stated staff monitor the residents with behaviors and they did the best they could. He said they could not have all residents on 1:1, so they would identify the residents who needed more monitoring for staff to keep their eyes on them. Phone interview on 11/20/2025 at 6:09 pm, [NAME] A stated Resident #1 punched Resident #2 in the face, and Resident #2's face was red. He said Resident #1 was aggressive at the time of the incident. [NAME] A stated he did not see Resident #2 eat Resident #1's food during the incident. Record review of facility policy titled, Recognizing Signs and Symptoms of Abuse/Neglect, revised April 2021, revealed All types of resident abuse, neglect, exploitation or misappropriation of resident property are strictly prohibited.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: - The facility failed to keep kitchen equipment clean and free of grease build up. - The facility failed to label foods for identification and dated with expiration date. - The facility failed to ensure that expired food items and products were not stored in the walk- in refrigerator. These failures could place residents at risk for food-borne illness and/or transmission-based infections. Findings included: Kitchen observation and interview on [DATE] at 8:40am, revealed one of one commercial can opener had a dark looking substance around the cutting blades and the blade holder. The deep fryer had dark looking grease with white floating substances on top of the grease. [NAME] G said she was off for three days and today [DATE] was her first day back. She said the grease was usually changed once a week but not sure of when it was changed last. Observation of the walk-in cooler and interview on ([DATE] at 8:45AM revealed the following food items. -Half 32oz Ready care dairy drink with expiration date of [DATE] -Sandwich in a small tray without label, [NAME] G said they were made this morning for snacks. -A plastic container of coleslaw dated [DATE] no label. -A plastic container of crushed pineapple-no date and no label. -Assorted sandwich meat undated and unlabeled all in a plastic bag -5 lbs. container of Cottage cheese dated [DATE] -32 oz of baking buttered milk dated [DATE]. -,d+[DATE] full gallon of yellow mustard dated [DATE] -32oz of enchilada source dated [DATE] -1Lbs (16oz) Margarin half covered, and half exposed on the shelve with dark brown substance around the butter. -16oz cholate syrup dated [DATE]. -48oz box of Lemon Crust Mix dated [DATE]. -An unknown substance in a grocery bag. [NAME] G said she does not know what it was and have no idea who left it in the walk-in cooler. All undated and unlabeled items were identified and removed from the kitchen walk in cooler by cook G. During an interview with [NAME] G on [DATE] at 8:55AM, she said she expected all food items in the kitchen to be labeled with food item for identification and a used by date to prevent food burn, illness, and food poisoning. Attempt was made to communicate with the Dietary Manager on [DATE] at 2:00PM and was difficult due to hearing impairment. In an interview with the facility's Administrator, DON, and the Regional Clinical director on [DATE] at 4:00 PM, the Administrator said cleaning of the kitchen should be the responsibility of all staff. He said the Dietary Manager had some challenges and he was new to the position. The regional Director of Operation said the Dietary Manager would have more training on management. During an interview with the Registered Dietitian on [DATE] at 12:00PM, she said she expected the kitchen to be cleaned, all food items properly labeled and dated with date prepared and expiration date. She said all precooked food products are to be discard after 3 days if not used. Record review of facility's policy dated 2000 revised 2006 revealed- Policy Statement Food storage areas shall be maintained in a clean, safe, and sanitary manner. 1. Food Services, or other designated staff, will maintain clean, food storage areas at all times . 5 Prepared food stored in the refrigerator until service shall be dated with an expiration date. Such food will be tightly sealed with plastic wrap, foil, or a lid. 10 The Food Services Manager, or his/her designee, will check refrigerators and freezers daily for proper temperatures. The Food Services Manager will maintain records of such information.

Based on observations, interviews and record reviews, the facility failed to develop and implement comprehensive care plans with measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs identified in the comprehensive assessment for of 20 residents reviewed for care plan accuracy(Residents # 59, 123, 17) ---there were no comprehensive care plans in Resident #'s 59, 123, and 17 elctronic medical records. These failures placed residents at risk of receiving inadequate care due to incomplete care plans. Findings include: Resident # 59 Record review of Resident # 59's face sheet revealed admitted [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (lung conditions causing airflow obstruction), hypertension (high blood pressure), heart failure (inability of heart to pump blood as it should), muscle weakness, lack of coordination (problems with balance). Record review of Resident # 59's Admission MDS dated [DATE] revealed a BIMS score of 12, indicating moderate cognitive impairment, understands others and understood by others, frequently incontinent of bowel and bladder, partial/moderate assistance required for bathing and toileting, and supervision/set up for hygiene. Record review of Resident # 59's undated comprehensive care plan revealed it was blank: there were no focus areas, goals or interventions developed to assist direct care staff in providing care for Resident # 59. Resident # 123 Record review of Resident # 123's face sheet revealed admitted [DATE] with diagnoses including Parkinson's (central nervous system disorder affecting movement), unqualified visual loss, both eyes, hypertension (high blood pressure), chronic obstructive pulmonary disease (lung conditions causing airflow obstruction), anxiety disorder (excessive worry, fear, nervousness), depression (loss of interest in activities). Record review of Resident # 123's Admission MDS dated [DATE] revealed a BIMS score of 15, indicating intact cognitive functioning, severely impaired visual functioning, understood by others and understands others, always continent, Hospice while a resident, partial/moderate assistance required for eating, hygiene, toileting, dressing, and maximum assistance needed for bathing. Record review of Resident # 123's undated comprehensive care plan revealed it was blank: there were no focus areas, goals or interventions developed to assist direct care staff in providing care for Resident # 123. Resident # 17 Record review of Resident # 17's face sheet revealed admitted [DATE] with diagnoses including dementia (impairment in memory, thinking and social abilities), peripheral neuropathy (nerve damage causing pain and numbness in hands and/or feet), transient ischemic attack (temporary interruption of blood flow to the brain), heart failure (inability of heart to pump blood as it should), osteoarthritis (deterioration of tissue at the ends of bones), cervicalgia (neck pain). Record review of Resident # 17's Admission MDS dated [DATE] revealed BIMS score of 14 indicating intact cognitive ability, understands others and understood by others, always incontinent of bowel and bladder, partial/moderate assistance required for hygiene, and maximum assistance needed for toileting and dressing. Record review of Resident # 17's undated comprehensive care plan revealed it was blank: there were no focus areas, goals or interventions developed to assist direct care staff in providing care for Resident # 17. In an interview on 5/14/25 at 12:30pm, the DON said the MDS coordinator did not put the care plan into the EMR. She said the triggered areas from the MDS would be used to build the care plan, but it was not done for Residents # 59, # 123, and# 17. She said there would need to be someone hired to complete the care plans. In an interview on 5/14/25 at 12:40pm, the ADON said the DON and MDS nurse would be responsible for care plans, and she looks at the baseline care plan to determine if anything needed to be addressed. In an interview on 5/14/25 at 3:30pm, the RDO, DON, and ADON said they did not know what happened and why there were so many care plans missing. They said there have been 3 MDS nurses working here since September 2024. The MDS nurse would develop the care plan from information from the IDT meeting and input from the nurses. The risk of having incomplete care plans would residents not receive correct care. Record review of facility policy Care Plans, Comprehensive Resident Centered, revised December 2016, revealed, in part: .the comprehensive person-centered care plan is developed within 7 days of the required comprehensive assessment (MDS) .assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .

Based on interview and record review, the facility failed to ensure that assessments accurately reflected residents' status for 3 (Resident #7, #16, #22) of 10 residents reviewed for accuracy of assessments. -The facility failed to ensure that Resident #7's falls that occurred on 4/20/25 were documented on their annual MDS assessment dated [DATE]. -The facility failed to ensure that Resident # 16 's falls were documented on her Annual MDS assessment dated [DATE], quarterly MDS dated [DATE] and 12/11/24. - The facility failed to ensure that Resident # 22 's falls were documented on her Annual MDS assessment dated [DATE], quarterly MDS dated [DATE] and 12/23/24. These failures could place residents at risk of receiving inadequate care and services based on inaccurate assessments. Findings included: Resident #7 Record review of Resident #7's face sheet dated 5/13/2025, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Acute on Chronic Systolic (Congestive) Heart Failure (disorder where the heard does not pump blood as well as it should) and Muscle Weakness. Record review of Resident #7's care plan with last review 5/13/25 revealed she had two falls on 4/20/25. Record review of Resident #7's Fall Nurses' Note dated 4/20/25 at 5:36 a.m. revealed resident had an un-witnessed fall with no injury. Record review of Resident #7's Fall Nurses' Note dated 4/20/25 at 12:33 p.m. revealed resident had an un-witnessed fall with no injury. Record review of Resident #7's Progress Notes for date range 4/19-4/21/25 revealed on 4/20/25 at 5:25 a.m. Resident #7 was found on the floor and on 4/20/25 at 12:47 p.m. Resident #7 was found lying on her right side. Record review of Resident #7's annual MDS dated [DATE] and printed 5/12/24 revealed a BIMS score of 00 that indicated severe cognitive impairment. Record review also revealed no falls since admission/entry or reentry or the prior assessment in section J1800. During interview on 5/14/25 at 10:25 a.m., the DON said Resident #7's falls on 4/20/25 should have been claimed on the MDS dated [DATE]. During interview on 5/14/25 at 1:33 p.m., the Director of Reimbursement said a fall should be coded if it occurred on 4/20/25 and the MDS was on 5/1/25. The Director of Reimbursement said if the MDS was not coded correctly then that triggered on care plans which could prevent interventions that could prevent future falls. Resident #16 Record review of Resident #16's face sheet dated 5/13/2025, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included lack of coordination, unsteady feet, difficulty in walking, chronic respiratory failure, chronic pain, Hypertension (high blood pressure), depression, generalized anxiety, and muscle weakness. Record review of facility's accidents and incident's log dated 05/12/25 indicated Resident #16 had un-witnessed fall on 11/14/24, and witnessed falls on 12/30/24, 01/08/25, and 03/17/25. Record review of Resident #16's Care plan dated 04/16/24 revealed Resident #16 was care-planned for falls: Resident #16 has had an actual fall 3/16/25 - unwitnessed fall no injury Date Initiated: 04/16/2025, Revision on: 04/16/2025. Record review of Resident #16's annual MDS dated [DATE], indicated the section on fall assessment were left blank section on falls since admission, re-admission was coded 0 which indicated no fall history. Record review of Resident #16's Quarterly MDS dated [DATE] indicated the section on fall assessment were left blank section on falls since admission, re-admission was coded 0 which indicated no fall history Record review of Resident #16's Quarterly MDS dated [DATE] indicated the section on fall assessment were left blank section on falls since admission, re-admission was coded 0 which indicated no fall history. Resident #22 Record review of Resident #22's face sheet dated 5/13/2025, revealed a-72-year -old male resident admitted to the facility initially on 09/14/22 and readmitted on [DATE]. Record review of facility's accidents and incident's log dated 05/12/25 indicated Resident #22 had multiple falls as followed witnessed Falls on- 01/18/25 01/23/25 3/18/25 Unwitnessed Falls on 02/01/25 02/06/25 Record review of Resident #22's care plan dated 09/23/22 with a revision date of 04/16/25 indicated Resident #22 was care planned for falls: Focus-Resident # 22 had a fall on 1/18/25 - Witnessed Fall, 1/23/25 - Witnessed Fall,2/1/25 - Unwitnessed Fall, 2/6/25 - Unwitnessed Fall, 3/18/25 - Witnessed fall, Date Initiated: 09/23/2022. Goal: Resident #22 will be free of minor injury through the target date 03/27/2025. Resident #22 will not sustain serious injury through the target date 03/27/2025 . Record review of Resident #22's Significant change MDS assessment dated [DATE] and quarterly MDS dated [DATE], revealed the sections on fall assessment were left blank, section on falls since admission/ re-admission was coded 0 which indicated no fall history. During interview on 05/12/25 at 10:15 am Resident #22's sitter said she sits with Resident #22 due to multiple falls. Resident #22 was unable to communicate. During interview on 5/14/25 at 1:20 p.m. the CDO said if the MDS was coded inaccurately then the resident could have adverse effects but did not elaborate. During interview on 5/14/25 at 1:54 p.m., the MDS Consultant said if a MDS was not coded correctly then the care provided or needed could be affected, the care planning process could be affected, and could affect everything all the way around. 51036

Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care was provided such care, consistent with professional standards of practice for 2 (Residents #27 and #32) of 4 residents reviewed for respiratory care. The facility failed to ensure Resident #27's oxygen humidifier was not empty and Resident #32's oxygen concentrator was working appropriately by not beeping. The failure could place residents at risk of developing respiratory complications or having decreased quality of care from dry nasal passages that could lead to nosebleeds or sores. Findings included: Resident #27 Record review of Resident #27's face sheet dated 5/13/2025, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (progressive brain disorder that destroys memory and thinking skills) and Heart Failure (disorder when the heart does not pump blood as well as it should). Record review of Resident #27's quarterly MDS dated [DATE] revealed a BIMS score of 00 that indicated severe cognitive impairment. Record review also revealed under section O: oxygen therapy was received. Record review of Resident #27's Order Summary Report dated 5/13/25 revealed Change O2 tubing/water every week on Sunday night shift and PRN. Record review of Resident #27's May TAR printed 5/13/25 revealed Change O2 tubing/water every week on Sunday night shift and PRN. Record review of Resident #27's care plan printed 5/13/25 revealed the resident has oxygen therapy related to Congestive Heart Failure (disorder when the heart does not pump blood as well as it should) with intervention of oxygen settings of oxygen via nasal cannula at 3 liters continuously. Observation on 5/12/25 at 10:10 a.m. revealed Resident #27's humidifier bottle on her oxygen concentrator was empty while she was wearing oxygen at 2 liters via nasal cannula. Observation on 5/13/25 at 8:51 a.m. revealed Resident #27's humidifier bottle on her oxygen concentrator was empty while she was wearing oxygen at 2 liters via nasal cannula. During interview on 5/13/25 at 8:53 a.m., the DON observed Resident #27's oxygen concentrator and the DON said it was the nurse's responsibility to refill the oxygen humidifiers and should be done on Sundays. Resident #32 Record review of Resident #32's face sheet dated 5/13/2025, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus (high blood sugar) without complications and Heart Failure (disorder when the heart does not pump blood as well as it should). Record review of Resident #32's quarterly MDS dated [DATE] revealed a BIMS score of 11 that indicated moderate cognitive impairment. Record review also revealed oxygen therapy while a resident documented under section O for Resident #32. Record review of Resident #32's Order Summary Report dated 5/13/25 revealed Change O2 tubing/water every week on Sunday and PRN. Record review of Resident #32's May TAR printed 5/13/25 revealed Change O2 tubing/water every week on Sunday and PRN. Record review of Resident #32's care plan printed 5/13/25 revealed the resident has oxygen therapy related to Congestive Heart Failure (disorder when the heart does not pump blood as well as it should) with intervention to change oxygen tubing and water every week on Sunday and as needed. During interview and observation on 5/12/25 at 9:08 a.m., Resident #32 said she almost ran out of water in the oxygen humidifier bottle, and it bothered her nose, but she could not remember when the incident happened. Resident #32 was observed wearing oxygen at 4 liters via nasal cannula and there was about 3/4 inch of water in the humidifier bottle on the oxygen concentrator. Resident #32's oxygen concentrator was noted to be beeping. During interview and observation on 5/13/25 at 8:55 a.m., Resident #32 said my nose tells me I need some water because her nose felt dry. Observation of Resident #32 revealed she was wearing oxygen at 4 liters via nasal cannula and there was about one centimeter of water in the humidifier bottle on the oxygen concentrator. Oxygen concentrator was beeping. During interview on 5/14/25 at 9:02 a.m., LVN H said she normally worked the hallways where Resident #27 and #32 resided. LVN H said she checked oxygen humidifier bottles daily when she made her first rounds. LVN H said Sunday night nursing staff was responsible for refilling the humidifier bottles on the oxygen concentrators. LVN H said an effect a resident could experience if the oxygen humidifier bottle was empty was the resident's sinuses could dry out or possible have thicken secretions. During interview on 5/14/25 10:25 a.m., the DON said if a resident's oxygen humidifier was not filled then the resident's nasal cavity could dry out causing a nosebleed. The DON said they would have an in-service regarding oxygen humidifiers. During interview on 5/14/25 at 12:04 a.m., the ADON said if a resident's oxygen concentrator's humidifier was empty then the resident could have dried out nares which could lead to nosebleeds or ulcers. During interview on 5/14/25 at 3:06 p.m., the Administrator said they did not have any previous trainings to provide regarding oxygen care this year. Record review of facility's policy Oxygen Administration revealed Periodically re-check water lever in humidifying jar.

Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out Activities of Daily Living received the necessary services to maintain grooming and personal hygiene for 1 (Resident #7) of 5 residents reviewed for Activities of Daily Living. The facility failed to provide Resident #7 with adequate oral care. This failure could place residents at risk of diminished quality of life or decreased self-esteem. Findings included: Record review of Resident #7's face sheet dated 5/13/2025, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Need for Assistance with Personal Care. Record review of Resident #7's annual MDS dated [DATE] revealed a BIMS score of 00 that indicated severe cognitive impairment. Record review also revealed score of 03 which was partial/moderate assistance for oral hygiene in Section GG0130. Record review of Resident #7's care plan printed 5/13/25 revealed the resident required extensive assistance by staff with personal hygiene and oral care Record review of Resident #7's POC Response History printed 5/12/25 with look back for 14 days showed documentation regarding personal hygiene (How resident maintains personal hygiene, including brushing teeth) from 4/29/25-5/4/25 and 5/6/25-5/8/25. Further review revealed there was no documentation on 5/5/25 and from 5/9/25-5/12/25. During interview on 5/12/25 at 11:31 a.m., Resident #7's family member stated she had previously put a sign above the resident's bed that said please help me brush my teeth. She stated Resident #7 was able to brush her teeth with set up assistance prior to recent decline. Resident #7 was no longer able to brush her teeth. Resident #7's family member said Resident #7's mouth was horrible, and she was disheartened when she saw the state of her mouth on 5/11/25. Resident #7's family member said she went to the nurse at that time and asked for mouth swabs and tried to do oral care but was not trained how to do oral care. Observation and interview on 5/12/25 at 2 p.m. of Resident #7 revealed dried brown crustiness to Resident #7's lips. LVN G removed the dried brown crusty substance from Resident #7's lips. There was a dry brown substance noted inside Resident #7's mouth coating her upper and lower teeth. LVN G and the DON then provided care to Resident #7. LVN G said she was not sure how often oral care should be completed. The DON said the aides were responsible for oral care and should provide oral care first thing in the morning and then as needed. During interview on 5/12/25 at 2:40 p.m., CNA K said they had not done oral care on Resident #7 as they had not worked with her in a while, and she had declined since they last worked with her, and they did not want to disturb her. CNA K said oral care was done once per shift. CNA K said they had oral care training during orientation and was checked off performing oral care on a resident. CNA K said if a resident was unable to brush their teeth, then they used a sponge to provide oral care. Observation on 5/13/25 at 10:42 a.m. of Resident #7 revealed no buildup noted on Resident #7's teeth or lips. During interview on 5/14/25 at 9:02 a.m., LVN H said she normally worked the hallways where Resident #7 resided. LVN H said the nurse was responsible for overseeing oral care, but the aides could perform oral care. LVN H said if a resident was unable to brush their teeth, then staff could use swabs which should be done after meals. LVN H said if a resident did not receive oral care, then the resident could get ulcers in the mouth or cavities or possible gum breakdown or infections. During interview on 5/14/25 at 9:32 a.m., CNA L said they should do oral care every day on the residents. CNA L said they used a sponge for oral care if the resident was unable to brush their teeth and would also do oral care after every meal. CNA L said they recently started at the facility and had not had any ongoing trainings regarding oral care and maybe had oral care training during orientation. CNA L said they worked on the hallway where Resident #7 resided. During interview on 5/14/25 10:25 a.m., the DON said if oral care was not completed then the resident could get oral decay, dental issues, dry tongue or could be hard for them to take anything in. The DON said they would do an in-serve regarding oral hygiene. During interview on 5/14/25 at 12:04 a.m., the ADON said if oral care was not completed then a resident could have dehydrated or parched mouth, cavities, or infection. During interview on 5/14/25 at 3:06 p.m., the Administrator said they did not have any previous trainings to provide regarding oral care this year. Record review of facility's procedure Oral Care revealed The purposes of this procedure are to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent oral infection. Record review of facility's policy Activities of Daily Living (ADLs), Supporting revealed 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 interviews and record review, the facility failed to electronically transmit encoded, accurate, and complete MDS data to the CMS System, within 14 days, upon a resident's transfer, reentry, discharge, and death, for 1 of 18 residents (Resident #35) reviewed for transmitted MDS data to the CMS System. The facility failed to complete Resident #35's Admission MDS assessment within 14 days of admission. This failure could place residents at risk of not having their assessments transmitted timely which could cause a delay in treatment. The findings included: Record review of Resident #35's face sheet dated 05/13/25 revealed a -[AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #35's admission MDS assessment, dated 12/18/2024, revealed the signature page indicated it was signed as completed on 12/30/24, 18 days after admission. During an interview with the DON on 5/13//25 at 2:00pm the DON said the MDS staff signed a few days ago. She said the MDS were being done remotely and the facility was in the process of hiring an MDS nurse. During interview on 5/14/25 at 1:33 p.m., the Director of Reimbursement said the former MDS Coordinator was a no call/no show yesterday 5/13/25 and they were in the process of hiring an MDS nurse. The Director of Reimbursement said that herself and the MDS Consultant would fill in the gap till the facility hired an MDS coordinator. The Director of Reimbursement said if the MDS was not completed timely, could result in delay in services. During interview on 5/14/25 at 1:54 p.m., the MDS Consultant said she had provided oversight to the facility since September of 2024. The MDS Consultant said it was a team effort between her and the Director or Reimbursement to cover the facility regarding MDS. The MDS Consultant said they would have someone soon to cover MDS remotely. The MDS Consultant said she trained staff at the facility in person regarding MDS by going over the policy and procedures, coding of the MDS, RAI manual and guidelines. The MDS Consultant said the previous MDS Coordinator had started at the facility in February of 2025 and had 2-3 years of prior experience. During an interview with the Facility's Administrator on 05/13/25 at 3:30PM, he said the facility had gone through several MDS staff for the past few months. He said late MDS may result in delay in providing needed services to resident. Policy on MDS completion was requested on 05/13/25 at 3:30pm and the Administrator said the facility followed the RAI manual.

Based on observation, interviews, and record reviews the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for one of five residents (Resident #1), reviewed for Quality of Care. -The facility failed to ensure Resident #1 received podiatry services on 3/29/24 and failed to ensure staff accurately and thoroughly reported Resident #1's change in condition to his third toe on his right foot, to his physician on 04/01/24. NP A was asked by Resident #1 to assess his right foot when he reported pain on 04/04/24. Resident #1 was sent to the hospital on 04/04/25 and had the third toe of his right foot amputated on 04/07/24 and the remaining toes on his right foot amputated on 5/12/24. Resident #1 no longer walked independently and used a wheelchair for mobility since 4/7/24. His right foot remained unhealed on 04/10/25 and he continued to receive n-going wound care and treatments related to repeated infections and other complications. An IJ was identified on 04/16/25 at 5:36pm. While the IJ was lowered on 04/19/25, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not immediate jeopardy. These failures resulted in Resident #1 losing all of the toes on his right foot, significantly impacted his activities of daily living/mobility and placed residents at risk for infections, unwanted hospitalization s, amputation/s, and decreased quality of life. Finding included: Record review of Resident #1's Admission Record revealed he was a [AGE] year old male who admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of intellectual disabilities, Down syndrome, (a genetic chromosome 21 disorder causing developmental and intellectual delays), Type II diabetes mellitus with other circulatory complications (a long-term chronic condition in which the body has trouble controlling high levels of sugar in the blood), peripheral vascular disease, (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs/extremities) and acute osteomyelitis, right ankle and foot (a bone infection characterized by recent onset and can affect one or more parts of a bone). Record review of Resident #1's admission MDS dated [DATE] revealed he had a BIMS score of 11 out of 15 indicating he had moderate cognitive impairment. He was coded as having no wounds, wound infections or pressure injuries and was set-up assistance with all of his ADL's including ambulating without an assistive device. Record review of Resident #1's undated care plan revealed the following: Resident #1 is prone to skin tears, rashes and bruising of unknown origin related to fragile skin .Resident #1 will remain free from serious injury or complications from minor injury .All injuries will sic me monitored until they are resolved .Notify MD and sic RR of any abnormal findings .and was dated as initiated on 10/17/2024 and revised on 4/15/25 with a target date of 7/3/2025. Continued record review of undated care plan also revealed, the following care area initiated on 9/26/2014, Resident #1 has potential for impaired peripheral blood flow to lower extremities r/t Peripheral Vascular Disease (PVD) .Resident #1 will remain free of complications related to PVD through review date .Resident #1's extremities will be pain, pallor, rubor, coldness, edema and skin lesions through the review date . Educate the resident on the importance of proper foot care including: proper fitting shoes, wash and dry feet thoroughly, keep toenails cut, inspect feet daily, daily change of hosiery and socks .Monitor the extremities for /sx of injury, infection or ulcers .Monitor/document/report PRN and s/sx of complications of extremities: coldness of extremity, pallor, rubor, cyanosis and pain .Monitor/document/report PRN any s/sx of skin problems related to PVD: Redness, Edema, Blistering, Itching, Burning, Cuts, Other skin lesions. The following intervention was dated as initiated on 10/15/24, Clean right stump surgical with NS, apply dry dressing. Record review of Resident #1's Physician Orders for the month of March 2024, revealed there were no wound care orders. Record review of facility undated podiatry list for Resident #1 revealed he had been seen by podiatry on 12/29/23 and was scheduled to see podiatry on 3/29/24 (3 months later) but did not. There were no records, despite repeated attempts with facility staff and podiatry company to retrieve records on why Resident #1 was never seen by podiatry on 3/29/24. Surveyor team did not receive any explanatory documentation or interviews prior to facility exit on 04/19/25. Record review of Resident #1's Physician Orders for the month of April 2024, revealed there were no wound care orders. Record review of Resident #1's Physician Orders for the month of May 2024 revealed the following physician orders dated 4/23/24 and listed as active: - Notify NP A for PCP A if any increased drainage, redness, odor or s/s infection in right foot surgical wound. - Cleanse with NS, apply iodosorb (antimicrobial gel that can be used to treat skin wounds and ulcers), cover with absorptive dressing using 4x4's and kerlix as needed for surgical wound right dorsal foot. - Cleanse with NS, apply iodosorb, cover with absorptive dressing using 4x4's and kerlix, everyday shift for surgical wound R dorsal foot - Bactrim DS Oral Tablet 800-160 MG 1 tablet by mouth two times a day for cellulitis right lower leg and foot for 10 days. - Doxycycline Hyclate Oral Tablet 100 MG Give 1 tablet by mouth two times a day for cellulitis right lower leg and foot for 10 days. Record review of Resident #1's Health Status Note dated 4/1/24 at 5:46pm revealed the following documentation by LVN A: Resident c/o pain to toes on right foot. This nurse took off resident's sock and small opening to the third toe noted with swelling. Resident stated that he thinks his new shoes are too tight. Toe cleansed, applied TAO and bandage. Continued record review of nursing progress notes revealed there were no other progress notes, or physician orders regarding Resident #1's toe. There was no documentation of LVN A notifying Resident #1's MD, NP, or RP. Record review of Resident #1's weekly skin assessment dated [DATE] revealed No new skin issues observed. Continued record review revealed LVN A completed a weekly skin assessment dated [DATE] and read in part: Right toe Pressure .third toe on right foot with edema. Record review of Resident #1's Skin/Wound Note by Wound Care Nurse B dated 4/4/24 at 9:55 am revealed 3rd toe on right foot ischemic (not receiving enough blood flow), macerated (when skin softens and breaks down due to prolonged exposure to moisture). Bandaid removed that resident had previously placed around toe. NP at bedside evaluating resident, orders will be given to charge nurse. Record review of NP A progress note dated 4/4/24 revealed in part: Patient stopped this provider during rounds and asked that I evaluate his foot. He reports pain to right foot. Right third toe with soft black eschar (dead tissue) to entire toe, significant maceration (softened skin caused by prolonged exposure to moisture), foul odor, full thickness wound (one that extends beyond the skin's superficial layers and penetrates into the fat, muscle, bone or tendon) with exposed bone to lateral third toe between third and fourth toe .Patient sent to Hospital A. Called RP discussed wound infection with bone involvement. Wound will be difficult to heal secondary to patients' diagnoses .patient will need aggressive management, evaluation by ID (Infectious Disease), Vascular, Podiatry. Need eval for amputation of digit. Record review of Resident #1's hospital records with an admitted : 4/04/2024 discharge date : 4/10/2024 revealed in part: Primary Discharge Diagnosis: Gangrene of right third toe. Diabetic foot infection. Assessment Plan . Principal Problem: Fungal infection .Gangrene right 3rd toe .4/7/24 amputation of right 3rd toe. Continued record review revealed Resident #1 returned to the facility on [DATE]. Record review of Resident #1's EMR revealed one wound care consultant note dated 4/23/24 by Wound Care MD A, which read in part: Wound Status .Wound Number: 2 .Wound Location: Right, Dorsal (back) foot (other distal) .Wound Type: Surgical Wound .Date Acquired: 04/23/2024. There was no other documentation from 4/10/24 when Resident #1 was discharged from the hospital until 4/23/24 from a Wound Care MD and documentation on 4/23/24 did not mention the amputation of the right foot third toe, located at the top anterior (front) of Resident #1's foot. Attempted to contact Wound Care MD A on 4/16/25 at 3:41pm and again on 4/17/24 at 12:02 pm. Did not receive a return call from Wound Care MD A prior to facility exit. Record review of Resident #1's EMR revealed Resident #1 received wound care from Wound Care MD A and Wound Care Company A from 4/23/2024 through 6/25/2024. There were no Wound Care MD A notes from 6/25/24 through 7/30/24. Continued record reviews revealed Resident #1 was seen by Wound Care MD B from 9/12/24 through facility exit on 4/9/25. Attempted on 4/15/25 at 2:12 pm to contact Wound Care Nurse A for interview and was advised by facility DON and HR they had no contact information for Wound Care Nurse A. DON and HR both said that Wound Care Nurse A and Wound Care MD A no longer worked for the facility. Record review of NP A Progress Note dated 5/6/24 revealed the following: Evaluated patient rapid progression of ischemia and eschar noted, orders given to transfer to Hospital A for inpatient management, patient requires urgent vascular eval, will likely need additional debridement, possible further amputation .Skin: Right third toe digit status post amputation, increased light yellow slough/brown eschar to base of amputation site, gangrenous changes to right fourth toe, dry eschar to anterior second toe, unable to separate first and second toes, fourth and fifth toes for evaluation due to eschar (thick crusty layer of dead tissue that forms over a wound or burn) and slough (dead tissue separated from living tissue often seen in wounds or ulcers) DTI to anterior foot .Site is clinically worsening now with new ischemic areas/gangrenous changes to second and fourth toes .unable to palpate pedal pulses (inability to feel pulses in the feet). Record review of Resident #1's hospital records with a Surgery Date: 5/12/24 .Procedure Transmetatarsal (bones in the foot between the toes and the ankle) amputation right foot .gangrene noted to right 4th and 2nd toe with malodor and drainage noted. Fungal infection noted to bilateral feet. Incision site dehisced (burst open; split). Record review of NP A History and Physical note dated 5/16/24 revealed in part: Patient was transferred to Hospital A on 5/6/24 due to worsening necrotic changes/ischemia at surgical site and to multiple toes of right foot. He was seen by ID, noted to have weight gangrene with osteomyelitis to the second metatarsal head, third metatarsal, fourth proximal phalanx with right foot cellulitis .Patient is now status post right TMA on 5/12/2024 .Gangrene associated with type 2 diabetes mellitus status post right TMA status post IV antibiotics as per ID. discharged on course of oral antibiotic through 5/19/2024 .NWB RLE until surgical site healed .Osteomyelitis right foot .Status post amputation of right foot through metatarsal bone. Telephone interview with LVN A on 4/15/2025 at 2:04 pm they said they no longer worked at the facility but remembered working with Resident #. LVN A said they remembered the issue with Resident #1's foot or toe but did not recall specifics. LVN A said they could not recall if they notified Resident #1's MD, NP, or RP about Resident #1's toe. LVN A said they could not recall if they got an order for the TAO and Band-Aid, they applied to Resident #1's toe. LVN A said they did not recall if they notified the facility wound care nurse but said the facility had a wound care nurse at the time but could not recall their name. LVN A said they did not complete any type of SBAR/change in condition form or incident/accident report. LVN A said they only completed a progress note and most likely put the information on the facility 24-hour nurse report LVN A said they did not recall notifying the DON, ADON or Administrator about Resident #1's toe. Interview on 4/15/25 at 2:15 pm with DON who said they began working at the facility as the DON in January 2025 and was unaware of anything that happened at the facility in 2024 and was unaware of the origin of right foot issues for Resident #1. Requested copy of nursing 24-hour report from 4/1/24. DON said they did not have access to that report. Interview and observation of Resident #1 on 4/15/25 at 3:55pm who was seated in his wheelchair in his room. He was wearing fingerless gloves and propelling himself around his room using his left leg and both arms. His right foot was completely bandaged in clean white gauze wrap up to and above his ankle. None of the right foot was visible underneath the dressing. He was wearing loose sweatpants and a white velcro sneaker on his left foot. Resident #1 said he had surgery on his right foot 2 times and said he used to walk before I lost my toes. When asked how many toes he had lost on his right foot, he replied, all of them. Resident #1 said he wished he could walk again because he did not walk now and could only use his wheelchair. Resident #1 said he liked his wheelchair, but it was not the same as walking. Resident #1 said he had no pain at the time or whenever his dressings were changed. Resident #1 said it only hurt when they cut my toes and after. Resident #1 refused at this interview for surveyor to observe the wound on his right foot. Interview with CNA C on 4/26/25 at 9:41am who said they worked at the facility since 2009 and was familiar with Resident #1. CNA C said they were rarely assigned to provide direct care for Resident #1 but would sometimes help him shower and did not recall observing any issues with his feet or toes. CNA C said Resident #1 was very nice and used to be independent for ADL's and used to walk around the facility with no walker, cane, or wheelchair. CNA C said he was saddened, and it was a sad circumstance that Resident #1 no longer walked around and had to use a wheelchair because Resident #1 used to love to go on facility outings and on outings with his family, but it seemed like Resident #1 could no longer do as much because of being in a wheelchair. Interview with CNA A on 4/16/25 at 9:50 am who said they worked with Resident #1 in the past and present and had worked at the facility for 4 years. CNA A said Resident #1 used to walk and was independent with mostly all of his ADL's but can now only use a wheelchair after his toes were amputated on his right foot. CNA A said they did not know any specific details about Resident #1's toes because he never complained to her about anything, and she never saw anything when she provided care. CNA C said that whatever happened, it started around the same time last year. CNA C said that if Resident #1 had complained to her she would have documented in her CNA notes and immediately reported it to the charge nurse at the time. Interview with CNA B on 4/16/25 at 10:00 am who said they worked the same unit that Resident #1 resided on but did not regularly provide direct care to Resident #1. CNA B said they worked at the facility since 2017 and was never aware of any issues with Resident #1's feet or toes until after the amputation. CNA B said they remembered Resident #1 as independent and used to walk freely but was now confined to a wheelchair. Attempted telephone interview with NP A on 4/16/25 at 12:09pm. Surveyor notified by DON that NP A declined to have contact information shared with surveyor and NP A refused to speak with any state surveyor or representative without legal representation present. DON provided surveyor with administrative office number to schedule an appointment. Surveyor left messages twice on administrative office voicemail with surveyor contact information and purpose of call and never received a return call prior to exit. Attempted interview with Wound Care Nurse A on 4/16/25 at 1:33pm but advised by DON and HR there were no contact numbers or information for Wound Care Nurse A after company change in September of 2024 and they did not know when Wound Care Nurse A's last date of employment was because they had no access to a lot of records after the company change in September of 2024. Telephone interview with Wound Care Nurse B on 4/16/25 at 3:48 pm who confirmed that they were the current facility wound care nurse and provided care and treatments as ordered to Resident #1. Wound Care Nurse B said they had only been working as the facility wound care nurse for 1 month and did not know who the previous wound care nurse was. Wound Care Nurse B said Wound Care MD B, saw and evaluating Resident #1 weekly. Wound Care Nurse B said they were responsible for completing the weekly skin assessments for Resident #1. Wound Care Nurse B said Resident #1 had 2 areas on his right foot currently and no issue or wound on his heel. Wound Care Nurse B said that Resident #1 had a small opening on the lateral side of his right foot and an opening in the area were his big toe used to be that will not close. Wound Care Nurse B said that neither area had any signs or symptoms of infection and Resident #1 tolerated and was compliant with the dressing changes and treatments well and did not complain of pain much. Wound Care Nurse B said they were not familiar with Resident #1 prior to amputation. Interview on 4/17/25 at 12:31 pm with Wound Care MD B who said they had been seeing Resident #1 since the fall of 2024. When asked if they knew the origin of Resident #1's wound, Wound Care MD B said they did not know what the wound looked like when it first started. Wound Care MD B said Resident #1's was not healing since the first amputation, due to the residents' history and issues with poor circulation and peripheral vascular disease. When asked if Wound Care MD B felt in their professional medical opinion if a 3-day delay in communication between the nurse identifying Resident #1's third right toe change in condition and when NP A evaluated Resident #1 three days later, because Resident #1 requested an evaluation, could have caused a wound that serious, Wound Care MD B could not say. Wound Care MD B said it would be hard to say if the 3-day delay in communication caused Resident #1's toe wound to deteriorate that quickly because he did not know what the toe looked like at the time it started but due to Resident #1's underlying vascular issues/PVD and diabetes history, it was possible that a wound like his could have developed in that short period of time. Attempted telephone interview on 4/17/25 at 12:37 pm with facility Medical Director and advised by facility ADON that Medical Director was off and with family and would return surveyor call if possible. Surveyor left voicemail message with contact information and purpose for call and never received a return call prior to exit. Interview with Administrator and DON on 4/17/25 at 1:44pm they both said they had no additional records for Resident #1. They both said they started working at the facility in their current roles after Resident #1 had his toes amputated. Administrator said they started working at the end of December 2024 and the DON said she started working at the facility in January 2025. They both said there had been a change in the company that owns the facility in 2024 and not all of the previous resident or staff records were available or accessible. They said they did not have information for Wound Care Nurse A, the former facility Social Worker and did not have any information from Podiatry Company A on why Resident #1 was not seen or treated on 3/29/24. They said they had no information on why LVN A documented on Resident #1's change in condition of right third toe but did not document the appropriate notifications to MD and RP. They said that was not their current practice, policy or procedure but had no control over what happened in the past. They said they had not completed any recent staff training on wound care, physician notifications or change in condition but staff completed whatever topic was on the monthly CBT's. Record review of Resident #1's current Wound Assessment Report created by Wound Care MD B dated 4/10/25 revealed in part: Location: Right Lateral Forefoot .Arterial Ulcer .Stage/Severity: Full Thickness .Location: Right Medial TMA .Surgical Wound .Stage/Severity: Full Thickness. Indicating Resident #1 had 2 areas on his right foot that remained unhealed from April 2024. Record review of LVN A's personnel file revealed there were no completed trainings listed and no competency checks in the file provided. Record review of at least 4 current facility nursing staff personnel files, ADON, Wound Care Nurse B, DON and LVN B on 4/15/25 at 4:48 pm revealed no specific documented training/curriculum for change in condition, wound care/skin, or physician notification. Record review of facility policy and procedure titled: Change in a Resident's Condition or Status Revised September 2017 read in part, .The facility shall notify the resident, his or her attending physician and representative (sponsor) of changes in the resident's condition and/or status.3. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in a resident's condition or status. Record review of the facility policy and procedure titled: Guidelines for Notifying Physicians of Clinical Problems Revised January 2017 read in part under the heading Overview, .These guidelines are intended to help ensure that 1) medical care problems are communicated to the medical staff in a timely, efficient and effective manner . The policy did not include information on wounds, skin, or foot problems. On 04/16/25 at 5:36 pm an IJ and Substandard Quality of Care (SQC) in area of Quality of Care were called with the Administrator, DON, ADON and RCO. They were informed that the IJ had been identified due to the above failures, the IJ template was provided, and they were asked to provide a plan of removal at that time. The plan of removal was accepted on 4/17/25 at 1:10 pm after revisions. The POR read in part: Plan of Removal for Immediate Jeopardy Actions that the facility will take to prevent serious harm from occurring or recurring for treatment and services to prevent complications for a resident who received foot care. 1. Facility in-serviced nurses regarding physician notification for changes of condition in resident skin integrity was initiated with licensed clinical staff on 4/16/25 by the DON and ADON. Scheduled staff will be completed before allowing patient assignment care. 2. The Medical Director was initially made aware of the Immediate Jeopardy 4/16/25 at 6:15 pm and had been involved in the development of the plan of removal. 3. All Nurses had an in-service regarding skin integrity and assessment protocol with a specific focus on lower extremity, foot and diabetic wounds from policy and procedure was initiated by the DON on 4/16/25. Scheduled staff will be completed by designee continuation before allowing patient assignment care. 4. The facility will identify skin conditions by completing skin assessments performed on each active resident in the facility by the ADON/DON/Designee starting 4/16/25. The update will be documented on the weekly skin in PCC-electronic medical record and any abnormal findings will be immediately communicated to the physician and or medical director for orders. This was with all licensed clinical staff and any scheduled staff will have the in-service completed prior to allowing patient care. 5. RNC (regional nurse-corporate) completed an in-service with DON and ADON regarding physician notification of changes in condition of skin and order implementation per policy and procedure. This was completed 4/16/25. 6. An in-service with nursing staff regarding POC ADL documentation including skin monitoring and reporting changes in skin from policy and procedure was initiated by the DON on 4/15/25 and continues, showers including skin assessment and reporting changes in skin or refusals to the nurse from policy and procedure was initiated by the DON on 4/14/25 and continues. Scheduled staff will be completed by designee continuation before allowing patient assignment care. Nursing administration monitors compliance and will review weekly skin documents for 2 weeks and follow up accordingly on MD notifications and orders. All CNA's had in-services on 4/14/2025 and were trained on making observations and reporting any resident changes in condition, how to report any changes, who to report any changes to, and what changes to look for, in residents while performing any care. Any CNA unable to attend would be individually trained before the start of their next shift. Monitoring: Observations on 4/17/25 of random and sample residents revealed call lights in place. Interviews on 4/17/25 with 2 CNA's, 1 LVN and 1 RN on all halls to verify in-service training on recognizing Change in condition and the procedure/s for reporting changes in condition, physician notifications and skin assessments and documentation. Questions asked of the staff included what the steps were to take when a resident had a change of condition in skin/wounds. Answers were to notify the charge nurse of any changes in a residents' condition and to document in POC and shower sheets. Charge nurses said they would assess the resident and complete a progress note, notify the physician, transcribe orders, and implement orders. The charge nurses also said they would notify the residents responsible party and the DON and then complete a skin assessment form as needed. Record review of nursing staffing sheets provided for the week of April 15, 2025, through April 17, 2025, provided signed in-service sheets for all current licensed nurses, certified CNAs and MAs on the POC ADL documentation including skin monitoring and reporting changes in skin from policies and procedures revealed compliance. Record review also revealed all staff work 12-hour shifts from either 6 am-6 pm or 6 pm -6 am. Observation of Resident #1 on 4/17/25 at 1:15 pm who declined to have wound or wound care observation conducted by surveyor at that time. Observation rounds on 4/17/25 at 10:22 am and 2:55 pm of staff members making rounds and checking on the status of residents including those dependent for ADL's, bathing/showers and with type II diabetes mellitus, current wounds, PU and NPU. Call lights were observed in place and staff observed responding to call lights in a timely manner. Record review on 4/17/25 at 5:08 pm confirmed training and in-services initiated on all facility shifts. RNC in-service training with DON and ADON had been completed. Copy of change in condition and physician notification policy and procedures were received, reviewed, and attached to the staff trainings. 100 % Audit of the facility census 73 of skin assessments had been completed. Audit of all physician notifications, as a result of facility wide skin audit had been completed. Audit on 4/18/25 of new hire nursing staff revealed no new staff hired that required new trainings. Audit on 4/18/25 of facility wide skin assessments revealed 15 residents identified with skin concerns with new orders received and implemented as prescribed. Interviews on 4/18/25 with 4 CNA's, 3 LVN's and 2 MA's on all halls to verify in-service training on recognizing Change in condition and the procedure/s for reporting changes in condition, physician notifications and skin assessments and documentation. Questions asked of the staff included what the steps were to take when a resident had a change of condition in skin/wounds. Answers were to notify the charge nurse of any changes in a residents' condition and to document in POC and shower sheets. Charge nurses said they would assess the resident and complete a progress note, notify the physician, transcribe orders, and implement orders. The charge nurses also said they would notify the residents responsible party and the DON and then complete a skin assessment form as needed. Interview with RNC/RCO on 4/18/25 at 4:47 pm who said skin audit was completed for facility. Audit of 5 of 15 residents identified with skin concerns and new orders revealed they had weekly skin assessments, progress notes that included documentation of MD and RP notifications and orders had been transcribed and implemented as ordered. Interviews on 4/19/25 at what time with 11 staff on all halls and spanning all shifts confirmed training on recognizing Change in condition and the procedure/s for reporting changes in condition, physician notifications and skin assessments and documentation. Questions asked of the staff included what the steps were to take when a resident had a change of condition in skin/wounds. Answers were to notify the charge nurse of any changes in a residents' condition and to document in POC and shower sheets. Charge nurses said they would assess the resident and complete a progress note, notify the physician, transcribe orders, and implement orders. The charge nurses also said they would notify the residents responsible party and the DON and then complete a skin assessment form as needed. Record review on 4/19/25 of training documents and nursing competencies of staff scheduled to work had been completed. On 4/19/25 at 1:10 pm the Administrator, RCO, and RDO were notified that the immediacy had been lowered, however, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not immediate jeopardy. The facility was continuing to monitor their plan.

Based on observation, interviews, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident # 2) reviewed for adequate supervision. --The facility failed to provide adequate supervision and put measures in place to prevent residents from eloping. Resident #2 had a history of exit seeking behaviors and wandering and eloped from the facility on 3/15/25. He was found walking on the street in front of the facility. The resident discharged to home 3/21/25. This noncompliance was identified as Past Non-Compliance. The IJ began on 3/15/25 and ended on 3/15/25. The facility corrected the noncompliance by conducting elopement assessments, updating care plans, providing in-servicing to staff, elopement drills, and ensuring all door locks were operating securely prior to surveyor entrance. This failure placed residents at risk of potential accidents, injuries, harm, or death. Findings included: Record review of Resident #2's face sheet revealed admitted [DATE] with diagnoses including: Dementia with behavioral disturbance (loss of cognitive functioning with disturbances to mood, behavior, and perception), depression (persistent sadness, loss of interest affecting sense of well-being), hypertension (high blood pressure), psychosis (disconnection from reality), schizoaffective disorder (mood disorder symptoms). Record review of resident #2's admission MDS dated [DATE] revealed a BIMS of 3, indicating severely impaired cognitive skills. Resident # 2 was independent in ambulation with no assistive devices and required supervision with ADLs, with partial/moderate assistance with bathing. Record review of the baseline care plan dated 2/28/25 revealed Resident # 2 was a fall/safety risk and safety measures included re-direct to use walker when walking. Behavior symptom measures included re-direct to go back to his room. Record review of Resident # 2's assessments revealed he had an admission elopement assessment dated [DATE], but it was not completed for safety measures. Record review of Resident # 2's care plan, initiated 3/21/25, revised 3/26/25, revealed he was an elopement risk, wanderer, wanders aimlessly. Interventions were to distract by offering pleasant diversions, structural activities, food, conversation, television, books, and provide a wander guard bracelet. Record review of progress notes dated 3/2/25 revealed Resident #2 attempted to elope from the facility multiple times: 6:08 am-attempted to elope, re-directed back to his room, re-educated on safety, resident expressed understanding; 7:22 am-attempted to elope by pushing the back door in cafeteria, was re-directed back to his room, re-educated on safety, resident expressed understanding; 7:50 am-attempted to elope at end of 300 hall, was re-directed back to his room, re-educated on safety, resident expressed understanding; 8:30am- attempted to elope tried to push open the front doors, was re-directed back to his room, re-educated on safety, resident expressed understanding; 8:50 am- attempted to elope through back door of 500 hall, was re-directed back to his room, re-educated on safety, resident expressed understanding; 9:15 am- attempted to force open the door leading out of cafeteria, was re-directed back to his room, re-educated on safety, resident expressed understanding; 11:22 am- attempted to force the front doors open, became combative when re-directed back to his room; 12:21 pm- attempted to elope from back door by cafeteria, became combative when re-directed back to his room; 1:54 pm - attempt to elope out front door, became combative when re-directed back to his room. MD, RP were notified. A telephone message was left with LVN E on 4/18/25 at 4:00pm, the call was returned on 4/23/25 at 2:30 pm. In telephone interview, LVN E confirmed the events in the progress note on 3/2/25 occurred, and Resident # 2 was confused and wandered in the facility. Record review of the Incident report dated 3/15/25 at 2:30 pm revealed: at approximately 2:15 the resident was escorted to his room, at apprx. 2:30 resident was then seen being escorted back into facility by staff. It was explained to nurse on duty that resident was seen walking down the street on the same side of the street as the facility going towards the gas station. The staff member explained the resident was confused and was not complaining of pain or discomfort at the time. Resident has clean clothes on and rubber sole shoes. Resident was alert and stable at time of return to facility. Resident stated he was going by a friend when asked where he was going. Resident could not explain which friend he was attempting to go by. Resident had skin assessment performed and no skin issues were found. v/s were taken and found to be WNL. MD and RP were notified. Resident was placed on 1 on 1 monitoring. Record review of the 24-hour report dated 3/15/2025 at 7:50 pm revealed the nursing progress note: approximately 2:15 pm resident was escorted to his room and at approximately 2:30 pm, resident was seen being escorted back to the facility by staff. It was explained the resident was seen walking down the street on same side as the facility going toward the gas station. The staff member explained the resident was confused, and there were no complaints of pain or discomfort at the time. The resident had clean clothes on and rubber soled shoes. Resident was alert, stable at time of return to facility. Resident had skin assessment performed, no skin issues found. Vital signs WNL. Resident was placed on 1:1 monitoring. MD and RP notified. Record review of Resident # 2's progress notes dated 3/15/ 25 revealed at approximately 2:15 pm resident was escorted to his room and at approximately 2:30 pm, resident was seen being escorted back to the facility by staff. It was explained the resident was seen walking down the street on same side as the facility going toward the gas station. The staff member explained the resident was confused, and there were no complaints of pain or discomfort at the time. The resident had clean clothes on and rubber soled shoes. Resident was alert, stable at time of return to facility. Resident had skin assessment performed, no skin issues found. Vital signs WNL. Resident was placed on 1:1 monitoring. MD and RP notified. Record review of Provider Investigation Report dated 3/15/25 revealed nursing was doing rounds on the 500 hall and noticed the resident was not in his room, the resident was a wanderer, search party was started. He was located outside the facility 15 minutes later, was assessed with no injuries or adverse effects, elopement assessment was completed, and resident was placed on 1:1 monitoring while the investigation was being completed. Resident was monitored closely after in-services were completed. All residents were counted, Maintenance Director checked all door alarms/wander guard systems, and a local fire and safety company was called to check the systems. In-services were initiated on Elopement protocols/Missing residents. The resident discharged to home 3/21/25. Record review of facility's in-service on Elopement, Missing Residents, and Wandering and Elopements was conducted with all staff 3/16/25 to 3/22/25, to allow for training of all disciplines on all shifts. Staff received training on the Elopement policy, including what to do in case a resident was seen leaving the premises, when a resident was missing, and when a missing resident returned to the premises. Record review of additional in-person in-services with all staff revealed Elopement/Missing Resident training on 12/30/24, including training on the Elopement and Missing Resident policies and procedures. In addition, the facility has online training available to staff at any time, including preventing, recognizing, reporting Abuse/Neglect, Managing behaviors, Resident Rights. Record review of facility Incident/Accident report dated 4/15/25 revealed no other elopements occured since 3/15/25. Interview with the DON on 4/16/25 at 11:20 am stated she was notified when Resident # 2 was missing on 3/15/25. She said Resident # 2 had a habit of wandering in the facility, and often had to be re-directed. She said she did not remember who found him, but he was found walking on the street outside the facility and was brought back into the facility. She said an assessment was done, and he had no injuries and did not complain of pain. He was placed on 1:1 monitoring. She said the staff knew to notify her of any incidents that occurred. Interview with MA A on 4/16/25 at 3:15 pm stated she works 6am to 6pm, and she had an in-service on elopement, the last one was about 3 weeks ago, after a resident eloped. She said she was the one who found him on 3/15/25 at around 2 pm, she was sitting in her car and saw him walking in the parking lot. She said she recognized him and went to re-direct him and bring him back into the facility. She said he was confused, and he cooperated when she brought him back inside. MA A said Resident #2 walked around a lot and she would see staff taking him back to his room, but she had never heard of him eloping until the time she found him and re-directed him back inside on 3/15/25. Interviews with LVN B and LVN C on 4/16/25 from 3:25 pm to 3:30 pm stated they had training on elopement about a month ago, including alert staff, inform the authorities and start searching for the resident. They said some residents are wanderers and would have to be monitored more closely and re-direct if they attempted to open a door or elope. The LVNs said they were not working on the day Resident # 2 eloped. Interview with the Receptionist on 4/16/25 at 3:40 pm stated if she saw any resident trying to get out the door, she said she would call the Administrator, make sure the code was set, and tell them they could not go out the door. She said at that point, they would usually turn around and return to their room or the hallway. Interview with the Administrator on 4/16/25 at 5:15 pm, stated Resident #2 would sometimes be seen standing by the front door looking at the code, like he was trying to get the door code. He said he was not seen trying to follow anyone out the door. Interviews with CNA D, CNA E, and CNA F on 4/17/25 from 12:15 pm to 12:30 pm stated they work the day shift, 6am to 6pm, and had training on elopement about a month ago, with instructions on what to do if a resident tried to get out or had gone outside the doors. They said the first thing would be to notify the nurse and Administrator and start searching for the missing resident. They said they had to watch some residents more closely since they tended to wander and had to re-direct them if they attempted to elope. The CNAs said they were not working when Resident # 2 eloped. Interview with MA B on 4/17/25 at 12:35 pm stated she works the day shift, 6am to 6pm, and had training on elopement about 3 weeks ago and had instructions on what to do if a resident was missing. She said the first thing would be to let the nurse know, and then start trying to find the resident. She said there is an Elopement Binder at the nurse's station with pictures of residents who are an elopement risk, so staff would be aware of residents who might try to elope. She said she was not working when Resident # 2 eloped. Interview with the Activity Director on 4/17/25 at 12:45 pm stated they had elopement training about 3 weeks ago, on what to do if a resident eloped and was missing. She said call the DON and Administrator and start searching for the resident. She said she was not working when Resident # 2 eloped and heard about it later. She remembered him., and said he was confused often and would sometimes come in her activity room. Interview with OT A and OT B on 4/17/25 at 1:55 pm stated they had elopement training about a month ago, with instructions on what to do if a resident attempted to elope, or if they eloped. They said to alert the nurses, Administrator, DON and try to keep the resident in the facility after they return. They said they were not working with Resident # 2 when he eloped, but he was on therapy service for a short time, and had PT, OT and ST. Interview with MA C on 4/18/25 at 9:40 am stated she works the day shift, 6am to 6pm, and had elopement training about 3 weeks ago, and it went over what to do if a resident eloped or tried to elope. She said if a resident was trying to elope, you would re-direct them, distract them by talking about family or other things. She said she was not working when Resident # 2 eloped but heard about it after it happened. She remembered him, and said he was easy to re-direct if he was wandering, but she did not see him trying to open the doors. Interview with MA D on 4/18/25 at 9:55 am revealed he works 6am to 6pm. He said he has had elopement training, with instructions on what to do if a resident eloped or tried to elope. He said he was not working when Resident # 2 eloped, but he did remember him. He said Resident # 2 was confused but easily re-directed. MA D said he would take Resident # 2 outside in the enclosed patio area and sit in the sun sometimes and he seemed to like that. Observations of the door locks with the Administrator on 4/18/25 at 10:40 am revealed 3 of the egress doors have added keypads for exit, along with magnetic locks and wander guard alarms. He said there are work orders in process, valid until 5/18/25, to have delayed egress hardware installed on the other egress doors. Interviews with CNA L, CNA M, CNA P, CNA R on 4/19/25 revealed they work the night shift, 6pm to 6am, and work weekends if needed. They said they have elopement training, and the last one was about 3 weeks ago. They said the training goes over the elopement policy, and what to do if a resident elopes or tries to elope. The main thing would be to let the nurse know and try to find the resident by searching inside and outside the facility. On 4/16/25 at 5:41 pm, the Administrator was provided the past noncompliance IJ template. A plan of removal was not requested. An IJ template was provided to the administrator via email. The noncompliance began on 3/15/25 and ended on 3/15/25. The facility had corrected the noncompliance before the investigation began. The following interventions were implemented prior to survey entry and surveyor confirmed Past Non-Compliance: Resident #2 was immediately assessed. Resident #2 was placed on 1:1 level of supervision. Resident #2's care plan was updated to reflect elopement risk. Facility notification of abuse incident to responsible party, MD, Ombudsman and HHSC. Completion of in-services on abuse and elopements. Staff and management recognizing the steps to report abuse and neglect and interventions for elopement. Record review of facility policy Elopements, revised April 2006, revealed: it is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the Charge Nurse as soon as practical. Should an employee observe a resident leaving the premises, he/she should attempt to prevent the departure, obtain assistance from other staff members, be courteous in preventing the departure; upon return to the facility: examine the resident for injuries, contact the physician, contact the resident's representative, complete an incident report, make notation in the medical record; should an employee discover a resident is missing from the facility, thoroughly search the building and premises, notify Administrator and DON, notify resident's representative, notify physician, notify law enforcement, provide search teams, make extensive search of surrounding areas. Record review of facility policy Wandering and Elopements, revised March 2019, revealed: the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents .If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Record review of facility policy Emergency Procedures - Missing Resident, revised August 2018, revealed instructions including: alert department heads and pertinent staff of missing resident; note the time the resident was discovered missing; notify Administrator, Director of Maintenance, DON; initiate a thorough search by staff members to locate the resident; if search is unsuccessful, notify the police to report the resident missing; notify the responsible party and physician if resident not found in the facility or on the grounds.

Based on observation, interviews, and record reviews the facility failed to immediately inform the resident's physician of a significant change in a resident's physical condition for one of five residents (Resident #1) reviewed for notification of change. -The facility failed to ensure Resident #1 received podiatry services on 3/29/24 and failed to ensure staff accurately and thoroughly reported Resident #1's change in condition to his third toe on his right foot, to his physician on 04/01/24. NP A was asked by Resident #1 to assess his right foot when he reported pain on 04/04/24. Resident #1 was sent to the hospital on 04/04/25 and had the third toe of his right foot amputated on 04/07/24 and the remaining toes on his right foot amputated on 5/12/24. Resident #1 no longer walked independently and used a wheelchair for mobility since 4/7/24. His right foot remained unhealed on 04/10/25 and he continued to receive n-going wound care and treatments related to repeated infections and other complications. An IJ was identified on 04/16/25 at 5:36pm. While the IJ was lowered on 04/19/25, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not immediate jeopardy. These failures resulted in Resident #1 losing all of the toes on his right foot, significantly impacted his activities of daily living/mobility and placed residents at risk for infections, unwanted hospitalization s, amputation/s, and decreased quality of life. Finding included: Record review of Resident #1's Admission Record revealed he was a [AGE] year old male who admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of intellectual disabilities, Down syndrome, (a genetic chromosome 21 disorder causing developmental and intellectual delays), Type II diabetes mellitus with other circulatory complications (a long-term chronic condition in which the body has trouble controlling high levels of sugar in the blood), peripheral vascular disease, (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs/extremities) and acute osteomyelitis, right ankle and foot (a bone infection characterized by recent onset and can affect one or more parts of a bone). Record review of Resident #1's admission MDS dated [DATE] revealed he had a BIMS score of 11 out of 15 indicating he had moderate cognitive impairment. He was coded as having no wounds, wound infections or pressure injuries and was set-up assistance with all of his ADL's including ambulating without an assistive device. Record review of Resident #1's undated care plan revealed the following: Resident #1 is prone to skin tears, rashes and bruising of unknown origin related to fragile skin .Resident #1 will remain free from serious injury or complications from minor injury .All injuries will sic me monitored until they are resolved .Notify MD and sic RR of any abnormal findings .and was dated as initiated on 10/17/2024 and revised on 4/15/25 with a target date of 7/3/2025. Continued record review of undated care plan also revealed, the following care area initiated on 9/26/2014, Resident #1 has potential for impaired peripheral blood flow to lower extremities r/t Peripheral Vascular Disease (PVD) .Resident #1 will remain free of complications related to PVD through review date .Resident #1's extremities will be pain, pallor, rubor, coldness, edema and skin lesions through the review date . Educate the resident on the importance of proper foot care including: proper fitting shoes, wash and dry feet thoroughly, keep toenails cut, inspect feet daily, daily change of hosiery and socks .Monitor the extremities for /sx of injury, infection or ulcers .Monitor/document/report PRN and s/sx of complications of extremities: coldness of extremity, pallor, rubor, cyanosis and pain .Monitor/document/report PRN any s/sx of skin problems related to PVD: Redness, Edema, Blistering, Itching, Burning, Cuts, Other skin lesions. The following intervention was dated as initiated on 10/15/24, Clean right stump surgical with NS, apply dry dressing. Record review of Resident #1's Physician Orders for the month of March 2024, revealed there were no wound care orders. Record review of facility undated podiatry list for Resident #1 revealed he had been seen by podiatry on 12/29/23 and was scheduled to see podiatry on 3/29/24 (3 months later) but did not. There were no records, despite repeated attempts with facility staff and podiatry company to retrieve records on why Resident #1 was never seen by podiatry on 3/29/24. Surveyor team did not receive any explanatory documentation or interviews prior to facility exit on 04/19/25. Record review of Resident #1's Physician Orders for the month of April 2024, revealed there were no wound care orders. Record review of Resident #1's Physician Orders for the month of May 2024 revealed the following physician orders dated 4/23/24 and listed as active: - Notify NP A for PCP A if any increased drainage, redness, odor or s/s infection in right foot surgical wound. - Cleanse with NS, apply iodosorb (antimicrobial gel that can be used to treat skin wounds and ulcers), cover with absorptive dressing using 4x4's and kerlix as needed for surgical wound right dorsal foot. - Cleanse with NS, apply iodosorb, cover with absorptive dressing using 4x4's and kerlix, everyday shift for surgical wound R dorsal foot - Bactrim DS Oral Tablet 800-160 MG 1 tablet by mouth two times a day for cellulitis right lower leg and foot for 10 days. - Doxycycline Hyclate Oral Tablet 100 MG Give 1 tablet by mouth two times a day for cellulitis right lower leg and foot for 10 days. Record review of Resident #1's Health Status Note dated 4/1/24 at 5:46pm revealed the following documentation by LVN A: Resident c/o pain to toes on right foot. This nurse took off resident's sock and small opening to the third toe noted with swelling. Resident stated that he thinks his new shoes are too tight. Toe cleansed, applied TAO and bandage. Continued record review of nursing progress notes revealed there were no other progress notes, or physician orders regarding Resident #1's toe. There was no documentation of LVN A notifying Resident #1's MD, NP, or RP. Record review of Resident #1's weekly skin assessment dated [DATE] revealed No new skin issues observed. Continued record review revealed LVN A completed a weekly skin assessment dated [DATE] and read in part: Right toe Pressure .third toe on right foot with edema. Record review of Resident #1's Skin/Wound Note by Wound Care Nurse B dated 4/4/24 at 9:55 am revealed 3rd toe on right foot ischemic (not receiving enough blood flow), macerated (when skin softens and breaks down due to prolonged exposure to moisture). Bandaid removed that resident had previously placed around toe. NP at bedside evaluating resident, orders will be given to charge nurse. Record review of NP A progress note dated 4/4/24 revealed in part: Patient stopped this provider during rounds and asked that I evaluate his foot. He reports pain to right foot. Right third toe with soft black eschar (dead tissue) to entire toe, significant maceration (softened skin caused by prolonged exposure to moisture), foul odor, full thickness wound (one that extends beyond the skin's superficial layers and penetrates into the fat, muscle, bone or tendon) with exposed bone to lateral third toe between third and fourth toe .Patient sent to Hospital A. Called RP discussed wound infection with bone involvement. Wound will be difficult to heal secondary to patients' diagnoses .patient will need aggressive management, evaluation by ID (Infectious Disease), Vascular, Podiatry. Need eval for amputation of digit. Record review of Resident #1's hospital records with an admitted : 4/04/2024 discharge date : 4/10/2024 revealed in part: Primary Discharge Diagnosis: Gangrene of right third toe. Diabetic foot infection. Assessment Plan . Principal Problem: Fungal infection .Gangrene right 3rd toe .4/7/24 amputation of right 3rd toe. Continued record review revealed Resident #1 returned to the facility on [DATE]. Record review of Resident #1's EMR revealed one wound care consultant note dated 4/23/24 by Wound Care MD A, which read in part: Wound Status .Wound Number: 2 .Wound Location: Right, Dorsal (back) foot (other distal) .Wound Type: Surgical Wound .Date Acquired: 04/23/2024. There was no other documentation from 4/10/24 when Resident #1 was discharged from the hospital until 4/23/24 from a Wound Care MD and documentation on 4/23/24 did not mention the amputation of the right foot third toe, located at the top anterior (front) of Resident #1's foot. Attempted to contact Wound Care MD A on 4/16/25 at 3:41pm and again on 4/17/24 at 12:02 pm. Did not receive a return call from Wound Care MD A prior to facility exit. Record review of Resident #1's EMR revealed Resident #1 received wound care from Wound Care MD A and Wound Care Company A from 4/23/2024 through 6/25/2024. There were no Wound Care MD A notes from 6/25/24 through 7/30/24. Continued record reviews revealed Resident #1 was seen by Wound Care MD B from 9/12/24 through facility exit on 4/9/25. Attempted on 4/15/25 at 2:12 pm to contact Wound Care Nurse A for interview and was advised by facility DON and HR they had no contact information for Wound Care Nurse A. DON and HR both said that Wound Care Nurse A and Wound Care MD A no longer worked for the facility. Record review of NP A Progress Note dated 5/6/24 revealed the following: Evaluated patient rapid progression of ischemia and eschar noted, orders given to transfer to Hospital A for inpatient management, patient requires urgent vascular eval, will likely need additional debridement, possible further amputation .Skin: Right third toe digit status post amputation, increased light yellow slough/brown eschar to base of amputation site, gangrenous changes to right fourth toe, dry eschar to anterior second toe, unable to separate first and second toes, fourth and fifth toes for evaluation due to eschar (thick crusty layer of dead tissue that forms over a wound or burn) and slough (dead tissue separated from living tissue often seen in wounds or ulcers) DTI to anterior foot .Site is clinically worsening now with new ischemic areas/gangrenous changes to second and fourth toes .unable to palpate pedal pulses (inability to feel pulses in the feet). Record review of Resident #1's hospital records with a Surgery Date: 5/12/24 .Procedure Transmetatarsal (bones in the foot between the toes and the ankle) amputation right foot .gangrene noted to right 4th and 2nd toe with malodor and drainage noted. Fungal infection noted to bilateral feet. Incision site dehisced (burst open; split). Record review of NP A History and Physical note dated 5/16/24 revealed in part: Patient was transferred to Hospital A on 5/6/24 due to worsening necrotic changes/ischemia at surgical site and to multiple toes of right foot. He was seen by ID, noted to have weight gangrene with osteomyelitis to the second metatarsal head, third metatarsal, fourth proximal phalanx with right foot cellulitis .Patient is now status post right TMA on 5/12/2024 .Gangrene associated with type 2 diabetes mellitus status post right TMA status post IV antibiotics as per ID. discharged on course of oral antibiotic through 5/19/2024 .NWB RLE until surgical site healed .Osteomyelitis right foot .Status post amputation of right foot through metatarsal bone. Telephone interview with LVN A on 4/15/2025 at 2:04 pm they said they no longer worked at the facility but remembered working with Resident #. LVN A said they remembered the issue with Resident #1's foot or toe but did not recall specifics. LVN A said they could not recall if they notified Resident #1's MD, NP, or RP about Resident #1's toe. LVN A said they could not recall if they got an order for the TAO and Band-Aid, they applied to Resident #1's toe. LVN A said they did not recall if they notified the facility wound care nurse but said the facility had a wound care nurse at the time but could not recall their name. LVN A said they did not complete any type of SBAR/change in condition form or incident/accident report. LVN A said they only completed a progress note and most likely put the information on the facility 24-hour nurse report LVN A said they did not recall notifying the DON, ADON or Administrator about Resident #1's toe. Interview on 4/15/25 at 2:15 pm with DON who said they began working at the facility as the DON in January 2025 and was unaware of anything that happened at the facility in 2024 and was unaware of the origin of right foot issues for Resident #1. Requested copy of nursing 24-hour report from 4/1/24. DON said they did not have access to that report. Interview and observation of Resident #1 on 4/15/25 at 3:55pm who was seated in his wheelchair in his room. He was wearing fingerless gloves and propelling himself around his room using his left leg and both arms. His right foot was completely bandaged in clean white gauze wrap up to and above his ankle. None of the right foot was visible underneath the dressing. He was wearing loose sweatpants and a white velcro sneaker on his left foot. Resident #1 said he had surgery on his right foot 2 times and said he used to walk before I lost my toes. When asked how many toes he had lost on his right foot, he replied, all of them. Resident #1 said he wished he could walk again because he did not walk now and could only use his wheelchair. Resident #1 said he liked his wheelchair, but it was not the same as walking. Resident #1 said he had no pain at the time or whenever his dressings were changed. Resident #1 said it only hurt when they cut my toes and after. Resident #1 refused at this interview for surveyor to observe the wound on his right foot. Interview with CNA C on 4/26/25 at 9:41am who said they worked at the facility since 2009 and was familiar with Resident #1. CNA C said they were rarely assigned to provide direct care for Resident #1 but would sometimes help him shower and did not recall observing any issues with his feet or toes. CNA C said Resident #1 was very nice and used to be independent for ADL's and used to walk around the facility with no walker, cane, or wheelchair. CNA C said he was saddened, and it was a sad circumstance that Resident #1 no longer walked around and had to use a wheelchair because Resident #1 used to love to go on facility outings and on outings with his family, but it seemed like Resident #1 could no longer do as much because of being in a wheelchair. Interview with CNA A on 4/16/25 at 9:50 am who said they worked with Resident #1 in the past and present and had worked at the facility for 4 years. CNA A said Resident #1 used to walk and was independent with mostly all of his ADL's but can now only use a wheelchair after his toes were amputated on his right foot. CNA A said they did not know any specific details about Resident #1's toes because he never complained to her about anything, and she never saw anything when she provided care. CNA C said that whatever happened, it started around the same time last year. CNA C said that if Resident #1 had complained to her she would have documented in her CNA notes and immediately reported it to the charge nurse at the time. Interview with CNA B on 4/16/25 at 10:00 am who said they worked the same unit that Resident #1 resided on but did not regularly provide direct care to Resident #1. CNA B said they worked at the facility since 2017 and was never aware of any issues with Resident #1's feet or toes until after the amputation. CNA B said they remembered Resident #1 as independent and used to walk freely but was now confined to a wheelchair. Attempted telephone interview with NP A on 4/16/25 at 12:09pm. Surveyor notified by DON that NP A declined to have contact information shared with surveyor and NP A refused to speak with any state surveyor or representative without legal representation present. DON provided surveyor with administrative office number to schedule an appointment. Surveyor left messages twice on administrative office voicemail with surveyor contact information and purpose of call and never received a return call prior to exit. Attempted interview with Wound Care Nurse A on 4/16/25 at 1:33pm but advised by DON and HR there were no contact numbers or information for Wound Care Nurse A after company change in September of 2024 and they did not know when Wound Care Nurse A's last date of employment was because they had no access to a lot of records after the company change in September of 2024. Telephone interview with Wound Care Nurse B on 4/16/25 at 3:48 pm who confirmed that they were the current facility wound care nurse and provided care and treatments as ordered to Resident #1. Wound Care Nurse B said they had only been working as the facility wound care nurse for 1 month and did not know who the previous wound care nurse was. Wound Care Nurse B said Wound Care MD B, saw and evaluating Resident #1 weekly. Wound Care Nurse B said they were responsible for completing the weekly skin assessments for Resident #1. Wound Care Nurse B said Resident #1 had 2 areas on his right foot currently and no issue or wound on his heel. Wound Care Nurse B said that Resident #1 had a small opening on the lateral side of his right foot and an opening in the area were his big toe used to be that will not close. Wound Care Nurse B said that neither area had any signs or symptoms of infection and Resident #1 tolerated and was compliant with the dressing changes and treatments well and did not complain of pain much. Wound Care Nurse B said they were not familiar with Resident #1 prior to amputation. Interview on 4/17/25 at 12:31 pm with Wound Care MD B who said they had been seeing Resident #1 since the fall of 2024. When asked if they knew the origin of Resident #1's wound, Wound Care MD B said they did not know what the wound looked like when it first started. Wound Care MD B said Resident #1's was not healing since the first amputation, due to the residents' history and issues with poor circulation and peripheral vascular disease. When asked if Wound Care MD B felt in their professional medical opinion if a 3-day delay in communication between the nurse identifying Resident #1's third right toe change in condition and when NP A evaluated Resident #1 three days later, because Resident #1 requested an evaluation, could have caused a wound that serious, Wound Care MD B could not say. Wound Care MD B said it would be hard to say if the 3-day delay in communication caused Resident #1's toe wound to deteriorate that quickly because he did not know what the toe looked like at the time it started but due to Resident #1's underlying vascular issues/PVD and diabetes history, it was possible that a wound like his could have developed in that short period of time. Attempted telephone interview on 4/17/25 at 12:37 pm with facility Medical Director and advised by facility ADON that Medical Director was off and with family and would return surveyor call if possible. Surveyor left voicemail message with contact information and purpose for call and never received a return call prior to exit. Interview with Administrator and DON on 4/17/25 at 1:44pm they both said they had no additional records for Resident #1. They both said they started working at the facility in their current roles after Resident #1 had his toes amputated. Administrator said they started working at the end of December 2024 and the DON said she started working at the facility in January 2025. They both said there had been a change in the company that owns the facility in 2024 and not all of the previous resident or staff records were available or accessible. They said they did not have information for Wound Care Nurse A, the former facility Social Worker and did not have any information from Podiatry Company A on why Resident #1 was not seen or treated on 3/29/24. They said they had no information on why LVN A documented on Resident #1's change in condition of right third toe but did not document the appropriate notifications to MD and RP. They said that was not their current practice, policy or procedure but had no control over what happened in the past. They said they had not completed any recent staff training on wound care, physician notifications or change in condition but staff completed whatever topic was on the monthly CBT's. Record review of Resident #1's current Wound Assessment Report created by Wound Care MD B dated 4/10/25 revealed in part: Location: Right Lateral Forefoot .Arterial Ulcer .Stage/Severity: Full Thickness .Location: Right Medial TMA .Surgical Wound .Stage/Severity: Full Thickness. Indicating Resident #1 had 2 areas on his right foot that remained unhealed from April 2024. Record review of LVN A's personnel file revealed there were no completed trainings listed and no competency checks in the file provided. Record review of at least 4 current facility nursing staff personnel files, ADON, Wound Care Nurse B, DON and LVN B on 4/15/25 at 4:48 pm revealed no specific documented training/curriculum for change in condition, wound care/skin, or physician notification. Record review of facility policy and procedure titled: Change in a Resident's Condition or Status Revised September 2017 read in part, .The facility shall notify the resident, his or her attending physician and representative (sponsor) of changes in the resident's condition and/or status.3. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in a resident's condition or status. Record review of the facility policy and procedure titled: Guidelines for Notifying Physicians of Clinical Problems Revised January 2017 read in part under the heading Overview, .These guidelines are intended to help ensure that 1) medical care problems are communicated to the medical staff in a timely, efficient and effective manner . The policy did not include information on wounds, skin, or foot problems. On 04/16/25 at 5:36 pm an IJ and Substandard Quality of Care (SQC) in area of Quality of Care were called with the Administrator, DON, ADON and RCO. They were informed that the IJ had been identified due to the above failures, the IJ template was provided, and they were asked to provide a plan of removal at that time. The plan of removal was accepted on 4/17/25 at 1:10 pm after revisions. The POR read in part: Plan of Removal for Immediate Jeopardy Actions that the facility will take to prevent serious harm from occurring or recurring for treatment and services to prevent complications for a resident who received foot care. 1. Facility in-serviced nurses regarding physician notification for changes of condition in resident skin integrity was initiated with licensed clinical staff on 4/16/25 by the DON and ADON. Scheduled staff will be completed before allowing patient assignment care. 2. The Medical Director was initially made aware of the Immediate Jeopardy 4/16/25 at 6:15 pm and had been involved in the development of the plan of removal. 3. All Nurses had an in-service regarding skin integrity and assessment protocol with a specific focus on lower extremity, foot and diabetic wounds from policy and procedure was initiated by the DON on 4/16/25. Scheduled staff will be completed by designee continuation before allowing patient assignment care. 4. The facility will identify skin conditions by completing skin assessments performed on each active resident in the facility by the ADON/DON/Designee starting 4/16/25. The update will be documented on the weekly skin in PCC-electronic medical record and any abnormal findings will be immediately communicated to the physician and or medical director for orders. This was with all licensed clinical staff and any scheduled staff will have the in-service completed prior to allowing patient care. 5. RNC (regional nurse-corporate) completed an in-service with DON and ADON regarding physician notification of changes in condition of skin and order implementation per policy and procedure. This was completed 4/16/25. 6. An in-service with nursing staff regarding POC ADL documentation including skin monitoring and reporting changes in skin from policy and procedure was initiated by the DON on 4/15/25 and continues, showers including skin assessment and reporting changes in skin or refusals to the nurse from policy and procedure was initiated by the DON on 4/14/25 and continues. Scheduled staff will be completed by designee continuation before allowing patient assignment care. Nursing administration monitors compliance and will review weekly skin documents for 2 weeks and follow up accordingly on MD notifications and orders. All CNA's had in-services on 4/14/2025 and were trained on making observations and reporting any resident changes in condition, how to report any changes, who to report any changes to, and what changes to look for, in residents while performing any care. Any CNA unable to attend would be individually trained before the start of their next shift. Monitoring: Observations on 4/17/25 of random and sample residents revealed call lights in place. Interviews on 4/17/25 with 2 CNA's, 1 LVN and 1 RN on all halls to verify in-service training on recognizing Change in condition and the procedure/s for reporting changes in condition, physician notifications and skin assessments and documentation. Questions asked of the staff included what the steps were to take when a resident had a change of condition in skin/wounds. Answers were to notify the charge nurse of any changes in a residents' condition and to document in POC and shower sheets. Charge nurses said they would assess the resident and complete a progress note, notify the physician, transcribe orders, and implement orders. The charge nurses also said they would notify the residents responsible party and the DON and then complete a skin assessment form as needed. Record review of nursing staffing sheets provided for the week of April 15, 2025, through April 17, 2025, provided signed in-service sheets for all current licensed nurses, certified CNAs and MAs on the POC ADL documentation including skin monitoring and reporting changes in skin from policies and procedures revealed compliance. Record review also revealed all staff work 12-hour shifts from either 6 am-6 pm or 6 pm -6 am. Observation of Resident #1 on 4/17/25 at 1:15 pm who declined to have wound or wound care observation conducted by surveyor at that time. Observation rounds on 4/17/25 at 10:22 am and 2:55 pm of staff members making rounds and checking on the status of residents including those dependent for ADL's, bathing/showers and with type II diabetes mellitus, current wounds, PU and NPU. Call lights were observed in place and staff observed responding to call lights in a timely manner. Record review on 4/17/25 at 5:08 pm confirmed training and in-services initiated on all facility shifts. RNC in-service training with DON and ADON had been completed. Copy of change in condition and physician notification policy and procedures were received, reviewed, and attached to the staff trainings. 100 % Audit of the facility census 73 of skin assessments had been completed. Audit of all physician notifications, as a result of facility wide skin audit had been completed. Audit on 4/18/25 of new hire nursing staff revealed no new staff hired that required new trainings. Audit on 4/18/25 of facility wide skin assessments revealed 15 residents identified with skin concerns with new orders received and implemented as prescribed. Interviews on 4/18/25 with 4 CNA's, 3 LVN's and 2 MA's on all halls to verify in-service training on recognizing Change in condition and the procedure/s for reporting changes in condition, physician notifications and skin assessments and documentation. Questions asked of the staff included what the steps were to take when a resident had a change of condition in skin/wounds. Answers were to notify the charge nurse of any changes in a residents' condition and to document in POC and shower sheets. Charge nurses said they would assess the resident and complete a progress note, notify the physician, transcribe orders, and implement orders. The charge nurses also said they would notify the residents responsible party and the DON and then complete a skin assessment form as needed. Interview with RNC/RCO on 4/18/25 at 4:47 pm who said skin audit was completed for facility. Audit of 5 of 15 residents identified with skin concerns and new orders revealed they had weekly skin assessments, progress notes that included documentation of MD and RP notifications and orders had been transcribed and implemented as ordered. Interviews on 4/19/25 at what time with 11 staff on all halls and spanning all shifts confirmed training on recognizing Change in condition and the procedure/s for reporting changes in condition, physician notifications and skin assessments and documentation. Questions asked of the staff included what the steps were to take when a resident had a change of condition in skin/wounds. Answers were to notify the charge nurse of any changes in a residents' condition and to document in POC and shower sheets. Charge nurses said they would assess the resident and complete a progress note, notify the physician, transcribe orders, and implement orders. The charge nurses also said they would notify the residents responsible party and the DON and then complete a skin assessment form as needed. Record review on 4/19/25 of training documents and nursing competencies of staff scheduled to work had been completed. On 4/19/25 at 1:10 pm the Administrator, RCO, and RDO were notified that the immediacy had been lowered, however, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not immediate jeopardy. The facility was continuing to monitor their plan.

Based on observation, interview and record review, the facility failed to coordinate with Pre-Admission and Resident Review program (PASRR) under Medicaid and initiate services within 20 days after the date that the services are agreed upon in the IDT meeting, to ensure that individuals with intellectual developmental disabilities receive the care and services they need in the most appropriate setting for 1 of 31 residents (Resident#1) reviewed for PASRR. The facility failed to complete and submit therapy evaluations for Habilitative services for PT, OT and ST services agreed upon in an IDT meeting on 10/17/24 addressing Resident #1's needs. This failure could affect residents with intellectual and developmental disabilities requiring PASRR services at risk of a delay in or not receiving specialized services that would enhance their highest level of functioning. Finding included: Record review of Resident #1's Admission Record revealed he was a [AGE] year old male who admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of intellectual disabilities, Down syndrome, (a genetic chromosome 21 disorder causing developmental and intellectual delays), Type II diabetes mellitus with other circulatory complications (a long-term chronic condition in which the body has trouble controlling high levels of sugar in the blood), peripheral vascular disease, (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs/extremities) and acute osteomyelitis, right ankle and foot (a bone infection characterized by recent onset and can affect one or more parts of a bone). Record review of Resident #1's admission MDS dated [DATE] revealed he had a BIMS score of 11 out of 15 indicating he had moderate cognitive impairment. He was coded as having no wounds, wound infections or pressure injuries and was set-up assistance with all of his ADL's including ambulating without an assistive device. Record review on 4/15/25 of an interdisciplinary team conference meeting conducted on 10/17/24 page 4 of 8 revealed the following: A2700. Nursing Facility Specialized Services Indication .A. I certify that the need for all habilitation therapies (not habilitative therapies) were discussed .A2800. Nursing Facility Specialized Services .D. Specialized Assessment Occupational Therapy (OT) .E. Specialized Assessment Physical Therapy (PT) .F. Specialized Assessment Speech Therapy (ST) .G. Specialized Occupational Therapy (OT) .H. Specialized Physical Therapy (PT) .I. Specialized Speech Therapy (ST). All were coded in the second column as the number 2=New. A3000. IDD Specialized Services .F. Habilitation Coordination was coded as the number 3=on-going. IDT meeting held with attendees above. Services agreed upon as noted above. Resident wishes to start therapy PT/OT/ST. 3500 LA-IDD Specialized Services and Participation Confirmation .A. I am confirmed the IDD section .B. All IDD Specialized Services selected were agreed to by the IDT. And was coded as 1=Yes. Annual SPT was held. Individual will get new assessments for OT, PT and ST to start services and will continue with HAB Coordination for monthly monitoring . Record review of NFSS form dated 12/2/24 read in part: ST .Status: Denied .1. HHSC did not receive information previously requested from the nursing facility necessary to establish eligibility for the service .12/12/24 .Status: Denied .12/12/24 .TMHP: This therapy service cannot be processed because the individual does not have a valid assessment on file .Request type: Habilitative Therapies OT PT .OT .12/9/24 TMHP: NFSS form for Occupational Therapy was not submitted within 30 calendar days of IDT meeting .PT .12/9/24 TMHP: NFSS form for Physical Therapy was not submitted within 30 calendar days of IDT meeting. Interview on 4/15/25 at 1:43 pm with DOR/DOT they said they started working at the facility in September of 2024. They said they had some records from the previous company but not many records from before 9/1/24 when the current company took over. The DOR/DOT said Resident #1 most recently received habilitative services per the PASRR service plan from 1/3/25 through 3/21/25. The DOR/DOT said Resident #1 was on Medicare part A services from 4/10/24 through 5/6/24 and again from 5/15/24 through 7/27/24 and then Medicare B services from 9/23/24 through 10/17/24. Interview on 4/15/25 at 1:55 pm with HR they could not find any contact information on MDS Nurse A. Interview with MDS Nurse B on 4/15/25 at 2:08 pm who said they had only worked at the facility as the MDS Coordinator since February of 2025. MDS Nurse A said Resident #1 was receiving habilitative services for PT/OT/ST services since they had been in the MDS Coordinator role. MDS Nurse B said they did not know what happened regarding Resident #1's habilitative therapy services for PT/OT/ST prior to February 2025. Observation and interview with Resident #1 on 4/15/25 at 3:55 pm who was seated in his wheelchair in his room. He was wearing fingerless gloves and propelling himself around his room using his left leg and both arms. His right foot was completely bandaged in clean white gauze wrap up to and above the ankle. None of his right foot was visible underneath the dressing. He was wearing loose sweatpants and a white Velcro sneaker on his left foot. Resident #1 said he had surgery on his right foot 2 times and said he used to walk before I lost my toes. When asked how many toes he had lost on his right foot, he replied, all of them. Resident #1 said he wished he could walk again because he did not walk now and could only use his wheelchair. Interview with DON and Administrator on 4/17/25 at 1:44pm they both said there had been a change in the company that owns the facility in 2024 and not all of the previous resident or staff records were available or accessible. They said they did not have information for MDS Nurse A and did not know when they stopped working at the facility. Record review of facility policy and procedure titled Policy and Procedure for PL1/PASRR/NFSS//1012/PCSP/ Revised 1/16/2019 revealed in part: The facility will ensure compliance with all Phase I and II guidelines of the PASRR process for Long Term Care .All specialized services identified by the Local Authority must be added to the Comprehensive care plan and initiated within 25 days of the meeting date where the recommendations are ordered .If it is determined that the PE positive resident requires any additional services such as PT, OT, ST .complete the PCSP form marking recommended items .Notify physicians and obtain orders for recommended items, write orders in PCC, notify therapy of new orders, and submit NFSS forms for specific recommendations. Remember the recommendations must be completed within 25 days of the submission of the IDT form .Check the alerts tab daily .to see the progress of all NFSS forms and ensure everything is processed/complete.

Based on interviews and record reviews the facility failed to ensure a comprehensive care plan was developed within 7 days after completion of the comprehensive assessment and reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 4 (Resident #1) residents reviewed for IDT meetings/ care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #1. This deficient practice could place residents at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs. Findings included: 1. Record review of Resident #1's face sheet, dated 3/21/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had a diagnoses which included: Enterocolitis Due to Clostridium Difficile, recurrent (A serious inflammation of the colon that can lead to severe symptoms like diarrhea, abdominal pain, and fever), Elevated white blood cell count, other schizoaffective disorders, Unspecified psychosis not due to a substance or known physiological condition, Ataxic gait (an abnormal walking pattern characterized by poor coordination and unsteadiness), Cognitive Communication Deficit, Unspecified Dementia, Unspecified Severity, with Behavioral disturbance. Record review of Resident #1's initial MDS assessment, dated 03/04/2025, reflected a BIMS score of 03, which indicated Resident #1's cognition was severely impaired . Record review of Section GG-Functional Abilities of Resident #1's MDS revealed Resident #1 received Partial/Moderate assistance with Eating, Oral hygiene, Upper body dressing. Attempted record review of Resident #1's electronic health record revealed the care plan was not completed. In an interview with the DON on 03/21/2025 at 2:46pm, she stated she opened the care plans and her and MDS worked together to complete the care plans. She stated she had been on vacation for a week. She stated when she was not at the facility the MDS was responsible. She stated she was not sure why Resident #1's care plan was not completed. She stated that there could have been a miscommunication between her and the MDS worker. She stated the risk of the care plan not being completed was the resident missing care or something happening to the resident. She stated they were behind on their care plans because the staff had quit so they hadn't been able to update all of the care plans yet. In an interview with MDS on 03/21/2025 at 2:54pm, she stated the care plan was a team effort and IDT completes it together. She stated she was not sure why the care plan wasn't completed. She stated the care plan had to be open by an RN and reported any RN could open the care plan. She stated the risk of the care plan not being completed was the staff may not know what care to provide to the resident. Record review of the Comprehensive Person-Centered Policy, revised December 2016, revealed The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS).

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 1 of 7 residents (Resident #1) reviewed for infection control. The Administrator failed to wash or sanitize his hands and did not donn appropriate personal protective equipment (PPE) when he entered and exited Resident #1's room. Resident #1 had COVID-19 and was on droplet precautions. The facility failed to ensure the Administrator wore appropriate PPE, which included a gown, gloves, and N95 mask, when entering Resident #1's room on 3/14/2025, who was on droplet precautions (steps taken in the hospital to prevent spreading infections) for COVID-19. The failures could place residents at risk of infectious diseases due to improper infection control practices. Findings include: Record review of Resident #1's face sheet dated 3/14/2025 revealed an [AGE] year-old female admitted on [DATE] with diagnoses of lymphedema (condition of localized swelling), anemia (the blood has a reduced ability to carry oxygen), and hypertension (high blood pressure). Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 which indicated the resident was cognitively intact. Record review of Resident #1's Physician Order Summary Report dated 3/14/2025 revealed the following: Order date: 3/9/2025, Start Date: 3/9/2025, End Date: 3/17/2025. Resident requires strict isolation for COVID (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) (in a single occupancy room. All therapy and treatments are to be provided in the room. All meals are to be served in the room. Order Date: 3/7/2025, Start Date: 3/7/2025. Benzonatate Oral Capsule 100 mg - Given 1 capsule by mouth every 8 hours as needed for cough. Record review of Resident #1's Nursing Progress Note dated 3/7/2025 revealed the following: . [Resident #1] is positive for COVID .Patient has new COVID . In an observation on 3/14/2025 at 8:57 a.m. of Resident #1's closed door revealed signage that reflected, STOP - DROPLET PRECAUTIONS - EVERYONE MUST: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Remove face protection before room exit. There was a three-draw container with hazard bags in the bottom drawer, gowns in the middle drawer, and the top drawer was empty. There was a package of personal cleansing wipes on top. In an observation on 3/14/2025 at 8:58 a.m., the Administrator entered Resident #1's closed room with a surgical mask on (Surveyor stood outside of the room). He did not sanitize his hands, put on gloves, a gown or eye protection before he entered the room. After he entered the room, he left the door open. Resident #1 was sitting with a meal tray in front of her. The Administrator assisted Resident #1 with pouring a liquid into a bowl. Resident #1 asked for more milk. The Administrator left the room and went to the next hall toward the kitchen. He did not sanitize or wash his hands before leaving Resident #1's room. The Administrator walked up to an open window with a counter. The Administrator placed his hands on the countertop. He asked a dietary aide for a cup of milk. He left the counter and entered back into Resident #1's room (left the door open). He did not sanitize or, wash his hands, or put on additional PPE. The Administrator assisted Resident #1 with the milk, walked out of the room and closed the door. In an interview on 3/14/2025 at 9:06 a.m. the Administrator said Resident #1 was on droplet precautions and initially said he did not need to gown up because Resident #1 had not touched her plate wear or food. He said he could not say without certainty if Resident #1 touched her dishes or food. He said he forgot to sanitize his hands when he entered the room, he was focused that the call light was on and went to answer it. He said he did not think his action was a risk for other residents or staff. He said he was trained on PPE and universal infection control protocols. In an interview on 3/14/2025 at 3:16 p.m. the DON said when a resident was on droplet precaution, staff should put on a N95 mask, eye protection, gown and wash or sanitize their hands when they entered the room. She said staff or visitors should take off all the PPE, throw it away before they left the room and wash or sanitize their hands after they have left the room. She said when the Administrator entered Resident #1's room without the required PPE and left the room and did the wash or sanitize his hands, he placed residents and staff at risk of spreading infection. She said Resident #1 was on droplet precaution because she tested positive for COVID on 3/9/2025. In a phone interview on 3/14/2025 at 3:33 p.m. the ADON (Infection Control Preventionist) said all staff, including the administrator, was required to wear N95 mask, eye protection, a gown, gloves, and shoe protection. She said the shoe protection was optional. She said staff should wash their hands before entering and exiting the room. She said universal infection control included sanitizing their hands before resident contact. She said there was a risk of spreading germs to residents and staff. Record review of facility's In-service Training and Education - Infection Control - Hand Hygiene Efforts (dated February 2025) revealed the following in part: Hand-Hygiene Practices: You must use hand sanitizer on your hands appropriately before entering patient rooms & exiting the room despite proper handwashing efforts in efforts completed, you must use hand sanitizer again once you exited the room. Should you touch surfaces such as doorknobs, carts, etc. it is always better air on the side of caution and just use hand sanitizer, its easy, its available and its best practice! You must wash hands OR use hand sanitizer before donning PPE. This is to prevent to prevent the potential of cross contamination - spreading infections. This is the proactive of IFC: Infection Control. Record review of the facility's Infection Prevention and Control Program policy (revised October 2018) reflected in part, . An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . (7) implementing appropriate isolation precautions when necessary; and (8) following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC).] Record review of CDC guidance Droplet Precaution (dated 3/2024) reflected Use Droplet Precautions for patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking. Source control: put a mask on the patient. Ensure appropriate patient placement in a single room if possible. In acute care hospitals, if single rooms are not available, utilize the recommendations for alternative patient placement considerations in the Guideline for Isolation Precautions. In long-term care and other residential settings, make decisions regarding patient placement on a case-by-case basis considering infection risks to other patients in the room and available alternatives. In ambulatory settings, place patients who require Droplet Precautions in an exam room or cubicle as soon as possible and instruct patients to follow Respiratory Hygiene/Cough Etiquette recommendations. Use personal protective equipment (PPE) appropriately. [NAME] mask upon entry into the patient room or patient space. Limit transport and movement of patients outside of the room to medically-necessary purposes. If transport or movement outside of the room is necessary, instruct patient to wear a mask and follow Respiratory Hygiene/Cough Etiquette.

Based on observations, interviews, and record review, the facility failed to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress for 1 of 6 residents (Resident #27) reviewed for abuse and neglect. The facility failed to prevent and correct alleged violation of abuse regarding Resident #27 that was reported on 2/21/2024. It was alleged that abused occurred on 2/20/2024 when a charge nurse witnessed Resident #27's family member shaking her hard by her shoulders and was screaming at her. Resident #27 was heard saying that resident #27 yelled saying her family member was trying to kill her. Resident #27 family member was instructed to leave the facility. The facility did not put in place a care plan or interventions to prevent the abuse from occurring again. After the abuse, the family member went to Resident #27's doctor appointment on 2/27/24 and told the provider to continue providing care even though the resident was screaming and saying no. LVN B had previously witnessed heated exchange of words in the past prior to the abuse incident. The facility failed to thoroughly investigate the abuse allegation and mitigate further harm while they continue to investigate. There were no safety restrictions in place, and staff were unaware there was an issue with the family member or that she was not supposed to be visiting Resident #27. The family member went with Resident #27 to a podiatrist appointment after the abuse incident on 2/27/24. The facility failed to do a thorough investigation as the Social Worker did not do any assessments on Resident #27 after the abuse incident and there were no head-to-toe assessments completed by LVN B or the DON. This failure could place the census of 74 residents at risk of not having allegations of abuse or neglect investigated. These findings included: Record review of Resident #27's face sheet revealed she was a [AGE] year-old woman, admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), urinary tract infection, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), anxiety disorder, cognitive communication deficit (difficulty with thinking and how someone uses language), lack of coordination, and gastro-esophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining). Record review of Resident #27's quarterly MDS assessment dated [DATE] revealed a BIMS score of 6, indicating severely impaired cognition. Further review of Resident #27's MDS revealed she was dependent for toileting hygiene, shower/bath, and personal hygiene. She needed supervision or touching assistance eating, and oral hygiene, and she did not attempt to sit to lying, sit to stand, and chair/bed-to-chair transfer due to medical conditions or safety concerns. Record review of Resident #27's care plan date (unknown) revealed Resident #27 was dependent on staff for meeting emotional, intellectual, physical, and social needs r/t cognitive deficit, and immobility. Interventions dated 1/3/2024: Encourage ongoing family involvement. Invite the resident's family to attend special events, activities, and meals. Record Review of Resident #27's progress notes dated 2/27/2024 revealed, Resident #27 went to podiatry appt accompanied by CNA A from the facility. CNA A stated Resident #27's family member arrived at the appointment after they were already in the room with the PD. CNA A went on to say that Resident #27 and her family member greeted each other with a hug and the PD was already attempting to provide care on Resident #27's feet. CNA A stated that Resident #27 was screaming anytime the PD would touch her feet. Resident #27's family member told the PD to continue to provide care even though Resident #27 was screaming and saying no and the PD stated that he could not continue since she was refusing. When the appointment was over, Resident #27's family member stated that she would come and see her tonight on 2/27/2024 at 8:00 p.m. DON notified. Observation and interview on 2/26/2024 at 10:20a.m. with Resident #27, revealed her sitting up in bed wearing briefs and a t-shirt. She was using an oxygen machine. Resident #27 was trying to explain herself but had a hard time communicating. There was a wheelchair next to her bed. Her nails were long. She said she wanted to be changed. She pointed to her brief and said she was burning in the back. Observation and interview on 2/29/2024 at 11:00a.m. with Resident #27 revealed her sitting up in bed, wearing brief, and a t-shirt. Resident #27 was not able to explain the incident that occurred with her and her family member. Resident #27 was not able to communicate if she felt safe with her family member coming to visit her. Resident #27 was not able to communicate effectively and was not able to explain what happened the night her family member came to visit her. Resident #27 was able to say she was doing fine. In an interview on 2/28/2024 3:52p.m. with LVN B, she said Resident #27 had been her resident for a while now. She said the family member took care of things for Resident #27 and visits regularly. She said the family member normally visits late in the evening around 8:00p.m or 9:00p.m. She said the family member always woke up Resident #27 when she came to visit. She said Resident #27 was anxious and confused during those hours. She said she had witnessed in the past, heated exchange of words between Resident #27 and her family member but was not sure what was said. She said she did not tell anyone about it. She said they just seemed to be arguing, but nothing else was happening. She said on the night of the incident, she heard raised voices, and she went to the doorway to see what was going on. She said the family member was shaking her hard. She said her hands were on her shoulders and Resident #27 was trying to push the family member away. She said Resident #27 was yelling and said her family member was trying to kill her. LVN B said she asked the family member to stop, and she told her Resident #27 pushed her. She said she questioned the family member's mental state. She said she was elderly as well. She said she notified LVN C because she was normally the weekend supervisor, but on 2/28/2024 she was covering the halls. She said she asked what to do in this situation because she did not know what to do. She said LVN C told her to text the DON and she did just that. She said the DON said it should have been a phone call. She said she saw Resident #27 wearing a hospital gown, and by looking at her when she changed her brief, there were no marks. She said she did not document that she assessed Resident #27. She said she was not sure if she assessed Resident #27. She said Resident #27 was agitated. She said she sat and talked with Resident #27 and calmed her and she went right to sleep. She said she received an in-service annually and that the Administrator was the abuse coordinator. She said he had not gone over anything with her regarding abuse training. She said there was no protocol set in place and if she were to witness abuse at the facility, she was not sure about what to do. She said she was not aware of the process. She said she had been working at the facility for four years. In an interview on 2/27/2024 at 4:00p.m. with the DON, she said the next day after the incident occurred and when she returned to work, Resident #27 was assessed from head to toe for bruising. She said a head-to-toe assessment was not completed the night of the incident because the nurse was busy consoling Resident #27 and keeping her calm. She said Resident #27's family member was from City A, and she drove back and forth. She said she did not put anything in place regarding the family member and Resident #27, but she said she told the family member not to visit for a while and the family member agreed. She said the family member had not been back to the facility. She said the police were called and a report was made. She said the charge nurse asked the family member to leave and she complied. In an interview on 2/28/2024 at 10:30a.m. with the Administrator and the DON, the Administrator said he had set up a meeting with Resident #27 to see if she felt safe with her family member visiting her or would she like her banned from the facility. He said he did not know the family member was going to show up to her appointment. He said had she come to the building she would not have been allowed inside. The DON said she spoke with the family member yesterday and told her she was not allowed to visit until she heard from them. She said she will talk to the resident to see what she would like to happen regarding her family member coming to visit her. In an interview on 2/28/2024 at 11:55a.m. with the Social Worker, she said the DON notified her that Resident #27's family member was coming to visit her at her podiatrist appointment. She said she went and asked Resident #27 if it was okay for her family member to be there. She said Resident #27 told her the family member grabbed her by the face and not just her arm. She said Resident #27 did not have dementia. She said her BIMS score was a 6. She said she felt she needed to do what was necessary for Resident #27's safety for the appointment, so she requested a CNA to go to the appointment. She said she informed the DON of the new allegations that was made by Resident #27. She said Resident #27 said this has always happened to her. She said she told the DON that Resident #27 said she did not want the family member to come to the visit. She said on 2/28/2024 in the meeting, they could not understand what Resident #27 was saying. She said there was a safety issue, and she should have put supervision in place. She said Resident #27 was her own RP. The Social Worker said she was responsible for writing the care plans. She said she just started working at the facility in January and had not been trained on how to complete the care plans which was why the incident was not documented in the care plan. During a follow-up interview on 2/28/2024 at 3:42p.m. with the Social Worker, she said she completed a brief trauma questionnaire a day before the incident because the MDS nurse and the UDA s was showing that it was outstanding, so she did the questionnaire. She said it showed how many days they were behind. She said they were behind because the facility was without a social worker for a month. She said if there was something serious going on such as abuse, she would call APS. She said no assessments were done when the incident occurred because she was not aware of any assessments she was supposed to complete. She said she has not had the proper training to complete the assessments. She said the facility could not afford her to go out to training because they need her at the facility. She said she had a lot of things to catch up on. In an interview on 2/29/2024 at 10:50a.m. with the Administrator, he said he was made aware of the incident regarding Resident #27 when he came into work the next day. He said the DON told him about the incident by a text she received from a staff member. He said he called in the report on 2/21/2024. He said he will make sure the residents were protected going forward. He said he was more focused on the physical part of the allegations rather than the documentation. He said if the family member were to come back to visit Resident #27, she would not be allowed to enter the facility. He said the protocol for abuse was to report it to the state, remove the threat immediately, and design a plan so that it would not happen again. He said he felt like he protected Resident #27, but he did not communicate effectively with staff. In an interview on 2/29/2024 at 11:14a.m. with CNA A, she said she arrived at the podiatrist appointment with Resident #27 and the PD came into the room. She said the PD tried to touch Resident #27's feet and she started to scream. She said the family member knocked on the door and the PD allowed her to come inside the room. She said management wanted her to accompany Resident #27, but no one told the PD that the family member was not supposed to be around Resident #27. She said she the PD told her he could not ask the family member to leave the appointment and she said she was not in the position to ask her to leave as well. She said Resident #27 and the family member hugged and kissed each other goodbye. She said she was not told that the family member was supposed to stay away from Resident #27. She said no one explained that to her. She said she was aggravated and did not know why she had to accompany Resident #27. She said she thought someone called the family member about the appointment. She said the Social Worker was worried about Resident #27. She said she was asked to write a statement after the podiatrist appointment with Resident #27. She said she was not sure as to why she did not write a statement when the incident happened. She said the incident happened over a week ago. In an interview on 2/29/2024 at 11:56a.m. with CNA B, she said she had been working at the facility for a month. She said she had never been told by a staff member that a particular family member was banned from seeing Resident #27. She said she was not told that a family member could not enter the building. She said she was not aware of the abuse incident that occurred at the facility. She said if she were to witness abuse at the facility, she would inform the Administrator, the DON, and a nurse. She said she had been in-serviced at the facility on abuse and neglect. In an interview on 2/29/2024 at 12:05p.m. with CNA C, she said she had been working at the facility for a month. She said she heard about the incident, but she was not made aware that a family member was restricted from coming inside the building. She said if she were to ever witness abuse, she would report it to the Administrator, tell the DON and a nurse. She said she had never witnessed abuse at the facility. In an interview on 2/29/2024 at 12:11p.m. with CNA D, she said she started orientation on 2/7/2024 or 2/10/2024. She said she had never been told by the Administrator that a family member was prohibited from coming inside the facility and had to stay away from Resident #27. She said if she witnessed abuse at the facility, she would report it immediately to the Administrator. She said she must make a phone call to the Administrator within 24 hours. She said she was told about abuse and neglect through an in-service. She said she never witnessed abuse in the facility. In an interview on 2/29/2024 at 12:23p.m. with CNA E, she said she had been working at the facility for 3 months. She said she had never witnessed abuse at the facility. She said if she were to witness abuse at the facility, she would report it to the Administrator, the DON, or the ADON within 24 hrs. She said she received an in-service today, 2/29/2024 about a resident, but she was not sure what resident they were speaking of. In an interview on 2/29/2024 at 3:29p.m. the Family Member said Resident #27 was her only family member she had left. She said she is her POA . She said Resident #27 broke her hip and was in and out of the hospital. She said her family member was very friendly, but she would suddenly turn on you. She said there were several times she told her she was leaving and was not coming back to see her although she came back. She said she always came late to visit Resident #27 because she was busy during the day. She said she lives in City A. She said she goes back and forth every week to pick up her mail in City B. She said the night of the incident she brought Resident #27 food because she does not eat the food at the facility. She said Resident #27 started telling her she had on nice clothes but accused her of using her money to buy her clothes. She said Resident #27 pushed her away and she grabbed her hands to talk to her. She said she never grabbed Resident #27's shoulders. She said the door was open and LVN A asked her to leave. She said she grabbed her belongings and left. She said Resident #27 was not screaming. She said LVN A told her she would report the incident. She said she told LVN A to be mindful of how she reported the incident. She said the DON called her on 2/25/2024. She said when the DON first called her on 2/25/2024 she wanted to know what happened between her and Resident #27. She said she had gone to all of Resident #27's appointments. She said she kept tabs on her and paid her insurance. She said she knew she had an appointment with the foot doctor since the appointment was first scheduled. She said she scheduled the appointment. She said she was told by the DON she could not come into the building. She said she did not want Resident #27 to be at a facility where she could not visit her. She said the police called her to find out what the incident was about as well. She said the DON called her and asked for a picture. Record Review of the facility's policy titled Abuse and Neglect - Clinical Protocol, dated 10/01/2020, read in part, . Abuse is defined at S483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. Neglect, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The nurse will assess the individual and document related findings .

Based on observations, interviews, and record review, the facility failed to ensure a resident was free from abuse, neglect, and exploitation for 1 of 6 residents (Resident #27) reviewed for abuse and neglect. The facility failed to prevent and correct alleged violation of abuse regarding Resident #27 that was reported on 2/21/2024. It was alleged that on 2/20/2024 a charge nurse witnessed Resident #27's family member shaking the resident hard by her shoulders and was screaming at her. Resident #27 family member was instructed to leave the facility. The facility did not put in place a care plan or interventions to prevent the abuse from occurring again. The facility failed to thoroughly investigate the abuse allegation and mitigate further harm while they continue to investigate. This failure could place the census of 74 residents at risk of not having allegations of abuse or neglect investigated. These findings included: Record review of Resident #27's face sheet revealed she was a [AGE] year-old woman, admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnosis included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), urinary tract infection, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), anxiety disorder, cognitive communication deficit (difficulty with thinking and how someone uses language), lack of coordination, and gastro-esophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining). Record review of Resident #27's quarterly MDS assessment dated [DATE] revealed a BIMS score of 6, indicating severely impaired cognition. Further review of Resident #27's MDS revealed she was dependent for toileting hygiene, shower/bath, and personal hygiene. She needed supervision or touching assistance eating, and oral hygiene, and she did not attempt to sit to lying, sit to stand, and chair/bed-to-chair transfer due to medical conditions or safety concerns. Record review of Resident #27's care plan date (unknown) revealed Resident #27 is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t cognitive deficit, and immobility. Interventions dated 1/3/2024: Encourage ongoing family involvement. Invite the resident's family to attend special events, activities, meals. Record Review of Resident #27's progress notes dated 2/27/2024 revealed, Resident #27's went to podiatry appt accompanied by CNA A from the facility. CNA A stated Resident #27's family member arrived at the appointment after they were already in room with the PD. CNA A went on to say that Resident #27's and her family member greeted each other with a hug and the PD was already attempting to provide care on Resident #27's feet. CNA A stated that Resident #27 was screaming anytime the PD would touch her feet. Resident #27's family member told the PD to continue to provide care even though Resident #27 was screaming and saying no and the PD stated that he could not continue since she was refusing. When the appointment was over, Resident #27 family member stated that she would come and see her tonight on 2/27/2024 at 8:00 p.m. DON notified. Observation and interview on 2/26/2024 at 10:20a.m. with Resident #27, revealed her sitting up in bed wearing briefs and a t-shirt. She was using an oxygen machine. Resident #27 was trying to explain herself but had a hard time communicating. There was a wheelchair next to her bed. Her nails were long. She said she wanted to be changed. She pointed to her briefs and said she was burning in the back. Observation and interview on 2/29/2029 at 11:00a.m. with Resident #27 revealed her sitting up in bed, wearing briefs and a t-shirt. Resident #27 was not able to explain the incident that occurred with her and her family member. Resident #27 was not able to communicate if she felt safe with her family member coming to visit her. Resident #27 was not able to communicate effectively and was not able to explain what happened the night her family member came to visit her. Resident #27 was able to say she was doing fine. Interview on 2/27/2024 at 4:00p.m. with the DON and she said the next day after the incident occurred and when she returned to work, Resident #27 was assessed from head to toe for bruising. She said a head-to-toe assessment was not completed the night of the incident because the nurse was busy consoling Resident #27 and keeping her calm. She said Resident #27's family member is from City A, and she drives back and forth. She said she did not put anything in place regarding the family member and Resident #27, but she said she told the family member not to visit for a while and the family member agreed. She said the family member had not been back to the facility. She said the police was called and a report was made. She said the charge nurse asked the family member to leave and she complied. Interview on 2/28/2024 at 10:30a.m. with the Administrator and the DON, and the Administrator said he had set up a meeting with Resident #27 to see if she felt safe with her family member visiting her or would she like her banned from the facility. He said he did not know the family member was going to show up to her appointment. He said had she come to the building she would not have been allowed inside. The DON said she spoke with the family member on yesterday and told her she was not allowed to visit until she heard from them. She said she will talk to the resident to see what she would like to happen regarding her family member coming to visit her. Interview on 2/28/2024 at 11:55a.m. with the Social Worker and she said the DON notified her that Resident #27's family member was coming to visit her at her podiatrist appointment. She said she went and asked Resident #27 if it was okay for her family member to be there. She said Resident #27 told her the family member grabbed her by the face and not just her arm. She said Resident #27 did not have dementia. She said her BIMS score was a 6. She said she felt she needed to do what was necessary for the Resident #27's safety for the appointment, so she requested a CNA to go to the appointment. She said she informed the DON of the new allegations that was made by Resident #27. She said Resident #27 said it had always happened to her. She said she told the DON that Resident #27 said she did not want the family member to come to the visit. She said on 2/28/2024 in the meeting, they could not understand what Resident #27 was saying. She said there was a safety issue, and she should have put supervision in place. She said Resident #27 was her own RP. The Social Worker said she was responsible for writing the care plans. She said she just started working at the facility in January and had not been trained on how to complete the care plans which was why the incident was not documented in the care plan. Follow up- interview on 2/28/2024 at 3:42p.m. with the Social Worker and she said she completed a brief trauma questionnaire a day before the incident because the MDS and the UDAs was showing that it was outstanding, so she did the questionnaire. She said it showed how many days they were behind. She said they were behind because the facility was without a social worker for a month. She said if there was something serious going on such as abuse, she would call APS. She said no assessments were done when the incident occurred because she was not aware of any assessments she was supposed to complete. She said she has not had the proper training to complete the assessments. She said the facility could not afford her to go out to training because they need her at the facility. She said she had a lot of things to catch up on. Interview on 2/28/2024 3:52p.m. with LVN B and she said Resident #27 had been her resident for a while now. She said the family member takes care of things for Resident #27 and visits regularly. She said the family member normally visits late in the evening around 8:00p.m or 9:00p.m. She said the family member always wake up Resident #27 when she came to visit. She said Resident #27 is anxious and confused during those hours. She said she had witnessed in the past, heated exchange of words between Resident #27 and her family member but was not sure what was said. She said she did not tell anyone about it. She said it they just seemed to be arguing but nothing else was happening. She said on the night of the incident, she heard raised voices, and she went to the doorway to see what was going on. She said the family member was shaking her hard. She said her hands were on her shoulders and Resident #27 was trying to push the family member away. She said Resident #27 was yelling and said her family member was trying to kill her. LVN B said she asked the family member to stop, and she told her Resident #27 pushed her. She said she questioned the family member's mental state. She said she is elderly as well. She said she notified LVN C because she is normally the weekend supervisor, but on 2/28/2024 she was covering the halls. She said she asked what to do in this situation because she did not know what to do. She said LVN C told her to text the DON and she did just that. She said the DON said it should have been a phone call. She said she saw Resident #27 wearing hospital gown, and by looking at her when she changed her briefs, there were no marks. She said she did not document that she assessed Resident #27. She said she was not sure if she assessed Resident #27. She said Resident #27 was agitated. She said sat and talked with Resident #27 and calmed her and she went right to sleep. She said she received an in-service annually and that the Administrator is the abuse coordinator. She said he had not gone over anything with her regarding abuse training. She said there was no protocol set in place and if she were to witness abuse at the facility, she was not sure about what to do. She said she is not aware of the process. She said she had been working at the facility for four years. Interview on 2/29/2024 at 10:50a.m. with the Administrator and he said he was made aware of the incident regarding Resident #27 when he came into work the next day. He said the DON told him about the incident by a text she received from a staff member. He said he called in the report on 2/21/2024. He said he will make sure the residents are protected going forward. He said he was more focused on the physical part of the allegations rather than the documentation. He said if the family member were to come back to visit Resident #27, she would not be allowed to enter the facility. He said the protocol for abuse is to report it to the state, remove the threat immediately and design a plan so that it would not happen again. He said he felt like he protected Resident #27, but he did not communicate effectively with staff. Interview on 2/29/2024 at 11:14a.m. with CNA A and she said she arrived at the podiatrist appointment with Resident #27 and the PD came into the room. She said the PD tried to touch Resident #27 feet and she started to scream. She said the family member knocked on the door and the PD allowed her to come inside the room. She said management wanted her to accompany Resident #27, but no one told the PD that the family member was not supposed to be around Resident #27. She said she the PD told her he could not ask the family member to leave the appointment and she said she was not in the position to ask her to leave as well. She said Resident #27 and the family member hugged and kissed each other goodbye. She said she was not told that the family member was supposed to stay away from Resident #27. She said no one explained that to her. She said she was aggravated and did not know why she had to accompany Resident #27. She said she thought someone called the family member about the appointment. She said the Social Worker was worried about Resident #27. She said she was asked to write a statement after the podiatrist appointment with Resident #27. She said she was not sure as to why she did not write a statement when the incident happened. She said the incident happened over a week ago. Interview on 2/29/2024 at 11:56a.m. with CNA B and she said she had been working at the facility for a month. She said she had never been told by a staff member that a particular family member was banned from seeing Resident #27. She said she was not told that a family member could not enter the building. She said she was not aware of the abuse incident that occurred at the facility. She said if she were to witness abuse at the facility, she would inform the Administrator, the DON, and a nurse. She said she had been in-serviced at the facility on abuse and neglect. Interview on 2/29/2024 at 12:05p.m. with CNA C and said she had been working at the facility for a month. She said she heard about the incident, but she was not made aware that a family member was restricted from coming inside the building. She said if she were to ever witness abuse, she would report it to the Administrator, tell the DON and a nurse. She said she had never witnessed abuse at the facility. Interview on 2/29/2024 at 12:11p.m. with CNA D and she said she started orientation on 2/7/2024 or 2/10/2024. She said she had never been told by the Administrator that a family member was prohibited from coming inside the facility and had to stay away from Resident #27. She said if she witnessed abuse at the facility, she would report it immediately to the Administrator. She said you must make a phone call to the Administrator with 24 hours. She said she was told about abuse and neglect through in-service. She said she never witnessed abuse in the facility. Interview on 2/29/2024 at 12:23p.m. with CNA E and said she had been working at the facility for 3 months. She said she had never witnessed abuse at the facility. She said if she were to witness abuse at the facility, she would report it to the Administrator, the DON or the ADON within 24 hrs. She said she received an in-service today, 2/29/2024 about a resident, but she was not sure what resident they are speaking of. Interview on 2/29/2024 at 3:29p.m. the Family Member and she said Resident #27 was her only family member she had left. She said she is her POA. She said Resident #27 broke her hip and was in and out of the hospital. She said her family member is very friendly, but she would suddenly turn on you. She said there were several times she told her she was leaving and was not coming back to see her although she came back. She said she always come late to visit Resident #27 because she is busy during the day. She said she lives in City A. She said goes back and forth every week to pick up her mail to City B. She said the night of the incident she brought Resident #27 food because she does not eat the food at the facility. She said Resident #27 started telling her she had on nice clothes but accused her of using her money to buy her clothes. She said Resident #27 pushed her away and she grabbed her hands to talk to her. She said she never grabbed Resident #27's shoulders. She said the door was open and LVN A asked her to leave. She said she grabbed her belongings and left. She said the Resident #27 was not screaming. She said LVN A told her she would report the incident. She said she told LVN A to be mindful of how she reported the incident. She said the DON called her on 2/25/2024. She said when the DON first called her on 2/25/2024 she wanted to know what happened between her and Resident #27. She said she had gone to all of Resident #27 appointments. She said she kept tabs on her and paid her insurance. She said she knew she had an appointment with the foot doctor since the appointment was first scheduled. She said she scheduled the appointment. She said she was told by the DON she could not come into the building. She said she did not want Resident #27 to be at a facility where she could not visit her. She said the police called her to find out what the incident was about as well. She said the DON called her and asked for a picture. Record Review of the facility's policy titled Abuse and Neglect - Clinical Protocol, dated 10/01/2020, read in part, . Abuse is defined at S483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. Neglect, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The nurse will assess the individual and document related findings. Assessment data will include injury assessment (bleeding, bruising deformity, swelling etc.); Pain assessment; Current behavior; Patient's age and sex; All current medications, especially anticoagulants, NSAIDs, salicylate; Other platelet inhibitors; Vital signs; Behavior over last 24 hours (bruise could be related to movement disorder or aggressive behavior). The nurse will report findings to the physician. As needed, the physician will assess the resident/patient to verify or clarify such findings, especially if the cause or source of the problem is unclear .

Based on observations, interviews, and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. Twenty-five opportunities were observed with a total of two errors, resulting in an eight percent medication error rate involving 2 residents (Residents #4 and #66) and 2 of 7 staff (LVN J and LVN L) reviewed for medication errors, in that: -LVN L administered the wrong dose of Prostat AWC (indicated for increased protein needs in low volume related to stages 2 to 4 pressure injuries, multiple pressure injuries, hard-to-heal wounds, unintentional muscle loss, protein-energy malnutrition, low serum proteins, and sarcopenia) to Resident #4. -LVN J administered Morphine Sulfate to Resident #66 using the wrong route. These failures affected 2 residents and placed other residents at risk for not receiving medications as ordered by the physician and not receiving the intended therapeutic benefit of their medications. Findings include: Resident # 4 Record review of clinical record facesheet for Resident #4 revealed that she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, aphasia (loss of ability to understand or express speech, caused by brain damage), pressure ulcer of the right heel, diabetes mellitus, and hypertension. Record review of Resident #4's physician orders dated 09/29/2021 revealed an order for Prostat AWC, give 30mls via PEG Tube two times a day for dietitian recommendation related to Type 2 Diabetes. Observation on 02/29/2024 at 10:00 a.m. revealed LVN L administered Prostat AWC, 25mls (Milliliters) via PEG Tube to Resident # 4 with scheduled daily medications. Interview on 02/29/2024 at 10:15 p.m. LVN L revealed that she did not administer Prostat AWC, 30mls in error. She said that Resident #4 should have been given 30mls of Prostat AWC, but she gave 25mls and failed to administer the remaining 5mls. LVN L said that placed Resident #4 at risk for delayed wound healing and additional skin breakdown by not administering the right dose of medication to Resident #4. LVN L confirmed that the facility had provided training related to administering medications and that she was knowledgeable to the facility policy. Resident #66 Record review of the clinical record facesheet for Resident # 66 revealed that she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, pressure ulcer of the right buttock, anxiety disorder, gastro-esophageal reflux disease, and hypertension. Record review of Resident #66's physician orders dated 01/13/2024 revealed an order for Morphine Sulfate Oral Solution 0.5ml to be given via G-Tube (Gastrostomy Tubes) route every 4 hours for pain and shortness of breath. Observation on 02/29/2024 at 1:03 p.m. revealed LVN J administered Morphine Sulfate to Resident #66 and used the wrong route (oral route). Interview on 02/29/2024 at 1:05 p.m. LVN J revealed the order read that Morphine Sulfate Oral Solution 0.5ml should be given via oral route. LVN J said that she did not realize that the physician ordered the medication to be given via the G-Tube route. LVN J said that she failed to confirm that with the physician order. She said that resident could have serious effects when administering medication via the wrong route. LVN J confirmed that that the facility had provided training related to administering medications and that she was knowledgeable to the facility policy. Interview on 02/29/2024 at 1:15 p.m. the DON said that medications should be checked for the correct dosage and route with each medication pass. The DON said that when medications were administered in error via the wrong route and dose that it can cause serious, sometimes long-term effects to the resident. The DON said that all nurses and CMA staff have been trained and were knowledgeable of the medication administration policy. The DON said that additional training will be provided. Record review of the facility's policy for Medication Administration revised April 2019 read in part: . Medications are administered in accordance with prescriber orders . The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the mediation .

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents, hazards, and supervision. --The facility failed to provide adequate assistance and supervision to Resident #1 during dinner when soup was spilled in her lap. As a result, she sustained 2nd [MEDICAL CONDITION] her inner thighs. This failure affected 1 resident and placed her at risk of not receiving appropriate supervision to prevent accidents and a decline in health. Findings Include: Record review of Resident #1's face sheet revealed she was [AGE] years old. She was admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed she had a BIMS (Brief Interview for Mental Status) score of 6 out of 15 that indicated her cognition was severely impaired. She was totally dependent on one staff for eating. Record review of Resident #1's (MONTH) 2019 Physician Order summary report revealed the following orders: -Cut up all foods at meals three times a day for ease of self eating related to [MEDICAL CONDITION] .dietitian recommendation; -No Added Salt, Regular Consistency diet, regular texture, regular consistency, add divided plate for ease of self feeding.Add cut up meats and no raw veg's (vegetables) for ease of chewing per dietitian recommendation . Record review of Resident #1's Care Plan dated 3/27/19 revealed, -Resident #1 has an ADL performance deficit r/t (related to) Dementia, [MEDICAL CONDITION] with hand tremors, Limited ROM (Range of Motion) and Muscle Weakness. Interventions included .in part, EATING: Resident #1 requires Extensive assistance by (1) staff with the set-up help only to eat.EATING: The resident requires (weighted utensils) to maximize independence with eating. -Resident #1 has potential for unavoidable decline in both cognitive and physical status r/t [MEDICAL CONDITION]/Dementia, with interventions that included, Assist as needed with oral intake (meals/snacks/fluids) assist as needed . Record review of the facility Provider Investigation Report revealed that on 6/16/19 at 5:45 p.m. Resident #1 was eating soup in the dining room when she spilled her soup on her lap. The charge nurse did not do an assessment. The resident [MEDICAL CONDITION] both of her legs. Record review of Resident #1's Incident Note dated 6/17/19 at 1:47 am signed by LVN B revealed in part, CNA informed nurse of rash to inner thighs that was not there the day prior. Resident was sitting on toilet. Nurse observed a very red rash and resident seemed to be very much excoriated. NOD (nurse on duty) was unable to fully assess due to the resident's position on the toilet and Resident refusing to lie down at that time Around 2110 (9:10 p.m.) CNA was assisting the resident to bed, CNA came and got the nurse again due to the rash being blistered and open. NOD assessed the rash again, Nurse observed blisters and open area to inner thighs, looking like a burn. NOD asked resident if she spilt (sic) anything hot on herself like coffee or soup. Resident responded with Yes. Dinner was vegetable soup, CNA informed the nurse that there was a lot of vegetable on her lap, between her legs and underneath her and that the resident was very wet. CNA informed the nurse that he had to wash the wheelchair because it was very dirty. Wound care was notified and to look at area in the morning. Area was cleaned, and dressing was placed. Nurse informed Responsible Party at 2130 (9:30 p.m.) of situation that wound care was aware and would be looking at it in the morning. RP was very upset about the situation. Stating I don't understand why the kitchen would serve soup so hot, was anyone helping her eat? Is she in pain? What does she get for pain? I want the wound care nurse to call me after she assesses it. NOD informed RP that resident receives scheduled Tylenol 325mg every 6 hrs (hours). Record review of the signed wound care physician note dated 6/18/19 revealed Resident #1 sustained partial thickness burn wounds to her left proximal medial thigh that was acquired on 6/16/19 at the facility, wound condition was acute and non-healed, size 7cm x 4.5 cm x 0.1 cm with a total area of 31.5 cm2 (squared); and partial thickness burn wounds to her right proximal medial thigh that was acquired on 6/16/19 at the facility, wound condition was acute and non-healed, size 8cm x 6cm x 0.1 cm with a total area of 48 cm2. During an interview with the Food Service Manager on 7/16/19 at 10:00 am she said the soup temperature was about 168 to 175 degrees Fahrenheit. She said they were serving the soup using a cup with a lid to avoid spillage. She said the staff would remove the lid from the cup, not the residents. She said they started that system after a resident spilled soup and got burned on her thighs. She said she was not working when the accident happened. During a phone interview with CNA A on 7/26/19 at 11:14 am she said she was in the assisted dining hall on (MONTH) 16, 2019 during dinner time. She said it was about 5:30 p.m. and she was sitting at the long table with Resident #1 and 5 other residents together along with CNA B and LVN [NAME] She said she, CNA B and LVN A were helping other residents to eat. She said, Nobody was feeding Resident #1 that time. She said then, she just heard Resident #1 say Oh, I spilled the soup. CNA A said she stood up and took Resident #1 to her room and looked for the staff assigned to the resident. When she could not find the CNA assigned to Resident #1 she saw another CNA in the hall and told him that Resident #1 needed to be changed because she spilled a soup on herself, but the CNA told her that he was not assigned to Resident #1 and told her he would just tell the CNA assigned to Resident#1 to change her. CNA A said she then went back to Resident #1's room and asked Resident #1 if she was ok. CNA A said Resident #1 told her that her pants were hot. CNA A said she put paper towels inside Resident #1's pants so that it would not get contact with the skin then she returned to the dining room. When asked if LVN A knew that Resident #1 spilled soup on herself, she said, Yes, he knew it. He just told me to bring Resident#1 in her room and inform the CNA assigned to her about the spill. Observation on 7/26/19 at 11:55 am in the assisted dining hall, Resident #1 was noted to be seated at the end of the long table together with 6 to 8 other residents and four staff members. A family member was observed to be feeding Resident #1. During an interview with the DON on 7/26/19 at 2:01 pm she said Resident #1 would like to feed herself. She said Resident #1 was not total assistance with one person assist for eating. She said the residents would have a longer clothing protector to prevent spills. She also said they were not allowing the residents to remove the lids on the cups. She said the staff would now remove the lids. The DON said the CNA did the right thing by putting paper towels between Resident #1's legs to soak up the soup and immediately took her to her room but, to her, she should have taken Resident #1's pants off so that it would take the heat away. She said the nurse went down to assess Resident #1 inside her room. The DON said she did and in-service for the staff to remove the clothes immediately after a spill of hot liquid. The DON also said they would be including this in their QAPI. During a phone interview with LVN B on 7/26/19 at 2:25 pm she said she never got a report during shift change about a skin redness or excoriation on Resident #1. She said CNA C informed her about the redness on Resident #1's thighs but could not see it clearly because the resident was on the toilet. She said at about 9:10 pm she was able to assess the resident because she was already in bed and that was when she saw that it was not an excoriation but there were blisters and some open areas that looked like a burn. She said she informed the responsible party, the Nurse Practitioner, and the DON. During an interview with the DON on 7/26/19 at 3:36 pm she said the facility was using the stop and watch for the CNAs to utilize when communicating changes that occurred to the residents. But in this case, she said it would not apply because it was immediate, and the CNA already told the nurse what happened so the nurse just made a written statement about the incident. Observation and interview of Resident #1 on 7/29/19 at 9:35 am revealed, she was sitting in her wheelchair beside her bed in her room. Her head was turned downward and her eyes were closed. She opened her eyes when the surveyor knocked on her door and she asked, What do you want? The surveyor introduced himself. She said, You can come in, and she said she was was fine. She said she had a fire on her thighs and pointed to her left and right thighs as if trying to pull up her long shorts. Tremors were noticed on her hands especially on her right hand. She said she liked soup. She said chicken noodle soup was her favorite and she liked to drink the soup from the cup. She said she also used a spoon, but she liked it better when she drank it from the cup. When asked if there was somebody helping her during mealtimes she said, nobody. During a phone interview with LVN A on 7/29/19 at 12:20 pm he said he could not remember the exact time the incident happened, but it was dinner time. He said he was in the dining room at the table together with other residents and Resident #1 was one of them. LVN A was sitting on the opposite side of the table helping a resident. He said he heard a spill and a CNA pulled Resident #1 back to her room. He said he could not recall who the CNA was or whether she came back to the dining table. LVN A said, It happened on a shift change and the CNA did not come back to say anything. He said, The Administrator called me about 10:00 pm and told me about the scalding of Resident #1. He said no assessment was done after the spill of the soup because the CNA did not come back and inform him of anything. He also said that he did not see anybody helping Resident #1 that time but there was a CNA sitting near but he was not sure if that CNA was helping her. In an interview with LVN D (MDS Coordinator) on 7/29/19 at 1:04 pm she said that Resident #1 was totally dependent and had to be fed, but she was fluctuating, up and down so they were going back and forth. She said Resident #1 liked to feed herself. She said that Resident#1 was spoon fed but not all the time. She said but now she might go back to total assist again. Record review of the facility policy and procedure for Assistance with Meals revised (MONTH) (YEAR) revealed, . 2. Facility staff will serve resident trays and will help residents who require assistance with eating. 3. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity. Record review of the facility policy and procedure for Activities of daily Living (ADL), Supporting revised (MONTH) (YEAR) revealed, . 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. 2. Appropriate care and services will be provided for residents who are unable to carry out activities of daily living independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: d. Dining (meals and snacks).5. A resident's ability to perform ADL's will be measured using clinical tools, including the MDS. Functional decline or improvement will be evaluated in reference to Assessment Reference Date (ARD) and following MDS definitions: .e. Total Dependence - Full staff performance of an activity with no participation by resident for any aspect of the ADL activity. Record review of the facility policy and procedure titled First Aid Treatment dated (MONTH) 2011 read in part, . Residents and employees who experience minor injuries shall be treated at the facility. If the injuries cannot be treated with basic Red Cross first aid intervention, the emergency medical system (EMS) will be activated. Basic first aid intervention includes intervention for the following; .b.[MEDICAL CONDITION](chemical, heat, electrical) .2. The goal of emergency intervention is to stabilize the resident and the situation until further treatment is available. Record review of the facility policy and procedure titled Acute Condition Changes - Clinical Protocol revised (MONTH) (YEAR) read in part, .3. Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, changes in skin color or condition) and how to communicate these changes to the nurse.

Based on observation, interview, and record review the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents (Resident# 1) reviewed for quality of care. -The facility failed to timely assess and treat Resident #1'[MEDICAL CONDITION] after soup was spilled in her lap for over 3 hours resulting in 2nd [MEDICAL CONDITION] her thighs. This failure affected 1 resident and placed her at risk of not receiving needed care and treatment and at risk of a decrease in health and a diminished quality of life. Findings Include: Record review of Resident #1's face sheet revealed she was [AGE] years old. She was admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed she had a BIMS (Brief Interview for Mental Status) score of 6 out of 15 that indicated her cognition was severely impaired. She was totally dependent on one staff for eating. Record review of Resident #1's (MONTH) 2019 Physician Order summary report revealed the following orders: -Cut up all foods at meals three times a day for ease of self eating related to [MEDICAL CONDITION] .dietitian recommendation; -No Added Salt, Regular Consistency diet, regular texture, regular consistency, add divided plate for ease of self feeding.Add cut up meats and no raw veg's (vegetables) for ease of chewing per dietitian recommendation . Record review of Resident #1's Care Plan dated 3/27/19 revealed, -Resident #1 has an ADL performance deficit r/t (related to) Dementia, [MEDICAL CONDITION] with hand tremors, Limited ROM (Range of Motion) and Muscle Weakness. Interventions included .in part, EATING: Resident #1 requires Extensive assistance by (1) staff with the set-up help only to eat.EATING: The resident requires (weighted utensils) to maximize independence with eating. -Resident #1 has potential for unavoidable decline in both cognitive and physical status r/t [MEDICAL CONDITION]/Dementia, with interventions that included, Assist as needed with oral intake (meals/snacks/fluids) assist as needed . Record review of the facility Provider Investigation Report revealed that on 6/16/19 at 5:45 p.m. Resident #1 was eating soup in the dining room when she spilled her soup on her lap. The charge nurse did not do an assessment. The resident [MEDICAL CONDITION] both of her legs. Record review of Resident #1's Incident Note dated 6/17/19 at 1:47 am signed by LVN B revealed in part, CNA informed nurse of rash to inner thighs that was not there the day prior. Resident was sitting on toilet. Nurse observed a very red rash and resident seemed to be very much excoriated. NOD (nurse on duty) was unable to fully assess due to the resident's position on the toilet and Resident refusing to lie down at that time Around 2110 (9:10 p.m.) CNA was assisting the resident to bed, CNA came and got the nurse again due to the rash being blistered and open. NOD assessed the rash again, Nurse observed blisters and open area to inner thighs, looking like a burn. NOD asked resident if she spilt (sic) anything hot on herself like coffee or soup. Resident responded with Yes. Dinner was vegetable soup, CNA informed the nurse that there was a lot of vegetable on her lap, between her legs and underneath her and that the resident was very wet. CNA informed the nurse that he had to wash the wheelchair because it was very dirty. Wound care was notified and to look at area in the morning. Area was cleaned, and dressing was placed. Nurse informed Responsible Party at 2130 (9:30 p.m.) of situation that wound care was aware and would be looking at it in the morning. RP was very upset about the situation. Stating I don't understand why the kitchen would serve soup so hot, was anyone helping her eat? Is she in pain? What does she get for pain? I want the wound care nurse to call me after she assesses it. NOD informed RP that resident receives scheduled Tylenol 325mg every 6 hrs (hours). Record review of the signed wound care physician note dated 6/18/19 revealed Resident #1 sustained partial thickness burn wounds to her left proximal medial thigh that was acquired on 6/16/19 at the facility, wound condition was acute and non-healed, size 7cm x 4.5 cm x 0.1 cm with a total area of 31.5 cm2 (squared); and partial thickness burn wounds to her right proximal medial thigh that was acquired on 6/16/19 at the facility, wound condition was acute and non-healed, size 8cm x 6cm x 0.1 cm with a total area of 48 cm2. During an interview with the Food Service Manager on 7/16/19 at 10:00 am she said the soup temperature was about 168 to 175 degrees Fahrenheit. She said they were serving the soup using a cup with a lid to avoid spillage. She said the staff would remove the lid from the cup, not the residents. She said they started that system after a resident spilled soup and got burned on her thighs. She said she was not working when the accident happened. During a phone interview with CNA A on 7/26/19 at 11:14 am she said she was in the assisted dining hall on (MONTH) 16, 2019 during dinner time. She said it was about 5:30 p.m. and she was sitting at the long table with Resident #1 and 5 other residents together along with CNA B and LVN [NAME] She said she, CNA B and LVN A were helping other residents to eat. She said, Nobody was feeding Resident #1 that time. She said then, she just heard Resident #1 say Oh, I spilled the soup. CNA A said she stood up and took Resident #1 to her room and looked for the staff assigned to the resident. When she could not find the CNA assigned to Resident #1 she saw another CNA in the hall and told him that Resident #1 needed to be changed because she spilled a soup on herself, but the CNA told her that he was not assigned to Resident #1 and told her he would just tell the CNA assigned to Resident#1 to change her. CNA A said she then went back to Resident #1's room and asked Resident #1 if she was ok. CNA A said Resident #1 told her that her pants were hot. CNA A said she put paper towels inside Resident #1's pants so that it would not get contact with the skin then she returned to the dining room. When asked if LVN A knew that Resident #1 spilled soup on herself, she said, Yes, he knew it. He just told me to bring Resident#1 in her room and inform the CNA assigned to her about the spill. Observation on 7/26/19 at 11:55 am in the assisted dining hall, Resident #1 was noted to be seated at the end of the long table together with 6 to 8 other residents and four staff members. A family member was observed to be feeding Resident #1. During an interview with the DON on 7/26/19 at 2:01 pm she said Resident #1 would like to feed herself. She said Resident #1 was not total assistance with one person assist for eating. She said the residents would have a longer clothing protector to prevent spills. She also said they were not allowing the residents to remove the lids on the cups. She said the staff would now remove the lids. The DON said the CNA did the right thing by putting paper towels between Resident #1's legs to soak up the soup and immediately took her to her room but, to her, she should have taken Resident #1's pants off so that it would take the heat away. She said the nurse went down to assess Resident #1 inside her room. The DON said she did and in-service for the staff to remove the clothes immediately after a spill of hot liquid. The DON also said they would be including this in their QAPI. During a phone interview with LVN B on 7/26/19 at 2:25 pm she said she never got a report during shift change about a skin redness or excoriation on Resident #1. She said CNA C informed her about the redness on Resident #1's thighs but could not see it clearly because the resident was on the toilet. She said at about 9:10 pm she was able to assess the resident because she was already in bed and that was when she saw that it was not an excoriation but there were blisters and some open areas that looked like a burn. She said she informed the responsible party, the Nurse Practitioner, and the DON. During an interview with the DON on 7/26/19 at 3:36 pm she said the facility was using the stop and watch for the CNAs to utilize when communicating changes that occurred to the residents. But in this case, she said it would not apply because it was immediate, and the CNA already told the nurse what happened so the nurse just made a written statement about the incident. Observation and interview of Resident #1 on 7/29/19 at 9:35 am revealed, she was sitting in her wheelchair beside her bed in her room. Her head was turned downward and her eyes were closed. She opened her eyes when the surveyor knocked on her door and she asked, What do you want? The surveyor introduced himself. She said, You can come in, and she said she was was fine. She said she had a fire on her thighs and pointed to her left and right thighs as if trying to pull up her long shorts. Tremors were noticed on her hands especially on her right hand. She said she liked soup. She said chicken noodle soup was her favorite and she liked to drink the soup from the cup. She said she also used a spoon, but she liked it better when she drank it from the cup. When asked if there was somebody helping her during mealtimes she said, nobody. During a phone interview with LVN A on 7/29/19 at 12:20 pm he said he could not remember the exact time the incident happened, but it was dinner time. He said he was in the dining room at the table together with other residents and Resident #1 was one of them. LVN A was sitting on the opposite side of the table helping a resident. He said he heard a spill and a CNA pulled Resident #1 back to her room. He said he could not recall who the CNA was or whether she came back to the dining table. LVN A said, It happened on a shift change and the CNA did not come back to say anything. He said, The Administrator called me about 10:00 pm and told me about the scalding of Resident #1. He said no assessment was done after the spill of the soup because the CNA did not come back and inform him of anything. He also said that he did not see anybody helping Resident #1 that time but there was a CNA sitting near but he was not sure if that CNA was helping her. In an interview with LVN D (MDS Coordinator) on 7/29/19 at 1:04 pm she said that Resident #1 was totally dependent and had to be fed, but she was fluctuating, up and down so they were going back and forth. She said Resident #1 liked to feed herself. She said that Resident#1 was spoon fed but not all the time. She said but now she might go back to total assist again. Record review of the facility policy and procedure for Assistance with Meals revised (MONTH) (YEAR) revealed, . 2. Facility staff will serve resident trays and will help residents who require assistance with eating. 3. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity. Record review of the facility policy and procedure for Activities of daily Living (ADL), Supporting revised (MONTH) (YEAR) revealed, . 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. 2. Appropriate care and services will be provided for residents who are unable to carry out activities of daily living independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: d. Dining (meals and snacks).5. A resident's ability to perform ADL's will be measured using clinical tools, including the MDS. Functional decline or improvement will be evaluated in reference to Assessment Reference Date (ARD) and following MDS definitions: .e. Total Dependence - Full staff performance of an activity with no participation by resident for any aspect of the ADL activity. Record review of the facility policy and procedure titled First Aid Treatment dated (MONTH) 2011 read in part, . Residents and employees who experience minor injuries shall be treated at the facility. If the injuries cannot be treated with basic Red Cross first aid intervention, the emergency medical system (EMS) will be activated. Basic first aid intervention includes intervention for the following; .b.[MEDICAL CONDITION](chemical, heat, electrical) .2. The goal of emergency intervention is to stabilize the resident and the situation until further treatment is available. Record review of the facility policy and procedure titled Acute Condition Changes - Clinical Protocol revised (MONTH) (YEAR) read in part, .3. Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, changes in skin color or condition) and how to communicate these changes to the nurse.

Based on interview and record review the facility failed to implement their policy on neglect for 1 of 8 residents (CR #1) reviewed for neglect: --CR #1 was left unsupervised and fell . She sustained a head injury. She was sent to the hospital. This failure affected 1 prior resident and placed an additional 81 current residents who were in a chair all or most of the time at risk of injury due to staff being unfamiliar with their individualized needs for care and services. Intake # TX0024 8788/ Intake 6 Findings Included: Record review of CR #1's face sheet revealed she was an [AGE] year old female who was admitted on [DATE] and discharged on [DATE] to the hospital. Her [DIAGNOSES REDACTED]. muscle wasting and atrophy, and generalized muscle weakness. Record review of CR#1's plan of care dated as initiated 7/16/15 revealed a plan of care for activities of daily living (ADLs) documenting her need of being totally dependent on one to two staff for her ADLs. Her plan of care for limited physical mobility related to dementia, contractures, [MEDICAL CONDITION], muscle weakness and muscle wasting/atrophy revealed a goal of no falls with interventions including she was totally dependent on one staff for locomotion. Further review of CR#1's plan of care dated as initiated 8/25/16 revealed a plan of care for actual fall with no injury with a goal of, .will not sustain serious injury through the review date (1/15/17). There was no documentation of a plan of care specifically addressing her specialized wheelchair. Record review of the Provider Investigation Report dated 11/4/16 revealed CR#1 needed total assistance with her activities of daily living. She was not interviewable, and did not have the ability to make informed decisions. The report revealed that on 10/29/16 at 12:00 p.m. the resident was placed in the dining room in upright position and fell out of her tilt-n-space wheel chair onto the floor. It was not known who placed the resident in the dining room. The Provider Response section revealed the facility treated the wound, called 911, and informed CR #1's family member and physician. Staff, residents, and visitors were interviewed in an attempt to determine who placed the resident in the dining room. An in-service to staff was completed regarding wheelchair positioning. The tilt-n-space wheelchair was inspected for any defects. Record review of the nurses' notes dated 10/29/16 at 1:03 p.m. revealed CR #1 was transported to a local hospital for sustained traumatic injury to the head. CR#1 fell out of the wheel chair and had sustained a large skin tear to her forehead. Record review of SBAR nursing note dated 10/29/16 revealed the writer entered the dining room to see Nurse #2 who was designated to the dining room to oversee all residents, holding and applying pressure to patient's forehead from which blood was seeping out. Immediately called 911 while Nurse #2 stayed with patient. EMS arrived between 12:20 and 12:30 hour. In an interview on 11/8/16 with the Administrator and DON at 9:45 a.m. the Administrator said that on Saturday before noon, there were 2 CNA's that got CR #1 ready for lunch and she was placed in her wheel chair, and titled back in the chair. The two CNA's moved CR #1 into the hallway. At some point someone moved CR #1 and brought her to the dining room and had her in the upright position at the table. Someone saw CR #1 in mid fall, but there were no staff present in the dining hall. The facility assisted CR#1 and called 911. She was transferred to the hospital. The Administrator explained that CR#1 was moved into the hallway while they were getting another resident ready in the room so they put CR #1 alongside the wall in the hallway. The Administrator said that based on all interviews no one could identify who moved the resident to the dining room table. The staff knew what table CR#1 sat at and she was not at that table. CR #1 used a bedside table over the table in order to not bump her feet. The CNA's assumed that another staff came by and moved the resident to the dining room. CR#1 was no longer at the facility. She was taken home with her family. The DON said that the CNA's normally placed the residents outside of the room while they got another resident ready. The DON said that CR #1 did not sit at a standard table and that she sat at a bedside table. In an interview on 11/8/16 at 1:00 p.m. with PT #1 she said that CR #1 was not a therapy patient and that she received brief services starting on 2/16/16 and was discharged on [DATE]. CR #1 received services for at least 5 days; she was contracted and was totally dependent for bed mobility. PT #1 said that a tilt chair rocks the entire body, it can lay back, there is a break at the back and someone has to operate it. The chair prevents falls and when the chair is inclined it locks upright. The break has to be pressed to release it. In an interview on 11/8/16 at 1:20 p.m. with CNA #1 she said that her job was to transfer, change, shower, and feed the residents and to provide whatever care they needed. CNA #1 said she liked to put the residents directly into the dining room when she got them ready to go to the dining hall. CNA #1 said that she never left the resident in the hallway. When the resident finishes eating, they bring them back to their room. CNA #1 said that she saw CR #1 fall, and she did not move anything. CNA #1 said that she did not know why she fell and that maybe a CNA put the resident straight up in her wheel chair. CNA #1 stated that there were only two CNA ' s working that day, so they were shorthanded. CNA #1 said the resident fell before lunch and that somebody had put her in the dining room sitting straight up. In an interview on 11/8/16 at 1:45 p.m. with CNA #2 she said that CNA #3 took CR #1 to the fish tank while they got the other residents ready to go to the dining hall. The staff didn't know who took CR #1 to the dining hall and they heard the resident scream. The nurse that was helping the resident just left her there and did not look to see where the blood was coming from. The staff had not called 911, but a sitter in the facility called the ambulance. CNA #2 stated that it took a good 15 minutes before the ambulance was called. The incident occurred on the Saturday before Halloween. CNA #2 stated that whoever brought the resident to the dining room did not know where the resident sat because she had her own spot and all the regular staff should know. The wheelchair was sitting straight up, so whoever sat the resident up did not know her personally. CR #1 was not at the right table and she was facing the wrong way. On a normal day, every hall was supposed to have three aides, but 200 Hall had 2 aides, 300 Hall had 2 aides, 500 Hall had 3 aides and 400 Hall had 3 aides. In an interview on 11/8/16 at 2:10 p.m. with CNA #3 she said that she did not know what happened with CR #1 and that she and CNA #4 pushed CR #1 to the fish tank aquarium. CNA #3 said they had the wheelchair reclined some. CNA #3 said that she and CNA #4 never made it to the dining hall. CNA #3 said that it was 11:50 a.m. and she and CNA #4 tried to get everybody to the dining hall and they just lined the resident up outside by the fish tank and someone came to get the residents. CNA #3 said that they did not position CR #1 in the wheelchair straight up. All the staff knew CR #1's table and how she was fed. It had to be a stranger that put CR #1 there. CR #1 was on the floor from 11:50 a.m. to 12:15 p.m. and a family member asked why CR #1 was still on the floor and asked did they need to call 911. Someone who knew the family called and notified CR #1's family member before they called 911 and she was mad. In an interview on 11/8/16 at 2:25 p.m. with CNA #4 she said that she and CNA #3 were pushing a lot of residents outside to the fish tank in the hallway because they were shorthanded. CNA #4 said they were hoping for someone to help them to get the residents to the dining hall because they were shorthanded. It was late that day and they were short 1 person and they asked for help all day starting at 5:30 a.m. to 1:45 p.m., then someone came. In an interview on 11/15/16 with the Director of Rehab at 12:20 p.m. she said that if therapy orders the wheel chair, then they will in-service the staff on how to properly use it. She said that she had been at the facility since March and they had not had a patient with the type of chair that CR # 1 had. The therapy department had not done any in services to properly train staff on how to use CR #1's Tilt wheel chair. In an interview on 11/30/16 with CNA #5 at 10:02 a.m. she said that she was off on the days of the incident, but someone signed up to work for her and did not come. The facility normally had 3 CNA's working on the hall, but that day there were only two. The CNA's take the residents out of their rooms and bring them to the dining hall. When the CNA's run behind sometimes they put the residents in the hallway, but usually they only put one there. CNA #5 said that the Restorative Nurse trained her on how to work with CR #1's Tilt wheel chair. CNA #5 said that she and CNA #3 and CNA #4 got together to learn how to operate CR #1's wheel chair and she thought that the Restorative Nurse was there along with a Unit Manager. CNA #5 said that the 3 staff who worked with CR #1 on 300 Hall knew how to work the chair. CR #1 said that maybe someone was not trained who assisted with transporting CR #1 to the dining hall. In an interview on 11/30/16 with the DON at 10:40 a.m. she said that the facility was short one person and it caused the CNA's to be behind. The DON said she did not know if they had formal training on the Tilt chair that CR #1 had, but the Restorative Nurse did train everyone. In an interview on 11/30/16 at 11:17 a.m. with the Restorative Nurse she said that she honestly did not know too much about CR #1's wheel chair. The Restorative Nurse stated that she was not able to explain the chair, and she did not train anyone on CR #1's Tilt N Space wheel chair. The Restorative Nurse said she herself had gotten trained on the chair years ago, but CR #1's wheel chair was different. The Restorative Nurse said that she had not trained the staff on how to use the Tilt N Space wheelchair. Record review of the facility Policy on Abuse Prohibition- Standards for Abuse, Neglect and Misappropriation of Property dated 10/2/2012 revealed that the facility's leadership will prohibit neglect, mental or physical abuse, including involuntary seclusion and misappropriation of property, of patients/residents from staff, visitors, or other patients/residents. The CMS 672 revealed 81 residents in a chair all or most of the time.

Based on interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and to provide adequate supervision for 1 of 8 residents (CR #1) reviewed for accidents/hazards in that: --CR #1 was left unsupervised and fell . She sustained a head injury. She was sent to the hospital. These failures affected 1 prior resident and placed an additional 81 current residents who were in a chair all or most of the time at risk of injury due to staff being unfamiliar with their individualized needs for care and services and a diminished quality of life that could result in hospitalization or death. Intake # TX0024 8788/ Intake 6 Findings Included: Record review of CR #1's face sheet revealed she was an [AGE] year old female who was admitted on [DATE] and discharged on [DATE] to the hospital. Her [DIAGNOSES REDACTED]. muscle wasting and atrophy, and generalized muscle weakness. Record review of CR#1's plan of care dated as initiated 7/16/15 revealed a plan of care for activities of daily living (ADLs) documenting her need of being totally dependent on one to two staff for her ADLs. Her plan of care for limited physical mobility related to dementia, contractures, osteoarthritis, muscle weakness and muscle wasting/atrophy revealed a goal of no falls with interventions including she was totally dependent on one staff for locomotion. Further review of CR#1's plan of care dated as initiated 8/25/16 revealed a plan of care for actual fall with no injury with a goal of, .will not sustain serious injury through the review date (1/15/17). There was no documentation of a plan of care specifically addressing her specialized wheelchair. Record review of the Provider Investigation Report dated 11/4/16 revealed CR#1 needed total assistance with her activities of daily living. She was not interviewable, and did not have the ability to make informed decisions. The report revealed that on 10/29/16 at 12:00 p.m. the resident was placed in the dining room in upright position and fell out of her tilt-n-space wheel chair onto the floor. It was not known who placed the resident in the dining room. The Provider Response section revealed the facility treated the wound, called 911, and informed CR #1's family member and physician. Staff, residents, and visitors were interviewed in an attempt to determine who placed the resident in the dining room. An in-service to staff was completed regarding wheelchair positioning. The tilt-n-space wheelchair was inspected for any defects. Record review of the nurses' notes dated 10/29/16 at 1:03 p.m. revealed CR #1 was transported to a local hospital for sustained traumatic injury to the head. CR#1 fell out of the wheel chair and had sustained a large skin tear to her forehead. Record review of SBAR nursing note dated 10/29/16 revealed the writer entered the dining room to see Nurse #2 who was designated to the dining room to oversee all residents, holding and applying pressure to patient's forehead from which blood was seeping out. Immediately called 911 while Nurse #2 stayed with patient. EMS arrived between 12:20 and 12:30 hour. In an interview on 11/8/16 with the Administrator and DON at 9:45 a.m. the Administrator said that on Saturday before noon, there were 2 CNA's that got CR #1 ready for lunch and she was placed in her wheel chair, and titled back in the chair. The two CNA's moved CR #1 into the hallway. At some point someone moved CR #1 and brought her to the dining room and had her in the upright position at the table. Someone saw CR #1 in mid fall, but there were no staff present in the dining hall. The facility assisted CR#1 and called 911. She was transferred to the hospital. The Administrator explained that CR#1 was moved into the hallway while they were getting another resident ready in the room so they put CR #1 alongside the wall in the hallway. The Administrator said that based on all interviews no one could identify who moved the resident to the dining room table. The staff knew what table CR#1 sat at and she was not at that table. CR #1 used a bedside table over the table in order to not bump her feet. The CNA's assumed that another staff came by and moved the resident to the dining room. CR#1 was no longer at the facility. She was taken home with her family. The DON said that the CNA's normally placed the residents outside of the room while they got another resident ready. The DON said that CR #1 did not sit at a standard table and that she sat at a bedside table. In an interview on 11/8/16 at 1:00 p.m. with PT #1 she said that CR #1 was not a therapy patient and that she received brief services starting on 2/16/16 and was discharged on [DATE]. CR #1 received services for at least 5 days; she was contracted and was totally dependent for bed mobility. PT #1 said that a tilt chair rocks the entire body, it can lay back, there is a break at the back and someone has to operate it. The chair prevents falls and when the chair is inclined it locks upright. The break has to be pressed to release it. In an interview on 11/8/16 at 1:20 p.m. with CNA #1 she said that her job was to transfer, change, shower, and feed the residents and to provide whatever care they needed. CNA #1 said she liked to put the residents directly into the dining room when she got them ready to go to the dining hall. CNA #1 said that she never left the resident in the hallway. When the resident finishes eating, they bring them back to their room. CNA #1 said that she saw CR #1 fall, and she did not move anything. CNA #1 said that she did not know why she fell and that maybe a CNA put the resident straight up in her wheel chair. CNA #1 stated that there were only two CNA ' s working that day, so they were shorthanded. CNA #1 said the resident fell before lunch and that somebody had put her in the dining room sitting straight up. In an interview on 11/8/16 at 1:45 p.m. with CNA #2 she said that CNA #3 took CR #1 to the fish tank while they got the other residents ready to go to the dining hall. The staff didn't know who took CR #1 to the dining hall and they heard the resident scream. The nurse that was helping the resident just left her there and did not look to see where the blood was coming from. The staff had not called 911, but a sitter in the facility called the ambulance. CNA #2 stated that it took a good 15 minutes before the ambulance was called. The incident occurred on the Saturday before Halloween. CNA #2 stated that whoever brought the resident to the dining room did not know where the resident sat because she had her own spot and all the regular staff should know. The wheelchair was sitting straight up, so whoever sat the resident up did not know her personally. CR #1 was not at the right table and she was facing the wrong way. On a normal day, every hall was supposed to have three aides, but 200 Hall had 2 aides, 300 Hall had 2 aides, 500 Hall had 3 aides and 400 Hall had 3 aides. In an interview on 11/8/16 at 2:10 p.m. with CNA #3 she said that she did not know what happened with CR #1 and that she and CNA #4 pushed CR #1 to the fish tank aquarium. CNA #3 said they had the wheelchair reclined some. CNA #3 said that she and CNA #4 never made it to the dining hall. CNA #3 said that it was 11:50 a.m. and she and CNA #4 tried to get everybody to the dining hall and they just lined the resident up outside by the fish tank and someone came to get the residents. CNA #3 said that they did not position CR #1 in the wheelchair straight up. All the staff knew CR #1's table and how she was fed. It had to be a stranger that put CR #1 there. CR #1 was on the floor from 11:50 a.m. to 12:15 p.m. and a family member asked why CR #1 was still on the floor and asked did they need to call 911. Someone who knew the family called and notified CR #1's family member before they called 911 and she was mad. In an interview on 11/8/16 at 2:25 p.m. with CNA #4 she said that she and CNA #3 were pushing a lot of residents outside to the fish tank in the hallway because they were shorthanded. CNA #4 said they were hoping for someone to help them to get the residents to the dining hall because they were shorthanded. It was late that day and they were short 1 person and they asked for help all day starting at 5:30 a.m. to 1:45 p.m., then someone came. In an interview on 11/15/16 with the Director of Rehab at 12:20 p.m. she said that if therapy orders the wheel chair, then they will in-service the staff on how to properly use it. She said that she had been at the facility since March and they had not had a patient with the type of chair that CR # 1 had. The therapy department had not done any in services to properly train staff on how to use CR #1's Tilt wheel chair. In an interview on 11/30/16 with CNA #5 at 10:02 a.m. she said that she was off on the days of the incident, but someone signed up to work for her and did not come. The facility normally had 3 CNA's working on the hall, but that day there were only two. The CNA's take the residents out of their rooms and bring them to the dining hall. When the CNA's run behind sometimes they put the residents in the hallway, but usually they only put one there. CNA #5 said that the Restorative Nurse trained her on how to work with CR #1's Tilt wheel chair. CNA #5 said that she and CNA #3 and CNA #4 got together to learn how to operate CR #1's wheel chair and she thought that the Restorative Nurse was there along with a Unit Manager. CNA #5 said that the 3 staff who worked with CR #1 on 300 Hall knew how to work the chair. CR #1 said that maybe someone was not trained who assisted with transporting CR #1 to the dining hall. In an interview on 11/30/16 with the DON at 10:40 a.m. she said that the facility was short one person and it caused the CNA's to be behind. The DON said she did not know if they had formal training on the Tilt chair that CR #1 had, but the Restorative Nurse did train everyone. In an interview on 11/30/16 at 11:17 a.m. with the Restorative Nurse she said that she honestly did not know too much about CR #1's wheel chair. The Restorative Nurse stated that she was not able to explain the chair, and she did not train anyone on CR #1's Tilt N Space wheel chair. The Restorative Nurse said she herself had gotten trained on the chair years ago, but CR #1's wheel chair was different. The Restorative Nurse said that she had not trained the staff on how to use the Tilt N Space wheelchair. Record review of the facility Policy on Abuse Prohibition- Standards for Abuse, Neglect and Misappropriation of Property dated 10/2/2012 revealed that the facility's leadership will prohibit neglect, mental or physical abuse, including involuntary seclusion and misappropriation of property, of patients/residents from staff, visitors, or other patients/residents. The CMS 672 revealed 81 residents in a chair all or most of the time.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for mechanical lift transfers and repositioning, as evidenced by: -CNA B and NAS heard a pop when they repositioned Resident #1 in her wheelchair because they used improper repositioning procedure with the mechanical lift sling. Resident #1 sustained a fracture of the humerus. This failure affected 1 Resident and placed the remaining 16 residents who were transferred by a mechanical lift at risk of pain, accidents and injury. Findings include: Record review of her Admission Record revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's Annual MDS dated [DATE] revealed she was able to understand others and make herself understood. She was cognitively intact, with a BIMS score of 15 out of 15. Resident #1 required total assistance of at least 2 staff members for transfers. She required at least extensive assistance of at least 1 staff member for other activities of daily living. During an observation and interview on 10/6/15 at 12:40 p.m., Resident #1 was sitting in her wheelchair in the lobby. She was very well-groomed. Resident #1 said the 2 aides, CNA B and NAS, were going to pull her up in her wheelchair without using the Hoyer (mechanical) lift, because she was already lying in her wheelchair. She said it was the aides' choice to do it that way. Resident #1 said she did not tell the aides to transfer her that way. She said Actually, I preferred the Hoyer. They (CNA B and NAS) were in kind of a hurry and they made it sound like they could make it happen in just a few minutes. It was their own judgment. Resident #1 said one aide was on each side of her and each aide had their arm under Resident #1's shoulders. She said when they started to pull there was a pop and the aides stopped and went to get a nurse. In further observation and interview on that date and time, Resident #1 said my pain right now is pretty much between 5 and 10. I'm grunting on my arm right now. Resident #1 was observed to be talking with difficulty, as she was making sounds in between her words. Resident #1 continued to say she thought the nurse knew she needed pain medication and she did not think she had it yet. In an interview on 10/6/15 at 1:00 p.m. LVN G said Resident #1 had her pain medication right before lunch but she could get her a prn. Record review of Resident #1's consultant note dated 9/28/15 revealed, History of Present Illness. The patient is a [AGE] year old female who presents with complaints of sharp pain in the right shoulder that occurs constantly. The onset was sudden with injury which occurred on 9/26/15.The injury was caused by nursing home .Patient states the nursing home was picking her up and broke it. The report continued, can't rule out pathologic cause. During the entrance conference on 10/6/15 at 9:50 a.m. the Administrator said the facility had received a phone call from OIG (Office of the Inspector General) regarding this investigation and already did an investigation. He provided a copy of the investigation for review. Record review of the facility's investigation provided to the OIG revealed that on 9/19/15 LVN C was called to Resident #1's room by NAS. Resident verbalized that the two aide (sic) were trying to move her up in the wheelchair, they lowered her head and each of them tried to pull her up using her upper arm and she noticed her right arm popped from the joint. Further review of the facility's investigation provided to the OIG revealed NAS in a written statement wrote CNA B and I lay her (Resident #1) on her back of the wheelchair and pull her pad's on the both side up her shoulders and there we heard pop so I run outside to get the nurses to check. (sic). Further review of the facility's investigation revealed an unsigned paragraph which read the Resident stated, they reached under her arms and grabbed a hold of the sling (mechanical lift sling). So at this point I stopped the resident and asked her if I could use her blanket . to reenact what she was stating and she said sure. So I said the top blanket is your arm and the bottom blanket is the Hoyer sling, she state yes, so they reach under you (sic) arm and grabbed the sling as I grabbed the bottom blanket like this, she said yes. So they were not grabbing you by the arm they were under your arm to reach the sling again the resident stated yes. (sic) Record review of the Education/Training Report dated 9/21/15 revealed CNA B and NAS were trained on the Hoyer Lift on 9/22/15 - 9/28/15 and CNA B had been trained on 12/30/14 and 3/13/15 as well. During an interview and record review on 10/6/15 at 1:45 p.m. the DON said only CNA B was suspended because she was the one operating the Hoyer lift. When asked if NAS had received any training on the mechanical lift prior to the incident on 9/19/15 the DON did not provide evidence of training prior to exit. During a telephone interview on 10/6/15 at 2:04 p.m. CNA B said NAS was a trainee following another CNA on the hall that day. CNA B and the other CNA agreed that NAS could help CNA B transfer Resident #1. CNA B said she asked the Resident how to pull her up in the chair without using the Hoyer lift. During this telephone interview, CNA B was asked asked how she was trained to reposition a resident who required a mechanical lift. CNA B said that two staff would be needed to ensure the resident had been positioned on the sling correctly. When asked how she would reposition a resident who was already in a chair and wanted to be pulled up, CNA B said she had not been trained how to about that. She said that she did what Resident #1 asked her to do. When asked how she would respond if someone asked her to do something she did not know how to do, CNA B said she would get the nurse. During an interview on 10/6/15 at 2:29 p.m. the DON said NAS was not even out of orientation yet. The DON said as NAS went through orientation she would be checked off on her skills by the RA. The DON said if a resident requiring a Hoyer (mechanical lift) was not repositioned correctly the staff should change the hooks to reposition the resident. During an interview on 10/6/15 at 2:34 p.m. the RA was asked to describe how she trained CNAs how to reposition residents who require transfers using mechanical lifts when they are already in their chairs. RA said she always trained two CNAs at one time. If a resident's chair would recline all the way to lie flat, she taught staff to stand one on each side of the resident and then hold the Hoyer sling by the top and the bottom. She said each staff member was observed during skill checks during new employee orientation. When asked if the facility normally allowed CNAs to work with residents before they were trained, she said no. She said that normally they would go through orientation, then shadow another CNA for 3 days. They could be the second person in the room, but could not operate the Hoyer lift themselves during this period. She said the NAS was not trained on the Hoyer lift until after the incident with Resident #1. During an interview on 10/6/15 at 2:46 p.m. the NAS said she had been trained on use of the Hoyer lift by the person she was orienting her prior to the incident with Resident #1. NAS admitted the person she was orienting her had not watched her transfer anyone. The NAS said she and CNA B only reached for the Hoyer slings under Resident #1's shoulder and they all heard the pop. When asked why CNA B did not use the Hoyer lift, itself, to reposition, the NAS said Resident #1 told them to just scoot her up in the chair. She repeated that she and CNA B did not use the top and bottom of the sling; they were just reaching under Resident #1's arm to try to reach the handle under Resident #1's back. She said they would stand on the sides to move a Resident up if they were in the bed. CNAs were asked to describe the correct procedures for repositioning residents in their chairs who required a mechanical lift for transfers. - During an interview on 10/6/15 at 1:11 p.m. CNA D answered that if residents were sliding down in their chairs, they should be repositioned using the Hoyer lift. She said that if the chair could lie flat, the resident could also be repositioned by using the Hoyer sling. This would be done with two CNAs, one on each side of the resident. Each CNA would hold the top and the bottom of the sling. The two CNAs would not stand at the top of the sling and and pull the top of the sling. - During interviews on 10/6/15 at 3:20 p.m. and 3:25 p.m. CNA E and CNA F both said if a resident needed to be repositioned, they would transfer the resident back to the bed with the mechanical lift and then return the resident back into the chair. Record review of the Safe Lifting and Movement Policy, undated, gave instructions about transferring a resident using a Hoyer lift but did not include instructions on how to reposition a resident once the transfer had been completed. During an interview on 10/6/15 at 4:32 p.m. the HR Director provided an unbound copy of the facility's handbook, undated, which NAS had signed for. It included Occupational Safety and Health Administration's (OSHA's) Ergonomics Guidelines which had only general information about portable lift devices but did not give specific instructions about how to transfer or reposition a resident with a Hoyer lift. A list provided by the facility's DON listed 17 residents in the facility were transferred by mechanical lift.

Based on observation, interview, and record review, the facility failed to ensure 2 of 2 staff (CNA B and NAS) were able to demonstrate competency in skills and techniques necessary to care for resident's needs in the area of repositioning of a resident requiring transfers by mechanical lift for 1 of 3 residents (Resident #1) reviewed for mechanical lift transfers and repositioning, as evidenced by: -CNA B and NAS heard a pop when they repositioned Resident #1 in her wheelchair using improper repositioning procedure. Resident #1 sustained a [MEDICAL CONDITION]. This failure affected 1 Resident and placed the remaining 16 residents who were transferred by a mechanical lift at risk of pain, accidents and injury. Findings include: Record review of her Admission Record revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's Annual MDS dated [DATE] revealed she was able to understand others and make herself understood. She was cognitively intact, with a BIMS score of 15 out of 15. Resident #1 required total assistance of at least 2 staff members for transfers. She required at least extensive assistance of at least 1 staff member for other activities of daily living. During an observation and interview on 10/6/15 at 12:40 p.m., Resident #1 was sitting in her wheelchair in the lobby. She was very well-groomed. Resident #1 said the 2 aides, CNA B and NAS, were going to pull her up in her wheelchair without using the Hoyer (mechanical) lift, because she was already lying in her wheelchair. She said it was the aides' choice to do it that way. Resident #1 said she did not tell the aides to transfer her that way. She said Actually, I preferred the Hoyer. They (CNA B and NAS) were in kind of a hurry and they made it sound like they could make it happen in just a few minutes. It was their own judgment. Resident #1 said one aide was on each side of her and each aide had their arm under Resident #1's shoulders. She said when they started to pull there was a pop and the aides stopped and went to get a nurse. In further observation and interview on that date and time, Resident #1 said my pain right now is pretty much between 5 and 10. I'm grunting on my arm right now. Resident #1 was observed to be talking with difficulty, as she was making sounds in between her words. Resident #1 continued to say she thought the nurse knew she needed pain medication and she did not think she had it yet. In an interview on 10/6/15 at 1:00 p.m. LVN G said Resident #1 had her pain medication right before lunch but she could get her a prn. Record review of Resident #1's consultant note dated 9/28/15 revealed, History of Present Illness. The patient is a [AGE] year old female who presents with complaints of sharp pain in the right shoulder that occurs constantly. The onset was sudden with injury which occurred on 9/26/15.The injury was caused by nursing home .Patient states the nursing home was picking her up and broke it. The report continued, can't rule out pathologic cause. During the entrance conference on 10/6/15 at 9:50 a.m. the Administrator said the facility had received a phone call from OIG (Office of the Inspector General) regarding this investigation and already did an investigation. He provided a copy of the investigation for review. Record review of the facility's investigation provided to the OIG revealed that on 9/19/15 LVN C was called to Resident #1's room by NAS. Resident verbalized that the two aide (sic) were trying to move her up in the wheelchair, they lowered her head and each of them tried to pull her up using her upper arm and she noticed her right arm popped from the joint. Further review of the facility's investigation provided to the OIG revealed NAS in a written statement wrote CNA B and I lay her (Resident #1) on her back of the wheelchair and pull her pad's on the both side up her shoulders and there we heard pop so I run outside to get the nurses to check. (sic). Further review of the facility's investigation revealed an unsigned paragraph which read the Resident stated, they reached under her arms and grabbed a hold of the sling (mechanical lift sling). So at this point I stopped the resident and asked her if I could use her blanket . to reenact what she was stating and she said sure. So I said the top blanket is your arm and the bottom blanket is the Hoyer sling, she state yes, so they reach under you (sic) arm and grabbed the sling as I grabbed the bottom blanket like this, she said yes. So they were not grabbing you by the arm they were under your arm to reach the sling again the resident stated yes. (sic) Record review of the Education/Training Report dated 9/21/15 revealed CNA B and NAS were trained on the Hoyer Lift on 9/22/15 - 9/28/15 and CNA B had been trained on 12/30/14 and 3/13/15 as well. During an interview and record review on 10/6/15 at 1:45 p.m. the DON said only CNA B was suspended because she was the one operating the Hoyer lift. When asked if NAS had received any training on the mechanical lift prior to the incident on 9/19/15 the DON did not provide evidence of training prior to exit. During a telephone interview on 10/6/15 at 2:04 p.m. CNA B said NAS was a trainee following another CNA on the hall that day. CNA B and the other CNA agreed that NAS could help CNA B transfer Resident #1. CNA B said she asked the Resident how to pull her up in the chair without using the Hoyer lift. During this telephone interview, CNA B was asked asked how she was trained to reposition a resident who required a mechanical lift. CNA B said that two staff would be needed to ensure the resident had been positioned on the sling correctly. When asked how she would reposition a resident who was already in a chair and wanted to be pulled up, CNA B said she had not been trained how to about that. She said that she did what Resident #1 asked her to do. When asked how she would respond if someone asked her to do something she did not know how to do, CNA B said she would get the nurse. During an interview on 10/6/15 at 2:29 p.m. the DON said NAS was not even out of orientation yet. The DON said as NAS went through orientation she would be checked off on her skills by the RA. The DON said if a resident requiring a Hoyer (mechanical lift) was not repositioned correctly the staff should change the hooks to reposition the resident. During an interview on 10/6/15 at 2:34 p.m. the RA was asked to describe how she trained CNAs how to reposition residents who require transfers using mechanical lifts when they are already in their chairs. RA said she always trained two CNAs at one time. If a resident's chair would recline all the way to lie flat, she taught staff to stand one on each side of the resident and then hold the Hoyer sling by the top and the bottom. She said each staff member was observed during skill checks during new employee orientation. When asked if the facility normally allowed CNAs to work with residents before they were trained, she said no. She said that normally they would go through orientation, then shadow another CNA for 3 days. They could be the second person in the room, but could not operate the Hoyer lift themselves during this period. She said the NAS was not trained on the Hoyer lift until after the incident with Resident #1. During an interview on 10/6/15 at 2:46 p.m. the NAS said she had been trained on use of the Hoyer lift by the person she was orienting her prior to the incident with Resident #1. NAS admitted the person she was orienting her had not watched her transfer anyone. The NAS said she and CNA B only reached for the Hoyer slings under Resident #1's shoulder and they all heard the pop. When asked why CNA B did not use the Hoyer lift, itself, to reposition, the NAS said Resident #1 told them to just scoot her up in the chair. She repeated that she and CNA B did not use the top and bottom of the sling; they were just reaching under Resident #1's arm to try to reach the handle under Resident #1's back. She said they would stand on the sides to move a Resident up if they were in the bed. CNAs were asked to describe the correct procedures for repositioning residents in their chairs who required a mechanical lift for transfers. - During an interview on 10/6/15 at 1:11 p.m. CNA D answered that if residents were sliding down in their chairs, they should be repositioned using the Hoyer lift. She said that if the chair could lie flat, the resident could also be repositioned by using the Hoyer sling. This would be done with two CNAs, one on each side of the resident. Each CNA would hold the top and the bottom of the sling. The two CNAs would not stand at the top of the sling and and pull the top of the sling. - During interviews on 10/6/15 at 3:20 p.m. and 3:25 p.m. CNA E and CNA F both said if a resident needed to be repositioned, they would transfer the resident back to the bed with the mechanical lift and then return the resident back into the chair. Record review of the Safe Lifting and Movement Policy, undated, gave instructions about transferring a resident using a Hoyer lift but did not include instructions on how to reposition a resident once the transfer had been completed. During an interview on 10/6/15 at 4:32 p.m. the HR Director provided an unbound copy of the facility's handbook, undated, which NAS had signed for. It included Occupational Safety and Health Administration's (OSHA's) Ergonomics Guidelines which had only general information about portable lift devices but did not give specific instructions about how to transfer or reposition a resident with a Hoyer lift. A list provided by the facility's DON listed 17 residents in the facility were transferred by mechanical lift.