Every finding on record at Reunion Plaza Senior Care and Rehabilitation Cente

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1 was in a safe position when CNA A briefly left the room to get supplies, resulting in Resident #1 falling from the bed in an elevated position on 8/01/26 and CNA A did not follow the Kardex (care plan for CNAs) related to Resident #1 being a two person assist with bed mobility and toileting.The noncompliance was identified as PNC. The noncompliance began on 8/01/26 and ended on 8/01/26. The facility had corrected the noncompliance before the survey began.This failure could place residents at risk of injury.Findings included:Record review of Resident #1's face sheet dated 8/18/26 indicated he was [AGE] years old and admitted to the facility on [DATE] with diagnoses including hydrocephalus (medical condition where extra cerebrospinal fluid {clear, watery liquid that flows around and inside the brain and spinal cord}builds up deep inside the brain), osteomyelitis of vertebra/sacral (severe infection of the bone and bone marrow in the bones of the lower back at the end of the spine), pressure ulcer of sacral region (wound resulting from pressure to an area causing skin/tissue, severe protein-calorie malnutrition (life-threatening lack of essential nutrients and calories), respiratory failure, dysphagia (difficulty swallowing), cognitive communication deficit, lack of coordination, weakness, hypertension (high blood pressure), Methicillin resistant Staphylococcus aureus (a type of bacteria that does not get better with common antibiotics like penicillin and methicillin), Klebsiella pneumoniae (healthcare associated infections, including pneumonia {infection in lung}), bloodstream infections, and wound infections, Pseudomonas aeruginosa (opportunistic pathogen commonly found in soil, water, and moist environments that rarely harms healthy people, but causes severe, hard-to-treat infections in hospitalized or immunocompromised individuals through multi-drug resistance).Record review of Resident #1's admission Data dated 7/23/26 indicated he required two or more persons to assist with ADLs. He was not able to sit up without support.Record review of Resident #1's Fall Risk Assessment on admission dated 7/23/26 indicated he had a score of 10, which placed him at high risk for falls.Record review of Resident #1's admission MDS assessment dated [DATE] revealed he admitted to the facility on [DATE] from a short-term general hospital. The MDS indicated Resident #1 had no speech and was rarely/never understood or understood others. The MDS indicated Resident #1 was not able to complete the BIMS because he was rarely/never understood. The MDS indicated Resident #1 was dependent on staff for all ADLs. The MDS indicated Resident #1 had surgery for insertion or removal of spinal or brain cerebrospinal fluid drainage device and a feeding tube.Record review of Resident #1's Baseline Care Plan dated 7/24/26 revealed there were no care areas completed and showed to be incomplete in the assessment list.Record review of Resident #1's undated Plan of Care-Current indicated he had a problem area of Activities of Daily Living with an effective date of 8/01/26 with interventions including he was dependent on staff with all ADLs, a two person assist with bed mobility and peri-care (incontinent care). The care plan indicated Resident #1 had a problem area of Falls with an effective date of 8/07/26 and interventions including resident would receive two person assist for bed mobility, cares, while on an alternating air mattress, position resident safely in bed, fall mat at beside.Record review of Resident #1's undated Kardex (care plan for the CNAs) indicated he was dependent on two staff for all ADLs, including bed mobility, dressing, toileting, hygiene, and bathing. The Kardex indicated Resident #1 was on a low air loss mattress.Record review of Resident #1's Interdisciplinary Progress Notes, dated 8/01/26 at 3:30 PM, indicated RN B was summoned to his room by CNA A and found Resident #1 on the floor with a moderate amount of bloody drainage observed. RN B documented CNA A reported that she had turned Resident #1 on his side to perform incontinent care, then left the room to get a diaper and went back and found Resident #1 on the floor.Record review of Resident #1's hospital records dated 8/01/26 indicated he reportedly fell out of his bed while he was being cleaned up by one of the staff. There was a confirmed head strike with noted small laceration to the left back scalp just behind his ear and it was repaired with staples. The patient was apparently at his baseline which was largely non-verbal. The hospital records physical examination indicated he was not in acute distress The hospital records indicated the CT scan (imaging test to make detailed cross-sectional pictures of the inside of the body) of Resident #1's head results were negative for acute fracture or hemorrhage (bleeding). The hospital records indicated Resident #1 was not taking blood thinners. The hospital records indicated Resident #1 was discharged back to the nursing facility and his condition at discharge was good.During an observation and attempted interview on 8/18/26 at 2:01 PM, Resident #1 was lying on his back in bed on a low air loss mattress. Resident #1's eyes were closed and he did not respond when spoken to. Resident #1 had a urinary catheter bag hanging on the side of his bed. Resident #1 had fall mats on both sides of his bed, his bed was in low position, and his feeding pump pole had padding to the legs/feet of the pole.During an interview on 8/18/26 at 2:20 PM, CNA A said she went to check Resident #1 to see if he was dirty and rolled him onto his right side with the bed elevated. CNA A said Resident #1 had a wound on his bottom and it had drained onto his brief. CNA A said he had a catheter and he was not wet or dirty, but she decided to change his brief because of the drainage and realized she did not have a brief. CNA A said she stepped out of the room just outside the door in the hall to get a brief from the linen cart and when she came back in, he was on the floor on his back between his bed and the window. CNA A said they mentioned something about the air mattress pumping and it could have moved him. CNA A said Resident #1 was on his right side and she moved his left leg over the top of his right leg to keep him steady, since she was doing the care by herself. CNA A said she usually worked on the 600 hall by herself, sometimes the nurses would help her, but some of them would not even answer the call lights. CNA A said the computer let them know how much assistance the resident required, but CNA A said she had not checked the computer (Kardex) for Resident #1. CNA A said Resident #1 was a small man and she felt she could provide his care by herself. CNA A said she did not know about the air mattress moving and Resident #1 required two person assist at the time of the incident. CNA A said she reported the incident immediately to RN B. CNA A said the nurse came and assessed him and then they sent him to the hospital. CNA A said Resident #1 was bleeding from the back of his head. CNA A said she had provided care to Resident #1 before by herself without any issues. CNA A said she was making her first rounds after clocking in at 2:00 PM when it happened. CNA A said Resident #1's bed was elevated to where she could provide care for him, when she left the room to go get a brief. CNA A said she was initially just checking to see if he was wet or dirty when she noticed his wound had drained in his brief and decided she should change it. CNA A said she thought Resident #1 was in a safe position, when she left him for just a few seconds, and in her mind, she did not think of the mattress moving at all. CNA A said she could have pushed the call light the day of the incident for assistance, but she did not, because the nurse on duty that day did not even help answer the call lights, so it would not have done any good. CNA A said it was an accident and she did not mean for that to happen. CNA A said the accident happened and Resident #1 was injured because of leaving the room with him on his side on an air mattress in an elevated bed. CNA A said nothing like that had ever happened to her before, I'm so sorry, I guess I just wasn't thinking and thought I could just run real quick and get the brief. CNA A said Resident #1 was not able to turn himself or assist at all. CNA A said she should have looked at the computer and waited for assistance if Resident #1 was a two person assist for incontinent care and bed mobility. CNA A said they suspended her after the incident. CNA A said she knew not to leave a resident's bed in an elevated position when leaving the room, but she guessed she just did not think and tried to get the brief quickly. CNA A said she was in-serviced when she returned to work on: how the air mattress alternates air in the mattress to help with pressure wounds, to always have two people for residents on an air mattress while providing care, put the bed in low position before leaving a resident, place the resident on their back, make sure to have all your supplies prior to providing care, put the call light on for assistance, and do not ever leave a resident who was on an air mattress if they were not lying on their back with the bed in low position.During an interview on 8/18/26 at 4:18 PM, RN B said she had worked at the facility for a little over a year. RN B said she was summoned to Resident #1's room by CNA A. RN B said the aide had left Resident #1's bed in a high position on his right side and left his room to get a brief. RN B said she had asked CNA A prior to that if she needed any help and she said no, she was just getting a brief. RN B said she found the resident on the floor, bleeding from the back of his head. RN B said she applied ice to the back of Resident #1's head, notified the physician, and was instructed to send him to the hospital for a CT scan. RN B said all of Resident #1's vital signs were within normal limits for the resident. RN B said Resident #1 came back to the facility shortly after shift change after she had left. RN B said CNA A had told her there were not any briefs on the linen cart and she had to go to the storage closet down the hall. RN B said she notified all the required people of the incident, his family, the physician, the ADON, and the DON. RN B said she even counseled CNA A immediately after the resident was transferred to the hospital, about never leaving a resident in an elevated bed and he was a two person assist for care. RN B said by leaving Resident #1 with the bed in high position on his side, put the resident at risk of falls and he actually fell off the bed. RN B said the aide could have put on the call light for assistance or at least put the bed in the lowest position with him in a safe position, if she had to leave the resident. RN B said he should not have been left on his side with his bed in a high position for his safety. RN B said that was nursing 101 for safety.During an interview on 8/18/26 at 5:12 PM, the ADON said he had worked at the facility for a little over two years. The ADON said the DON was on vacation. The ADON said when a new resident was admitted to the facility, the admitting nurse would communicate with the care staff on what the resident required for their care needs. The ADON said the admitting nurse also built the Kardex during the admission. The ADON said the Kardex told the CNAs what type of assistance the resident required and included any resident preferences, diets, bathing, pain, how they move, what they eat, any precautions, oxygen requirements, all the essential items, and assistive devices. The ADON said if those items were not on the Kardex, they should refer to the nurse for guidance. The ADON was able to pull up the Kardex for Resident #1, and it showed the resident was a 2-person assist from admission. The ADON said all residents on an air mattress should be a two person assist for safety even prior to the incident with Resident #1. The ADON said to his knowledge it had always been two people with a resident on an air mattress for safety. The ADON said all staff knew to place residents' beds in a low position with their call lights in reach, prior to leaving the room. The ADON said CNA A placed Resident #1 at risk for fall and injury, and it did happen when she left the room with him on his side with the bed in a high position and not following the Kardex of two person assist for incontinent care or bed mobility.During an interview on 8/19/26 at 2:55 PM, Resident #1's family member said she was notified of the incident when Resident #1 rolled off the bed. Resident #1's family member said she thought the incident was related to the specific staff member being careless and not thinking. Resident #1's family member said other than that, the care had been very good, he was always clean, his wound did not have an odor, the staff had been real good and she had no concerns with his care. Resident #1's family member said he did not seem to have had any changes related to the fall.During an interview on 8/19/26 at 3:30 PM, MA C said she had worked at the facility for about nine years. MA C said she worked the 8AM-8PM shift as the medication aide for most of 100 hall and all of 600 hall. MA C said she was working on hall 600 at the time Resident #1 fell off the bed, but she said she was in another resident's room on 600 hall at the time and did not witness anything, just heard about it. MA C said she also helped reposition residents and pull up residents when needed, passed ice and snacks, passed meal trays, and helped answer call lights. MA C said all staff knew they should never leave a resident's bed in a high position and leave the room. MA C said it would put the resident at risk for fall and injury. MA C said the resident could be injured worse if they fall from a higher position. MA C said just like using a mechanical lift, staff had to have two people for safety and there should be two people to care for a resident on an air mattress for safety. MA C said the aide working 600 hall on the day Resident #1 fell from the bed, did not ask her to help her with Resident #1's care prior to his fall. MA C said she would have helped her.During an interview on 8/19/26 at 4:18 PM, the ADM said he was called about the incident related to Resident #1 falling off the bed. The ADM said he came to Resident #1's room to look at the circumstances surrounding his fall and while he was in Resident #1's room, the air mattress made a sound, and he saw the mattress move and realized the mattress could have caused the resident to fall if he was not in a safe position. The ADM said Resident #1 returned from the emergency room the same evening and he did not show any new issues. The ADM said he suspended CNA A and educated her on the low air loss mattress. The ADM said Resident #1's family did request CNA A to not care for Resident #1 and they removed CNA A from 600 hall. The ADM said they re-educated staff on not leaving a resident in an unsafe position and always lower the bed and turn them on their back to put the resident in the safest possible position. The ADM said if a person was a two person assist on the Kardex/care plan, then they were a two person assist, but they added a safety precaution if a resident was on an air loss mattress, then they were a two person assist also. The ADM said he would expect staff to leave the residents in a safe position prior to the staff leaving the room for resident safety. The ADM said he would expect staff to follow the Kardex if the resident was a two person assist because it was their care path. The ADM said it could affect the safety and outcomes for the resident if the Kardex was not followed, leaving the resident in an elevated bed, in an unsafe position.Record review of the facility's Clinical Skills Fair CNA Packet dated 7/26/26, indicated CNA A had a checkmark in the column labeled Met for all skills. The Competency Evaluation for Urinary Catheter listed gather materials and raise the bed to appropriate working height, but it did not address lowering the bed after completion of the skill. The Competency Evaluation for Perineal Care without a catheter raised the bed to an appropriate working height, organizes correct equipment for perineal care, positions resident comfortably, give table and call light, but it did not address lowering the bed after completion of the skill. The Competency Evaluation for Bed Bath skill check list listed gathered materials, raised the bed to an appropriate working height and toward the end of the procedure it said lower bed to lowest setting and ensured resident comfort.Record review of the facility's policy titled Fall Management dated January 12, 2018, indicated . The community would identify each resident who was at risk for falls and would plan care and implement interventions to manage falls . The community would manage falls by providing an environment that was free from potential hazards . The qualified staff would complete the Fall Risk Data Collection upon admission and . A resident fall management program would be implemented that educated staff in creative, functional strategies while encouraging resident rights and their need to maintain the highest practical level of function . the qualified staff assessed all residents for fall risk through the admission Nursing Assessment form upon admission . Upon determination that the resident was at risk, the qualified staff created an individualized plan of care that included the appropriate preventative interventions to reduce potential for fall .The facility had corrected the noncompliance and implemented their corrective actions sufficiently prior to survey as evidenced by the following:In-serviced licensed and direct care staff on:When providing incontinent care to residents on an alternating pressure air mattress, two clinical staff members must always be present.When walking away from resident, please ensure resident is in the safest position (bed in low position, resident on their back, etc.)Before beginning incontinent care, ensure that all necessary supplies and equipment are available at the resident's bedside. If you realize during care that additional items are needed, activate the call light and request assistance. Do not leave the residents unattended under any circumstances.If you are unsure whether a resident requires a one-person or two-person assist, refer to Kardex, which provides information regarding the resident's care needs and required level of assistance.Suspended CNA A during investigation,In-serviced CNA A:2-person assist for peri care provided to residents on an alternating pressure air mattressTo always leave the resident in the safest position, bed in low position, covered and on the back (unless contraindicated).To gather supplies needed prior to starting care.Use call light to call for assistance if need supplies or leave in a safe position and come back.Never leave a resident unattended in an elevated bed in an unsafe position.On use of the Kardex for level of assistance required.Applied fall mats to both sides of Resident #1's bed.Padded Resident #1's feeding tube pole legs.All staff interviewed (CNA A, RN B, CNA/MA C, ADON D, CNA E, CNA F, LVN G, CNA H, CNA J, CNA K, LVN L, CNA M, CNA N, CNA O, CNA/MA P, LVN Q, LVN R, LVN S, RN T, LVN U, CNA V, CNA W, CNA X, & CNA Y) from 8/18/26 through 8/19/25 from all shifts which included: 2 of 8 RNs, 6 of 15 LVNs, and 13 of 37 CNAs, and 2 of 3 CNA/MAs, 1 of 2 ADONs were able to verbalize:When providing incontinent care to residents on an alternating pressure air mattress, two clinical staff members must always be present.When walking away from resident, please ensure resident is in the safest position (bed in low position, resident on their back, etc.)Before beginning incontinent care, ensure that all necessary supplies and equipment are available at the resident's bedside. If you realize during care that additional items are needed, activate the call light and request assistance. Do not leave the residents unattended under any circumstances.If you are unsure whether a resident requires a one-person or two-person assist, refer to Kardex, which provides information regarding the resident's care needs and required level of assistance.All interviewed staff stated they knew prior to the incident to not leave residents' beds in an elevated position when leaving the resident's room.All interviewed staff stated they knew prior to the incident to refer to the resident's Kardex or Care Plan to know what care assistance the resident required for ADL care.During an observation on 8/18/26 at 2:01 PM, Resident #1 had fall mats on both sides of his bed, his bed was in low position, and his feeding pump pole had padding to the legs/feet of the pole.During an observation and interview on 8/18/26 beginning at 4:50 PM, CNA E and CNA F performed incontinent care on Resident #2. CNA E and CNA F positioned themselves on each side of Resident #2's bed and performed safe bed positioning while performing incontinent care on an air loss mattress. CNA E and CNA F performed the bed position and incontinent care appropriately and once care was completed, they placed the resident's bed in the low position with her call light in reach. Resident #2 said she loved the staff at the facility and had no concerns with her care.Record review of an In-service Form with training topic titled Peri-Care, Peri-Care provided to resident on air mattress, and Resident Care and dated 8/01/26 indicated all nursing staff had signed the in-service.

Based on observation, interview, and record review, the facility failed to develop and implement a Baseline Care Plan within forty-eight hours of admission that included the instructions for resident care needed to provide effective and person-centered care for 1 of 5 residents reviewed for new admissions. (Resident #1).The facility failed to ensure Resident #1's baseline care plan was completed within 48 hours of admission to the facility. This failure could place residents at risk of not receiving care and services to meet their needs.Findings included:Record review of Resident #1's face sheet dated 8/18/26 indicated he was [AGE] years old and admitted to the facility on [DATE] with diagnoses including hydrocephalus (medical condition where extra cerebrospinal fluid {clear, watery liquid that flows around and inside the brain and spinal cord}builds up deep inside the brain), osteomyelitis of vertebra/sacral (severe infection of the bone and bone marrow in the bones of the lower back at the end of the spine), pressure ulcer of sacral region (wound resulting from pressure to an area causing skin/tissue), severe protein-calorie malnutrition (life-threatening lack of essential nutrients and calories), respiratory failure, dysphagia (difficulty swallowing), cognitive communication deficit, lack of coordination, weakness, hypertension (high blood pressure), Methicillin resistant Staphylococcus aureus (a type of bacteria that does not get better with common antibiotics like penicillin and methicillin), Klebsiella pneumoniae (healthcare associated infections, including pneumonia {infection in lung}), bloodstream infections, and wound infections, Pseudomonas aeruginosa (opportunistic pathogen commonly found in soil, water, and moist environments that rarely harms healthy people, but causes severe, hard-to-treat infections in hospitalized or immunocompromised individuals through multi-drug resistance).Record review of Resident #1's admission MDS assessment dated [DATE] revealed he admitted to the facility on [DATE] from a short-term general hospital. The MDS indicated Resident #1 had no speech and was rarely/never understood or understood others. The MDS indicated Resident #1 was not able to complete the BIMS because he was rarely/never understood. Resident #1 was dependent on staff for all ADLs. The MDS indicated Resident #1 had an indwelling catheter (tube inserted into the bladder to drain urine) and he was always incontinent of bowel. The MDS indicated Resident #1 had surgery for insertion or removal of spinal or brain cerebrospinal fluid drainage device and a feeding tube. The MDS indicated Resident #1 had a feeding tube. The MDS indicated Resident #1 was at risk for developing pressure ulcers. The MDS indicated Resident #1 had one unhealed stage 4 (severe, deep wound with full-thickness tissue loss that exposed muscle, tendons, ligament, or bone) pressure ulcer present on admission. The MDS indicated Resident #1 had a PICC (Peripherally Inserted Central Catheter) line (thin, flexible tube inserted into a vein in the arm and threaded to a large vein near the heart for long-term intravenous medication administration).Record review of Resident #1's Baseline Care Plan dated 7/24/26 revealed there were no care areas completed and showed to be incomplete in the assessment list.During an observation and attempted interview on 8/18/26 at 2:01 PM, Resident #1 was lying on his back in bed on a low air loss mattress. Resident #1's eyes were closed and he did not respond when spoken to. Resident #1 had a urinary catheter bag hanging on the side of his bed. Resident #1 had fall mats on both sides of his bed, his bed was in low position, and his feeding pump pole had padding to the legs/feet of the pole.During an interview 8/18/26 at 2:50 PM, ADON D reviewed Resident #1's Baseline Care Plan on his computer during the interview. ADON D said Resident #1's Baseline Care Plan was not completed and did not have the care assistance for ADLs listed to show what care the resident needed. ADON D said the Baseline Care Plan should be completed within forty-eight hours of admission, but he told his staff to have it completed within two hand-offs, which would be two twelve-hour shifts. ADON D said the ADON would be responsible for ensuring the Baseline Care Plan was completed timely. ADON D said he had an admission checklist he used to ensure everything was completed. ADON D said Resident #1's Baseline Care Plan was listed in the assessments list, but he must have missed that it was not completed. ADON D said if the Baseline Care Plan was not completed or completed timely, staff could miss something in the resident's care that the resident needed, but with all the other assessments with the admission, he felt the areas were getting addressed. ADON D said the purpose of the Baseline Care Plan was to build a care plan for educational purposes for the resident and family and would show staff what the initial care needs were for the resident and it was built on as the comprehensive care plan was built. During an interview on 8/19/26 at 3:15 PM, RN B said she had worked at the facility for a little over a year. RN B said the purpose of the Baseline Care Plan was to ensure the plan of care was focused on what care the resident needed and implementation of their care. RN B said the Baseline Care Plan should be completed within forty-eight hours of the resident admitting to the facility. RN B said the admitting nurse would be responsible for ensuring the Baseline Care Plan was completed within the timeframe. RN B said if the Baseline Care Plan was not completed or was not completed timely, there could be a delay in care for the resident.During an interview on 8/19/26 at 4:18 PM, the ADM said he would expect the Baseline Care Plan policy to be followed per the facility's policy. The ADM said the purpose of the Baseline Care Plan was to establish the basics of what the residents' care needs were. The ADM said if the Baseline Care Plan was not developed or not developed timely, the staff would not have a clear picture of what the resident needed.Record review of the facility's policy dated revised February 12, 2020, and titled Care Plans-Process, indicated . The interdisciplinary team will coordinate with the resident and their legal representative an appropriate care plan for the resident's needs or wishes based on the assessment and the reassessment process within the required timeframes . Procedure: 1. Initiate a Baseline Care Plan and complete within forty-eight (48) hours of admission based on the physician's orders and nursing evaluation . 2. The Baseline Plan of Care facilitates care until the Comprehensive Care Plan was developed within the first fourteen days after admission .

Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 5 residents reviewed for ADLs (Residents #1.)1. The facility failed to reposition Resident #1 at least every two hours on the 6/10/26 10:00 PM to 6:00 AM (6/11/26) shift.2. The facility failed to ensure LVN F provided appropriate incontinent care to include cleansing Resident #1's skin to his front and back private areas on 6/11/26.3. The facility failed to ensure CNA E turned Resident #1 to cleanse urine from his skin on the back side of his body or to check under the pad for wetness on 6/16/26.4. The facility failed to ensure CNA C provided appropriate incontinent care to include cleansing Resident #1's skin to his front and back private areas or turning Resident #1to check his under pad for wetness on 6/17/26.These failures could place residents at risk of not receiving care and services to meet their needs, resulting in poor care, risk for skin breakdown, feelings of poor self-esteem, and lack of dignity.Findings included:Record review of Resident #1's face sheet, dated 6/24/26, indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #1 had diagnoses including quadriplegia (unable to move body, typically caused from damage to the spinal cord in the neck), gastrostomy (also called PEG tube-soft tube inserted through the skin and abdominal wall directly into the stomach), colostomy (surgical procedure to bring part of the large intestine out through the abdominal wall to an opening on the outside of the body for feces to be collected in a bag), neuromuscular dysfunction of bladder (unable to control urine flow), and aphasia (inability to speak).Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated he had no speech and was rarely/never understood and sometimes understood others. Resident #1 was unable to complete the BIMS because he was rarely/never understood. Resident #1 was dependent on staff assistance for all ADLs. Resident #1 was always incontinent of urine. Resident #1 did not have bowel incontinence because he had a colostomy.Record review of Resident #1's undated Care Plan indicated he had problem areas including:Activities of Daily Living and was dependent on staff for all ADLs with interventions to assist with daily care needs and daily living tasks.Incontinent of bowel and bladder with interventions including to assist with toileting needs and to check and change, keep clean and dry.Urinary incontinence related to neurogenic bladder with interventions including monitor skin for redness when providing care, hygiene as needed after every incontinent episode to maintain dignity, and provide adult briefs/pullups/pads, assist with changing as needed.Diagnosis of Quadriplegia with interventions including to provide assistance with all ADLs and mobility, position for comfort and reposition every two hours as tolerated, and to monitor skin integrity.At risk for skin breakdown due to incontinence and impaired mobility with interventions including to assist resident to turn and reposition frequently, keep skin clean and moisturized, and pressure relieving mattress and chair cushion.Record review of Resident #1's skin assessments, dated 6/10/26 and 6/17/26, indicated he did not have any skin issues.Record review of video footage, dated 6/11/26 beginning at 12:05 AM, Resident #1 was lying on his back, eyes closed, with his right hand on top of his pillow laid across his abdomen with his television remote and call light attached.Record review of video footage, dated 6/11/26 beginning at 12:31 AM, Resident #1 was lying on his back, eyes closed, with his right hand on top of his pillow laid across his abdomen with his television remote and call light attached.Record review of video footage, dated 6/11/26 beginning at 1:17 AM, Resident #1 was lying on his back, eyes closed, with his right hand on top of his pillow laid across his abdomen with his television remote and call light attached.Record review of video footage, dated 6/11/26 beginning at 2:09 AM, Resident #1 was lying on his back, eyes closed, with his right hand on top of his pillow laid across his abdomen with his television remote and call light attached.Record review of video footage, dated 6/11/26 beginning at 2:13 AM, Resident #1 was lying on his back, eyes closed, moving his right hand on top of his pillow laid across his abdomen/chest area with his television remote and call light attached.Record review of video footage dated 6/11/26 beginning at 2:24 AM, Resident #1 was lying on his back, eyes closed, with his right hand on top of his pillow laid across his abdomen/chest area with his television remote and call light attached.Record review of video footage, dated 6/11/26 beginning at 2:48 AM, Resident #1 was lying on his back, eyes closed, with his right hand around the bottom of his pillow and it was pulled up to his upper chest area and had his television remote and call light attached.Record review of video footage dated 6/11/26 beginning at 2:58 AM, Resident #1 continued lying on his back, eyes closed, with his right hand around the bottom of his pillow and it was pulled up to his upper chest area and had his television remote and call light attached.Record review of video footage, dated 6/11/26 beginning at 3:15 AM, Resident #1 was lying on his back, eyes closed, with his right hand over the top of his pillow laid across his chest and had his television remote and call light attached.Record review of video footage, dated 6/11/26 beginning at 3:42 AM, Resident #1 was lying on his back, eyes closed, with his right hand over the top of his pillow laid across his chest and had his television remote and call light attached. LVN D entered the room carrying feeding tube supplies. LVN D provided care to Resident #1's feeding tube. LVN D, at 3:48 AM, removed old feeding tube supplies and placed them in the trash and removed his gloves and left the view of the camera. LVN D returned at 3:52 AM and placed a stack of linens on the end of the bedside table, which included a blue under pad, a sheet, and towels, then adjusted the feeding pump and left the room.Record review of video footage, dated 6/11/26 beginning at 6:36 AM, Resident #1 continued lying on his back, awake, with his right hand on top of his pillow laid across his abdomen area with his television remote and call light attached. The stack of linens continued to be sitting on the end of the bedside table, which included a blue under pad, a sheet, and towels.Record review of video footage, dated 6/11/26 beginning at 8:39 AM, Resident #1 continued lying on his back, awake, with his right hand on top of his pillow laid across his abdomen area with his television remote and call light attached. The stack of linens continued to be sitting on the end of the bedside table, which included a blue under pad, a sheet, and towels.Record review of video footage, dated 6/11/26 beginning at 9:16 AM, Resident #1 continued lying on his back, awake, with his pillow laid across his abdomen with his television remote and call light attached. The stack of linens continued to be sitting on the end of the bedside table, which included a blue under pad, a sheet, and towels. LVN F entered the camera view wearing gloves. At 9:17 AM, LVN F was at Resident #1's bedside and she lifted Resident #1's left arm and positioned a towel across his chest and under his chin. LVN F then pulled his covers down and with her left hand pulled his adult brief from between his legs and threw it in the trash. LVN F then, with the same gloves on, pushed Resident #1's bedside table to the side and walked to the other side of the bed (by window) and obtained a new adult brief, opened it and then proceeded to place the brief between Resident #1's legs and over his front private area and pulled his gown down. LVN F did not cleanse Resident #1's skin prior to applying a new adult brief on him and did not roll him to cleanse his skin on his back private areas and did ensure the pad under him was not wet.Record review of video footage, dated 6/16/26 beginning at 2:25 PM, CNA E was at Resident #1's bedside wearing gloves. CNA E lifted his pillow that was laid across his lap with his television remote and call light attached and pulled back the bed covers under the pillow. CNA E moved the pillow toward the foot of the bed. CNA E then walked around the end of the bed and picked up a package of wipes from the dresser at the end of the bed. CNA E obtained a clean adult brief and wipes from the package and then set the brief on top of Resident #1's pillow with his television remote and call light attached. CNA E then raised Resident #1's bed covers and pulled his adult brief from between his legs using both gloved hands and threw it in the trash. CNA E then used the wipes to clean Resident #1's front private areas. CNA E used the same gloved hands to place the clean adult brief over his front private area and then pushed the remainder of the brief down between his legs. CNA E removed Resident #1's gown and replaced it with a clean gown. CNA E then pulled his gown down, pulled his covers up over him, placed a towel over his chest and under his chin, wiped both sides of his mouth with the corners of the towel, placed his pillow over his abdomen with his television remote and call light attached, and then removed her gloves and threw them in the trash. CNA E did not roll Resident #1 to cleanse his skin on his back private areas and did ensure the pad under him was not wet.Record review of video footage, dated 6/16/26 beginning at 3:03 PM to 4:01 PM, showed Resident #1's family member entered his room and performed various tasks including cutting the flaps off the adult briefs. At 4:01 PM, Resident #1's family member removed two pillows that were stuffed under Resident #1's left side and placed them in a chair. Resident #1's family member removed her phone from her pocket and took a picture of Resident #1's under pad.Record review of a picture, dated 6/16/26 with a time of 4:01 PM, showed Resident #1's under pad with a dark yellowish brown outer ring that extended from approximately Resident #1's middle back area to below his buttocks, which indicated the under pad had not been changed and the urine was old and had dried and then been wet again and dried again.Record review of video footage, dated 6/17/26 beginning at 2:22 AM, CNA C entered Resident #1's room and walked over to the call light button on the wall and pushed the button. CNA C walked to the end of Resident #1's bed, moved the covers and repositioned Resident #1's feet from being crossed and CNA C was not wearing gloves or a gown. CNA C then, with her bare hands, picked up Resident #1's pillow from over his abdomen, with his television remote and call light attached, with her right hand and then pulled the covers down, raised his gown, and grabbed his adult brief with her bare left hand and pulled it out from between his legs and threw it in the trash. CNA C then walked out of the view of the camera and returned wearing gloves. CNA C walked around to the other side of the bed and obtained a clean adult brief and placed the top of the brief over Resident #1's front private areas and then pushed the other end between his legs. CNA C did not cleanse Resident #1's skin prior to placing a clean brief on him and did not turn him to clean his bottom side or to check his under pad for wetness.During an interview on 6/24/26 at 9:19 AM, Resident #1's family member said she had reported to the nurses on several occasions about Resident #1 being soiled to the point of being soaked in urine up his back and staff were not cleaning his urine off of his skin when they performed incontinent care and often just removed the soiled brief and put a clean one back on and not even checking to see if his under pad was wet. Resident #1's family member said the staff were supposed to be repositioning him at least every two hours and there was one night it did not appear he was repositioned all night after midnight. Resident #1's family member said she wanted Resident #1 to be cared for, kept clean and dry, and repositioned for comfort and to prevent skin breakdown.During an observation and interview on 6/24/26 at 1:15 PM, Resident #1 was lying in bed and appeared clean with no odors noted. CNA A and CNA G were at bedside and said Resident #1 had a shower that morning and had been sitting up in his chair and they had just gotten him back to bed.During an observation and interview on 6/25/26 at 11:23 AM, LVN F said she had worked at the facility for about 12 years. LVN F viewed the 6/11/26 video of her in Resident #1's room and said she did not wear a gown while providing care. LVN F said his adult brief/pad was soaked with urine and she felt it needed to be taken care of immediately. LVN F said she could tell Resident #1 was soaked and his gown was wet from either urine or sweat. LVN F said she removed his adult brief and put a dry one on him. LVN F said Resident #1 was soaked and she changed his adult brief, so he would not continue to soak himself more and then went and told the aide he needed everything changed. LVN F said Resident #1 appeared he had not been changed in quite a while. LVN F said she occasionally came in on the morning shift and found Resident #1 was soaked. LVN F said she told the aides to always round immediately after coming in, to ensure the residents were clean and dry.During an observation and interview on 6/25/26 at 11:52 AM, the DON viewed the videos and identified the staff members present in the videos. The DON said residents who could not turn themselves should be repositioned and checked for incontinence at least every two hours to prevent skin breakdown. The DON said she expected staff to be checking the resident's under pad for wetness also during incontinent care. The DON said staff should be cleansing the resident's skin, clean the front private areas first and then clean the back too. The DON said it should be common sense because urine runs down because of gravity and if the resident was a male and was lying on their back, the under pad would most likely be wet also. The DON said Resident #1's family member cuts the flaps/tabs off the adult briefs and just wanted the brief placed over his front private area and placed between his legs and if he was lying on his back, the urine was just going to run down to the under pad. The DON said staff should be cleansing the resident's skin because urine on the skin could cause the skin to break down and it would be a dignity thing. The DON said the dark urine ring on the 6/16/26 4:01 PM picture of Resident #1's under pad indicated it was old urine. The DON said her staff had been repeatedly in-serviced and she felt like she was beating a dead horse.During an interview on 6/25/26 at 1:28 PM, CNA C said she did not remember not wearing gloves to remove Resident #1's brief on 6/17/26. CNA C said she just removed Resident #1's brief and replaced it, so it would not be the same one on him from the previous shift. CNA C said she did not check the under pad because nothing was soiled and his brief was dry. CNA C said a resident should be turned every two hours and checked for incontinence, so the resident did not get bed sores and was relieved of pressure. CNA C said the resident could get a bed sore and contractures if they were not turned and repositioned at least every two hours. CNA C said she always checked the under pad when Resident #1's adult brief was wet because the pad could be wet too, and most likely was. CNA C said it was important to cleanse the skin of urine to be clean, and no one wanted to be dirty. CNA C said she did not remember if she worked the night of 6/10/26 into the 6/11/26 morning (10 PM to 6 AM shift), but if she was scheduled she most likely worked her shift. CNA C said she rounded on residents at least every two hours to check for incontinence and turned and repositioned the residents.During an attempted interview on 6/25/26 at 1:30 PM, CNA E was called but there was no answer and was unable to leave a voicemail. CNA E was sent a text message on 6/25/26 at 1:32 PM requesting a return call. CNA E did not return call prior to exiting the facility. Per the DON, CNA E no longer worked for the facility.During an attempted interview on 6/25/26 at 1:45 PM, LVN D was called but there was no answer and was unable to leave a voicemail. LVN D was sent a text message on 6/25/26 at 2:45 PM requesting a return call. LVN D did not return call prior to exiting the facility.During an interview on 6/25/26 at 2:05 PM, the ADM said he would expect staff to follow the facility's policies and cleanse the resident's skin during incontinent care to prevent the potential for skin breakdown. He said he would expect the staff to turn and reposition residents to prevent pressure injuries and potential for skin breakdown. The ADM said it was mortifying to think residents were not being cleaned during incontinent care.Record review of the facility's Nursing assignment schedule for 6/10/26 indicated CNA C was assigned to Resident #1's hall on the 10:00 PM to 6:00 AM (6/11/26) shift.Record review of CNA C's time punches from 6/10/26 indicated she clocked in at 10:07 PM, clocked out at 1:58 AM (6/11/26), clocked back in at 2:20 AM, and clocked out at 6:00 AM.Record review of the facility's grievance logs for April, May, and June of 2026 did not reveal Resident #1's family had filed a formal grievance/complaint.Record review of the facility's Training In-service Form with the in-service topic of Two-hour Rounding and Repositioning and dated 6/15/26 indicated LVN F had signed the in-service form. The in-service did not indicate CNA C, LVN D, or CNA E had received or signed the in-service.Record review of the facility's policy titled, Perineal Care, dated reviewed April 2024, revealed, . Staff will provide perineal (private areas) care in accordance with the standard of practice to prevent skin breakdown and infection . Procedure: . 2. Assemble supplies. Utilize disposable wipes or if periwash was used, use washcloth and warm water in clean basin . 3. Perform hand hygiene. Apply clean gloves . 5. Perineal Care for Male: . b. Drape resident with linens to provide privacy . d. Wash tip of penis at urethral meatus (opening at the end of the penis) first using circular motion . Clean from the meatus outward . Discard wipe/washcloth and repeat until penis is clean . f. Cleanse the shaft of the penis and scrotum with new washcloth or wipe. Gently lift scrotum to clean skinfolds underneath . 7. Lower legs and assist resident to side lying position . 8. Turn resident to clean all areas of buttocks with new wipe or section of washcloth wiping front to back to remove feces present. Observe for redness, bruising, open skin, rash, or other abnormalities . 9. Dispose of gloves and used supplies and perform hand hygiene . 10. Apply new gloves and place new brief and change linens as needed . 11. Position resident comfortably with call light in reach .Record review of the facility's policy titled, An Overview of Wound Care dated July 2018, indicated, . Purpose . To provide guidance for educational purposes about skin and wound care with an emphasis on Pressure Ulcers/Injuries and other common wounds . Pressure ulcers/injuries are mainly caused by increased time of a bony prominence against a surface . These wounds can develop very rapidly and take a long time to close . These wounds are significant and can be attributed to a perception of poor care provided by healthcare institutions and clinicians . the main goal of prevention and treatment is to reduce the amount of time a person is in one position while focusing on bony prominences, while addressing other factors that may increase the amount of risk of breakdown or further problems . can lead to local and systemic infections, increased pain, and death . Repositioning . or relieving constant pressure is a common, effective intervention for an individual with a pressure ulcer/injury or who is at risk of developing one . repositioning is critical for a resident who is immobile or dependent upon staff for repositioning, as the resident is unable to small movements on their own that would help to relieve prolonged pressure to one area . many clinicians recommend position change off-loading hourly for dependent residents who are sitting or who are in a bed or a reclining chair with the head of the bed or back of the chair raised 30 degrees or more . the care plan for a resident who is reclining and is dependent on staff for repositioning should address position changes to maintain the resident's skin integrity . this may include repositioning at least every two hours or more frequently depending upon the resident's condition and specific needs .

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 6 residents (Resident #1) reviewed for infection control practices.1. The facility failed to ensure LVN D wore a gown and gloves while providing direct care to Resident #1, who was on EBP, while performing PEG tube care on 6/11/26.2. The facility failed to ensure LVN D did not place paper towels that had fallen onto the floor back into Resident #1's bed on 6/11/26.3. The facility failed to ensure LVN F wore a gown and gloves while providing direct care to Resident #1, who was on EBP, while performing incontinent care or flushing his PEG tube on 6/11/26.4. The facility failed to ensure LVN F changed her gloves and performed hand hygiene after performing incontinent care on Resident #1 prior to providing care to his PEG tube.5. The facility failed to ensure CNA E wore a gown and gloves while providing direct care to Resident #1, who was on EBP, while performing incontinent care and changing his gown on 6/16/26.6. The facility failed to ensure CNA E changed her gloves and performed hand hygiene after performing incontinent care and prior to touching Resident #1, his bedding, pillow, and clean gown.7. The facility failed to ensure CNA C wore a gown and gloves while providing direct care to Resident #1, who was on EBP, while providing incontinent care on 6/17/26.8. The facility failed to ensure CNA C and LVN D wore gown and gloves while providing direct care to Resident #1, who was on EBP, while pulling Resident #1 up in bed on 6/17/26.9. The facility failed to ensure CNA A and CNA B wore gown and gloves while providing direct care to Resident #1, who was on EBP, while performing a bed bath on 6/17/26.10. The facility failed to ensure CNA A and CNA G wore gown and gloves while providing direct care to Resident #1, who was on EBP, while performing a mechanical lift transfer from wheelchair to bed and positioning him in bed on 6/24/26.These failures could place residents at risk for cross contamination, at an increased risk of infection, and the spread of infection.Findings included:Record review of Resident #1's face sheet, dated 6/24/26, indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #1 had diagnoses including quadriplegia (unable to move body, typically caused from damage to the spinal cord in the neck), gastrostomy (also called PEG tube-soft tube inserted through the skin and abdominal wall directly into the stomach), colostomy (surgical procedure to bring part of the large intestine out through the abdominal wall to an opening on the outside of the body for feces to be collected in a bag), neuromuscular dysfunction of bladder (unable to control urine flow), and aphasia (inability to speak).Record review of Resident #1's quarterly MDS assessment, dated 5/04/2026, indicated he had no speech and was rarely/never understood and sometimes understood others. Resident #1 was unable to complete the BIMS because he was rarely/never understood. Resident #1 was dependent on staff assistance for all ADLs. Resident #1 was always incontinent of urine. Resident #1 did not have bowel incontinence because he had a colostomy. Resident #1 had a feeding tube.Record review of Resident #1's undated Care Plan indicated he had problem areas including:Activities of Daily Living and he was dependent on staff for all his ADLs.Incontinent of bowel and bladder.Needed to be lifted mechanically using a lift with two staff.Feeding tube necessary for nutritional needs due to dysphagia (unable to swallow).Enhanced Barrier Precautions with interventions of gown and gloves during high contact activities as outlined in guidelines.Needs ostomy care for a colostomy and peg tube with intervention for ostomy care per MD order.Record review of Resident #1's Physician Orders, dated 5/27/26-6/25/26, included orders for:Enhanced Barrier Precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities) every shift with an order date of 6/13/25.Peg-tube dressing change on night shift with an order date of 6/18/25.Peg-tube flush 30-50 cc water before and after medications every shift, use 30-50 cc of water flush between each medication administrated with an order date of 6/23/25.Osmolite (liquid nutrition) 1.5 Cal 0.06 gram - 1.5 kcal/ml oral liquid at 70 ml per hour for a total infused volume of 1400 ml per day with an order date of 9/26/25.Peg-tube flush with 150 ml of water every four hours (time: 01:00 AM, 5:00 AM, 9:00 AM, 1:00 PM, 5:00 PM, 9:00 PM) with an order date of 11/30/25.Record review of video footage, dated 6/11/26, beginning at 3:46 AM, LVN D was at Resident #1's bedside wearing gloves, but he was not wearing a gown. LVN D was priming (filling the feeding tube with fluid) the feeding tube line and hung the feeding tube over the feeding tube pole. LVN D picked up the PEG tube syringe with the plunger extended, from the bedside table, and laid it on the bed. LVN D placed paper towels on the bed in the area of his PEG tube (the view was blocked by bedding) and then the paper towels fell onto the floor. LVN D picked up the paper towels from the floor and placed them back onto Resident #1's bed. LVN D then appeared to flush Resident #1's PEG tube with the syringe and the plunger was pushed in when he pulled the syringe out from behind the bedding and then placed the syringe back into the plastic bag. LVN D obtained the feeding tube line from the feeding tube pole and appeared to attach the feeding tube to Resident #1's PEG tube (the view was blocked by bedding). LVN D then removed old feeding tube supplies and placed them in the trash and removed his gloves.Record review of video footage, dated 6/11/26, beginning at 9:16 AM, LVN F entered the camera view wearing gloves, but she was not wearing a gown. LVN F has two cups, one with clear liquid and one with a pink liquid and placed them on the bedside table. LVN F pushed the bedside table toward the end of the bed with both gloved hands and then went and picked up the trash can with her right hand and placed it near the bedside table. LVN F picked up Resident #1's pillow with his television remote and call light attached with both same gloved hands and moved it toward the end of the bed. LVN F used the towel on Resident #1's chest and wiped his mouth using her same gloved left hand and then removed the towel and walked out of the camera view. The video resumed at 9:17 AM with LVN F at Resident #1's bedside and she lifted Resident #1's left arm and positioned a towel across his chest and under his chin. LVN F then pulled his covers down and with her left hand pulled his adult brief from between his legs and threw it in the trash. LVN F then with the same gloves on, she pushed his bedside table to the side and walked to the other side of the bed (by window with blinds closed) and obtained a new adult brief, opened it and proceeded to place the brief between Resident #1's legs and over his front private area and pulled his gown down. LVN F proceeded to walk back around the end of Resident #1's bed and touched the end of the bed frame with the same gloved hand. LVN F went to the pole where his feeding tube was hung and took down a plastic bag with his PEG tube flush syringe in it. LVN F reached down with the same gloved right hand and pulled the trash can closer and then removed the PEG tube flush syringe from the package. LVN F placed the end of the syringe in a cup of clear liquid on the bedside table and pulled liquid into the syringe. LVN F grabbed the bedside table with both hands on the end corners and pulled the bedside table closer to bed. LVN F then went to Resident #1 and pulled his gown up with the syringe in her hand and the video ended.Record review of video footage, dated 6/16/26, beginning at 2:25 PM, CNA E was at Resident #1's bedside wearing gloves, but she was not wearing a gown. CNA E lifted his pillow that was laid across his lap with his television remote and call light attached and pulled back the bed covers under the pillow. CNA E moved the pillow toward the foot of the bed. CNA E then started to walk around the end of the bed and placed her right hand on the end of the bed frame and picked up a package of wipes from the dresser at the end of the bed. CNA E obtained a clean adult brief and wipes from the package and then set the brief on top of Resident #1's pillow with his television remote and call light attached and then picked up pillows out of the chair at the end of the bed and placed them on the bed on the other side of the room. CNA E then raised Resident #1's bed covers and pulled his adult brief from between his legs using both gloved hands and threw it in the trash. CNA E then used the wipes to clean Resident #1's front private areas. CNA E used the same gloved hands to place the clean adult brief over his front private area and then pushed the remainder of the brief down between his legs while leaning over his bed, allowing the front of her clothing to come into contact with his bedding. CNA E removed a towel from over Resident #1's chest and begun to unsnap the left sleeve of his gown and then reached behind his neck to untie the gown, wearing the same gloves used to perform incontinent care. CNA E then leaned over the top of Resident #1 to unsnap the sleeve of his gown on the other arm and then pulled the gown off of him. CNA E placed a clean gown on Resident #1 while allowing the front of her clothes to contact his bedding and clean gown. CNA E then pulled his gown down, pulled his covers up over him, placed a towel over his chest and under his chin, wiped both sides of his mouth with the corners of the towel, placed his pillow over his abdomen with his television remote and call light attached, and then removed her gloves and threw them in the trash. CNA E did not change her gloves or wear a gown throughout the care she provided to Resident #1.Record review of video footage, dated 6/17/26, beginning at 2:22 AM, CNA C entered the Resident #1's room and walked over to the call light button on the wall and pushed the button. CNA C walked to the end of Resident #1's bed, moved the covers and repositioned Resident #1's feet from being crossed and CNA C was not wearing gloves or a gown. CNA C then with her bare hands, picked up Resident #1's pillow from over his abdomen, with his bed remote and call light attached, with her right hand and then pulled the covers down, raised his gown, and grabbed his modified adult brief with her bare left hand and pulled it out from between his legs and threw it in the trash. CNA C then placed both of her hands in the pockets of her shirt and walked out of the view of the camera and returned wearing gloves, but she still did not have a gown on. CNA C walked around to the other side of the bed and obtained a clean modified adult brief and placed the top of the brief over Resident #1's front private areas and then pushed the other end between his legs. CNA C did not cleanse Resident #1's skin prior to placing a clean brief on him and did not turn him to clean his bottom side. LVN D entered the room and put on gloves but did not put on a gown. CNA C removed Resident #1's sheet, repositioned his feet and pillow under his feet and allowed her clothing and long hair to touch the resident's bedding. CNA C placed Resident #1's pillow with his bed remote and call light attached onto his abdomen. LVN D and CNA C grabbed the draw sheet under Resident #1 and pulled him up toward the head of the bed. LVN D raised Resident #1's head using the bed remote and CNA C adjusted the sheet covering his feet and they exited the room. CNA C did not change her gloves or wear a gown throughout the care she provided to Resident #1. LVN D did not wear a gown throughout the care he provided to Resident #1.Record review of video footage, dated 6/17/26, beginning at 9:21 AM, CNA A and CNA B were positioned on each side of the bed, bathing Resident #1 in the bed closest to the window. Resident #1 was completely naked and fully exposed during the bathing of his front and back sides. CNA A and CNA B wore gloves but did not wear a gown while providing a bed bath to Resident #1. CNA B washed Resident #1's left leg and worked her way up to his abdomen and chest. CNA A and CNA B both took towels and dried Resident #1. CNA B obtained a black bottle (later determined to be coconut body oil) and squirted some in CNA A's hand and then in her own hand, still wearing the same gloves used to wash Resident #1. CNA A and CNA B both start rubbing the oil over Resident #1. CNA B started rubbing the oil on Resident #1's legs, then across his abdomen, and then she put more oil in her same gloved hand and begun rubbing the oil all over his head, face, and neck. CNA A reached over Resident #1 and grabbed the pad under him and pulled him toward her and let the pad fall back onto the bed while she held him on his side. CNA B wetted a wash cloth with soap and water and leaned against the bed while she washed Resident #1's back, back private area and discarded the wash cloth. CNA B wetted another washcloth and washed Resident #1's back private area again, while CNA A used a towel to dry his back and then his back private area. CNA B used a towel previously used to dry Resident #1 to wipe the bed mattress and then she squirted more oil into CNA A's same gloved hand, and she rubbed oil over his back, buttocks, and back of legs. CNA B obtained clean draw sheet and an under pad and rolled them halfway and as CNA A pulled the resident against her, CNA B stuffed it under Resident #1 wearing the same gloves. CNA B then pulled Resident #1 toward her as CNA A removed the old linen and pulled the clean linen from under the resident. CNA A and CNA B rolled Resident #1 onto his back and the video ended. CNA A and CNA B did not change their gloves or wear a gown throughout the care provided to Resident #1.During an observation and interview on 6/24/26 at 1:15 PM, Resident #1 was lying in bed and appeared clean with no odors noted. CNA A and CNA G were positioned on each side of Resident #1's bed and both were wearing gloves, but they were not wearing gowns. There was a mechanical lift in the room. CNA A and CNA G said they had just performed a mechanical lift to put Resident #1 back to bed after he had his shower and had sat up in his chair. CNA A and CNA G pulled Resident #1 up toward the head of the bed, pulled his covers up over him, and placed his pillow with his television remote and call light attached, over his abdomen within his reach. CNA A and CNA G did not wear a gown while providing care to Resident #1.During an interview 6/24/26 at 1:39 PM, CNA A and CNA G said Resident #1 was on EBP because he had a feeding tube. CNA A and CNA G said they were supposed to wear gloves and a gown when providing direct patient care. CNA G said they just had an in-service about EBP not long ago. CNA A and CNA G said EBP was to protect them and the resident from getting infections and so they do not spread infections from resident-to- resident. CNA A and CNA G said Resident #1 had been up in his wheelchair and they performed a two person transfer with the mechanical lift back to his bed and then repositioned him for comfort. CNA A and CNA G said they were not wearing the required gown and gloves for a resident on EBP. CNA A and CNA G said if they were not wearing the required gown and gloves while providing direct care to a resident on EBP, they could spread infection to the resident or to other residents and even themselves. CNA A and CNA G said Resident #1 did not like to be up in his chair and he was trying to get out of his chair and they just rushed and forgot to put a gown on.During an observation and interview on 6/24/26 at 2:59 PM, Resident #1's family member was at his bedside and LVN F came into the room and was putting on a gown and gloves. Resident #1's family member asked LVN F what the gown was for and LVN F said they were supposed to be wearing a gown and gloves every time they provided care to Resident #1. Resident #1's family member said the staff never wear a gown while providing care to Resident #1.During an interview on 6/25/26 at 11:23 AM, LVN F said she had worked at the facility for about 12 years. LVN F said EBP was to protect the resident from infections, so staff did not bring in any bugs/infections to resident and to protect themselves also. LVN F said she knew a resident was on EBP by having the PPE cart outside their door and the resident should have some type of paper on the outside of the door to say what time of isolation they were on. LVN F said residents on EBP were any residents with a feeding tube/PEG, wounds, urinary catheters, or any indwelling medical devices. LVN F said staff should be wearing a gown, mask and gloves anytime they entered a resident's room who was on EBP. LVN F said if staff did not wear the required gown and gloves for a resident on EBP, staff could bring in infection and put the resident at risk for bacteria to enter the open areas. LVN F viewed the 6/11/26 video of her in Resident #1's room and she said she did not wear a gown while providing care. LVN F she said his adult brief/pad was soaked with urine and she felt it needed to be taken care of immediately. LVN F said she could tell Resident #1 was soaked and his gown was wet from either urine or sweat. LVN F said she removed his adult brief and put a dry one on him. LVN F said, Oh my, I didn't change my gloves. LVN F said she should had changed her gloves prior to handling Resident #1's feeding tube/PEG tube. LVN F said she could have passed any bacteria from the perineal area (private area) to his feeding/PEG tube and caused an infection. LVN F said Resident #1 was soaked and she changed his adult brief, so he would not continue to soak more and then went and told the aide he needed everything changed. LVN F said Resident #1 appeared he had not been changed in quite a while.During an interview on 6/25/26 at 11:52 AM, the DON viewed the videos and identified the staff members present in the videos. The DON said LVN D should had been wearing a gown and gloves while providing care to Resident #1's PEG tube on the 6/11/26 video beginning at 3:46 AM. The DON said LVN F should had been wearing a gown while providing direct care to Resident #1 on the 6/11/26 beginning at 9:16 AM and LVN F should have changed her gloves after performing incontinent care and prior to providing PEG tube care. The DON said CNA E should had been wearing a gown and should had changed her gloves after providing incontinent care before touching Resident #1, his clean gown, or his bedding in the video on 6/16/26 beginning at 2:25 PM. The DON said CNA E no longer worked at the facility. The DON said CNA C should have been wearing gloves and a gown when she was providing incontinent care to Resident #1 and changed her gloves before touching his bedding in the video on 6/17/26 beginning at 2:22 AM and LVN D should had been wearing a gown also when he assisted to pull Resident #1 up in bed. The DON said CNA A and CNA B should had been wearing a gown while bathing resident #1 and they should had changed their gloves after bathing him, before rubbing him down with oil, and they should had started from the head and worked their way down in the video on 6/17/26 beginning at 9:21 AM. The DON said staff should be changing their gloves when going between the resident's front perineal areas to back perineal areas and change their gloves between each interaction, such as between incontinent care and PEG tube care, when visibly soiled take them off, and when going from bottom to the head they should change their gloves. The DON said if staff were not changing their gloves appropriately, they could spread infection from one area to another. The DON said the purpose of EBP was to prevent possible infection, to prevent whatever was on the staff from getting on the residents with entry ways for infection, such as PEG tubes, PICC lines (long-term intravenous [IV] line inserted into a vein in the arm and ends near the heart), tracheostomies (artificial airways), urinary catheters, and wounds. The DON said the staff knew which residents were on EBP because they had blue name tags, indicating the resident was on EBP. The DON said the sign on the door was not required for residents on EBP. The DON said staff should be wearing a gown and gloves for residents on EBP during hands on care/interactions. The DON said not following the facility's Infection Control and EBP policies, placed the residents at risk for infections. The DON said her staff had been repeatedly in-serviced and she felt like she was beating a dead horse.During an attempted interview on 6/25/26 at 1:13 PM, CNA B was called but there was no answer, the voicemail was full and was unable to leave a message. At 1:14 PM, CNA B returned the call and was informed of the reason for calling and she stated she could not talk at that time and did not know when she would be available and hung up.During an interview on 6/25/26 at 1:28 PM, CNA C said she did not remember not wearing gloves to remove Resident #1's brief on 6/17/26. CNA C said she just removed Resident #1's brief and replaced it, so it would not be the same one on him from the previous shift. CNA C said she had reviewed the EBP policy and it was to prevent the spread of infection and for infection control. CNA C said there was a blue sign if a resident was on EBP. CNA C said if a resident was on EBPs, staff should be wearing a gown, gloves, and a mask. CNA C said the purpose of a resident being on EBP was so staff did not infect them, and they did not infect her. CNA C said she did not know Resident #1 was on EBP. CNA C said the resident could get sicker if staff were not wearing the appropriate PPE and the resident was on EBP. CNA C said staff should change their gloves when they were soiled. CNA C said staff should wash the resident's face first and work down the resident and not go from their bottom up. CNA C said gloves should be changed before touching other items in the room to not spread germs everywhere else.During an attempted interview on 6/25/26 at 1:30 PM, CNA E was called but there was no answer and was unable to leave a voicemail. CNA E was sent a text message on 6/25/26 at 1:32 PM requesting a return call. CNA E did not return call prior to exiting the facility. Per the DON, CNA E no longer worked for the facility.During an attempted interview on 6/25/26 at 1:45 PM, LVN D was called on 6/25/26 at 1:45 PM but there was no answer and was unable to leave a voicemail. LVN D was sent a text message on 6/25/26 at 2:45 PM requesting a return call. LVN D did not return call prior to exiting the facility.During an interview on 6/25/26 at 2:05 PM, the ADM said EBP was to prevent the potential spread of infection from person to person throughout the facility. The ADM said if staff were not following the EBP policy, there was a risk of spreading infection from staff to resident or resident to staff, and to other residents in the facility. The ADM said he expected staff to be following the facility's Infection Control and EBP policies to prevent the potential to spread infection and it was also just uncleanliness. During an interview on 6/25/26 at 2:46 PM, CNA A said neither she nor CNA B wore EBP when they bathed Resident #1 on 6/17/26 and only wore gloves. CNA A said they should have changed their gloves after bathing Resident #1 and before rubbing him down with the oil. CNA A said they should have started putting oil on him with clean gloves and started from his head and worked their way down. CNA A said they should not have used the same gloves they bathed him with to put oil on him because the gloves were dirty and could spread germs and infection and it just was not clean. CNA A said they should have changed their gloves before handling Resident #1's clean linen to prevent the spread of infection. CNA A said it was an infection control issue.Record review of the facility's Training In-service form, dated 5/11/26, with the in-service topic of EBP, Policy & Procedure, with the policy attached to the in-service indicated CNA A and CNA G had signed the in-service form. The in-service did not indicate CNA B, CNA C, LVN D, CNA E, or LVN F had received or signed the in-service.Record review of the facility's policy titled, Infection Control, dated revised February 2025, revealed, . 1. Standard/universal Precautions were intended to prevent the exposure of non-intact skin and mucus membranes of health care workers to other's blood and body fluids. Personnel will routinely use appropriate precautions when contact with the blood or other boy fluids except sweat of any resident was likely . 2. Gloves were an appropriate barrier for protection from blood or body substances likely to soil the hands. Vinyl, latex gloves, or other gloves approved for medical use to provide equal barrier protection . gloves were worn when . 1. Touching blood and body fluids . 2. Touching mucous membranes or non-intact skin of all residents . 3. Touching urine, stool or vomitous of any resident (e.g. while changing linens of incontinent resident; cleaning a resident following incontinence) . 6. Anytime required by the facility Policies and Procedures or regulations . Key Points . 1. B. Gloves were changed if contaminated with blood or body fluids before touching other parts of the same resident . 2. Hands were washed immediately after gloves were removed, before contact with another resident or the environment. May us alcohol-based hand sanitizer if hands were not visibly soiled . 3. Hands were washed or decontaminated prior to donning gloves .Record review of the facility's policy titled, Enhanced Barrier Precautions, dated revised March 2025, revealed, . Many residents in nursing homes are at increased risk of becoming colonized and developing infections with Multidrug-resistant organism (MDROs). This facility utilizes Enhanced Barrier Precautions (EBP) as a strategy to decrease transmission of CDC-targeted and epidemiologically important MDROs when Contact Precautions do not apply . Definitions: . Enhanced Barrier Precautions was not isolation . Standard/Universal Precautions were safety precautions used for every resident. Since you cannot identify every resident who may transmit infection, you must treat all human body fluids as if they were known to be infections . Enhanced Barrier Precautions was in infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities . EBP are used in conjunction with standard precautions and expand the use of PPE (personnel protective equipment) to donning (putting on) of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing . Indications . 1. Infection or colonization with CDC (Centers of Disease Control and Prevention) a targeted MDRO when Contact Precautions do not otherwise apply . 2. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO . c. Indwelling medical device include central lines, urinary catheters, feeding tubes . 3. High contact Resident Care Activities a. Dressing b. Bathing/showering c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use . feeding tube . Communication . 1. Indicate the residents who were on EBP by subtle means, such as an alternate color or the resident's name badge on door, to maintain a home-like environment .

Based on observation, interview, and record review, the facility failed to ensure the right to personal privacy was provided for 1 of 6 residents (Resident #1) reviewed for resident rights.The facility failed to ensure CNA A and CNA B pulled the curtain and covered Resident #1's genitalia while providing a bed bath on 6/17/26.This failure could place residents at risk of humiliation, diminished quality of life, loss of dignity, and self-worth.Findings included:Record review of Resident #1's face sheet, dated 6/24/26, indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #1 had diagnoses including quadriplegia (unable to move body, typically caused from damage to the spinal cord in the neck), gastrostomy (also called PEG tube-soft tube inserted through the skin and abdominal wall directly into the stomach), colostomy (surgical procedure to bring part of the large intestine out through the abdominal wall to an opening on the outside of the body for feces to be collected in a bag), neuromuscular dysfunction of bladder (unable to control urine flow), and aphasia (inability to speak).Record review of Resident #1's quarterly MDS assessment, dated 5/04/2026, indicated he had no speech and was rarely/never understood and sometimes understood others. Resident #1 was unable to complete the BIMS because he was rarely/never understood. Resident #1 was dependent on staff assistance for all ADLs. Resident #1 was always incontinent of urine. Resident #1 did not have bowel incontinence because he had a colostomy.Record review of Resident #1's undated Care Plan indicated he had a problem area of Activities of Daily Living Resident #1 was dependent on staff for all his ADLs.Record review of video footage, dated 6/17/26 beginning at 9:21 AM and ending at 9:24 AM, indicated CNA A and CNA B were bathing Resident #1 in the bed closest to the window, with the window blinds closed. The door to the room was closed, but the curtain was not pulled to block the view of Resident #1 if someone entered the door. Resident #1 was completely naked and fully exposed during the bathing of his front and back sides. CNA A and CNA B did not cover Resident #1's private areas during the bathing process.During an interview on 6/24/26 at 9:19 AM, Resident #1's family member said the staff bathed him like they were washing an object and not a human and left him fully exposed during his bed baths. Resident #1's family representative said staff could at least cover his private parts because no one wants to just lay there fully naked and exposed. Resident #1's family representative said anybody could walk in and the curtain was not pulled.During an observation on 6/24/26 at 2:59 PM, Resident #1 was lying in bed with head of the bed elevated. He appeared clean and no odors were noted. Resident #1 was non-interviewable.During an interview on 6/25/26 11:52 AM, the DON viewed the video dated 6/17/26 beginning at 9:21 AM and she identified the staff members as CNA A and CNA B. The DON said staff should provide privacy for the residents during bathing to promote dignity and to provide a safe space. The DON said CNA A and CNA B should have pulled the curtain and they should have covered Resident #1 with a sheet or towel to cover his genital area. The DON said if staff were bathing the top half of the resident, then they should cover the bottom half of the resident or if they were bathing the bottom half, they should cover the top half of the resident, so they were not just lying there fully exposed. The DON said if it was her family member receiving a bed bath, she would want them covered for dignity and privacy. The DON said she knew it was a dignity issue. The DON said her staff had been repeatedly in-serviced and she felt like she was beating a dead horse.During an interview on 6/25/26 at 2:46 PM, CNA A said her and CNA B bathed Resident #1 on 6/17/26. CNA A said they should have pulled the privacy curtain during Resident #1's bath to provide him privacy if someone walked in the door. CNA A said they should have kept a towel or something over his private areas for privacy and dignity. CNA A said she did not have a reason why they did not pull the curtain or cover his private areas while bathing Resident #1. CNA A said she would not want to be bathed by someone and left fully uncovered for anyone to see. CNA A said it would be a dignity issue.During an attempted interview, CNA B was called on 6/25/26 at 1:13 PM and there was no answer, the voicemail was full and was unable to leave a message. At 1:14 PM, CNA B returned the call and was informed of the reason for calling and she stated she could not talk at that time and did not know when she would be available and hung up.During an interview on 6/25/26 at 2:05 PM, the ADM said if residents were not covered while receiving a bed bath, it created a lack of dignity. The ADM said even if the door was closed, and the curtain was not pulled, someone could walk in and no one would feel comfortable in any state of well-being lying there fully exposed. The ADM said he expected his staff to follow the facility's policies and provide the residents with privacy and be treated with dignity.Record review of the facility's grievance logs for April, May, and June of 2026 did not reveal Resident #1's family had filed a formal grievance/complaint.Record review of the facility's policy titled, Resident Rights, dated revised August 14, 2022, indicated, . The staff will abide by and protect resident rights in accordance with state and federal guidelines. Staff will abide by resident rights as outlined within CMS State Operations Manual Appendix PP.Record review of the facility's policy titled, Bathing, dated revised February 12, 2020, indicated, .Staff will provide bathing services for residents within standard practice guidelines. perform hand hygiene and apply clean gloves. provide privacy and assist the resident to a comfortable position.

Based on observations, interviews and record review the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 4 residents (Resident #1) reviewed for pressure injury.The facility failed to ensure Resident #1 was turned/repositioned at a minimum of every two hours on 6/08/26.The facility failed to ensure Resident #1 had boot style heel protectors on both feet at all times per the physician orders on 6/08/26.The facility failed to provide cushioning/positioning devices between Resident #1's bony prominences (areas of bones that lie close to the skin's surface, with minimal protective cushioning of fat/muscle, including knees, ankles, feet, and heels) of her lower extremities (legs/knees/feet) on 6/08/26.These failures could place residents at risk for deterioration of wounds.Findings included:Record review of Resident #1's face sheet dated 6/08/26 indicated she was [AGE] years old and admitted to the facility on [DATE] initially and re-admitted [DATE]. Resident #1 had diagnoses which included Multiple Sclerosis (MS) (causes breakdown of the protective covering of nerves [transmits electrical and chemical signals throughout the body] which interrupts communication between the brain and the rest of the body and could cause numbness, weakness, trouble walking, vision changes, unable to walk on their own or move at all), polyneuropathy (simultaneous malfunction or damage of multiple peripheral [outside the brain and spinal cord] nerves throughout the body resulting in numbness, tingling, weakness and burning pain, frequently starting in the feet and hands), Heart disease, and history of Myocardial Infarction (heart attack-occurs when blood flow to part of the heart is blocked or severely reduced resulting in heart muscle damage).Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was usually understood and usually understood others. The MDS indicated Resident #1 had a BIMS score of 6 which indicated she had severe cognitive impairment. The MDS indicated Resident #1 had fluctuating inattention and disorganized thinking. The MDS did not indicate Resident #1 refused care. The MDS indicated Resident #1 had functional limitation in range of motion to both lower extremities (hip, knee, ankle and foot). The MDS indicated Resident #1 required substantial/maximal assistance to roll left and right, dressing upper body and was dependent on staff for most other ADLs. The MDS indicated Resident #1 was always incontinent of bladder and frequently incontinent of bowel. The MDS indicated Resident #1 was at risk for pressure ulcers/injuries but did not have any unhealed pressure ulcers/injuries at the time of the assessment. The MDS indicated Resident #1 was on hospice services.Record review of Resident #1's care plan printed 6/08/26 indicated she had a problem area of skin breakdown with the following interventions:Assist resident to turn and reposition frequently.Keep skin clean and moisturized.Inspect skin complete body head to toe every week and document results.Pressure reducing/relieving mattress.Administer skin/wound treatments as ordered.Record review of Resident #1's Active Order Report printed 6/08/26 revealed the following orders:Cleanse area to buttocks with soap and water, pat dry, apply barrier cream PRN with brief changes.Boot-style heel protector device to wear on both feet at all times with a start date of 5/06/26.Cleanse buttock with normal or wound cleaner, pat dry, apply calcium alginate, cover with super absorbent dressing daily on day shift and PRN soiled, saturated, or dislodged with a start date of 5/27/26.Prostat (liquid protein) sugar free 30 ml by mouth daily with a start date of 10/17/25.2.0 Medpass (nutrient dense supplement) 120 ml twice a day with a start date 9/25/25.Record review of Resident #1's skin assessments:4/28/26 indicated redness to her sacral area (area between the lower back bone and the tail bone).5/06/26 indicated redness to her sacral area, redness to her right heel and a scab (protective layer of dried blood and tissue that forms over a wound) to her left heel.5/14/26 indicated redness to her sacral area, redness to her right heel and a scab to her left heel.5/21/26 indicated redness to her sacral area, redness to her right heel and a scab to her left heel.5/26/26 indicated wounds at sacral area and right buttock with measurements of 4.3 cm length, 2.9 cm width, and 0.1 cm deep.5/28/26 indicated two open areas to her buttocks.6/02/26 indicated open area to her sacral area.6/04/26 indicated an open area to her sacral area.Record review of Resident #1's Progress Notes:5/01/26 LVN D documented Resident #1's right leg was showing signs of contracting and hospice was notified.5/06/26 LVN D documented she spoke with hospice regarding skin issues noted during Resident #1's skin assessment and hospice stated to apply heel protectors and keep heels floated as resident would allow.5/29/26 RN A documented she had a stage 2 (partial-thickness skin loss) pressure injury to buttocks.5/6/26-6/05/26 did not reveal any other documentation related to her feet/heels.During an observation and attempted interview on 6/08/26 at 1:30 PM, Resident #1 was lying in bed on her right side. Resident #1 would not or could not answer questions. Resident #1 nodded yes, indicating it was okay to observe her feet, and she was able to raise the covers. Resident #1's legs were pulled up, and her knees were out to her right side at approximately hip level, and her feet were pulled under her buttocks. Resident #1's knees were laid on top of each other allowing skin-to-skin contact. Resident #1's feet were laid on top of each other allowing skin to skin-to-skin contact. Resident #1's heels were pulled up to her buttocks, and her left heel was touching her lower right buttock. Resident #1 was noted to have multiple reddened areas to both feet and there was a dark covering over her left heel and her right heel appeared to be missing a layer of skin. There were no positioning devices or pillows between Resident #1's knees, ankles, or feet. Resident #1 had a large wound dressing in place to her sacral area. Resident #1's protective heel boots were noted to be placed on top of a dresser by the wall across the room.During an observation on 6/08/26 at 2:53 PM, Resident #1 continued to be lying in bed on her right side. Resident #1 nodded yes, indicating it was okay to observe her feet, and she was able to raise the covers. Resident #1's legs continued to be pulled up, and her knees were out to her right side at approximately hip level, and her feet were pulled under her buttocks. Resident #1's knees continued to be laid on top of each other allowing skin-to-skin contact. Resident #1's feet continued to be laid on top of each other allowing skin to skin-to-skin contact. Resident #1's heels continued to be pulled up to her buttocks, and her left heel was touching her lower right buttock. Resident #1 continued to have multiple reddened areas to both feet and there was a dark covering over her left heel, and her right heel appeared to be missing a layer of skin. There continued to be no positioning devices or pillows in place between Resident #1's knees, ankles, or feet. Resident #1 continued to have a large wound dressing in place to her sacral area. Resident #1's protective heel boots continued to be placed on top of a dresser by the wall across the room.During a phone interview on 6/08/26 at 3:16 PM, Resident #1's family member said the wound on Resident #1's bottom was getting better. Resident #1 said the facility got her up into a chair 6/07/26 and that was the first time Resident #1 had been out of bed in a while. Resident #1's family member said around the week of 5/18/26, she saw there was a pressure sore on the side of Resident #1's left heel. She said the skin was closed but it appeared to be a deep tissue pressure wound (serious type of pressure sore caused by prolonged pressure damages the soft tissue beneath the intact skin) and it had a scab. Resident #1's family member said Resident #1's right heel area was red and mushy/soft. Resident #1's family member said an order was obtained for heel protector boots to both of Resident #1's feet at that time.During an observation on 6/08/26 at 4:08 PM, Resident #1 continued to be lying in bed on her right side. Resident #1 nodded yes, indicating it was okay to observe her feet, and she was able to raise the covers. Resident #1's legs continued to be pulled up, and her knees were out to her right side at approximately hip level, and her feet were pulled under her buttocks. Resident #1's knees continued to be laid on top of each other allowing skin-to-skin contact. Resident #1's feet continued to be laid on top of each other allowing skin to skin-to-skin contact. Resident #1's heels continued to be pulled up to her buttocks, and her left heel was touching her lower right buttock. Resident #1 continued to have multiple reddened areas to both feet and there was a dark covering over her left heel, and her right heel appeared to be missing a layer of skin. There continued to be no positioning devices or pillows in place between Resident #1's knees, ankles, or feet. Resident #1 continued to have a large wound dressing in place to her sacral area. Resident #1's protective heel boots continued to be placed on top of a dresser by the wall across the room.During an observation and interview on 6/08/26 at 4:40 PM, Resident #1's family member was at her bedside. Resident #1 continued to be lying in bed on her right side. Resident #1's family member raised Resident #1's covers. Resident #1's legs continued to be pulled up, and her knees were out to her right side at approximately hip level, and her feet were pulled under her buttocks. Resident #1's knees continued to be laid on top of each other allowing skin-to-skin contact. Resident #1's family member lifted Resident #1's top knee and there was a reddened area approximately the size of a quarter to both inner knees. Resident #1's feet continued to be laid on top of each other allowing skin-to-skin contact. Resident #1's heels continued to be pulled up to her buttocks, and her left heel was touching her lower right buttock. Resident #1's family member lifted each foot for better visualization of areas. Resident #1 had a reddened area to the outside of the right great toe approximately the size of a dime. Resident #1 had a reddened area approximately the size of a quarter to the right ball area of the foot just below the great toe with the top layer of skin missing in the approximate size of a nickel with a small dark purple area toward the bottom of the area, it appeared to be dry and without drainage. Resident #1 had a reddened area to the inside middle part of her right foot with an approximate dime size dark purple area with intact skin. Resident #1's right heel had an area covering the base of the heel, that appeared to be missing a layer of skin and had a small dark purple area in the center, it appeared to be dry and without drainage. Resident #1 had a reddened area approximately the size of a nickel on the outside middle area of her right foot. Resident #1 had redness to the back of her left heel with an area approximately the size of a quarter with a dark purple/black covering in the center. Resident #1 had an intact area approximately the size of a dime to the inside of her left lower ankle with redness and a dark purple/black area in the center. There continued to be no positioning devices or pillows in place between Resident #1's knees, ankles, or feet. Resident #1 continued to have a large wound dressing in place to her sacral area. Resident #1's protective heel boots continued to be placed on top of a dresser by the wall across the room. Resident #1's family member said she was a nurse and she knew Resident #1 was on hospice and could be nearing the end of her life. Resident #1's family member said the wounds on her bottom and feet could be Kennedy ulcers (rapidly developing skin wound that can appear during a person's final weeks/hours of life. Resident #1's family member said she knew Resident #1 would refuse to turn/reposition at times and would kick her heel protector boots off at times, but the staff should be turning/repositioning her at least every two hours and trying to cushion between Resident #1's legs/feet and documenting if their efforts failed.During an observation and interview on 6/08/26 at 5:08 PM, Resident #1's family member was at her bedside. Resident #1's family member raised the covers and Resident #1 continued to be lying in bed on her right side. Resident #1's legs continued to be pulled up, and her knees were out to her right side at approximately hip level, but her feet were not pulled as close to her buttocks as previous observations. Resident #1 had her heel protector boots on both feet. Resident #1's family member said the ADON had come in and put Resident #1's heel protector boots on not long ago. Resident #1's knees continued to be laid on top of each other allowing skin-to-skin contact and there were no positioning devices/pillows between Resident #1's knees. During an interview on 6/08/26 at 11:30 AM, RN A said she was the Treatment Nurse. RN A said the floor nurses did the weekly skin assessments on all the residents. RN A said the nurses would let her know when they found new skin issues or if there was a problem with current skin issues. RN A said the wound specialist did not see residents on hospice, unless hospice agreed to it. RN A said if the nurses found a skin issue, they would notify her, but the nurse normally called the provider to get orders and either the nurse or herself would enter the order into the software. RN A said if the resident was on hospice, they had to contact the hospice provider for orders and normally the hospice nurse would come by and assess the wound and give them orders for the wound care.During an interview on 6/08/26 at 12:40 PM, RN B said she worked for Resident #1's hospice service and she had been seeing Resident #1 for some time. RN B said Resident #1 was not able to turn herself at all now. RN B said Resident #1 went from not being contracted in her legs to being completely contracted within about two weeks and Resident #1 would holler out if you tried to straighten her legs. RN B said part of her becoming contracted could be related to her disease process with her MS. RN B said Resident #1 started getting dark spots on her heels, so they started pressure-relieving boots. RN B said Resident #1 would draw her feet up under her. RN B said often when she visited Resident #1, there would not be any pillows between her legs, and her pressure-relieving boots were not on. RN B said the facility let her know that the area on Resident #1's bottom had opened on 5/26/26 and orders were obtained to treat the wound on her bottom. RN B said they encouraged the facility to get the residents up out of bed, turning and repositioning, and using positioning devices/pillows to relieve pressure to areas and help prevent pressure injuries.During an interview on 6/08/26 at 2:58 PM, CNA C said she had worked at the facility for about a month. CNA C said she repositioned and turned residents every two hours and checked them for incontinence during her rounds. CNA C said she had just came in on her shift at 2:00 PM and was just fixing to start her rounds. CNA C said she was assigned to 100 hall (Resident #1's hall). CNA C said to help prevent pressure ulcers, she made sure the residents were clean and dry, kept barrier cream on them, and turned/repositioned residents who were not able to turn themselves, every two hours. CNA C said she may put a pillow between the resident's legs if needed for positioning. CNA C said if she saw a new skin issue, skin tear, skin breakdown, or a pressure sore on a resident, she would tell the nurse or the treatment nurse, so they could address it.During an interview on 6/08/26 at 4:10 PM, LVN D said she had worked at the facility since February 2026. LVN D said she normally worked on 100 hall on the 6 AM to 6 PM shift. LVN D said she rounded on the residents multiple times during the day. LVN D said she did a medication pass every 2 to 2 1/2 hours and peeked in on residents throughout the day. LVN D said she had not seen a problem with residents not being turned/repositioned. LVN D said the residents who could not turn themselves, she double checked to make sure they were being turned routinely. LVN D said she would make sure the heel protector boots were on the resident, if they had an order for them, put something like pillows or folded blankets between those joints such as knees and ankles to keep them from being on top of each other, make sure they are being turned and kept dry, to prevent pressure injuries. LVN D said Resident #1 had her heel protector boots on this morning (6/08/26) when she made her first rounds around 6 AM. LVN D said she did not notice Resident #1 had not had her boots on the rest of her shift. LVN D said to be honest, I did not thoroughly check and had just peaked in on her. LVN D said she had not looked at Resident #1's feet today (6/08/26) because she did not have Resident #1's skin assessment due. LVN D said she thought Resident #1's skin assessments were due on Thursdays. LVN D said Resident #1 was one that if you placed a blanket between her knees/ankles, she could pull it out. LVN D said she would not think Resident #1 could have taken her heel protector boots off. LVN D said Resident #1 liked to lay facing the door and not away from the door was what she had noticed. LVN D said sometimes when they tried to roll Resident #1, she would get frustrated and say no, no that she wanted to stay in a position. LVN D said with no padding in the bony areas, such as knees, ankles, and feet, it could cause skin breakdown, infections, and pressure ulcers. LVN D said it could cause the resident pain and overall decline in the resident's status. LVN D said she was off a couple days and when she came back, she noticed Resident #1 had started pulling her legs up. LVN D said she would try to straighten her legs out and stretch them for Resident #1 and she would say no, no and she would pull them back up. LVN D said Resident #1 was keeping her legs pulled up and then they were not able to straighten her legs without causing her pain.During an interview on 6/08/26 at 5:30 PM, ADON E said she had worked at the facility for about two months. ADON E said she put Resident #1's heel protector boots back on her about 30 minutes ago and Resident #1's family member was in there and said Resident #1 would probably kick them off. ADON E said Resident #1 was eating and she did not reposition her at that time. ADON E said Resident #1 had her boots on her this morning (6/08/26) and then the hospice aide came and bathed her before lunch, she thought. ADON E said they thought the hospice aide must have not put her heel protector boots back on after bathing her. ADON E said she did see the pressure areas to Resident #1's heels as she was placing the boots back on her but was talking to Resident #1's family member and did not really see the other areas. ADON E said staff should be repositioning, off-loading, educating, and padding bony prominences with pillows/boots to help prevent pressure areas. ADON E said if the resident was refusing care such as repositioning and not keeping her boots on, those should be care planned and the family notified. ADON E said if staff were not padding the bony prominence areas, pressure areas could develop or wounds could get worse and could cause the resident pain. During the interview, RN A, the treatment nurse, came in to bring all the measurements of Resident #1's wounds. RN A delivered a piece of paper with hand written measurements with a date of 5/27/26 with 4.3 x 2.9 x 0.1cm. RN A said she did not have any other measurements for the wound on Resident #1's bottom. RN A said she was not providing any care to Resident #1's feet and was only providing treatment to the wound on Resident #1's bottom and left the room. ADON E said she did not know the pressure areas/wounds to her feet and heels were not being addressed until RN A just came and said she was not doing anything to Resident #1's feet. ADON E said she would have thought there was some kind of treatment to feet/heels being done. ADON E said it was everyone's responsibility to ensure the resident was receiving care to their pressure ulcers. ADON E said the floor nurses and then treatment nurse would be responsible for ensuring the resident was receiving care for any identified pressure ulcers. ADON E said she did not really know if they had a system in place to make sure treatments were being done, other than looking in the Treatment Administration Record. ADON E said if there were no orders for wound care/treatment, the TAR would not show anything and that needed to be addressed, for sure, if there were not any orders.During an interview on 6/08/26 at 5:50 PM, the DON said she would expect staff to reposition Resident #1 if she allowed staff to do it. The DON said Resident #1's legs being contracted was something new related to her MS and she could position her upper body herself some. The DON said staff told her Resident #1 had her heel protector boots on that morning (6/08/26) and they thought the hospice aide did not put the boots back on her after bathing her. The DON said the staff should be repositioning residents or at least offering to reposition them every two hours. The DON said there EHR software did not have an area for the CNAs to document if a resident refused to be turned/repositioned. The DON said she would expect Resident #1 to have had some type of cushioning in the areas of breakdown on her feet/heels, if she would allow it. The DON said if a resident was refusing care or to be repositioned, it should be care planned. The DON said without any cushioning of the bony areas, there could be potential for breakdown, and it did not take long to happen and if the resident already had skin breakdown, it could worsen.During an interview on 6/08/26 at 6:06 PM, the ADM said they should routinely change the resident's position from side to side and to the resident's back to help relieve pressure areas. The ADM said hospice was a player in the situation, also with not putting her boots back on after bathing her. The ADM said they should have caught that Resident #1 did not have her heel protector boots on throughout the day, even if the hospice aide had left them off of her after bathing her that morning. The ADM said he would expect, if Resident #1 was refusing care, for it to be care planned. The ADM said if Resident #1 was not repositioned routinely and she did not have her heel protector boots in place or other padding, there could be an added potential for skin breakdown from not being turned and padded.Record review of the facility's policy titled An Overview of Wound Care dated July 2018 indicated . Purpose . To provide guidance for educational purposes about skin and wound care with an emphasis on Pressure Ulcers/Injuries and other common wounds . Pressure ulcers/injuries are mainly caused by increased time of a bony prominence against a surface . These wounds can develop very rapidly and take a long time to close . These wounds are significant and can be attributed to a perception of poor care provided by healthcare institutions and clinicians . the main goal of prevention and treatment is to reduce the amount of time a person is in one position while focusing on bony prominences, while addressing other factors that may increase the amount of risk of breakdown or further problems . can lead to local and systemic infections, increased pain, and death . Repositioning . or relieving constant pressure is a common, effective intervention for an individual with a pressure ulcer/injury or who is at risk of developing one . repositioning is critical for a resident who is immobile or dependent upon staff for repositioning, as the resident is unable to small movements on their own that would help to relieve prolonged pressure to one area . many clinicians recommend position change off-loading hourly for dependent residents who are sitting or who are in a bed or a reclining chair with the head of the bed or back of the chair raised 30 degrees or more . the care plan for a resident who is reclining and is dependent on staff for repositioning should address position changes to maintain the resident's skin integrity . this may include repositioning at least every two hours or more frequently depending upon the resident's condition and specific needs . Pressure Redistribution and Support Surfaces . A resident with severe flexion contractures also may require special attention to effectively reduce pressure on bony prominences or prevent breakdown from skin-to-skin contact . some products serve mainly to provide comfort and reduce friction . heel and elbow protectors . although these products are not effective in redistributing pressure, they (in addition to pillows, foam wedges, or other measures) may be employed to prevent bony prominences from rubbing together or on other surfaces .

Based on observations, interviews, 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 4 residents (Resident #1) reviewed for infection controlThe facility failed to ensure the Treatment Nurse A and ADON C wore appropriate PPE (gown and gloves) while performing wound care on Resident #1 on 05/07/26. Resident #1 was on Enhanced Barrier Precautions also known as EBP (an infection control strategy implemented in nursing homes to reduce the spread of multidrug-resistant organisms also known as MDROs).This failure could place any resident at the facility at risk for cross-contamination and the spread of infection.Finding included:Record review of Resident #1's face sheet, dated 05/07/26 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included, a wedge compression fracture (a spinal injury where the front (anterior) part of a vertebra collapses, creating a wedge-shaped bone while the back remains intact), heart failure (where the heart muscle cannot pump blood effectively to meet the body's needs for oxygen), stroke and high blood pressure. Record review of Resident #1's significant change MDS assessment, dated 03/10/26, indicated Resident #1 understood at times and was sometimes understood by others. Resident #1's BIMS score was 09 which indicated his cognition was moderately impaired. The MDS indicated Resident #1 required assistance with his ADLs. The MDS indicated Resident #1 was always incontinent of bladder. The MDS did not indicate a wound.Record review of Resident #1's comprehensive care plan, dated 05/07/26, indicated, Resident #1 had a non-pressure wound to his lower back. The intervention was for staff to do his treatment as ordered.Record review of Resident #1's Physician order, dated 05/04/26, indicated:*Cleanse wound to lower back with normal saline or wound cleaner. Pat dry. Apply Collagen sheet (medication used for wounds), cover with gauze dressing daily and as needed.*Enhanced barrier precautions every shift.During an observation and attempted interview on 05/07/26 at 11:56 a.m., Resident #1 was lying in his bed. Resident #1 had a cart inside his room which contained gloves, mask, and gowns. Resident #1 also had a blue name tag on his door. Resident #1 did not answer when asked about the cart inside his door, and was not able to say if he had a wound or not. During an observation on 05/07/26 at 12:00 p.m., Treatment Nurse A went into Resident #1's room to perform wound care. She explained what she was going to do, washed her hands, and applied gloves. ADON C assisted Treatment Nurse A to turn Resident #1 on his side. Treatment Nurse A began to perform his wound treatment by removing his old dressing, performed hand hygiene, and applied new gloves. She then cleaned the area, performed hand hygiene, applied new gloves, applied Collagen, and a dressing. Treatment Nurse A nor ADON C wore a gown while performing wound care.During an interview on 05/07/26 at 12:12 p.m., Treatment Nurse A said Resident #1 was on EBP. She said she was supposed to have worn a gown and gloves to prevent the transmission of infection. She said she was aware she needed to wear a gown and gloves, but just forgot. She said she had been in-serviced over infection control. She said she was aware of who required EBP because of the bins inside or outside the door and the residents who had blue tape on their names were the residents who required PPE.During an interview on 05/07/26 at 1:12 p.m., ADON C said she had been employed at the facility for about a week. She said she was not aware she was supposed to wear a gown when performing or assisting Treatment Nurse A with wound care until after they completed the wound care. She said she had been trained on infection control, but since she was new, it did not click in her mind that she and Treatment Nurse A were supposed to wear gowns and gloves while performing wound care. She said Resident #1 had the cart inside his room and his name plate was blue indicating he was on EBP precautions. She said without wearing the proper PPE (gown and gloves), it placed Resident #1 at risk of infection.During an interview on 05/07/26 at 7:55 p.m., ADON B, who was the Infection Preventionist, said he had trained the staff on PPE. He said all staff were supposed to wear PPE while performing care for residents who required EBP. He said he did in-services with staff randomly, and spot checks weekly to ensure residents had name plates that were blue and the carts were either inside their room or outside the door. He said failure for staff to wear PPE (gown and gloves) could cause infection.During an interview on 05/07/26 at 8:09 p.m., the DON said she expected staff to wear gowns and gloves when performing care to residents who required EBP. She said staff were aware if a resident required EBP because their name tag was in blue and the residents had a bin inside or outside their door. She said the infection preventionist oversaw the infection control process. She said she could not recall the last in-service, but believed it was in February of 2026. She said staff should wear proper PPE (gown and gloves) when caring for residents on EBP to prevent infection and cross-contamination.During an interview on 05/07/26 at 8:18 p.m., the Administrator said he expected all staff to wear PPE as needed. The Administrator said the nurse management were responsible for ensuring staff were trained on EPB and infection control. He said by not wearing the proper PPE (gown and gloves), it could place residents at risk for cross-contamination or infection.Record review of the facility's policy titled, Isolation Precautions, dated February 2025, indicated, Policy: To prevent unprotected exposure of residents, visitors, and staff to potentially infectious microorganisms or diseases and to decrease the spread of healthcare or community acquired infections. Enhanced Barrier Precautions: Used when the resident does not require Transmission Based Precautions but-has a higher risk or known colonization with Multi-Drug-Resistant organisms. See Specific Policy for EBP. Record review of the facility's policy titled, Enhanced Barrier Precautions, dated February 2025, indicated, Policy: Many residents in nursing homes are at increased risk of becoming colonized and developing infections with multi-drug-resistant organisms (MDROs). This facility utilizes Enhanced Barrier Precautions (EBP) as a strategy to decrease transmission of CDC-targeted and epidemiologically important MDROs when Contact Precautions do not apply. A. indications.2. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO.3. High Contact Resident Care Activities: included: a. Dressing f. Changing briefs or assisting with toileting. H Wound Care: any skin opening requiring a dressing (not for superficial wounds requiring an adhesive bandage, such as a skin tear or skin break).

Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practices for 1 of 1 resident (Resident #5) reviewed for respiratory care related to tracheostomy care.1. The facility failed to ensure LVN A, who worked for a staffing agency, had the needed competencies/knowledge to care for Resident #5 with a tracheostomy prior to attempting to perform tracheostomy (surgical procedure creating an opening (stoma) into the neck into the trachea (tube-windpipe- that allowed air to pass to and from lungs) to establish an airway)) care and suctioning on 2/25/26 and required surveyor intervention for the safety of the resident.2.The facility failed to ensure LVN A performed intratracheal (directly into the trachea-windpipe-airway) suctioning using sterile technique (used in healthcare to create a completely germ-free environment to prevent the introduction of germs to the resident-sterile items only touch sterile items).3. The facility failed to ensure staff answered the call light when LVN A pushed Resident #5's call light for assistance during tracheostomy care on 2/25/26.4. The facility failed to ensure Resident #5's suction tubing was not on the floor and was not stored unbagged on top of clean supplies in the nightstand drawer on separate occasions on 2/23/26.An Immediate Jeopardy (IJ) situation was identified on 2/25/26 at 5:28 PM. While the IJ was lifted on 2/26/26 at 12:38 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of their corrective systems.Findings included: Record review of Resident #5's face sheet dated 2/26/26 indicated she was [AGE] years old and was admitted to the facility on [DATE]. Resident #5 had diagnoses which included acute respiratory failure, epilepsy (seizures), hypertension (high blood pressure), and traumatic subdural hemorrhage (bleeding between the brain's surface and the lining caused from a head injury), resistance to multiple antibiotics, aphasia (unable to speak), and dysphagia (difficulty swallowing).Record review of Resident #5's admission MDS assessment dated [DATE] indicated she was rarely/never understood and was unable to complete the BIMS interview, which indicated she had severe cognitive impairment. Resident #5 was dependent on staff for all ADLs. Resident #5 had a tracheostomy. Resident #5 received respiratory treatments of suctioning and tracheostomy care.Record review of Resident #5's Care Plan dated 2/24/26 indicated she had impaired verbal communication related to an artificial airway due to tracheostomy, may get congested and need suctioning of tracheostomy, has tracheostomy related respiratory failure.Record review of Resident #5's Order Summary Report dated 2/25/26 indicated an order for trach (tracheostomy) care every shift, cleanse stoma (opening in neck), replace split gauze with an order date of 2/04/2026; may suction as needed for tracheostomy with a start date of 2/04/26; and Resident #5 was on Enhanced Barrier Precautions (EBP).During an observation on 2/23/26 at 11:00 AM, revealed Resident #5 was lying in bed. Resident #5 had a tracheostomy. There was a suction machine on top of the nightstand, and the canister was approximately 1/3 full of pale-yellow fluid. There was suction tubing attached to the suction canister, with a long red rubber tube on the end of the suction tubing lying directly on the floor and it was not bagged. The suction tubing was dated 2/12/26.During an observation on 2/23/26 at 3:45 PM, revealed Resident #5 was lying in bed. The suction machine continued to be on top of the nightstand. There continued to be suction tubing attached to the suction canister, with the same long red rubber tube on the end of the suction tubing dated 2/12/26 lying unbagged in the top drawer of the nightstand on top of clean sealed supplies.During an interview on 2/25/26 at 9:30 AM, the surveyor informed the nurse on the 600 hall, LVN A, of the need to observe tracheostomy care. LVN A said she worked for a staffing agency, and she would ask LVN M who they wanted to do the tracheostomy care and let the surveyor know when they were ready.During an interview on 2/25/26 at 12:15 PM, LVN M told the surveyor LVN A would be performing the tracheostomy care and was ready.During an observation on 2/25/26 beginning at 12:22 PM, revealed LVN A donned (put on) PPE (gloves and gown), washed her hands, and put on non-sterile gloves. LVN A opened a tracheostomy care tray and placed it on top of Resident #5's legs and poured sterile water into the basin of tracheostomy care tray. LVN A then removed Resident #5's inner cannula of her tracheostomy and placed it in the sterile water in the tray and attempted to clean the inner cannula with cleaning brushes included in the tray. LVN A had difficulty trying to remove thick stringy secretions from the inner cannula. LVN A removed her gloves and donned sterile gloves and reached into the nightstand top drawer and grabbed the suction tubing out of a plastic bag. LVN A contaminated her sterile gloves by touching non-sterile items, then opened a suction catheter and connected it to the suction tubing, contaminating the suction catheter by touching with it with contaminated sterile gloves, then suctioned Resident #5's tracheostomy with the contaminated suction catheter. LVN A suctioned a large amount of clear/white thick secretions from Resident #5's tracheostomy. LVN A then unhooked the suction catheter from the suction tubing and placed it on top of the bag it came out of, on top of the nightstand. Then LVN A donned another pair of sterile gloves and contaminated the gloves while putting them on by pulling them up over her sleeves. LVN A attempted to replace the inner cannula with the end of the inner cannula pointing up (upside down). LVN A was forcefully pushing it, and she did not secure the outer cannula at Resident #5's neck and while she pushed the inner cannula, the tracheostomy was pushed backwards. Resident #5 began forcefully coughing and coughed up a large amount of secretions covering the hand of LVN A. LVN A then removed the inner cannula and placed it back into the tray and said, I think I'm going to have to suction her again, but there aren't any more suction tubes. LVN A then looked through the nightstand and said, I don't know. and I'm sorry this is taking so long. LVN A then obtained a pair of gloves out of the top drawer of the nightstand that looked to have been a sterile pair but was not in the sterile packaging and donned them attempting to use sterile technique, and put on the right-hand glove, then touched her ungloved hand with her gloved hand. LVN A then used cotton tip applicators from the tracheostomy tray to clean the inside of Resident #5's outer canula. Resident #5's oxygen saturation (oxygen in blood) ranged from 90 to 97 % during care (considered normal for residents with chronic respiratory issues). LVN A then attempted to replace Resident #5's inner cannula again and had the tip of cannula pointing up and was forcefully pushing the inner cannula without stabilizing the outer cannula, which pushed the tracheostomy backwards. Resident #5 begun forcefully coughing and large amounts of secretions came out of the tracheostomy covering LVN A's hand. LVN A then placed the inner cannula back into the tracheostomy care tray and removed her gloves. LVN A said she needed more supplies and pushed Resident #5's call light at 1:17 PM for assistance. LVN A said, I'm so sorry this is taking so long. and stood there for a few minutes. LVN A then donned new sterile gloves, contaminated top of the gloves while pulling them on by the top of the cuffs and touching her forearm with her gloved fingers and then grabbed the top of each glove with her fingers and pulled the gloves up over her sleeves. LVN A then moved the gauze out of the tracheostomy tray and poured peroxide into the tray. LVN A placed the inner cannula in the peroxide and cleaned it with the peroxide and cleaning brushes and then rinsed it with sterile water. LVN A then shook off the water from the inner cannula and tapped it on the inside of the tracheostomy care tray. LVN A then placed the inner cannula back into the outer cannula and was trying to forcefully push the inner cannula back in with the curve of the inner cannula pointing up without securing the outer cannula, then would pull back some and then try to forcefully push the inner cannula in again, and said multiple times I don't know, I just don't know. for approximately 1 minute. Resident #5 was forcefully coughing, and large amounts of secretions were coming out of the tracheostomy. Observed oxygen saturation at 93%. The surveyor then notified the survey team coordinator via text at 1:38 PM that LVN A needed the assistance of the DON or someone. As LVN A was attempting again to forcefully push the inner cannula into the outer cannula upside down and not stabilizing the outer cannula, the surveyor intervened and questioned LVN A on which way the tip of the inner cannula was pointed. LVN A paused and looked at the tracheostomy and tried to forcefully push the inner cannula upside down again, without stabilizing the outer cannula, as Resident #5 continued to violently cough and large amounts of secretions were being expelled through the tracheostomy tube. At approximately 1:40 PM, the surveyor intervened and asked LVN A to stop and remove the inner cannula and questioned LVN A about how the tracheostomy was positioned in the resident's neck. LVN A then turned the inner cannula over with the tip pointing down and the inner cannula went into the outer cannula easily and it was clicked in place. Resident #5 quit coughing after LVN A had securely inserted the inner cannula. LVN A said, Oh my. I feel awful. I feel so dumb. I should have thought about the anatomy. The DON entered Resident #5's room at 1:50 PM and was informed LVN A had pushed the call light at 1:17 PM for assistance and no one had come. The DON donned a gown and gloves and came into the room and asked LVN A what she needed and LVN A told the DON she needed to suction the resident, and she did not have any suction tubes. The DON left to get supplies. While waiting for the DON to return, LVN A said today (2/25/26) was her first time to work in the facility. LVN A said she worked for a nurse staffing agency. LVN A said, I really feel dumb right now. LVN A said everywhere she had worked before had a respiratory therapist to provide tracheostomy care. At 1:59 PM, Resident #5's oxygen saturation was reading 99% and the resident was asleep. LVN A said she did not think she would suction Resident #5 at that time, since she was resting and her oxygen level was good. LVN A said it had been years since she had done tracheostomy care, and she knew she failed this care miserably. LVN A said she knew Resident #5 was her patient and she should be able to perform all care for her. When the DON returned with supplies, LVN A told her she decided not to suction the resident and let her rest. During an interview on 2/25/26 at 2:15 PM, LVN A said she had received report from the night shift nurse this morning (2/25/26) and she knew she had a resident with a tracheostomy. LVN A said she did not know that she would be the one to do tracheostomy care or suction the resident. LVN A said she had been trained on performing tracheostomy care, but it had been years, a long time. LVN A said the last time she had a resident with a tracheostomy was about a year ago and the facility had a 24-hour respiratory therapist that managed all the tracheostomy care. LVN A said intratracheal suctioning should be a sterile procedure. LVN A said it had probably been at least six years since donning (putting on) sterile gloves. LVN A said she knew she cross-contaminated when putting on her sterile gloves and then did the care before thinking about it. LVN A said she knew she lost her sterile field and contaminated her gloves and the suction catheter. LVN A said using contaminated gloves and a contaminated suction catheter to do intratracheal suctioning could cause bacteria build up and infection in the resident. LVN A said Resident #5 probably felt like she was going to choke when she was trying to push the inner cannula back in upside down and did not stabilize her outer tracheostomy cannula. LVN A said, Then you asked about the curvature of the cannula and how the tracheostomy was positioned in the neck and then I turned it over and it went right in. LVN A said she felt dumb. LVN A said she thought she was just meeting resistance. The surveyor asked LVN A how the care she provided to Resident #5 during tracheostomy care and intratracheal suctioning could have affected Resident #5 and she responded, It's not good.During an interview on 2/25/26 at 5:24 PM, the DON said the staffing agency profile should be set up to say what skills were needed to work at the facility when the account was created. The DON said all she could see in the staffing agency software when choosing nursing staff to work was if they had long-term care experience, their date of birth , name, and a phone number. The DON said she could look at the staff profile in the staffing agency software and see what assessments the potential staff had done in the agency software. The DON said she looked at the potential agency staff's years of experience and whether they had long-term care experience when choosing agency staff. The DON said she was responsible for the facility staff's competencies, and they did them annually and on hire. The DON said she had instructed her staff to make sure that facility staff would do all the skills the surveyors needed to see during the survey. The DON said she had told LVN M to perform the tracheostomy care and she did not know why the agency staff nurse did the tracheostomy care. The DON said she did not even know LVN A was the one doing the tracheostomy care. The DON said LVN A should have gotten someone if she did not know how to perform tracheostomy care. The DON said when she walked into Resident #5's room while LVN A was in there, along with surveyor, she could not hide her eyes because she was not pleased with what she saw when she walked in. The DON said she would not have set the sterile supplies on top of the resident while performing tracheostomy care. The DON said if staff attempted to perform tracheostomy care and were not knowledgeable of tracheostomy care and did not perform the tracheostomy care and suctioning using sterile technique, it could set up the resident for infections. The DON said trying to force the inner cannula of the tracheostomy back in upside down could cause trauma to the airway of Resident #5 and trying to force anything could be detrimental to the resident. The DON said intratracheal suctioning should be a sterile procedure. The DON said the resident could get an infection and overall compromise the respiratory system because you have put something directly into the airway. During an interview on 2/26/26 at 9:27 AM, RN L said she worked 2/23/26 and was Resident #5's nurse on the day shift. RN L said she did not recall seeing a red suction catheter on the floor 2/23/26. RN L said suctioning a tracheostomy was a sterile procedure and she used a new suction catheter each time she suctioned Resident #5. RN L said if a contaminated suction catheter was used to suction a tracheostomy, it could cause a terrible infection. RN L said tracheostomy care started with washing hands and gathering supplies. RN L said the inner cannula had to be rotated in a downward motion until it clicked into place when reinserting the inner cannula. RN L said if she was in the middle of tracheostomy care and the resident went into respiratory distress she would have to yell out for help and do the best she could until help arrived on Hall 600. RN L said if the inner cannula was forcefully pushed back into the outer cannula upside down, it could cause the resident to aspirate (when liquid, food, or other materials accidentally enter the airway and lungs) or cause the resident to go into respiratory distress.Record review of nursing competencies for all nursing staff that performed tracheostomy care for Resident #5 since she admitted to the facility on [DATE] through 2/25/26 indicated all facility nursing staff had been checked off as had met the performance requirements for Tracheostomy Care and Tracheal Suctioning on 8/27/25.A request for LVN A's nursing competencies was made on 2/25/26 at 3:00 PM and 4:15 PM from the Regional Nurse and was not provided with the requested documentation prior to exiting the facility.On 2/25/26 at 11:22 AM, requested a policy related to respiratory care-storage of suction equipment from the Regional Nurse.Interview on 2/26/26 at 2:30 PM, the Regional Nurse said they did not have a policy related to storage of suction equipment.Record review of the facility's policy titled Tracheostomy Care dated reviewed March 2, 2023, indicated . Staff will provide care for residents with a tracheostomy in accordance with standard practice guidelines . Procedure . perform hand hygiene and apply clean gloves . observe for the need of tracheostomy care due to secretions at the stoma site or in the tube . observe the skin around the tracheal stoma, under the tracheal tube, and under tracheal ties for skin breakdown . validate peripheral capillary oxygen saturation (Sp02) through pulse oximetry preoxygenate the resident for 30 seconds . provide suctioning per practice guidelines . use sterile kit for suctioning . emergency sterile tracheostomy equipment of the correct size will be kept at the bedside . replacement inner cannula . suction catheters (tracheal and oral) .Record review of the National Library of Medicine website article titled, Tracheal Trauma - StatPearls - NCBI Bookshelf accessed on 3/04/26 indicated . Tracheal Trauma was uncommon but was typically caused by iatrogenic (adverse, unintended health outcomes caused by medical treatment, errors, or negligence) . most experts believe the incidence of tracheal trauma was underestimated as iatrogenic injuries were underreported . suspicion resulting in early detection of tracheal trauma was one of the most crucial factors for reducing morbidity and mortality . clinical presentation of tracheal trauma may vary depending on the mechanism of injury and involvement of adjacent structures . symptoms included blood-tinged sputum, shortness of breath, . most iatrogenic tracheal injuries tend to occur in the posterior (back) membranous portion of the trachea .This was determined to be an Immediate Jeopardy (IJ) on 2/25/26 at 5:28 PM. The ADM, DON, and the Regional Nurse were notified 2/25/26 at 5:52 PM and provided the IJ template on 2/25/26 at 6:00 PM. The ADM, DON, and Regional Nurse expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested.The following plan of removal submitted by the facility was accepted on 2/26/26 at 10:35 AM:How other residents with the potential to be affected by the same deficient practice would be identified:Any resident with a tracheostomy had the potential to be affected by the deficient practice.What measures would be put in place or what systemic changes would be made to ensure that the deficit practice does not recur:Trach care was completed by LVN A on 2/25/2026. DON performed an assessment at 1:50 PM on 2/25/2026 and resident #5 did not require additional suctioning.DON again assessed Resident#5 for signs and symptoms of respiratory distress on 02/25/2026 at 17:30 with no adverse effects noted. Resident #5 had an order placed by DON/designee to check oxygen saturation hourly for 24 hours for continued monitoring. Regional nurse verified order in place on 2/25/26. DON/Designee notified NP of changes on 2/25/2026. Competency check-off to include sterile technique for suctioning and replacement of inner cannula was performed with LVN A on 2/25/2026.Trach care will be performed on 2/26/26 at 10:30 AM with inner cannula replacement.LVN A (Agency nurse) removed from facility schedule, with last shift being worked on 2/25/2026.Regional Nurse verified DON competency in trach care and sterile technique on suctioning on 2/25/26. Education will be provided to all staff regarding answering call lights in a timely manner by Administrator/designee by 11:59 PM on 2/25/2026. No employee will be allowed to work until education is received.Education and competencies with return demonstration will be provided by DON/Designee to all nursing staff prior to next scheduled shift regarding tracheostomy care. DON/Designee that have had competency verification, will perform competency with return demonstration and education to include sterile technique for suctioning and trach care prior to contract staff working in the facility. DON/designee will maintain list of contract staff that have completed the above competencies and verify competencies are completed prior to starting shift.How the corrective action(s) will be monitored to ensure the deficient practice is being corrected and will not recur (i.e., what program will be put into place to monitor the continued effectiveness of the system changes):Beginning 2/26/2026, DON/designee will observe trach care and sterile technique twice weekly on random nursing staff for 30 days then weekly for three months. Beginning 2/26/2026, DON/designee will do rounds throughout the facility to observe for call light response randomly five times weekly for two weeks then randomly for 30 days.Involvement of Medical Director:Medical Director notified by DON on 2/25/2026. Involvement of QA (Quality Assurance):An Ad Hoc QAPI meeting (created immediately to address a specific, urgent, temporary need) held with the Medical Director, Regional Director of Operations, Director of Nursing, and Regional Nurse Consultant on 2/25/2026. Administrator will forward results of audits monthly to the QAPI Committee for review and/or action.Who is responsible for implementation of process:The Director of Nursing/designee will be responsible for implementation of New Process for monitoring respiratory care. The New Process/ system for respiratory care will be started on 2/25/26 and no employee will be able to return to work until they complete the Inservice. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 2/25/26.The surveyor verification of the Plan of Removal from 2/26/26 was as follows:Record review of the Interdisciplinary Progress Note dated 2/25/26 at 1:50 PM indicated the DON assessed Resident #5 and resident was stable and had no signs of respiratory distress, respirations were even, nonlabored, and no secretions were noted at the trach site.Record review of the Interdisciplinary Progress Note dated 2/25/26 at 5:30 PM indicated the DON assessed Resident #5 and her breaths were even and nonlabored. Respirations were 18 with slightly diminished breath sounds to her left upper lobe of lung and clear all other areas. Resident #5's oxygen saturation was 92 % on oxygen. The DON instructed the assigned floor staff to administer scheduled breathing treatment and reassess breath sounds promptly.Record review of the Active Orders Report for Resident #5 revealed an order for oxygen saturation checks hourly for 24 hours with a start date and time of 2/25/26 at 4:00 PM.Record review of the Interdisciplinary Progress Notes documentation indicated the facility NP was notified of the events during trach care and suctioning, and resident status on 2/25/26 at 3:35 PM.Record review of Respiratory Competency Evaluations for Tracheal Suctioning and Tracheostomy Care revealed LVN A completed it with a Pass circled on 2/25/26 by the Regional Nurse.Observation and interview revealed tracheostomy care was provided on 2/26/26 at 10:30 AM for Resident #5 by LVN AA and the DON. LVN AA knocked, disinfected her hands by washing, set up a clean work area, rewashed her hands, and explained the procedure to the resident. LVN AA took the resident's vitals and listened to her lung sounds stating her lungs were clear. LVN AA rewashed her hands. LVN AA removed the inner cannula and disposed of it. Oxygen saturation was monitored by the DON, by speaking out the oxygen saturation throughout procedure. LVN AA was able to answer questions about sterile procedure. LVN AA donned sterile gloves. LVN AA suctioned and cleaned outer cannula and surrounding tissue and changed tracheostomy tie. LVN AA disposed of her gloves, washed her hands, and applied sterile gloves. LVN AA then inserted a new inner cannula. LVN AA reassessed Resident #5's vital signs including her lung sounds and reapplied her oxygen. Resident #5 was repositioned for comfort. Oxygen Saturation was between 99% and 91% during the procedure. LVN AA was interviewed, and she stated she was in-serviced with return demonstration for tracheostomy care. LVN AA stated she was taught, depending on the resident, she may need to have someone assist to add supplemental oxygen. LVN AA stated she was taught the procedure for suctioning and inner cannula changing was sterile. LVN AA said she was taught about the anatomy of the trachea and not forcing the cannula in. LVN AA stated she was taught to answer all call lights even if there was a staff member in the room.Record review of documentation LVN A (agency nurse) was removed from the facility schedule 2/25/26 and was marked in the agency staffing software as Do Not Return by the ADM related to an issue with tracheostomy care during shift on 2/26/26.Record review of a Respiratory Competency Evaluations for Tracheal Suctioning and Tracheostomy Care were completed with a Pass circled for the DON completed 2/25/26 by the Regional Nurse.Record review of Respiratory Competency Evaluations for Tracheal Suctioning and Tracheostomy Care were completed with a Pass circled for 14 nursing staff (including LVN A and the DON) completed 2/25/26 by the Regional Nurse.Record review of the QAPI Meeting sign-in sheet dated 2/25/26 indicated there were 4 staff members in attendance, including the Regional Nurse, the ADM, the DON, and the MD via phone.Record Review of a Training In-service Form indicated an in-service was held on 2/25/26 with In-service Topics of Call lights: policy and Procedure presented by the DON. The in-service stated . All staff members, both clinical and non-clinical, are responsible for answering call lights to help ensure they are addressed in a timely manner . if non-clinical staff members answer call light and resident requires physical assistance or clinical intervention, the staff member should immediately locate nearest clinical staff member and report need . if a staff member is already in resident's room and call light is on, another staff member should knock on and enter room to check if assistance is needed . if you are in a resident's room and require assistance . if residents are stable, ensure the residents are safe, step out briefly, and locate the nearest available staff member for assistance . if resident is unstable (actively falling, loss of consciousness, respiratory distress, sudden change of condition) remain with the resident and verbally call out/yell for help immediately . The in-service indicated 43 staff had signed the in-service.Record Review of a Training In-service Form indicated an in-service was held on 2/25/26 with In-service Topics of Trach Care, Trach Suctioning; Policy and Procedure with demonstration and returned demonstration presented by the Regional Nurse. The in-service included Respiratory Competency Evaluations for Tracheal Suctioning and Tracheostomy Care were completed with a Pass circled for 14 nurses including the DON and LVN A.During interviews with staff from all departments and across all shifts on 2/26/26 between 10:50 AM and 12:29 PM, with Housekeeper X, Housekeeper EE, Housekeeper ZZ, Laundry BBB, [NAME] XX, DA Y, DA MM, DM, CNA Z, CNA CC, CNA GG, CNA HH, CNA KK, CNA WW, CNA YY, CNA CCC, LVN T, LVN AA, LVN UU, LVN TT, LVN M, LVN AA, MA VV, RN K, RN FF, PT/OT Technician BB, OTA DD, Activity Director, Social Worker, HR Coordinator, Maintenance Supervisor, AC J, BOM AAA, Medical Records/Supply Coordinator Q, and the DON were able to verbalize call lights were everyone's responsibility to answer. They stated if a call light was on, it should have been answered as soon as it was noticed. If they were unable to assist the residents, then they were instructed to find someone who could have assisted the residents, after making sure the resident was safe and stable. They verbalized if they were unable to leave the resident, then they were to call out or use their cell phone to get help.During interview with nurses across all shifts on 2/26/26 between 10:50 AM and 12:29 PM, with LVN T, LVN AA, LVN TT, LVN UU, LVN M, RN K, RN FF, and the DON revealed they were able to verbalize the policy and procedure for tracheostomy care and suctioning. The nurses stated sterile technique was required for tracheostomy suctioning and the inner tracheostomy cannula was to be re-inserted with the tip facing downward. They verbalized they were required to perform tracheostomy care and suctioning check offs by performing a return demonstration.During an interview on 2/26/26 at 12:16 PM, NP DDD said she was notified of Resident #5 having lower oxygen saturation during tracheostomy care. NP DDD said she asked about how Resident #5's current oxygen saturations were, and she was back to her baseline. NP DDD said tracheal suctioning should be a sterile procedure. NP DDD said if tracheal suctioning was not performed sterilely, it could give the resident pneumonia, could lead to multiple organ failure with sepsis (life threating infection in the blood), it could be really bad. NP DDD said the inner cannula of the tracheostomy should have gone back in at an angle and twisted to point down until it clicked securely and the outer cannula should be stabilized to prevent dislodgement while inserting the inner cannula. NP DDD said if the outer cannula was not held securely and the staff member was trying to forcefully push the inner cannula into the tracheostomy upside down, it could cause stretching of the stoma site, causing a leak around the tracheostomy, and could cause damage to the trachea. NP DDD said tracheostomy care should be performed as a sterile procedure to prevent introducing any new bacteria into the resident's airway and causing an infection in the resident.During an interview on 2/26/2026 at 12:42 PM, the MD said intratracheal suctioning had to be done sterile because it could cause a bacterial infection in the resident. The MD said trying to forcefully put the inner tracheal cannula in upside down could cause some soft tissue trauma to the trachea, cause the resident pain, discomfort, and bleeding. The MD said that he did not feel that it would be life threatening. The MD said he was notified of the incident related to Resident #5's tracheostomy care and suctioning and participated in the QAPI meeting last night (2/25/26) and believed they now have a plan in place to prevent further incidents with tracheostomy care.During an interview on 2/26/26 at 2:26 PM, LVN M said she was the Staffing Coordinator. LVN M said she had communicated with DON and the Regional Nurse and told them she did not want to do the tracheostomy care on Resident #5 on 2/25/26 because she was nervous after performing the IV care with a surveyor. LVN M said the Regional Nurse asked LVN A if she was comfortable doing the tracheostomy care and had asked her how long it had been since she had performed tracheostomy care. LVN M said LVN A said it had been some time since she had performed tracheostomy care but did verbalize how to perform the care. LVN M said she even asked LVN A again if she was okay and comfortable with performing the tracheostomy care and LVN A said she would just go ahead and do it. During an interview on 2/26/26 at 2:42 PM, the DON said respiratory care was being re-in-serviced to the nursing staff on tracheostomy care/suctioning before working their next shift. The DON said the agency nurse was DNR (Do Not Return) in the agency staffing software, and hopefully, after next week they would no longer need

Based on observation, interview, and record review, the facility failed to ensure pain management was provided to residents who require such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 resident reviewed for pain management. (Resident #21) The facility failed to ensure Resident #21 had effective pain management by failing to administer routine pain medication timely. This failure could place residents at risk for increased pain and decreased quality of life.Findings included: Record review of an undated face sheet revealed Resident #21 was a [AGE] year-old male admitted on [DATE] with diagnoses of diabetes type II (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar), blindness to one eye, and chronic pain. Record review of a quarterly MDS assessment dated [DATE] revealed Resident #21 had a BIMS score of 15 which indicated no cognitive impairment. It revealed he had no behavior and had not refused care. Resident #21 was independent for ADLs. He was taking high risk medications from the following drug classes; antianxiety, antidepressant, hypnotic, diuretic, opioid, hypoglycemic, and anticonvulsants. Record review of the care plan dated 06/30/2025 revealed Resident #21 had a history of verbally aggressive behavior regarding medication. He has a history of becoming upset/angry when the nurse was not present to give the next pain pill at the exact time it was due to be given again. He has a known history of cursing staff. No care plan was noted for chronic pain, opioid use, or opioid dependence. Record review of 'Physician Orders' dated 06/24/2025 revealed Resident #21 had an order for Oxycodone Hcl 15mg orally every 4 hours for pain. To be administered at 3 a.m., 7 a.m., 11 a.m., 3 p.m., 7 p.m., and 11 p.m. Record review of EHR medication administration times for Resident #21 on 02/23/2026 revealed the following medication due and medication administration times: Oxycodone Hcl 15mg orally every 4 hours: Date: Time Due: Time Administered: Pain Level: Nurse: 02/22/2026 7 a.m. 9:41 a.m. 4 DON02/22/2026 11 a.m. 1:03 p.m. 7 LVN SS02/22/2026 3 p.m. 4:10 p.m. 6 LVN SS02/22/2026 7 p.m. 7:16 p.m. 0 LVN RR During an interview on 02/23/2026 at 11:10 a.m., Resident #21 stated he was extremely upset by the way he was treated over needing pain medication that past weekend. He stated because there was such a staffing shortage, the facility had no nurse show up for the day shift on 02/22/2026 and his pain medication was due at 7:00 a.m. Resident #21 stated he had been dependent on opioids for over 20 years to control his pain, and they must be taken routinely to maintain an acceptable level of pain relief. He stated that when one was missed or administered late his pain level increases rapidly, and it is hard to bring it back under control. He stated the DON was called to work the floor on his hall, but she did not make it to the facility until 8:30 a.m. He stated that when she came into the nurse's station, he approached her and asked if he could have his pain medication that was missed because he was beginning to hurt. Resident #21 stated an acceptable level of pain for him was 3 or less on a scale of 1-10. He stated at that point he was at a 4 or 5. He stated the DON told him she would get to him when she could, but she had to get organized and figure out a way to get back into time compliance with medications for all residents. He stated he waited until 9:00 a.m. and approached her again, this time, on the hall pushing the medication cart. He stated when he asked for his pain medication again, the DON told him she was going by the list in order of room number, and he would get his pain medication when she got to his name on the list. Resident #21 stated he was at a '5 or 6' at the time and it was not unbearable, but he feared it would be by the time she made it to the next to the last room on the hall (Resident #21's room). He stated at 9:30 a.m., he approached her again and she stated she was two rooms from his room, and she would be with him in a few minutes. He stated his pain remained '5 or 6' at this time. Resident #21 stated at 9:40 a.m., the DON approached him with pain medication. He stated he was very upset and cursed at her, but he felt like his pain made him act out of character. He stated he then questioned the DON about the next pain pill that was due in 1 hour and 20 minutes. Resident #21 stated the DON stated he would have to wait as late as possible to take that medication because it would be too close to the oxycodone he took at 9:40 a.m. Resident #21 stated he could not understand why he was treated like his pain did not matter. He stated he stayed in pain for the remainder of the day. He stated he did not miss any more oxycodone, but they were given late to try and get his schedule back on track. He stated his 11 a.m. dose was administered at after 1:00 p.m. and his 3 p.m. dose was late, as well. He stated he did not lose sleep, but felt it unnecessary to make a person in pain, remain in pain, because it was more convenient for the staff to go by room number. He stated he came to her, so she would not have to walk down the hall to him, and she still ignored his pain. During an interview on 02/23/2026 at 3:30 p.m., the DON stated she was called into work on 02/22/2026 and was late arriving. She stated someone called in at the last minute and she did not arrive at the facility until around 8:30 a.m. She stated she started late and Resident #21 was waiting at the nurses' station wanting his pain medication as soon as she arrived. She stated he told her he was in pain and that it was a '4' on a scale of 1-10 and she told him she was going to go down the hall and get all the residents back in time compliance with their medications. She stated he did approach her a few more times wanting his pain medication because he was concerned, he would not get his 11 a.m. dose. The DON stated that pain was an important condition that should be monitored and taken care of by the nurse in a timely manner. She stated she did not feel Resident #21 was in enough pain to cause him any distress by waiting an extra hour to receive his pain medication. She stated she realized pain was subjective. The DON stated pain could cause some people to act aggressively or angrily. She stated he cursed her multiple times, but that had no bearing on when she delivered his pain medication. The DON stated someone came in and took the floor from her around noon on 02/22/2026, and all the medication was in time compliance when she counted the medication cart down with the oncoming nurse. She stated she did not notify the MD of the late administration of medication. During an interview on 02/25/2026 at 9:20 a.m., LVN RR stated Resident #21 told her she should have given his pain medication before she left shift her 02/21/2026 night shift on 02/22/2026 morning. She stated she had not given it to him because he was not up at the nurse's station when she left at 8:00 a.m. She stated she gave him his medication on 02/22/2026 at 7 p.m., and his pain level was a 0. She stated she had to wake him to administer the medication and he was in no distress. During an interview on 02/25/2026 at 10:00 a.m., LVN SS stated she came in to relieve the DON on 02/22/2026. She stated she arrived around 11:50 a.m. and started on the floor a little after noon. She stated she administered Resident #21's 11 a.m. dose of oxycodone around 1:00 p.m. She stated she realized it was late, but she was trying to spread out the time and get his medication back in time compliance without giving him too much medication. She stated she had not notified the MD of the late medication administration. She stated Resident #21 rated his pain 7 on a scale of 1-10, but it was relieved when she followed up with him around 2 p.m. During an interview on 02/25/2026 at 4:00 p.m., the Administrator stated it was the expectation that pain be treated seriously and pain medication be administered timely. She stated late pain medication administration could lead to pain and decreased quality of life. Review of the facility's policy titled 'Pain Management and Basic Comfort Measures' dated 03/27/2023, revealed the staff was to evaluate pain and provide basic comfort measures in accordance with standard practice guidelines.utilize pain level scale to determine acceptable level of pain. No pain-0, Mild 1-3, Moderate 4-6, Severe 7-10, determine intensity.provide pain medication as prescribed by an authorized prescriber.

Based on observations, interviews, and record reviews, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population for 7 (Resident #4,#2,#47,#77,#78,#90 and #104) of 16 residents reviewed for nursing services. The facility failed to have sufficient staff available to provide resident ADL care routinely. This failure could put residents at risk of not receiving necessary care and supervision to maintain their highest practicable physical, mental, and psychosocial wellbeing. Findings Included: 1. Record review of an undated face sheet revealed Resident #4 was a [AGE] year-old male admitted on [DATE] with diagnoses of CVA (cerebral vascular accident [stroke], hemiplegia to right side (paralysis to single side of the body), and vascular ulcers (slow-healing, painful, and often recurring open sores, typically forming around the ankles due to chronic vein disease, such as poor circulation or faulty valves). Record review of a quarterly MDS assessment dated [DATE] revealed Resident #4 had a BIMS score of 15 which indicated no cognitive impairment. It revealed he had no behavior and had not refused care. Resident #4 required partial assistance (helper does less than half the work) for bed mobility, personal hygiene, dressing, and transfer. Record review of the care plan dated 01/15/2026 revealed Resident #4 had a venous stasis ulcer on his right lateral ankle, right medial calf, and a non-pressure ulcer to his right buttock. Record review of the February 2026 ADL sheet reviewed on 02/25/2026, revealed Resident #4 had not been bathed since 02/06/2026 when he received a shower on day shift. No other showers were shown for February 2026. During an observation and interview on 02/23/2026 at 9:30 a.m., Resident #4 stated he had several concerns with his care. He pointed out that he was 6'8 tall and his bed was uncomfortable. Resident #4's feet were hanging over the footboard of the bed. He stated the remote that let the head and feet up and down, had a short in it and had the short for over 2 months. He stated he talked with the maintenance man several times about replacing it, but it had not happened yet, so he was stuck in the position he was in with his head at about 45 degrees. Resident #4 stated that he leaned to the right side and is often left that way for hours before someone comes in and repositioned him. He stated he could reposition himself if he could let the bed up and down, but the remote does not work. Resident #4 was noted to be leaning to the right side lying on his paralyzed arm and hand and his right foot was dropped to the right side. Resident #4 stated he had not received a bath or shower in over 10 days. He stated there was a COVID outbreak in the building and the facility had less than a skeleton crew working and multiple different staff members including the DON told him they did not have time to bathe him. Resident #4 stated he understood he could not leave his room and would settle for a bed bath. He voiced concern over his body odor and stated it was embarrassing to smell like shit and musk. He also stated he requested a shave but not in bed. There was a strong smell of body odor present and overgrown facial hair. Resident #4 was dressed in a burnt orange T shirt with several white and brown stains on the front. Resident #4's sheets were soiled and covered in brown and red stains. Resident #4 stated he had not received his medication over the weekend. He stated the nurse was new and came in and told him she was not going to make it to him in time to give him his medications. He stated this was upsetting to him because he felt the doctor prescribed the medication because they were important to his health. During an observation and interview on 02/23/2025 at 11:00 a.m., Resident #4 stated the food was not edible. He stated it was always very cold like it had been sitting out for hours or days when it was served to him at the end of the hallway. He stated he wasn't sure if they were running out of food or not, but he seemed to get small portions and sometimes the items were burnt or clumped together like they were stuck to the bottom of the pot. Resident #4 continued to be positioned on his right side lying on his right arm and hand. Resident #4 attempted to let his head and feet up or down, but remote would not function. During an observation and interview on 02/23/2025 at 1:20 p.m., Resident #4 continued to be positioned on his right side lying on his paralyzed right arm and hand. Resident #4 stated at least he could not feel the arm and hand, but he would like to be turned and pulled up in the bed because his heel was starting to hurt from resting on the footrest. During an observation on 02/23/2025 at 3:40 p.m., Resident #4 continued to be positioned on his right side lying on his paralyzed right arm and hand. Resident #4's heels were resting on the footboard, and he stated he needed to be pulled up in the bed. He stated he asked the people that brought his lunch tray to pull him up in bed, but they said they were not nurses or aides. During an observation on 02/24/2026 at 9:00 a.m., Resident #4 had on the same burnt orange shirt with food stains covering it and the smell of his body odor was strong throughout the room. Resident #4's sheets had not been changed and were covered with food . During an interview on 02/24/2026 at 2:10 p.m., Resident #4 stated he requested a bed bath that morning and was told he was ascheduled for baths on Monday, Wednesday, Friday. During an observation and interview on 02/25/2026 at 10:10 a.m., Resident #4 stated he had still not gotten a bath. Resident #4 remained in the same burnt orange shirt with stains, and his sheets were the same stained sheets from the previous 2 days. The foul odor of feces and body odor was present upon entering the room. Resident #4 stated now I know if I can smell my sour-ass you can smell me. He stated he really would like to be cleaned up and he was having trouble sleeping with all the crumbs in his bed. During an interview on 02/25/2026 at 11:00 a.m., CNA B stated she was the aide for Resident #4 and was aware it was his bath day. She stated she was the aide for Resident #4 the previous day and she told him it was not his bath day. She stated she knew he needed a bath, but she had several others to do, and she could not physically get all of them done with everything else she had to do. She stated she did not have time to do everything required of her on her shift. CNA B stated she had 22 residents to care for and half of them were COVID positive. She stated she was to feed them 2 meals, keep them clean and dry, turn them every 2 hours, bathe 6-8 of them a day, and chart. She stated that it was an impossible task even if there was no COVID. CNA B stated she did her best to care for the residents. During an interview on 02/25/2026 at 11:45 a.m., LVN C stated she worked as the charge nurse for half of 200, 300, and all of 400 on 02/21/2026 day shift and 02/22/2026 night shift. She stated she would never return to the facility again after the two shifts because it was unsafe for the residents and her nursing license. She stated on 02/21/2026 she gave about 5 of the 39 residents their medications on time, because she was busy answering call lights and assisting the CNA on the hall. She stated there were residents that she did not provide medications because the medications were ordered multiple times daily and she felt it would be dangerous to give the medications too close together. She stated she notified the MD of the medications held. LVN C stated on Sunday night for about 4 hours, there were 4 staff members in the building caring for 88 residents,; included nurses and CNAs. 2. Record review of an undated face sheet revealed Resident #2 was [AGE] years old and admitted to the facility on [DATE] with diagnoses including diabetes, lack of coordination, and age-related physical disability. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and understood others. The MDS indicated Resident #2 had a BIMs of 15 which indicated his cognition was intact. The MDS indicated Resident #2 required substantial to maximal assistance with showers or baths. Record review of Care Plan last revised 12/29/25 indicated Resident #2 had impaired mobility and required assistance with ADLs. There was an intervention to assist the residents with daily living activities as needed. Record review of a CNA Flow Sheet dated 02/01/26 - 02/25/26 indicated Resident #2 had only received a bath on 02/01/26. There were no other baths documented. There was a refusal documented on 02/09/26. During an interview on 02/23/26 at 2:50 p.m., Resident #2 said he had not had a bath in a week. He said he had asked staff for a bath and they told him they did not have time. 3. Record review of the face sheet, dated 02/25/2026, reflected Resident #47 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disorder (COPD) (a progressive lung condition that makes it difficult to breath), and brain and lung cancer. Record review of the admission MDS assessment, dated 01/21/2026, reflected Resident #47 had unclear speech, was understood, and was able to understand others. Resident #47 had a BIMS score of 10, which indicated moderately impaired cognition. The MDS reflected Resident #47 had inattention and disorganized thinking that fluctuated. Resident #47 had no behaviors or refusal of care during the look-back period. The MDS reflected Resident #47 had a functional limitation in range of motion that interfered with daily functions or placed him at risk for injury to one side of his lower extremities, and he used a wheelchair. Resident #47 usually required partial/moderate assistance with showering, which reflected the helper completed less than half of the effort. Record review of the comprehensive care plan, dated 01/20/2026, reflected Resident #47 required assistance with ADLs. The interventions included: assist with daily care needs and daily living tasks and encourage to do as much as possible for self. Record review of the CNA Flow Sheet reviewed on 02/24/2026, dated 02/02/2026 to 02/24/2026, reflected Resident #47 received only one shower on 02/06/2026. During an observation and interview on 02/23/2026 at 9:26 a.m., Resident #47 was lying in bed with the head of his bed elevated slightly. His hair was cut short, and he had white and gray stubble around his mouth, on his cheeks, and his neck. He was wearing an black and yellow shirt. Resident #47 reported he did not always get his scheduled showers. He said he has only received a handful since being admitted to the facility. Resident #47 stated his shower days were Tuesday, Thursday, and Saturday. He said he did not receive his shower on Saturday. During an observation and interview on 02/24/2026 at 10:44 a.m., Resident #47 asked LVN O for a shower. He stated it had been days since he received a shower and he had been asking for it. LVN O said his shower was scheduled for 2 p.m. Resident #47 stated he preferred his showers in the morning time. He was wearing the same clothing from 02/23/2026. During an interview on 02/25/2026 at 2:09 p.m., CNA N stated she worked for agency and had been assigned to Resident #47's hallway. CNA N stated she had only been assigned to the right side of 100 hall, but ended up with all the residents on 100 hall, because staff had called in. CNA N stated it was impossible for her to complete all her assigned tasks including showers. CNA N was unable to remember if Resident #47 received his shower. CNA N said it was important to ensure showers were completed to prevent skin issues. CNA N stated it was important to maintain good hygiene. 4. Record review of an undated face sheet revealed Resident #77 was a [AGE] year-old female admitted on [DATE] with diagnoses of CVA (cerebral vascular accident [stroke], hemiplegia to right side (paralysis to single side of the body), and bipolar disorder (a mental health condition characterized by intense mood swings, alternating between high-energy manic or hypomanic episodes and low-energy depressive episodes). Record review of a quarterly MDS assessment dated [DATE] revealed Resident #77 had a BIMS score of 99 which indicated severe cognitive impairment. She had short- and long-term memory impairment and had moderately impaired decision-making ability. It revealed he had no behavior and had not refused care. Resident #77 required dependent assistance for bed mobility, bathing, personal hygiene, dressing, and transfer. Resident #77 was incontinent of bowel and bladder. Record review of the care plan dated 11/07/2025 revealed Resident #77 was dependent for ADLs and required complete staff assistance for personal hygiene and bathing. Record review of the February 2026 ADL sheet, reviewed on 02/25/2026, printed 02/25/2026 revealed Resident #77 had not been bathed in February of 2026. Resident #77 was scheduled to have a shower on Monday, Wednesday, and Friday. She received 0 of 11 scheduled showers in February. Resident #77's last recorded shower was 01/27/2026 During an observation on 02/23/2025 at 9:40 a.m., Resident #77 had a foul odor of ammonia and body odor. Resident #77 was unable to communicate her last bath. 5. Record review of an undated face sheet revealed Resident #78 was [AGE] years old and admitted to the facility on [DATE] with diagnoses which including quadriplegia (paralysis affecting all four limbs and the torso, typically caused by cervical spinal cord injury), seizures, and high blood pressure. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #78 was sometimes understood and sometimes understood others. The MDS indicated Resident #78 was unable to complete the BIMS interview. The MDS indicated Resident #78 was dependent on staff for all ADLs. Record review of Care Plan last revised 01/07/26 indicated Resident #78 was dependent on staff for all ADLs. There was an intervention to assist the resident with daily care needs and daily living tasks. The care plan indicated the resident had a diagnosis of quadriplegia with an intervention to provide assistance with ADLs. Record review of a CNA Flow Sheet dated 02/01/26 - 02/25/26 did not indicate any baths were given during that time period. The flow sheet did not indicate any refusals from the resident. Record review of an undated photo provided by Resident #78's family member revealed brown rings were on the pad under Resident #78 in his room. During an interview on 02/23/26 at 11:21 a.m., a family member for Resident #78 said he did not always get his baths. The family member said he was not gotten out of bed for showers. During an interview on 02/25/26 at 10:18 a.m., a family member for Resident #78 said the facility was not showering him. The family member said they had to come to the facility to wash and bathe him. The family member said his bottom was not being cleaned good and when she washed him, he was still dirty. The family member said they also had to do his oral care. The family member said they had come to the facility, and his eyes were crusty. The family member said there was dry stuff on his face and boogers coming out of his nose. She said she found brown rings on the pads that were under his bottom. During an interview on 02/25/26 at 11:53 a.m., CNA QQ said they did not have enough staff. She said there were residents that did not get baths because she could not get to them. She said they used to have a shower aide, but she left. She said she had never seen Resident #78 up in the shower. She said she had only known him to get bed baths. She said he had not missed any baths that she was aware of. 6. Record review of an undated face sheet revealed Resident #90 was a [AGE] year-old female admitted on [DATE] with diagnoses of heart failure, obesity, and hypothyroidism (abnormally low activity of the thyroid gland). Record review of an annual MDS assessment dated [DATE] revealed Resident #90 had a BIMS score of 14 indicating intact cognition. She required dependent assistance with ADLs. Resident #90 was incontinent of bowel and bladder. Record review of the February 2026 ADL sheet reviewed 02/25/2026 revealed Resident #90 had not been bathed in February of 2026. Resident #90 was scheduled to have a shower on Monday, Wednesday, and Friday. He received 0 of 11 scheduled showers in February. Record review of the January and February 2026 ADL sheet reviewed 02/25/2026 revealed the following documented number of times incontinent care was performed by staff for Resident #90: January 2026 February 2026-Day shift- 3 times -Day shift- 0 times-Evening shift-13 times -Evening shift-4 times-Night shift- 18 times -Night shift- 18 times During an observation and interview on 02/23/2026 at 9:30 a.m., Resident #90 stated she had not been bathed this month. She stated the facility was short on staff, and one aide cannot bathe all the people on the hall. She stated she knows she smells and her vagina was raw from urine and not getting a bath. She stated it was embarrassing to smell of urine and feel so dirty. Resident #90 stated she would report to the administrator, but he was out sick, and she never got to have a care plan meeting. She stated she had called the ombudsman for advice. Resident #90 stated she was out of things to do to make sure she was getting a bath and she felt defeated. Resident #90 stated she was having a major problem with the staff keeping her clean and dry. She stated on average she was cleaned and dried (incontinent care) once per shift. She stated on 2 occasions, this month, she had gone more than an entire day without being cleaned. She stated the CNAs often put blankets under her to catch the urine and keep the sheets dry. She stated she allowed them to do so because it was better than lying on a wet mattress. Resident #90 stated it had gotten so bad she reached out to the ombudsman because the social worker and DON were not doing anything to remedy the situation. She stated she felt it was her right to be cleaned and dry. She stated she understood that she was a bigger lady, and it took more than one person to perform pericare on her, but she still had the right to be clean and dry. During an observation and interview on 02/24/2026 at 10:45 a.m., CNA B and CNA D entered the room of Resident #90 to perform pericare. CNA B began pericare. During removal of the brief for Resident #90 it was noted the brief was completely saturated and urine visibly leaked from it as it was tucked under the resident to remove it, saturating the sheets. The strong smell of ammonia was present. CNA B stated this was the first time I touched her (Resident #90) today. She stated night shift had to have put the two blankets under her, because she did not double pad people. Resident #90 stated it was the first time she had been changed since around 2:00 a.m. and skin was sore on her thighs, buttock and vagina from being wet so long. During a phone interview on 02/24/2026 at 11:20 a.m., CNA E stated she worked the 2-10 shift. She stated it was hit or miss on having enough staff to get everything done in a shift. She stated the facility paid a $2.00 per hour shift differential to work 2-10 so it was the best staffed shift in the building. CNA E stated, since the beginning of February because of tax season and people receiving their tax returns, staffing had been short at least 2-3 shifts she worked per week to the point she could not bathe the residents she was assigned to bathe. She stated even with enough staff, there were care needs that are left unmet (oral care, hair care, denture cleaning, clipping nails) because it was too much to handle. She stated until about 2 months ago, the facility had a person designated as a shower aide and that took a lot of pressure off the CNAs trying to do all the care for each resident. Since the showers or baths were the responsibility of the floor CNAs, it was not always possible to complete baths, and she rarely was able to chart. During a phone interview on 02/24/2026 at 11:40 a.m., CNA F stated she worked all shifts. She stated the staffing coordinator was constantly asking for her to work over or another shift. She stated day shift was short and night shift was short. She stated the 2-10 shift was staffed well. CNA F stated during night shift, it was impossible to keep everyone clean and dry, and turned. CNA F stated she knew the residents are upset by the amount of time it takes to answer the call light, but when they are in a room, we cannot stop what we are doing to answer the light. She stated, at most, there were 4 CNAs, and nurses did not do CNA work because they had more than enough work of their own to complete. She stated, at best, 2 rounds would be done on each resident. She started her last round around 2:30 a.m. to ensure she got through everyone by 5:30 a.m. She stated it was possible that when day shift came on, the resident had not had incontinent care since 2:30 a.m. CNA F stated not getting incontinent care timely can lead to skin breakdown. During an interview on 02/25/2026 at 2:00 p.m., the Ombudsman stated she had visited Resident #90 and reported her care concerns of not being changed and bathed timely, due to not enough staff, to the DON and Administrator. She stated she told Resident #90 to contact the state and make a complaint against the facility if the care did not improve after letting them know the issues. 7. Record review of an undated face sheet revealed Resident #104 was [AGE] years old and admitted to the facility on [DATE] diagnoses including high blood pressure, malignant neoplasm of larynx (a common head and neck cancer, predominantly squamous cell carcinoma, that affects the voice box), and pain. Record review of Resident #104's electronic medical record accessed on 02/25/26 did not indicate a complete MDS. Record review of a baseline care plan for Resident #104 dated 02/20/26 indicated was independent with decision making skills. No indication of ADL status was noted. Record review on 02/25/2026 of a CNA Flow Sheet for Resident #104 dated 02/20/26 - 02/25/26 did not indicate any baths were given. The flow sheet did not indicate any refusals from the resident. During an interview on 02/25/26 at 10:56 a.m., Resident #104 said he had not had a bath since he was admitted to the facility on [DATE]. He said he had only had a light wipe down. He said at the very least a bed bath would feel good. He said he could not walk so a shower would be hard to do. During an interview on 02/25/2026 at 2:00 p.m., the Staffing Coordinator stated it was her responsibility to schedule CNAs, nurses and medication aides. She stated CNA staffing had been a challenge over the last few months. She stated she often worked as a nurse on the floor or a CNA and that all department heads had a call rotation that required them to work the floor if no one else could be found to work the shift. She stated she was instructed to staff 7 CNAs on day shift, 7 CNAs on evening shift, and 4 CNAs on night shift to stay in budget. She was not familiar with the facility assessment and stated she has never had permission to staff with 9 CNAs on days and evenings. She stated with so many residents in isolation the facility really needed the 9 CNAs on days and evenings. During an interview on 02/25/2026 at 3:00 p.m., the DON stated she was directed by corporate to staff 7 CNAs on days, 7 CNAs on evenings, and 4 CNAs on night shift. She stated she understood those numbers were not met several days in February 2026. She stated there were some vacancies, but corporations were allowing them to use agency to assist with staffing. She stated the acuity of the residents went up drastically over the last couple of weeks related to the COVID outbreak. She stated most of them were not acutely ill, but they still require full PPE isolation, and that is time consuming. She stated there are ads on employment sites with sign on bonuses, they pay shift differential, they are using agency as of 3 days ago, and they have a referral program to assist with getting staff. The DON stated that the census has grown rapidly in the past 2 months and she was not able to hire people fast enough to fill the positions. She stated she felt much of the missed ADL care was related to mismanagement of time. During an interview on 02/25/2026 at 4 p.m., the Administrator stated the facility did not have any written policies or procedures related to staffing levels. She stated the facility went by the acuity level of the residents and census number to determine how many CNAs were assigned each shift. The Administrator stated the facility had 3 CNA vacancies and several staff out with COVID, but they had sign on bonuses and were using staffing (agency) as of 02/21/2026 to supplement the staff. The Administrator stated she was unaware of the facility assessment numbers because she was interim and had not reviewed the data. Record review of the PBJ staffing Data Report indicated the facility triggered for a one-star staff rating (a one-star staffing rating from the Center for Medicare and Medicaid Services [CMS] indicates much below average nursing home staffing levels, based on 6 key measures including RN hours, total nurse hours, weekend staff, and staff turnover. This rating often results from low staffing levels below 155 points, poor retention, and high turnover) for quarter 4 of 2025. Record review of the facility assessment dated [DATE] revealed the following information:The facility typically hadhas the following average number of staff in the departments listed in the table below, in order to meet the staffing requirements and acuity level of residents/patients for the current census. Adjustments are made when the census or acuity levels increase to continue to meet the requirements and the acuity level of the residents. The average census range is 88-96. Certified Nurses' Aide (CNA): Ratio may vary due to resident needs: 9 Per Day shift 9 Per Evening shift 4 Per Night shift Record review of the 'COVID Positive Resident Log' printed on 02/24/2026 revealed 34 active COVID infections requiring isolation. Record review of the 'Detailed Punch Sheet' printed on 02/24/2026 revealed the following numbers of CNAs that worked each shift each day: Date Day Shift Evening Shift Night Shift02/14/26 4 3.5 302/15/26 4 3.5 302/16/26 4 6.5 3.502/17/26 4 8 202/18/26 7 6.5 1.502/19/26 5 3 302/20/26 4 5.5 302/21/26 6 8.5 4.502/22/26 4 4 402/23/26 5 7 2.5 Record review of the daily census on 02/25/2026 revealed an average census of 87 residents for the dates of 02/14/206- 02/23/2026. Requested 'Staffing Policy' from Administrator on 02/25/2026 at 11:00 a.m., and she stated there was not a policy specifically for staffing.

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 13 of 34 residents (Resident's #7, #17, #18, #22, #26, #29, #31, #41, #51, #66, #71, #83, and #85) reviewed for infection control practices.1. The facility failed to ensure facility staff followed infection control protocol during a COVID-19 outbreak at the facility.2. The facility failed to ensure the staff had access to the required PPE supplies for COVID positive rooms on 100 hall, on 02/23/2026, 02/24/2026, and 02/25/2026.3. The facility failed to ensure CNA N wore the required PPE while delivering meal trays to Resident's #7, #17, #18, #22, #26, #51, #66, #71, and #83, who were COVID positive and on droplet/respiratory isolation on 02/23/2026.4. The facility failed to ensure admission Coordinator (AC) J wore the required PPE while delivering a meal tray to Resident #29, who was COVID positive and on droplet/respiratory isolation on 02/23/26.5. The facility failed to ensure admission Coordinator (AC) J washed and sanitized hands after existing Resident 29's room, who was on droplet/respiratory isolation, prior to opening the ice chest on 400 hall and using the ice scoop to get ice in two cups then placed the ice scoop back in the storage area on 02/23/26.6. The facility failed to ensure the Dietary Manager (DM) wore the required PPE while delivering meal trays to Resident #41 and Resident #85 in room [ROOM NUMBER], who were COVID positive and on droplet/respiratory isolation on 02/23/26.7. The facility failed to ensure LVN T wore an N-95 mask and face shield or googles while performing Resident #26's blood sugar check, who was COVID positive, on 02/25/2026.8. The facility failed to ensure LVN T wore an N-95 mask, isolation gown, gloves, and a face shield or googles while in Resident #22's room, who was COVID positive, on 02/25/2026.9. The facility failed to ensure LVN O changed his gloves and performed hand hygiene after checking Resident #31's blood sugar and before administering her enteral tube medication on 02/24/2026.These failures could place residents and staff at risk for cross contamination, the spread of infections, and complications from the spread of COVID-19; an infectious disease.The findings included: 1. Record review of the face sheet, dated 02/25/2026, reflected Resident #7 was a [AGE] year-old male who admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (a progressive lung condition that makes it difficult to breath). Record review of the quarterly MDS assessment, dated 02/21/2026, reflected Resident #7 had unclear speech, was sometimes understood, and was usually able to understand others. Resident #7 had a BIMS score of 5, which indicated severe cognitive impairment. He had no shortness of breath during the look-back period. The MDS reflected he was on isolation precautions for an active infection disease. Record review of the comprehensive care plan, dated 02/17/2026, reflected Resident #7 was on isolation precautions related to COVID. The interventions included: Respiratory/droplet isolation, protective personal equipment to be worn, and infection control practices as indicated. Record review of Resident #7's active orders report, dated 02/26/2026, reflected an order which started 02/18/2026 for Isolation: Droplet/Respiratory. 2. Record review of the face sheet, dated 02/25/2026, reflected Resident #17 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of personal history of COVID-19 and cancer with neutropenia (too few white blood cells). Record review of the quarterly MDS assessment, dated 01/15/2026, reflected Resident #17 had clear speech, was understood, and was usually able to understand others. Resident #17 had a BIMS score of 7, which indicated severe cognitive impairment. Resident #17 had no shortness of breath during the look-back period. Record review of the comprehensive care plan, dated 02/20/2026, reflected Resident #17 was on isolation related to COVID. The interventions included: droplet/respiratory isolation, protective personal equipment to be worn, and infection control practices as indicated. Record review of the active orders report, dated 02/26/2026, reflected Resident #17 had no order for isolation precautions. 3. Record review of the face sheet, dated 02/25/2026, reflected Resident #18 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of non-ST elevation heart attack and neutropenia (too few white blood cells). Record review of the admission MDS assessment, dated 02/102/2026, reflected Resident #18 had clear speech, was understood, and was able to understand others. Resident #18 had a BIMS score of 13, which indicated no cognitive impairment. Resident #18 had no shortness of breath during the look-back period. Record review of the comprehensive care plan, dated 02/17/2026, reflected Resident #18 was on isolation precautions related to COVID. The interventions included: droplet/respiratory isolation, protective personal equipment to be worn, and infection control practices as indicated. Record review of the active orders report, dated 02/26/2026, reflected Resident #18 had an order, which started on 02/18/2026, for Isolation: Droplet/Respiratory. 4. Record review of the face sheet, dated 02/25/2026, reflected Resident #22 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of Non-Hodgkin lymphoma (blood cancer), cancer of the larynx, and COVID-19. Record review of the quarterly MDS assessment, dated 02/23/2026, reflected Resident #22 had clear speech, was understood, and was able to understand others. Resident #22 had a BIMS score of 6, which indicated severe cognitive impairment. Resident #22 had no shortness of breath during the look-back period. The MDS reflected Resident #22 was on isolation precautions for an active infectious disease. Record review of the comprehensive care plan, dated 02/25/2026, reflected 02/25/2026, reflected Resident #22 was on isolation precautions related to COVID. The interventions included: droplet/respiratory isolation, protective personal equipment to be worn, and infection control practices as indicated. Record review of the active orders report, dated 02/26/2026, reflected Resident #22 had an order, which started on 02/18/2026, for Isolation: Droplet/Respiratory. 5. Record review of the face sheet, dated 02/25/2026, reflected Resident #26 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (a progressive lung condition that makes it difficult to breath). Record review of the quarterly MDS assessment, dated 02/20/2026, reflected Resident #26 had clear speech, was understood, and was able to understand others. Resident #26 had a BIMS score of 15, which indicated no cognitive impairment. Resident #26 had shortness of breath while lying flat and was on isolations precautions for an active infectious disease. Record review of the comprehensive care plan, dated 02/17/2026, reflected Resident #26 was on isolation precautions related to COVID. The interventions included: The interventions included: droplet/respiratory isolation, protective personal equipment to be worn, and infection control practices as indicated. Record review of the active orders report, dated 02/26/2026, reflected Resident #26 had an order, which started on 02/16/2026 for Isolation: Respiratory/Droplet. 6. Record review of Resident #29's face sheet dated 02/25/2026 indicated he was [AGE] years old and was admitted to the facility on [DATE] and re-admitted [DATE]. Resident #29 had diagnoses which included non-progressive motor disorder resulting in involuntary, slow, and writhing (twisting) or jerky movements. Record review of Resident #29's annual MDS assessment dated [DATE] indicated he was usually understood and usually understood others. Resident #29 had a BIMS score of 00, which indicated he had severe cognitive impairment. Resident #29 was required set-up or clean-up assistance with eating. Resident #29 required substantial assistance to dependent on staff for most other ADLs. Record review of Resident #29's Care Plan dated 02/25/2026 indicated he was on isolation related to COVID positive with interventions of isolation per physician order, post signs at resident's door informing visitors to check in with licensed staff prior to entering, and protective personal equipment to be worn. Record review of Resident #29's Order Summary Report dated 02/25/2026 indicated an order for droplet/respiratory isolation with a start date of 02/18/2026. Record review of Resident #29's Interdisciplinary progress notes dated 02/18/2026 indicated he had tested positive for COVID-19. 7. Record review of Resident #41's face sheet dated 2/26/26 indicated she was [AGE] years old and was admitted to the facility on [DATE]. Resident #41 had diagnoses which included cerebral palsy (permanent, non-progressive neurological-brain disorder appearing in infancy that affects movement, posture, and muscle tone). Record review of Resident #41's annual MDS assessment dated [DATE] indicated she had a BIMS score of 7, which indicated she had severe cognitive impairment. Resident #41 was independent with eating. Record review of Resident #41's Care Plan dated 2/25/26 indicated she was on isolation related to COVID positive with interventions of droplet/respiratory isolation per physician order, post signs at resident's door informing visitors to check in with licensed staff prior to entering, and protective personal equipment to be worn. Record review of Resident #41's Order Summary Report dated 2/25/26 indicated an order for droplet/respiratory isolation with a start date of 2/18/26. Record review of Resident #41's Interdisciplinary progress notes dated 2/24/26 indicated she was positive for COVID-19. 8. Record review of the face sheet, dated 02/25/2026, reflected Resident #51 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis of cerebral palsy (group of permanent, non-progressive neurological disorders appearing in infancy or early childhood that affects body movement, muscle tone, balance, and posture). Record review of the quarterly MDS assessment, dated 11/27/2025, reflected Resident #51 had no speech, was rarely/never understood by staff, and was sometimes able to understand others. Resident #51's BIMS was unable to be assessed. The staff assessment for mental status reflected Resident #51's long-term and short-term memory was okay. She was able to recall the location of her own room and staff names and faces. Resident #51 had severely impaired decision-making ability. Resident #51 had no shortness of breath during the look-back period. Record review of the comprehensive care plan, dated 02/20/2026, reflected Resident #51 was on isolation precautions related to COVID. The interventions included: The interventions included: droplet/respiratory isolation, protective personal equipment to be worn, and infection control practices as indicated. Record review of the active orders report, dated 02/26/2026, reflected Resident #51 had no order for isolation precautions. 9. Record review of the face sheet, dated 02/25/2026, reflected Resident #66 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis of COVID. Record review of the quarterly MDS assessment, dated 01/23/2026, reflected Resident #66 had clear speech, was understood, and was able to understand others. Resident #66 had a BIMS score of 12, which indicated moderately impaired cognition. Resident #66 had no shortness of breath during the look-back period. Record review of the comprehensive care plan, dated 02/17/2026, reflected Resident #66 was on isolation precautions related to COVID. The interventions included: The interventions included: droplet/respiratory isolation, protective personal equipment to be worn, and infection control practices as indicated. Record review of the active orders report, dated 02/26/2026, reflected Resident #66 had an order, which started on 02/18/2026 for Isolation: Respiratory/Droplet. 10. Record review of the face sheet, dated 02/25/2026, reflected Resident #71 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of fractures to her back and ribs and COVID. Record review of the quarterly MDS assessment, dated 12/04/2025, reflected Resident #71 had clear speech, was understood, and was able to understand others. Resident #71's BIMS assessment was not assessed. Resident #71's short-term and long-term memory was okay. She was able to recall the current season, location of own room, and that she was in a nursing home. She had independent decision-making ability. Resident #71 had no shortness of breath during the look-back period. Record review of the comprehensive care plan, dated 02/20/2026, reflected Resident #71 was on isolation precautions related to COVID. The interventions included: The interventions included: droplet/respiratory isolation, protective personal equipment to be worn, and infection control practices as indicated. Record review of the active orders report, dated 02/26/2026, reflected Resident #71 had no order for isolation precautions. 11. Record review of Resident #85's face sheet dated 02/25/2026 indicated she was [AGE] years old and was admitted to the facility on [DATE] initially and re-admitted on [DATE]. Resident #85 had diagnoses which included hemiplegia (unable to move one side of body) and hemiparesis (weakness of one side of body) following cerebral infarction (stroke-brain tissue damage caused by block blood flow to brain). Record review of Resident #85's reentry MDS assessment dated [DATE] indicated she had a BIMS score of 14, which indicated she was cognitively intact. Resident #85 was independent with eating. Record review of Resident #85's Care Plan dated 02/25/2026 indicated she was on isolation related to COVID positive with interventions of droplet/respiratory isolation per physician order, post signs at resident's door informing visitors to check in with licensed staff prior to entering, and protective personal equipment to be worn. Record review of Resident #85's Order Summary Report dated 02/25/2026 indicated an order for droplet/respiratory isolation with a start date of 02/18/2026. Record review of Resident #85's Interdisciplinary progress notes dated 02/18/2026 indicated she tested positive for COVID-19. During an observation on 02/23/2026 between 12:48 p.m., and 1:10 p.m., CNA N passed meal trays to every room on hall 100 without the use of PPE (gown, gloves, N95 mask, or face shield or goggles) on the COVID positive rooms. CNA N went from COVID positive rooms to COVID negative rooms. Residents #7, #17, #18, #22, #26, #51, #66, and #71 were COVID positive and the use of PPE was required for each room. During an observation on 02/23/2026 beginning at 1:12 p.m., staff were passing meal trays on hall 400. The Dietary Manager (DM) was assisting in passing meal trays and he entered room [ROOM NUMBER]. The room had a sign on the door that read Droplet Precautions - STOP-EVERYONE MUST: CLEAN THEIR HANDS, INCLUDING BEFORE ENTERING AND WHEN LEAVING THE ROOM-Make sure eyes, nose and mouth are fully covered before room entry. Remove face protection before room exit. The DM only wore a KN95 mask (high-efficiency, disposable respirators) and did not wear gloves, gown, or face shield/goggles. The DM took a meal tray into room [ROOM NUMBER] and then carried out a meal tray and then touched the meal cart with his fingers of right hand looking at meal labels and then carried the meal tray down the hallway toward the kitchen. The DM did not sanitize his hands when he came out of room [ROOM NUMBER]. Then at 1:17 PM, the DM returned carrying a meal tray and re-entered room [ROOM NUMBER], only wearing a KN95 mask, no gloves, gown, or face shield/goggles and delivered a meal tray to Resident #85. The DM then exited the room and sanitized his hands. The DM then re-entered room [ROOM NUMBER] wearing only a KN95 mask, no gloves, gown, or face shield/goggles, and delivered a meal tray to Resident #41 and set up items on the bedside table and then brought a cup out of the room and carried it down the hallway toward the kitchen. The DM did not sanitize his hands when he came out of the room. Then at 1:23 PM, the DM went back into room [ROOM NUMBER] wearing only a KN95 mask, no gloves, gown, or face shield/goggles, with another cup, delivered it to Resident #41, and came out and sanitized his hands. At 1:25 PM, AC J was assisting in passing meal trays on hall 400. AC J took a meal tray into room [ROOM NUMBER] (Resident #29) and placed on his bedside table, wearing only a surgical mask, no gloves, gown, or face shield/goggles. There was a sign on the door of room [ROOM NUMBER] that read Droplet Precautions - STOP-EVERYONE MUST: CLEAN THEIR HANDS, INCLUDING BEFORE ENTERING AND WHEN LEAVING THE ROOM-Make sure eyes, nose and mouth are fully covered before room entry. Remove face protection before room exit. Then LVN G donned required PPE and pulled the meal cart with the roommate's tray to the doorway of room [ROOM NUMBER] and met AC J as she was exiting the room. LVN G then handed AC J two cups off the meal tray and asked AC J to put ice in the cups. AC J took the cups without sanitizing her hands after exiting the room. AC J then went to the ice chest on the 400 hall, pulled the ice scoop from the side pocket and proceeded to fill both cups with ice. AC J placed the scoop back in the storage area and returned the cups to LVN G. AC J then sanitized her hands. At 1:27 PM, the DM returned and took a cup of water into room [ROOM NUMBER], only wearing a KN95 mask; no gown, gloves, or face shield/goggles. The DM then came out of room [ROOM NUMBER] and sanitized his hands. During an observation on 02/23/2026 between 2:15 p.m., and 3:30 p.m., the following was observed: Resident #22, who was COVID positive, had no gloves or N-95 masks inside the PPE supply cart in his room. Resident #51, who was COVID positive, had no face shield or goggles, or N-95 masks inside the PPE supply cart in her room. Resident #17 and Resident #83, who were COVID positive, had no face shield or goggles, or N-95 masks inside the PPE supply cart in the hallway. Resident #7, who was COVID positive, had no gloves, face shield or goggles, or N-95 masks inside the PPE supply cart in the hallway. During an observation and interview on 02/25/2026 at 6:23 a.m., LVN T entered Resident #26's room wearing a KN-95 mask with no face shield or goggles. LVN T stated a KN-95 mask was appropriate to wear inside a COVID positive room and a face shield or goggles were optional. She stated there was no difference between the N-95 mask or the KN-95 mask. During an observation on 02/26/2026 at 10:00 a.m., LVN T was in Resident #22's room with a surgical mask, no isolation gown, no gloves, no face shield or goggles. She was assisting him with items on his bedside table. 12. Record review of the face sheet, dated 02/25/2026, reflected Resident #31 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of gastrointestinal hemorrhage (bleeding in the stomach or intestinal tract), dysphagia (difficulty swallowing), and gastrostomy status (surgically created opening in the stomach wall). Record review of the quarterly MDS assessment, dated 07/14/2026, reflected Resident #31 had clear speech, was usually understood, and was sometimes able to understand others. Resident #31 had a BIMS score of 03, which indicated severe cognitive impairment. The MDS reflected Resident #31 had a feeding tube and received 51% or greater total calories through the feeding tube. Record review of the comprehensive care plan, dated 10/17/3025, reflected Resident #31 had a feeding tube necessary for nutritional needs due to dysphagia. The interventions included: monitor for tube dislodgment, blockage, or leakage; monitor feeding tube site for redness or signs of infection; and observed tube placement before each feeding. Record review of Resident #31's active orders report, dated 02/26/2026, reflected an order which started 09/05/2025 for lorazepam 0.5 mg tablet via enteral tube three times a day, hold for sedation. Record review of the MAR, dated February 2026, reflected Resident #31 received lorazepam 0.5 mg via enteral tube three times a day. During an observation on 02/24/2026 at 11:28 a.m., LVN O checked Resident #31's blood sugar. After he was finished checking Resident #31's blood sugar, he continued proving care. LVN O administered Resident #31's medications with the same gloves used to check her blood sugar. During an interview on 02/24/2026 at 11:43 a.m., LVN O stated he normally changes gloves after checking Resident #31's blood sugar, but he was nervous with the surveyor watching him. LVN O stated it was important to ensure he changed his gloves and performed hand hygiene to prevent the spread of germs. LVN O stated gown, gloves, and an N-95 mask were required in COVID positive rooms. He said the face shield or goggles were optional. He stated he was unsure why there were no PPE supplies available on the 100 hall. He was unsure where to get PPE supplies or who stocked them. LVN O stated he was unsure if it was okay to take meal trays inside a room with no PPE. He stated it was important to wear the required PPE inside a COVID positive room to keep the residents safe and not bring any germs back out of the room. During an interview on 02/25/2026 at 11:48 a.m., AC J said she had worked at the facility for 5-6 years. AC J said she had not received any formal training on passing meal trays. AC J said she had received training on what PPE was required to go into COVID positive rooms, but it had been a while. AC J said staff must wear a gown, gloves, and a mask to go into a COVID positive rooms. AC J said she knew she had messed up and did not wear the appropriate PPE into Resident #29's room. AC J said she knew residents were COVID positive because there was a sign on the door of the residents. AC J said she took Resident #29's meal tray in and sat it on the over bed table and left the room. AC J said she realized she was not wearing the appropriate PPE when the LVN G came in the room with all the PPE on. AC J said she did not sanitize her hands when she went to the ice chest and filled the cups with ice. AC J said by not wearing the appropriate PPE or sanitizing her hands, she could have transferred germs to the ice chest/scoop and anything she touched. During an interview of 02/25/2026 at 11:58 a.m., RN K said she had worked at the facility for eight months. RN K said suction tubing/catheters should definitely not be in the floor. RN K said the red catheter should have been discarded if it was on the floor and not placed in the drawer with her clean supplies. RN K said by placing it in the drawer uncovered contaminated everything in the drawer. RN K said if someone did use the suction catheter that had been on the floor and placed uncovered in the drawer to suction Resident #5's tracheostomy, it could have introduced microorganisms and placed the resident at risk for infection. RN K said gloves, gowns, masks (N95), eye shield or goggles were required to enter a room with COVID positive residents. RN K said the required PPE was for droplet precautions so if the resident sneezed or coughed, it kept the droplets from getting on the staff's clothes, in their mucus membranes, and their hands. RN K said not wearing proper PPE could potentially spread the disease to other residents, the staff could get sick, and they could carry disease outside the building. During an interview on 02/25/2026 at 2:09 p.m., CNA N stated she was from agency staffing and did not believe she had to wear PPE inside a COVID positive room anymore, while passing meal trays. She stated she was passing meals trays again at the facility on 02/24/2026 and sought clarification from two different staff members, and each one told her something different. She said she ended up wearing PPE to pass trays on the second day. She stated the required PPE was a gown, KN-95 mask, and gloves. She said a regular surgical mask could have been worn. She stated she did not wear a face shield or goggles because they were not available. During an interview on 02/26/2026 at 10:20 a.m., the DM said he had worked at the facility for four months. The DM said to go into COVID positive rooms, staff were supposed to wear a gown, gloves, and whatever was in the bucket, and they should change their mask when coming out of the room and wash/sanitize their hands. The DM said he did not recall seeing the sign on room [ROOM NUMBER]'s door of being on isolation. The DM said not wearing appropriate PPE in rooms with COVID positive residents could make other residents sick as well. During an interview on 02/26/2026 at 12:53 p.m., the ADON said he was the Infection Preventionist. The ADON said staff should wear a gown, gloves, face shield or goggles, and an N95 mask when entering a room with COVID positive residents on Droplet/respiratory isolation. The ADON said he did not know the difference between KN95 or N95 masks. The ADON said, as the Infection Preventionist, he made sure signs were on the doors, isolation carts were outside the room or nearby, because they did not have enough for all the COVID positive rooms, and for testing staff and residents. The ADON said he was currently out sick with COVID. The ADON said the DON was doing the Infection Preventionist duties in his absence. The ADON said it had been all hands-on deck because they had so many staff out sick. The ADON said it was everyone's responsibility to ensure the isolation carts were stocked with required PPE and if items were needed to let someone know. The ADON said he did an in-service with all staff at shift change at the beginning of the COVID outbreak related to COVID. The ADON said not wearing proper PPE in COVID rooms and going from positive rooms to negative rooms would spread the infection and cross-contaminated rooms. During an interview on 02/26/2026 at 1:28 p.m., the DON stated she expected the staff to ensure infection control protocol was being followed according to the policy and procedures. She stated she expected the staff to ensure they were changing gloves and performing hand hygiene. She stated if the staff were unsure about what PPE to wear inside a COVID positive room, they should have asked. She stated the staff should have had access to the PPE supplies, but if they did not, she expected them to ask her. She stated she expected to be notified if PPE supplies were unavailable. She stated the required PPE inside a COVID positive room was a gown, gloves, N-95 mask, and a face shield or goggles. She stated she was unsure if there was a difference between a KN-95 mask or an N-95 mask. The DON said it was important to ensure infection control practices were followed to protect the staff and other residents from the spread of infection. She said the infection control preventionist was responsible for monitoring to ensure infection control practices were followed. During an interview on 02/26/2026 at 2:03 p.m., the Regional Administrator stated she expected the staff to ensure infection control policies and procedures were followed. She stated clinical management was responsible for monitoring to ensure infection control policies were followed. She said it was important to ensure infection control policies were followed to minimize the spread of infection. During an interview on 02/26/2026 at 2:26 p.m., LVN M said she was the staffing coordinator. LVN M said goggles/face shield, gown, gloves, mask or N95 should be worn in a room with COVID positive residents and then trash the mask when coming out of the room. LVN M said staff should wash/sanitize their hands prior to getting ice from the ice chest on the hall. LVN M said staff should have dumped the ice and sanitized the ice chest once it was determined it was contaminated. LVN M said not wearing appropriate PPE and not sanitizing hands after entering a COVID positive room, was an infection control issue and could spread COVID to other residents. During an interview on 02/26/2026 at 2:42 p.m., the DON said, at that time, during the COVID outbreak, all staff should be wearing a mask, including kitchen staff. The DON said all staff were wearing masks to protect other staff and residents. The DON said COVID spread like wildfire in the facility because a lot of the positive cases did not have any symptoms. During an interview on 02/26/2026 at 3:03 p.m., the Regional Administrator said she would expect staff to follow the policies of the facility. The Regional Administrator said if staff were not wearing appropriate PPE in COVID positive rooms, it could spread illness. Record review of the resident COVID testing log, dated 02/17/2026, 02/20/2206, and 02/24/2026, reflected 34 residents were COVID positive. Record review of the Coronavirus policy, dated March 2025, reflected .PPE.N95 along with goggles or face shield will be used for all COVID isolations residents.KN95s with goggles or face shield may be used for source control in all other rooms/areas not containing COVID-19.the required PPE for COVID-19 isolation rooms or when providing care or services to a COVID-19 positive resident or a resident suspected of having COVID-19, staff should wear an N95 mask, face shield or googles, gown, and gloves. Record review of the Isolation Precautions policy, dated February 2025, reflected Modified Isolation Precautions: Intended to prevent the transmission of novel or high consequence pathogens that could be easily disseminated or transmitted from person to person, for which methods of transmission are still under investigation, and/or for which there may be potential for high morbidity/mortality. This could include pathogens such as COVID-19.Modified Isolation Precautions. all personnel entering the room must wear isolation downs, gloves, N95/KN95 mask, and eye protection. Record review of the Infection Prevention, Control, and Surveillance policy, dated February 2025, reflected .handwashing is monitored by direct surveillance of persons performing their normal job functions.Appendix B Hand Hygiene. activity included: . After performing personal care for residents . after handling soiled items.after removing gloves. before handling medication. before handling food.between dirty and clean procedures.

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 the facility's only kitchen reviewed for food safety requirements.1. The facility failed to label and securely store a large white opened bag containing tan/brown granulated particles (identified as breadcrumbs by [NAME] LL) on 2/23/26.2. The facility failed to ensure DA MM wore a beard covering to cover facial hair while in the kitchen or a mask on 2/23/26 and 2/24/26.3. The facility failed to ensure [NAME] NN performed hand hygiene after pulling up her mask multiple times while preparing pureed (smooth pudding-like) foods on 2/24/26.4. The facility failed to ensure DA OO and DA PP performed hand hygiene after taking a meal ticket from a resident and a meal ticket from a staff member back into the kitchen on 2/24/26.5. The facility failed to ensure DA OO performed hand hygiene after pulling up his mask twice while prepping meal trays during meal service on 2/24/26.These failures could place residents at risk of food contamination and spread of illness.Findings included:During initial tour observations and interviews in the kitchen on 2/23/26 beginning at 9:10 AM, there was a large white paper bag of tan/brown granulated particles in a plastic trash bag lying flat on the bottom shelf of the dry pantry. The bag was not labeled or securely closed and was open to air with a piece of blue tape, with 1/4/26 wrote on it. [NAME] LL said it was breadcrumbs and the bag should have been tied up or the contents of the bag placed in a container. [NAME] LL said she had been off the weekend and did not know when the last time the bag had been used to feed the residents. [NAME] LL said with the bag of breadcrumbs being left open, anything such as bugs could get in it and it could make the residents sick. The DM entered the dry pantry, and he said the date on the bag was the date the bag was opened. The DM said the bag of breadcrumbs should be in a storage container or at least tied up securely to keep bugs out because it could make the residents sick. All staff in the kitchen were wearing masks, except DA MM. DA MM also was not wearing any facial covering to cover his approximately 1/2-inch mustache or sideburns. DA MM was preparing/pouring glasses of tea and water and placing on meal trays. Surveyor asked DA MM why everyone else was wearing a mask in the kitchen, he said he should be wearing a mask also due to the COVID outbreak to not spread germs or COVID. DA MM said if they were not in a COVID outbreak, he should have been wearing a beard cover to keep hair out of the residents' food. DA MM said not wearing a mask or not wearing a beard cover could make the residents' sick.During an observation and interviews on 2/24/26 beginning at 10:34 AM, [NAME] NN prepared pureed foods. [NAME] NN dipped noodles from a pot on the stove into a pan to bring to the blender. [NAME] NN used her right hand three times to pull up her mask and then proceeded to dip the noodles into the blender. [NAME] NN then placed the scoop inside the pan of noodles, and the scoop handle fell into the noodles when she left to go get milk. [NAME] NN microwaved the milk, and said the recipe required the milk to be warm. [NAME] NN then blended the noodles and milk; then [NAME] NN said the consistency was too thin. [NAME] NN then used the same scoop to add more noodles to the mixture. [NAME] NN washed her hands after washing the blender. [NAME] NN used her bare right hand to pull up her mask over her nose, then got the clean blender bowl, set it on the blender, and placed the blade inside the bowl with her same right bare hand.During on observation on 2/24/26 at 11:52 AM, DA MM came from the back of the kitchen and walked through the kitchen, out the doors into the dining area, and walked to the front area of the facility and without wearing a mask or a beard cover. DA MM then came back to the kitchen and put on a mask. DA MM had approximately 1/2-inch mustache and sideburns.During an observation on 2/24/26 at 12:00 PM, DA OO wrapped silverware and placed it on meal trays, added condiments, placed the cover over the food, and placed the meal trays on the meal cart on the opposite side of the food line. A resident came to the kitchen door and requested an alternate meal and handed her meal ticket to DA OO. and he handed the meal ticket to DA PP, who was setting up the meal trays with drinks and desserts, and placed the meal trays on the food line. DA PP handed the meal ticket to the DM. DA OO and DA PP did not wash or sanitize their hands after handling the meal ticket, continued to set up the meal trays, and placed them on the meal cart to be delivered to the other residents.During an observation on 12/24/26 at 12:17 PM, DA OO pulled his mask up twice, did not wash or sanitize his hands, continued setting up meal trays, wrapping silverware, adding condiments, covering the food, and placing the meal trays on the meal cart.During an observation on 12/24/26 at 12:37 PM, a staff member brought another resident's meal ticket to the kitchen and handed it to DA OO, and he handed it to DA PP. DA PP placed the meal ticket on a wire shelf in front of her. DA OO and DA PP did not wash or sanitize their hands after handling the meal ticket brought in from outside the kitchen and continued prepping meal trays for other residents.During an interview on 2/26/26 at 10:20 AM, the DM said he had worked at the facility for four months. The DM said the cook on Monday had opened the breadcrumbs to make pureed bread and forgot to close it back. The DM said the bag of breadcrumbs should have been tied up securely and labeled with an expiration date as well as an open date. The DM said staff should wash their hands after touching their face or anything. The DM not washing your hands after touching your face or mask would be cross-contamination and could make residents sick. The DM said when kitchen staff took a meal ticket from a resident or staff from outside the kitchen, it was cross-contamination and staff should have washed or sanitized their hands or let him know to help after touching the meal ticket. The DM said DA MM had worked at the facility for two months and DA MM did not know he could get a beard cover from his office when they were out where the beard covers were normally kept outside the kitchen. The DM said DA MM should have been wearing a mask in the kitchen, and the DM said he was supposed to have gotten DA MM one, but he had forgotten. The DM said if staff were not wearing masks during the COVID outbreak, it could make residents sick along with his staff as well. The DM said he would discuss the issues with DA MM.During an interview on 2/26/26 at 12:47 PM, DA PP said she had worked at the facility for about a year. DA PP said handling a meal ticket given back to them from a resident or staff member from outside the kitchen and not washing or sanitizing their hands during meal service was cross-contamination and could spread infection, especially with this COVID outbreak. DA PP said she knew not to accept a meal tray back into the kitchen, and she did not think about a piece of paper but could see where that was also cross-contamination. DA PP said staff should always wash or sanitize hands after touching their face, especially with this COVID now with the mask.An attempt was made to contact DA OO on 2/26/26 at 12:50 PM by phone. There was no answer and inability to leave a voicemail due to the mailbox being full. A detailed text message was sent, requesting a returned call. DA OO did not respond prior to exiting the facility.During an interview on 2/26/26 at 1:21 PM, [NAME] NN said she was aware she pulled up her mask multiple times and tried to wash her hands every time, but knew that she failed that too. [NAME] NN said she had been tested for COVID the last day she worked and it was negative. [NAME] NN said she had been sick and feeling bad all week. [NAME] NN said not washing or sanitizing hands after pulling her mask up caused cross-contamination and could make residents sick.During an interview on 2/26/26 at 1:52 PM, the [NAME] President of Nutrition said she did not observe the staff handling their masks and meal tickets from outside the kitchen and not washing or sanitizing their hands. The [NAME] President of Nutrition said their policy was anytime staff touch their face; they should wash their hands and change gloves. The [NAME] President of Nutrition said to refer to the ADON in regard to staff wearing masks in the kitchen. The [NAME] President of Nutrition said their policy said all facial hair should be covered with a restraint. The [NAME] President of Nutrition said staff should wash their hands anytime they changed tasks or washed anything to prevent cross-contamination.During an interview on 2/26/26 at 2:42 PM, the DON said she was responsible for ensuring Infection Prevention was being done in the absence of the ADON. The DON said at that time, all staff should be wearing masks, including kitchen staff. The DON said all staff were wearing masks to protect other staff and the residents. The DON said COVID was like a wildfire in the facility because a lot of the positive cases did not have any symptoms.During an interview on 2/26/26 at 3:03 PM, the ADM said she would expect staff to follow the policies of the facility in the kitchen. The ADM said not following proper sanitation in the kitchen could cross-contaminate and spread germs and illness. The ADM said they recommended staff to wear masks in the facility during the COVID outbreak, but they were not required.Record review of the facility's policy titled Food Storage dated revised February 6, 2024, indicated . Sufficient storage facilities are provided to keep food safe, wholesome, and appetizing. Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination . 1. Storeroom: . Air-tight containers or bags are used for all opened packages of food . All containers are accurately labeled with the item and the date opened .Record review of the facility's policy titled General Food Preparation and Handling dated revised February 6, 2024, indicated . Food items are prepared to conserve maximum nutritive value, develop and enhance flavor and to be free of harmful organisms and substances . 4. Food is prepared with clean tongs, scoops . to avoid manual contact of prepared foods .Record review of the facility's Nutrition Services policy titled Employee Infection Control dated revised April 8, 2025, indicated . All local, state, and federal standards and regulations are followed to ensure a safe and sanitary Nutrition Service Department . 1. Employees that have symptoms of communicable diseases . are not permitted to work in the kitchen . 5. Anyone who enters the kitchen will have all hair restrained using mesh or net bouffant caps and beard guards (as needed) . 7. Employees will wash their hands before handling food in preparation .Record review of the facility's Infection Control policy titled Coronavirus 2-2019;SARS-CoV-2; COVID-19 dated revised March 2025, did not address the use of masks as source control (prevention) during COVID outbreak.

Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 7 of 19 residents (Resident #2, Resident #4, Resident #9, Resident #21, Resident #33, Resident #61, Resident #81) and 7 anonymous residents reviewed palatable food. 1. The facility failed to ensure residents received food that was palatable. 2. The facility failed to ensure residents received food with an appetizing appearance, texture, and appropriate temperature.These failures could place residents at risk of weight loss, altered nutritional status, and diminished quality of life.Record review of a Resident Council Meeting Form dated 09/30/25 indicated, .Food sometimes served cold on the halls.1. Record review of an undated face sheet revealed Resident #2 was an [AGE] year-old male and was admitted to the facility on [DATE] with diagnoses including mild protein-calorie malnutrition (a severe, potentially life-threatening condition caused by inadequate intake of calories, protein, and essential nutrients, leading to muscle wasting, weakened immunity, and tissue degeneration), diabetes, and weakness.Record review of a quarterly MDS assessment dated [DATE] revealed Resident #2 was understood and was understood others. The MDS revealed Resident #2 had a BIMS score of 15, which indicated intact cognition.During an interview on 02/23/26 at 2:50 p.m., Resident #2 said the food did not taste good at all. He said it was very bland. He said it was not worth eating.2. Record review of an undated face sheet revealed Resident #4 was a [AGE] year-old male and was admitted to the facility originally on 10/13/23 with diagnoses including diabetes, weakness, depression, and Vitamin B deficiency.Record review of a quarterly MDS assessment dated [DATE] revealed Resident #4 was understood and understood others. The MDS revealed Resident #20 had a BIMS score of 15 which indicated the resident had intact cognition.During an interview on 02/23/26 at 11:00 a.m., Resident #4 said the food was not edible. He said it was always very cold like it had been sitting out for hours or days when it is served to him at the end of the hallway. He stated he was not sure if they were running out of food or not, but he seemed to get small portions and sometimes the items were burnt or clumped together like they were stuck to the bottom of the pot.During an interview on 02/24/26 at 2:10 p.m., Resident #4 said he was sadly disappointed in his lunch meal today (02/24/26). He said he got about 4 lima beans and a carrot as his mixed vegetables and some rubber things that were supposed to be noodles. He stated it looked and tasted a little like Playdough. He stated he had no way to get outside food, and the alternative was chicken nuggets that were hard to chew so he was forced to try and swallow it down.3. Record review of an undated face sheet revealed Resident #9 was a [AGE] year-old female and was originally admitted to the facility on [DATE] with diagnoses including heart failure, high blood pressure, and diabetes.Record review of a MDS assessment dated [DATE] revealed Resident #9 was understood and understood others. The MDS revealed Resident #21 had a BIMS score of 15 which indicated the resident had intact cognition.During an interview on 02/23/26 at 11:42 a.m., Resident #9 said the food was always lukewarm and bland. She said they did not get a lot of choices and were served chicken and hamburgers a lot of the time.4. Record review of an undated face sheet revealed Resident #21 was a [AGE] year-old male and was originally admitted to the facility on [DATE] with diagnoses including major depressive disorder (a serious mental health condition characterized by persistent, intense feelings of sadness, worthlessness, and loss of interest in activities lasting at least two weeks), vitamin deficiency, and generalized anxiety disorder.Record review of a quarterly MDS assessment dated [DATE] revealed Resident #21 was understood and understood others. The MDS revealed Resident #21 had a BIMS score of 15 which indicated the resident had intact cognition.During an interview on 02/23/26 at 11:17 a.m., Resident #21 said the food at the facility was not good enough to feed to a stray dog. He said it was always cold and the portions were not enough to keep a mouse alive. He stated his family [NAME] him snacks or he would starve to death. He said the worse part of the meals was the hashbrown casserole that had all breakfast foods mixed together and served in this ball like they scooped it out with the smallest ice cream scoop they could find. He said it had about 1/2 a sausage link and 1/2 scrambled egg mixed in shredded potatoes, and it was very bland and was always ice cold. He said there was not enough staff to ask anyone to go warm it up.During an interview on 02/25/26 at 1:01 p.m., Resident #21 said the potatoes in the soup for lunch today (02/25/26) were not done and were hard. He said he was concerned someone might choke5. Record review of an undated face sheet revealed Resident #33 was a [AGE] year-old male and was admitted to the facility on [DATE] with diagnoses including chronic obstruction pulmonary disease (chronic lung disease), depression, and anxiety.Record review of a quarterly MDS assessment dated [DATE] revealed Resident #33 was understood and understood others. The MDS revealed Resident #33 had a BIMS score of 15 which indicated the resident had intact cognition.During an interview on 02/23/26 at 3:10 p.m., Resident #22 said the food was terrible. He said it was cold and bland.6. Record review of an undated face sheet revealed Resident #61 was a [AGE] year-old male and was admitted to the facility on [DATE] with diagnoses including muscular dystrophy (a disease characterized by progressive muscle weakness, degeneration, and fat replacement, often resulting in lost mobility), weakness, and heart failure.Record review of a quarterly MDS assessment dated [DATE] for revealed Resident #61 was understood and understood others. The MDS revealed Resident #61 had a BIMS score of 15 which indicated the resident had intact cognition.During an interview on 02/23/26 at 11:05 a.m., Resident #61 said the food was not seasoned and did not taste good.7. Record review of an undated face sheet revealed Resident #81 was a [AGE] year-old female and was admitted to the facility on [DATE] with diagnoses including major depressive disorder (a serious mental health condition characterized by persistent, intense feelings of sadness, worthlessness, and loss of interest in activities lasting at least two weeks), chronic obstructive pulmonary disease (chronic lung disease), and lack of coordination.Record review of a quarterly MDS assessment dated [DATE] for revealed Resident #81 was understood and understood others. The MDS revealed Resident #81 had a BIMS score of 15 which indicated the resident had intact cognition.During an observation on 02/24/26 at 12:00 p.m., Resident #81 came to the kitchen to request chicken strips and potatoes. She requested the chicken strips be chopped up. During an observation on 02/24/26 at 1:00 p.m. Resident #81 was served a tray with chopped chicken strips and potatoes. The chicken strips were so chopped they looked like breadcrumbs.During an observation and interview on 02/24/26 at 3:36 p.m., Resident #81 said her chicken strips at lunch were pulverized. She said her food was supposed to be chopped. She said everything on her lunch tray was ice cold. She said it took them over 45 minutes to make her tray. She said she had to go to the kitchen to see what was taking so long. Her tray was still at bedside. The chicken strips on the plate looked like breadcrumbs. She said the chicken strips did not taste like chicken. She said they tasted like breadcrumbs. She said the potatoes were cold. She said some of them were hard and she could not eat them. She said they had a food committee once a month and the DM attends. She said he did listen. She said they have to ask for condiments.During an observation and interview on 02/24/26 at 1:15 p.m., a lunch tray was sampled by three surveyors and the Dietary Manager. The food tray consisted of baked fish, mixed vegetables, parmesan noodles, hushpuppies, and apple cobbler. The baked fish was bland and cold. The parmesan noodles were chewy, cold, and had no flavor. The hushpuppies were cold. The apple cobbler was cold. There was only fruit and no crust in the cobbler. The Dietary Manager said the cobbler should have had crust and was cold. He said it should have been served warm. He said the fish was bland and cold. He said the noodles were bland, cold, and chewy.8. During a confidential interview with 6 anonymous residents on 02/24/26 at 3:00 p.m., it was reported that the food was a concern. The anonymous residents agreed that the food was served cold most of the time. The residents said the portions served were small and the flavor was bland. Anonymous Resident #2 stated the food has been brought up during resident council meetings. Anonymous Resident #2 said the flavor of the food has improved some but still needed more improvement.During an interview on 02/25/26 at 11:53 a.m., CNA QQ said she heard a lot of food complaints concerning portion size, same meals over and over, and that the food was cold. She said when the food was cold, she warmed it up in the employee break room. She said she had never reported food complaints to the nurse or the kitchen staff.During an interview on 02/25/26 at 1:57 p.m., Dietary Manager said there was a food committee that met on Mondays and Wednesdays. He said the committee usually consisted of himself and approximately 7 residents. He said the last time they met was 02/18/26, and the only complaint the residents had were that the residents wanted more fruit. He said they also discussed their likes and dislikes. He said no one has complained to him about the food being cold. He said he had been told the food was bland. He said they had worked on it, and the residents had told him that it was better. He said lunch on 02/24/26 was a little off. He said he was just rushing to get everything together. He said he did hear that the potatoes in the soup today (02/25/26) were under cooked. He said he went to the resident to offer him something else, and the resident refused. He said residents who do not like their food could cause them to not want to eat, and they could lose weight.During an interview on 02/26/26 at 12:54 p.m., the DON said she heard food complaints. She said she always passed the complaints on to the Administrator. She said she heard complaints that food was cold, the coffee was cold and watered down, and some people say the food was bland. She said she would expect the kitchen to serve food the residents liked, and that was appealing to them. She said if someone did not like what you were eating, it could cause someone to lose weight. She said a resident might feel like their preferences were not being honored.During an interview on 02/26/26 at 1:14 p.m., the Administrator said she expected the kitchen staff to follow the recipes and the food to be palatable for the residents. She said residents who did not like their food could lead to weight loss and other problems.Record review of a Hot and Cold Food Temperatures facility policy last revised 02/06/24 indicated, .The temperatures of the food items will be managed to conserve maximum nutritive value and flavor and to be free of harmful organisms and substances.all hot food items must be served to the resident at a palatable temperature.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, and dispensing of routine drugs and biologicals to meet the needs of each resident for 1 of 7 resident's reviewed for pharmacy services. (Resident #1) The facility failed to administer Resident #1's physician ordered Debrox ear drops from 02/24/2026 to 02/26/2026. This failure could place residents at risk for medication errors and adverse effects from medication.The findings included: 1. Record review of face sheet, dated 02/25/2026, reflected Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnosis chronic obstructive pulmonary disease (chronic, progressive lung disease that makes it hard to breathe). Record review of the quarterly MDS assessment, dated 02/24/2026, reflected Resident #1 had clear speech, was understood, and was able to understand others. Resident #1 had a BIMS score of 12, which indicated moderately impaired cognition. Resident #1 had no behaviors or refusal of care. Record review of Resident #1 comprehensive care plan, dated 10/17/2025, did not reflect the new order for Debrox ear drops or acute hearing loss. Record review of the active orders report, dated 02/26/2026, reflected an order, which started on 02/24/2026 for Debrox 6.5% solution - 5 drops to both ears twice a day x 4 days for impacted cerumen (earwax). Record review of the MAR, dated February 2026, reflected Resident #1's order for Debrox ear drops was not given on 02/24/2026, 02/25/2026, and 02/26/2026. During an interview on 02/26/2026 at 9:45 a.m., LVN T stated Resident #1's order for Debrox ear drops was placed in the charting system on 02/24/2026. LVN T stated Resident #1's Debrox ear drops had not been delivered from the pharmacy, so they had not been started yet. She said she was going to call and follow up with the pharmacy when she had a chance. LVN T stated it was important to ensure medications were started timely after they were ordered so the acute problems did not become worse. During an interview on 02/26/2026 at 1:28 p.m., the DON stated Debrox ear drops were an over-the-counter medication that was not required to be sent from the pharmacy. She stated the medications were stocked in the medication room. She said she expected the nursing staff to communicate promptly when medications were running low or unavailable. The DON stated she expected the nursing staff to follow the MAR and administer medications by the physician orders. She said new staff or agency staff should be triple checking the MAR against the card to ensure the correct medication, the correct dose, and the correct medication route was administered. She said it was important to ensure medications were given promptly when ordered and were administered according to the physician orders because the medications were prescribed for a reason. She stated it was vital to receive medications to improve or maintain their health status. During an interview on 02/26/2026 at 2:03 p.m., the Regional Administrator stated she expected the nursing staff to ensure physician orders were followed. She stated nursing management was responsible for monitoring to ensure medications were administered as ordered by the physician. She stated it was important to ensure medications were administered according to the physician orders to ensure proper treatment was given. Record review of the facility's Medication Administration policy, dated January 2024, reflected Medications are administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication.prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record. compare the medication and dosage schedule on the resident's MAR with the medication label.medications are administered in accordance with written orders of the prescriber.the person who prepares the dose from administration is the person who administers the dose.verify medication is correct three times before administering the medication.when pulling medication package from med cart. when dose is prepared. before dose is administered.

Based on observation, interview, and record review, the facility failed to refrain from utilizing the DON as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents for reviewed for nursing services. 1. The DON worked as a charge nurse or CNA 6 times in January 2026 2. The DON worked as a charge nurse or CNA 4 times in February 2026 This failure could place residents at risk by leaving nursing staff without supervisory coverage and leaving essential DON functions undone. Findings included: During observation and interview on 02/23/2026 at 10:00 a.m., the DON was changing linen on a bed in a resident room and stated she had to work the floor several nights as a charge nurse, be a CNA on the floor when the facility was short staffed. The DON stated she knew she was not supposed to work the floor in a building of more than 60 average residents. The DON stated she would take the citation because she was not leaving the residents with no care. The DON stated she was the monitor for the weight system, the skin system, the antibiotic stewardship system, and the gradual dose reduction system. The DON stated she had ADONs to assist her, but ultimately the responsibilities were hers. The DON stated she had not had time to keep up with all the systems because she was working the floor. The DON stated she was responsible for checking behind the nurses for clean oxygen equipment, making sure admission orders were checked, making sure admission assessments were done, making sure everyone was on the correct antibiotic, and making sure interventions were in place for weight loss and falls. The DON listed the dates she had worked on the floor totaling 6 shifts in January 2026 and 4 shifts in February of 2026. Record review of sign in sheets for January2026 had not listed the DON as the floor nurse or CNA on any of the days. February showed the DON as the charge nurse on 02/22/2026 and the CNA on 400 hall 02/23/2026. Record review of the staffing sheets on 02/25/2026 indicated an average daily census of 86 for January and February of 2026. During an interview with the Administrator on 02/25/2026 at 3:00 p.m., the Administrator stated the DON had worked the floor several shifts. The Administrator stated the DON was salary, and she did not have to clock in and out when working the floor, so there was no way to track what days and hours she actually worked the floor. The Administrator stated she was sure working shifts on the floor, away from her work, would put the DON a little behind because she had many systems she oversaw, but a lot can be done in the downtime during the shift. The Administrator stated all the department head nurses took turns working the floor when someone called in. She said they each had responsibilities to keep the facility functioning well and it was her expectation that they keep up with their work. A relevant policy was requested from the Regional RN on 02/25/2026 at 10:00 a.m. and 02/26/2026 at 10:00 a.m., but none was provided prior to exit.

Based on observation, interview, and record review the facility failed to ensure necessary services to maintain grooming and personal hygiene were provided for 7 of 18 residents dependent on staff reviewed for ADLs. (Resident #2, Resident #4, Resident #47, Resident #77, Resident #78, Resident #90, and Resident #104) 1.The facility failed to ensure Resident #2, Resident #4, Resident #77, Resident #78, Resident #90, and Resident #104 received scheduled baths in February of 2026. 2.The facility failed to ensure Resident #4, and Resident #47 were groomed and shaved. These failures could place residents at risk of not receiving care or services, decreased quality of life, embarrassment, and decreased self-esteem. The findings included: 1. Record review of an undated face sheet revealed Resident #2 was [AGE] years old and admitted to the facility on [DATE] with diagnoses including diabetes, lack of coordination, and age-related physical disability. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and understood others. The MDS indicated Resident #2 had a BIMs of 15 which indicated his cognition was intact. The MDS indicated Resident #2 required substantial to maximal assistance with showers or baths. Record review of Care Plan last revised 12/29/25 indicated Resident #2 had impaired mobility and required assistance with ADLs. There was an intervention to assist the resident with daily living activities as needed. Record review of a CNA Flow Sheet dated 02/01/26 - 02/25/26 indicated Resident #2 had only received a bath on 02/01/26. There were no other baths documented. There was a refusal documented on 02/09/26. During an interview on 02/23/26 at 2:50 p.m., Resident #2 said he had not had a bath in a week. He said he had asked staff for a bath and they told him they did not have time. 2. Record review of an undated face sheet revealed Resident #4 was a [AGE] year-old male admitted on [DATE] with diagnoses of CVA (cerebral vascular accident [stroke], hemiplegia to right side (paralysis to single side of the body), and vascular ulcers (slow-healing, painful, and often recurring open sores, typically forming around the ankles due to chronic vein disease, such as poor circulation or faulty valves). Record review of a quarterly MDS assessment dated [DATE] revealed Resident #4 had a BIMS of 15 which indicated no cognitive impairment. The MDS revealed he had no behavior and had not refused care. Resident #4 required substantial (helper does more than half the work) for bed mobility, personal hygiene, dressing, and transfer. Record review of the care plan dated 01/15/2026 revealed Resident #4 had a venous stasis ulcer (slow-healing, chronic, and often painful open sores that typically form on the lower legs, usually near the ankle, due to poor blood flow and high pressure in the veins) on his right lateral (side of) ankle, right medial (mid) calf, and a non-pressure ulcer to his right buttock. There was no care plan for ADLs for Resident #4. Record review of the February 2026 ADL sheet printed 02/25/2026 revealed no documented evidence Resident #4 had been bathed since 02/06/2026 when he received a shower on the day shift. No other showers were reflected for February 2026. Resident #4 was scheduled to have a shower on Monday, Wednesday, and Friday. He received 1 of 11 scheduled showers in February. During an interview and observation on 02/23/2026 at 9:30 a.m., Resident #4 stated he had not received a bath or shower in over 10 days. He stated there was a COVID outbreak in the building and the facility had less than a skeleton crew working and multiple different staff members including the DON told him they did not have time to bathe him. Resident #4 stated he understood he could not leave his room and would settle for a bed bath. He voiced concern over his body odor and stated it was embarrassing to smell like shit and musk. He also stated he requested a shave but not in bed. There was a strong smell of body odor present and overgrown facial hair (growing an unwanted beard). Resident #4 was dressed in a burnt orange T shirt with several white and brown stains on the front. Resident #4's sheets were soiled and covered in (3 areas about quarter size) brown and (2 smeared areas about 1.5 inches wide by 6-8 inches long) red food stains. During an observation and interview on 02/24/2026 at 9:00 a.m., revealed Resident #4 had on the same burnt orange shirt with food stains covering it and the smell of his body odor was strong throughout the room. Resident #4's sheets had not been changed and were covered in food. Resident #4 stated he had not received a bath on 02/23/2026. During an observation and interview on 02/25/2026 at 10:10 a.m., Resident #4 stated he had still not gotten a bath. Resident #4 remained in the same burnt orange shirt with stains, and his sheets were the same stained sheets from the previous 2 days. The foul odor of feces and body odor was present upon entering the room. Resident #4 stated Now I know if I can smell my sour-ass you can smell me. He stated he really would like to be cleaned up and he was having trouble sleeping with all the crumbs in his bed. 3. Record review of the face sheet, dated 02/25/2026, reflected Resident #47 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disorder (COPD) (a progressive lung condition that makes it difficult to breath), and brain and lung cancer. Record review of the admission MDS assessment, dated 01/21/2026, reflected Resident #47 had unclear speech, was understood, and was able to understand others. Resident #47 had a BIMS score of 10, which indicated moderately impaired cognition. The MDS reflected Resident #47 had inattention and disorganized thinking that fluctuated. Resident #47 had no behaviors or refusal of care during the look-back period. The MDS reflected Resident #47 had a functional limitation in range of motion that interfered with daily functions or placed him at risk for injury to one side of his lower extremities and he used a wheelchair. Resident #47 usually required partial/moderate assistance with showering, which reflected the helper completed less than half of the effort. Record review of the comprehensive care plan, dated 01/20/2026, reflected Resident #47 required assistance with ADLs. The interventions included: assist with daily care needs and daily living tasks and encourage to do as much as possible for self. Record review of the CNA Flow Sheet, dated 02/02/2026 to 02/24/2026, reflected Resident #47 received only one shower. During an observation and interview on 02/23/2026 at 9:26 a.m., revealed Resident #47 was lying in bed with the head of his bed elevated slightly. His hair was cut short, and he had white and gray stubble around his mouth, on his cheeks, and his neck. He was wearing a black and yellow shirt. Resident #47 reported he did not always get his scheduled showers. He said he had only received a handful since being admitted to the facility. Resident #47 stated his shower days were Tuesday, Thursday, and Saturday. He said he did not receive his shower on Saturday. During an observation on 02/24/2026 at 10:44 a.m., revealed Resident #47 asked LVN O for a shower. He stated it had been days since he received a shower and he had been asking for it. LVN O said his shower was scheduled for 2 p.m. Resident #47 stated he preferred his showers in the morning time. He was wearing the same clothing from 02/23/2026. During an interview on 02/25/2026 at 2:09 p.m., CNA N stated she worked for agency and had been assigned to Resident #47's hallway. CNA N stated she had only been assigned to the right side of 100 hall, but ended up with all the residents on 100 hall, because staff had called in. CNA N stated it was impossible for her to complete all her assigned tasks including showers. CNA N was unable to remember if Resident #47 received his shower. CNA N said it was important to ensure showers were completed to prevent skin issues. CNA N stated it was important to maintain good hygiene. 4. Record review of an undated face sheet revealed Resident #77 was a [AGE] year-old female admitted on [DATE] with diagnoses of CVA (cerebral vascular accident [stroke], hemiplegia to right side (paralysis to single side of the body), and bipolar disorder (a mental health condition characterized by intense mood swings, alternating between high-energy manic or hypomanic episodes and low-energy depressive episodes). Record review of a quarterly MDS assessment dated [DATE] revealed Resident #77 had a BIMS of 99 which indicated severe cognitive impairment. She had short- and long-term memory impairment and had moderately impaired decision-making ability. It revealed he had no behavior and had not refused care. Resident #77 required dependent assistance for bed mobility, bathing, personal hygiene, dressing, and transfer. Resident #77 was incontinent of bowel and bladder. Record review of the care plan dated 11/07/2025 revealed Resident #77 was dependent for ADLs and required complete staff assistance for personal hygiene and bathing. Record review of the February 2026 ADL sheet printed 02/25/2026 revealed no documented evidence that Resident #77 had been bathed in February of 2026. Resident #77 was scheduled to have a shower on Monday, Wednesday, and Friday. He received 0 of 11 scheduled showers in February. During an observation on 02/23/2025 at 9:40 a.m., revealed Resident #77 had a foul odor of ammonia and body odor. Resident #77 was unable to communicate her last bath. 5. Record review of an undated face sheet revealed Resident #78 was [AGE] years old and admitted to the facility on [DATE] with diagnoses which including quadriplegia (paralysis affecting all four limbs and the torso, typically caused by cervical spinal cord injury), seizures, and high blood pressure. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #78 was sometimes understood and sometimes understood others. The MDS indicated Resident #78 was unable to complete the BIMS interview. The MDS indicated Resident #78 was dependent on staff for all ADLs. Record review of the care plan last revised 01/07/26 indicated Resident #78 was dependent on staff for all ADLs. There was an intervention to assist the resident with daily care needs and daily living tasks. The care plan indicated the resident had a diagnosis of quadriplegia with an intervention to provide assistance with ADLs. Record review of a CNA Flow Sheet for Resident #78 dated 02/01/26 - 02/25/26 did not indicate any baths. The flow sheet did not indicate any refusals from the resident. During an interview on 02/23/26 at 11:21 a.m., a family member for Resident #78 said he did not always get his baths. The family member said he was not gotten out of bed for showers. During an interview on 02/25/26 at 10:18 a.m., a family member for Resident #78 said the facility was not showering him. The family member said they had to come to the facility to wash and bathe him. The family member said his bottom was not being cleaned good and when she washed him, he was still dirty. The family member said they also had to do his oral care. The family member said they had come to the facility, and his eyes were crusty. The family member said there was dry stuff on his face and boogers coming out of his nose. She said she had seen brown rings on the pads that were under him. Record review of an undated photo provided by Resident #78's family member revealed brown rings on the pad under Resident #78. 6. Record review of an undated face sheet revealed Resident #90 was a [AGE] year-old female admitted on [DATE] with diagnoses of heart failure, obesity, and hypothyroidism (abnormally low activity of the thyroid gland). Record review of an annual MDS assessment dated [DATE] revealed Resident #90 had a BIMS of 14 indicating no cognitive impairment. She required dependent assistance with ADLs. Resident #90 was incontinent of bowel and bladder. Record review of the February 2026 ADL sheet printed 02/25/2026 revealed no documented evidence Resident #90 had been bathed in February of 2026. Resident #90 was scheduled to have a shower on Monday, Wednesday, and Friday. He received 0 of 11 scheduled showers in February. During an interview on 02/23/2026 at 9:30 a.m., Resident #90 stated she had not been bathed this month. She stated the facility was short on staff and one aide could not bath all the people on the hall. She stated she knew she smells and her vagina was raw from urine and not getting a bath. She stated it was embarrassing to smell of urine and feel so dirty. Resident #90 stated she would report to the Administrator, but he was out sick, and she never got to have a care plan meeting. She stated she had called the Ombudsman for advice. Resident #90 stated she was out of things to do to make sure she was getting a bath and she felt defeated. During an observation on 02/24/2026 at 11:00 a.m., revealed when Resident #90 was receiving incontinent care when she asked CNA B and CNA D when she would receive her bath. CNA B responded, It is not your bath day today, but I will give you a quick wash down. Resident #90 received a partial (extremities and hair not washed and bed linen not changed) bed bath. During an interview on 02/24/2026 at 11:00 a.m., CNA B stated she was the aide for Resident #4, Resident #77, and Resident #90 and was aware it was their bath days. She stated she did not have time to do everything required of her on her shift. CNA B stated she had 22 residents to care for and half of them were COVID positive. She stated she was to feed them 2 meals, keep them clean and dry, turn them every 2 hours, bathe 6-8 of them a day, and chart. She stated that it was an impossible task even if there was no COVID. CNA B stated she did her best to care for the residents. She stated she had to make sure the residents were fed and dry and that was about all she had time for. CNA B stated not getting a bath could make the residents feel dirty and uncared for. 7. Record review of an undated face sheet revealed Resident #104 was [AGE] years old and admitted to the facility on [DATE] diagnoses including high blood pressure, malignant neoplasm of larynx (a common head and neck cancer, predominantly squamous cell carcinoma, that affects the voice box), and pain. Record review of Resident #104's electronic medical record accessed on 02/25/26 did not indicate a complete MDS. Record review of a baseline care plan for Resident #104 dated 02/20/26 indicated the residents were independent with decision making skills. Record review of a CNA Flow Sheet for Resident #104 dated 02/20/26 - 02/25/26 did not indicate any baths were documented as provided. The flow sheet did not indicate any refusals from the resident. During an interview on 02/25/26 at 10:56 a.m., Resident #104 said he had not had a bath since he was admitted to the facility on [DATE]. He said he had only had a light wipe down. He said at the very least a bed bath would feel good. He said he could not walk so a shower would be hard to do. During an interview on 02/25/26 at 11:53 a.m., CNA QQ said they did not have enough staff. She said there were residents that did not get baths because she could not get to them. She said they used to have a shower aide, but she left. She said she had never seen Resident #104 up in the shower. She said she had only known him to get bed baths. She said he had not missed any baths that she was aware of. During an interview on 02/25/2026 at 3:00 p.m., the DON stated it was the responsibility of the CNAs to provide baths to all residents on their scheduled bath days. She stated every resident had a bath schedule in the system the CNAs charted in. She stated any refusals were to be recorded and reported to the charge nurse. She stated if the resident refused several times the family would be notified to attempt to intervene. The DON stated she was aware there had been some missed baths because staffing had been an issue with half of her staff out with COVID. She stated COVID had been going through the building for about 10 days. The DON stated the facility started using agency staff on 02/21/2026 to try and supplement the staff out with COVID and they did have a few vacancies in the schedule, as well. The DON stated there was no excuse for the CNA not giving a bath related to their time management. She stated she had worked on the floor as a CNA several times in the last few months and she was able to provide all care including baths. She stated she was the CNA on the 400 hall on 02/23/2026 and she did all the baths assigned that day. The DON stated Resident #4 refused his bath on 02/23/2026 and she failed to document his refusal. The DON stated bathing was important for health and keeping the residents feeling good about themselves. The DON stated not getting a bath for several days could make the residents feel neglected and uncared for. During an interview on 02/25/2026 at 4:00 p.m., the Administrator stated she was unaware of the issue the residents were having receiving their baths. She stated it was more than likely due to the number of staff that was out with COVID, but the residents still must be bathed. She stated it was the DON and ADON that monitored baths and were to ensure they were happening. The Administrator stated it could make the residents feel disgusting and like they don't matter when they are not cared for properly. Record review of the Activities of Daily Living (ADL), supporting policy, dated February 2025, reflected Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.appropriate care and services will be provided for residents who are unable to carry out ADLs independently.including appropriate support and assistance with. hygiene (bathing, dressing, grooming, and oral care).

Based on interview and record review, the facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility for 6 out of 6 anonymous residents during a confidential meeting. The facility failed to ensure the resident council grievances for call light timing and showers were promptly resolved. This failure could place residents at risk for a decreased quality of life and feeling as their voice was not heard.The findings included: Record review of the resident council meeting minutes, dated 09/30/2025, reflected the residents shared a concern regarding .CNA's respond to call light and tell them that the next shift will take care of needs and that it's time to get off. Record review of the resident council meeting minutes, dated 10/27/2025, reflected old business: .showers remain a concern and Nursing: Showers are not being given as scheduled. Record review of the resident council meeting minutes, dated 11/24/2025, reflected .Nursing: Nurse aides turning call lights off and do not respond to needs. Record review of the resident council meeting minutes, dated 12/30/2025, reflected Old business. showers not being. The nursing section was blank. Record review of the resident council meeting minutes, dated 01/28/2026, reflected .Nursing: residents stated that aides are not making rounds to check on them. Aides are turning off lights and not responding to needs. During a confidential interview with 6 anonymous residents reflected anonymous residents agreed they felt like their grievances on call light timing and showers were not resolved. The residents agreed that it would only get better for a few days but would return to the same issues. They agreed that call lights were not answered timely. Anonymous Resident #1 said on one occasion, she had to wait 3 hours and 42 minutes for her call light to be answered. The anonymous residents agreed that at times, only 2 CNAs for the entire building were scheduled. The residents said it was all shifts that were working short. The anonymous residents agreed that medications were given late and showers were not given as scheduled because of the staffing concerns. The residents stated they felt ignored and neglected. During an interview on 02/26/2026 at 9:55 a.m., the Activity Director stated she helped facilitate the resident council meetings. She said normally she attended the beginning of the meetings and then left so the meeting was conducted without the presence of staff. She said the residents usually recorded their own meeting minutes. The Activity Director stated the residents expressed ongoing concerns about the showers and call lights. She said when the residents started complaining about certain things, like showers or call lights, the complaints usually did not stop. She said when the residents complained about things during the resident council meeting, she wrote it up as a grievance and then took the concerns to the morning meetings with the department heads. The Activity Director stated nursing concerns were given to the DON. She said the DON was responsible for addressing and resolving the grievances for the nursing department. She said it was important to ensure that grievances were resolved to give the residents a sense of independence and it gave them a voice. During an interview on 02/26/2026 at 1:28 p.m., the DON stated she was aware of the ongoing grievances of the resident council regarding showers and call lights. The DON stated she had completed in-service education with the staff regarding showers and answering call lights, but the cause of the concerns fell back to staffing. She stated after completing in-service education with the staff, she followed up with the residents who said the issues were resolved. She said there was no on-going monitoring, after the in-service education. She said she did not always have time to follow back up. The DON stated it was important to ensure grievances were resolved for the residents' quality of life and so they felt heard. During an interview on 02/26/2026 at 2:03 p.m., the Regional Administrator stated she was sitting in the building while the Administrator was out. She said she expected the department heads to address the grievances of resident council and follow up with the next resident council to ensure the grievances were resolved. She stated management staff were responsible for monitoring to ensure grievances were resolved. She said it was important to ensure resident concerns were resolved because the facility was their home. Record review of the Resident Council policy, undated, reflected the policy was To aid the facility's sense of community, quality of life for the residents and meet the requirements of F565, the wellness department will assist, as required, to oversee the facility's Resident Council as assigned.concerns noted on the minutes should be group concerns. ask for clarification to assist department heads in solving issues appropriately.the recorded minutes will be provided to the facility Administrator to provide as needed facility department head team to address any concerns or suggestions within 48 hours of the meeting concluding.

Based on interview and record review, the facility failed to ensure that the residents and/or representatives had the right to participate in the development and implementation of his or her person-centered plan of care, and to ensure that the planning process facilitated the inclusion of the residents and/or representatives for 5 (Resident #4,Resident #21, Resident #51, Resident # 81, and Resident #90) of 18 residents reviewed for care plans. The facility failed to ensure the IDT, Resident #4, Resident #21, Resident #51, Resident #81, and Resident #90, were involved in the review of the comprehensive assessment and were able to discuss their individualized care needs for services to include their need for medical and nursing care, medications, therapy, psychological and dietary needs. This failure could affect residents by placing them at risk for not receiving adequate or individualized care. Findings include: 1. Record review of an undated face sheet revealed Resident #4 was a [AGE] year-old male admitted on [DATE] with diagnoses of CVA (cerebral vascular accident [stroke], hemiplegia to right side (paralysis to single side of the body), and vascular ulcers (slow-healing, painful, and often recurring open sores, typically forming around the ankles due to chronic vein disease, such as poor circulation or faulty valves). Record review of a quarterly MDS assessment dated [DATE] revealed Resident #4 had a BIMS of 15 which indicated no cognitive impairment. The MDS revealed he had no behavior and had not refused care. Resident #4 required partial (helper does less than half the work) for bed mobility, personal hygiene, dressing, and transfer. Record review of the last recorded care plan conference for Resident #4 was dated 03/26/2025. There was no record located for care plan meetings for June 2025, September 2025, or December of 2025. No other care plan conference meeting information was located. During an interview on 02/23/2026 at 11:00 a.m., Resident #4 stated he would like to participate in his care plan meetings so the facility could listen to ideas to improve how they cared for residents. He stated he had not been invited to nor participated in a care plan meeting since about a week after he was admitted around a year ago. He stated not being a part of his care planning process made him feel lost and left out. 2. Record review of an undated face sheet revealed Resident #21 was a [AGE] year-old male admitted on [DATE] with diagnoses of diabetes type II (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar), blindness to one eye, and chronic pain. Record review of a quarterly MDS assessment dated [DATE] revealed Resident #21 had a BIMS of 15 which indicated no cognitive impairment. The MDS revealed he had no behavior and had not refused care. Resident #21 was independent for ADLs. He was taking high risk medications from the following drug classes; antianxiety, antidepressant, hypnotic, diuretic, opioid, hypoglycemic, and anticonvulsants. Record review of the last recorded care plan conference for Resident #21 was dated 11/20/2024. There were no records found for February 2025, May 2025, August 2025, November 2025, or February 2026. No other care plan conference documentation was located. During an interview on 02/23/2026 at 11:20 a.m., Resident #21 stated he used to go to his care plan meetings each time the social worker scheduled one. He said that was the time when he could ask questions about his medication, ask for appointments, tell the facility his likes and dislikes on food and how the CNAs treated people. Resident #21 stated the facility had a high turnover rate for social workers and he didn't think the one the facility currently had cared about how the residents felt. He stated any problem he had ever brought to her she brushed off as insignificant. 3. Record review of an undated face sheet revealed Resident #51 was a [AGE] year-old female admitted on [DATE] with diagnoses of cerebral palsy (a group of permanent, non-progressive neurological disorders appearing in infancy that affect movement, posture, and muscle tone), dysphagia (difficulty swallowing, ranging from mild discomfort to total inability to swallow, often caused by neurological conditions [stroke, Parkinson's], esophageal blockage, or muscular disorders), and atrophic neurodermitis (chronic, itchy, inflammatory skin conditions). Record review of a quarterly MDS assessment dated [DATE] revealed Resident #51 was able to recognize the location of her room, staff faces, and her cognitive skills for decision making were moderately impaired. Resident #51 required substantial (helper does more than half the work) assistance with ADLs. Record review of the last recorded care plan conference for Resident #51 was dated 04/17/2025. There was no record located for care plan meetings for July 2025, October 2025, or January of 2026. No other care plan conference meeting information was located. 4. Record review of an undated face sheet revealed Resident #81 was a [AGE] year-old female admitted on [DATE] with diagnoses of parkinsonism (a clinical syndrome characterized by a combination of movement-related symptoms, most notably bradykinesia [slowness of movement], rigidity [stiffness], resting tremors, and postural instability, orthopnea (shortness of breath or difficulty breathing), and anemia. Record review of a quarterly MDS assessment dated [DATE] revealed Resident #81 had a BIMS of 15 indicating no cognitive impairment. She required set up with ADLs. Record review of the last recorded care plan conference for Resident #81 was dated 04/17/2025. There was no record located for care plan meetings for July 2025, October 2025, or January of 2026. No other care plan conference meeting information was located. During an interview on 02/23/2026 at 2:00 p.m., Resident #81 stated they had not received an invitation to a care plan meeting in about 1 year. Resident #51 stated they would like to be involved in decisions bout their care. 5. Record review of an undated face sheet revealed Resident #90 was a [AGE] year-old female admitted on [DATE] with diagnoses of heart failure, obesity, and hypothyroidism (abnormally low activity of the thyroid gland). Record review of an annual MDS assessment dated [DATE] revealed Resident #90 had a BIMS of 14 indicating no cognitive impairment. She required dependent assistance with ADLs. Record review of the last recorded care plan conference for Resident #90 was dated 07/23/2025. There was no record located for care plan meetings for October 2025 or January of 2026. No other care plan conference meeting information was located. During an interview on 02/23/2026 at 10:15 a.m., Resident #90 stated she was very upset that they were not including her in the planning of her care. She stated she was stuck in the bed or her chair and unable to visit all the nurses, aides, and people that cared for her. She stated it was unfair they discussed her without her present or worse yet, no at all. Resident #90 stated she had things to discuss about the pitiful care she has been receiving the last several months. During an interview on 02/25/2026 at 3:15 p.m., the Social Worker stated it was her job to keep a calendar and ensure the residents had a care plan meeting at least quarterly. She stated she sent letters out to the family to invite them to the care conferences. The Social Worker stated the IDT met 2 days a week to discuss care plans with the residents. The Social Worker stated the residents did not always attend their care plan meetings. She stated in a perfect world the care plan meeting schedule would align with the MDS schedule, but she had not gotten everyone on that schedule, yet. The Social Worker stated if the care plan conference form was not located in the EHR, the care plan conference had no taken place. She stated she knew the residents had a right to attend their care conferences, but it was not always possible to get to everyone each time they had a conference due. The Social Worker stated the residents could feel like they do not matter by not attending their own care plan meeting. During an interview on 02/25/2026 at 3:30 p.m., the DON stated it was the responsibility of the Social Worker to coordinate care conferences for all residents. She stated they should be done quarterly at the least and all departments should be represented, such as nursing, dietary, activities, therapy, and social services. The DON stated she was unaware this was not happening quarterly and stated it was her responsibility as the DON to ensure all systems were functioning properly in the building. She stated no residents or family members had complained to her about not having care plan meetings. The DON stated it could make the residents feel ignored and neglected to not be a part of their own care planning. During an interview on 02/25/2026 at 4:00 p.m., the Administrator stated it was absolutely the responsibility of the Social Worker and all department heads to ensure that the residents and all IDT members are present at resident care plan meetings. The Administrator stated Resident #4 had many concerns that could have been resolved during the care planning process. On 02/24/2026 at 4:00 p.m., 02/25/2026 at 10:00 a.m., and 02/26/2026 at 10:00 a.m. a policy for Care Planning Meeting/ Care Conferences was requested from the Regional DON. No policy was received prior to exit.

Based on interview and record review the facility failed to provide the resident access personal and medical records pertaining to him or herself, upon an oral or written request, in the form and format requested by the individual, if it is readily producible in such form and format (including in an electronic form or format when such records are maintained electronically, or, if not, in a readable hard copy from such other form and format as agreed to by the facility and the individual, within 24 hours (excluding weekends and holidays) and allow the resident to obtain a copy of the records or any portions thereof upon request and 2 working days advance notice to the facility for 1 of 7 residents (Resident #105) reviewed for access of records. The facility failed to provide Resident #105's legal representative copies of medical records after a request was submitted to the facility on [DATE]. This failure could place residents at risk of violation of their rights by not receiving copies of their medical records.The findings included: Record review of the face sheet, dated 02/26/2026, reflected Resident #105 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnosis of Alzheimer's disease (progressive, irreversible brain disorder in which it causes the slow destruction of nerved cells leading to a decline in memory, thinking, language, and behavior that severely impacts daily functioning). Record review of the discharge MDS assessment, dated 11/24/2025, reflected Resident #105 had an unplanned discharge from the facility with the anticipation of return. Record review of Resident #105's Attorney's office letter, dated 11/26/2026, reflected Resident #105's legal representative requested all correspondence with Texas Health and Human Services Commission from the last two years related to Resident #105's Medicaid for Nursing Resident benefits by 12/01/2025 so renewal of benefits could have been obtained. The letter also requested the daily plan of care, nursing logs, medication logs, incident reports, and any and all emails, letters, and notes related to Resident #105. Record review of HIPAA Authorization to Disclose Protected Health Information signed and dated on 11/25/2025 by Resident #105's legal representative, reflected [Attorney office] is permitted to receive the information and is hereby authorized to receive any and all information the releasing persons or organization may have concerning treatment or services rendered to [Resident #105] for any reason, whether inpatient or outpatient. During an interview on 02/24/2026 at 4:02 p.m., Attorney W stated she had still not received the records that were requested on 11/26/2025. Attorney W stated she had verified with Medical Records and the Administrator that the request had been received. Attorney W stated Resident #105's legal representative had signed the HIPAA release of information form which was sent with the letter. She said the delay in receiving Resident #105's medical records have caused her Medicaid benefits to lapse. During an interview on 02/24/2026 at 4:13 p.m., Medical Records stated if an attorney requested medical records, the request was sent to the corporate office and the facility's attorney, Attorney S. Medical Records stated the request was not handled at the facility. Medical Records said she was aware of Resident #105's record request from Attorney W. She said the request was sent to the Administrator, before he was out on leave. During an attempted phone interview on 02/24/2026 at 4:19 p.m., Attorney S did not answer the phone. A brief message was left with a call back number that was not returned upon exit from the facility. During an interview on 02/24/2026 at 5:03 p.m., the facility's attorney Chief Operating Officer stated Resident #105's record request was overlooked and missed. He stated that they were working on gathering the documents and would have them sent by the end of the week. During an interview on 02/26/2026 at 2:03 p.m., the Regional Administrator stated she was aware of the records request for Resident #105's attorney. She said the records request was sent directly to the attorney and the not the records request email. She stated there was not a process in place to monitor the request after it was sent to the attorney. She stated it was important to ensure residents and their representatives had access to medical records because it was the rules. Record review of the Release of Information Protocol, undated, reflected .2. *Send the signed HIPAA Authorization form to Medical Records Request [email]. 3. *Legal/Personal requests send to Medical Records Request [email]. After receiving the above documentation, a review will be completed and presented to Attorney S. He will determine the direction in which the facility should take.

Based on observation, interview and record review, the facility failed to promote resident self-determination through support of family choice for 1 of 19 residents reviewed for resident rights. (Resident #78)The facility failed to place Resident #78's shoes on his feet daily as requested by family.The facility failed to get Resident #78 up out of bed daily as requested by family. These failures could place dependent residents at risk for feelings of depression, lack self-determination and decreased quality of life.Record review of an undated face sheet revealed Resident #78 was [AGE] years old and admitted to the facility on [DATE] with diagnoses which including quadriplegia (paralysis affecting all four limbs and the torso, typically caused by cervical spinal cord injury), seizures, and high blood pressure.Record review of a quarterly MDS assessment dated [DATE] indicated Resident #78 was sometimes understood and sometimes understood others. The MDS indicated Resident #78 was unable to complete the BIMS interview. The MDS indicated Resident #78 was dependent on staff for all ADLs. Record review of Care Plan last revised 01/07/26 indicated Resident #78 was dependent on staff for all ADLs. There was an intervention to assist the resident with daily care needs and daily living tasks. The care plan indicated the resident had a diagnosis of quadriplegia with an intervention to provide assistance with ADLs. Record review of a CNA Flow Sheet for Resident #78 dated 02/01/26 - 02/24/26 did not indicate any refusals for putting on and taking off socks and shoe or other footwear that was appropriate. The flow sheet did not indicate any refusals of the resident being transferred from a bed to a wheelchair.Record review of Interdisciplinary Progress Notes for Resident #78 dated 02/20/26 - 02/24/26 did not indicate the resident had refused to get up out of bed or wear his shoes.During an observation and interview on 02/23/26 at 11:21 a.m., revealed Resident #78 was in bed. He had socks on his feet. There was a sign hanging on the curtain near his bed that indicated, (Resident #78) needs his shoes on from 2 - 4.). Resident #78's family member said he was supposed to be out of bed with shoes on his feet for a few hours each day.During an observation on 02/23/26 at 3:41 p.m., revealed Resident #78 was in bed asleep. The resident did not have on shoes, only socks.During an observation on 02/24/26 at 10:32 a.m., revealed Resident #78 was in bed awake. There were only socks on his feet.During an observation on 02/24/26 at 11:29 a.m., revealed Resident #78 was in bed. There were only socks on his feet.During an observation on 02/24/26 at 12:37 p.m., revealed Resident #78 was in bed. There were only socks on his feet.During an observation on 02/24/26 at 2:31 p.m., revealed Resident #78 was in bed. There were only socks on his feet.During an observation on 02/24/26 at 3:29 p.m., revealed Resident #78 was in bed. There were only socks on his feet.During an interview on 02/25/26 at 10:18 a.m., Resident #78's family member said during care plan meetings it was discussed Resident #78 being out of bed every day for at least 2 hours a day and his shoes on his feet. The family member said Resident #78 had drop foot (the inability to lift the front part of the foot due to muscle weakness or paralysis) and they wanted him up. The family member said they wanted the facility to do what they had discussed.During an observation on 02/25/26 at 11:00 a.m., revealed Resident #78 was in bed. There were only socks on his feet.During an interview on 02/25/26 at 11:53 a.m., CNA QQ said she was not sure if Resident #78 was to be gotten up daily. She said she had never seen him up out of bed and she had worked at the facility since August 2025. She said she had never offered to get him up out of bed. She said she did not know the family wanted him to have on shoes or noticed the sign in his room. She said she had never seen him with shoes on his feet.During an interview on 02/25/26 at 1:44 p.m., LVN T said if a family member or a resident requested to be out of bed and have shoes on, she would expect staff to do so, unless the resident did not want to be gotten up or not have shoes on. She said she had not worked with Resident #78 and had only worked at the facility five days.During an interview on 02/26/26 at 8:30 a.m., the Social Worker said the last care plan meeting for Resident #78 was in June 2025. She said she could not remember if him being gotten out of bed and having shoes on for a few hours a day was discussed. She said if the family had wanted these things to be done, she would have expected for staff to have been getting him up and putting his shoes on.During an interview on 02/26/26 at 12:54 p.m., the DON said she was aware that Resident #78 was supposed to be out of bed every day and have shoes on during the day. She said he required a mechanical lift and he was a two-man job. She said he had not been out of the bed. She said it was Resident #78's right to refuse. She said she could not say if any refusals were documented. She said she would expect for staff to be getting him up daily and putting him in his chair daily. She said she would expect for any refusals to be documented. She said CNAs should report refusals to the nurse so that they can make a note in the progress note. She said it should also be reflected on his Kardex. She said not being gotten up and not having shoes on could be a dignity thing. She said the family saw it as he could develop foot drop. She said Resident #78 could verbalize if he wanted to get up but was able refuse or agree to get up.During an interview on 02/26/26 at 1:14 p.m., the Administrator said if Resident #78 was willing she would have expected for him to have been gotten up daily with shoes on his feet. She said if he did refuse, she would have expected it to have been documented. She said a resident who was not being gotten up could lead to depression and further decline.Record review of a Resident Rights facility policy last revised 08/14/22 indicated, .The staff will abide by and protect resident rights in accordance with state and federal guidelines.Staff will abide by resident rights as outlined within CMS State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities.

Based on observation, interview, and record review the facility failed to ensure residents were free from accident hazards for 3 of 8 residents reviewed for accidents (Resident #1, Resident #2, and Resident #3.) Resident #1 had a fall on the facility van, Van Driver A did not call 911 for assistance, and he did not report the incident to the facility. The resident was not sure of the date or time frame, and the facility could not provide a time frame. Resident #2 complained of Van Driver A's unsafe and erratic driving. Resident #3 was not strapped into the van correctly and her wheelchair tipped over backward which caused her to hurt her head, hand, and arm. This noncompliance was identified as PNC (past non-compliance) Immediate Jeopardy. The noncompliance was corrected prior to entrance. This facility failure placed Residents at risk for serious injury.Findings included: Resident #1 Record review of Resident #1's face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #1's MDS indicated her cognitive status was intact with a BIMS score of 13. She used a wheelchair for ambulation. She was dependent on staff for standing from a sitting position, and she was dependent on staff for transfer from bed to chair or chair to bed. Record review of Resident #1's care plan dated 9/18/25 indicated the resident had dialysis treatment due to diabetes, and end stage renal disease three times a week. The goal was the resident would not have unrecognized complications related to dialysis. Record review of Resident #1's nursing notes did not indicate any falls from January 2025 to present at dialysis or on the van, and there were no incident reports indicating an incident occurred. During an interview on 9/18/25 at 4:39 p.m. Resident #1 said about 6 months ago during transportation to dialysis, Van Driver A was trying to miss hitting a car. Resident #1 said Van Driver A swerved and she fell to the floor of the van. She said she hurt her foot and tore a hole in her sock. She said there was a place on her foot[. She was not taken to the hospital, and she did not hit her head. Resident #1 said Van Driver A did not hit anything, he braked hard, and she fell to her knees. During an interview on 9/18/25 at 4:47 p.m. the Administrator said Van Driver A was terminated due to taking shortcuts, and complaints of erratic driving. The Administrator Van Driver A had not reported any incidents that occurred on the van with Resident #1. He said Resident #1 had not reported any incident that occurred on the van. During an interview on 9/23/25 at 10:50 a.m. the DON said she had talked to Resident #1 about the incident a few days ago and she said she had fallen on the van several months back. She said the resident did not have an exact time frame. The DON said she was not aware of the fall and Van Driver A had not reported any falls. The DON said Resident #1 said the nurses at dialysis had gotten her off the van floor. The DON said Resident #1 was not able to walk and required assistance with transfers. She said they did not receive a report from Van Driver A, no report from dialysis clinic, and Resident #1 had not reported the incident. During an interview on 9/23/25 at 11:00 a.m. the Administrator said he had received complaints from outside individuals calling about Van Driver A's erratic driving. The Administrator said the callers reported Van Driver A was speeding, and changing lanes frequently. The Administrator said Van Driver A denied there was any previous incident of a resident falling on the van. During a telephone interview on 9/23/25 at 1:48 p.m. Van Driver A said he did not remember Resident #1 falling while on the van during transport. During an interview on 9/24/25 at 10:05 a.m. Resident #1 said she remembered falling out of the wheelchair when Van Driver A did not put the seatbelt on her during transportation to her dialysis appointment. She said he was coming around a corner or something, but he hit the brakes, and she slid out of the wheelchair. She said she hit the floor and the nurses at the dialysis clinic came on the van and got her off the van floor. She remembered the incident but could not provide a time frame. She said it may have been 4 or 5 months ago. Resident #1 said she hurt her foot. She said she did not tell anyone because the nurses at the dialysis clinic knew, so when she came back to the facility, she did not tell the facility nurses. She said her wheelchair did not fall or tilt over, she just slid out of the chair. Resident #1 said the wheelchair was still strapped down. During an interview on 9/24/25 at 10:50 a.m. the Clinical Coordinator/RN[ at the dialysis clinic said she remembered the incident when Resident#1 had fallen on the van. She said she looked, and they did not have any notes. She said she was not there and could not find any staff that were working today that were present when the incident happened. She said she remembered it was on a Saturday and between her and the staff that were at the clinic today, they thought it was about two months ago. The Clinical Coordinator said she was not there but remembered the staff talking about Resident #1 falling on the van and they had to go and pick her up off the van floor. Resident #2 Record review of Resident #2's face sheet indicated he was a [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #2's BIMS indicated he had moderate cognitive impairment with a BIMS score of 12. Record review of a grievance form dated 8/11/25 indicted Resident #2 said the Van Driver A needed to pay better attention to the road. The Resident complained the Driver was not paying attention to the road during transport. The resolution was the Administrator spoke to Van Driver A about his erratic, inattentive driving. Van Driver A was informed his undivided attention was required during driving for safety. Van Driver A was informed, we would not have another conversation about safe driving. Signed by the Administrator. Record review of Resident #2's Discharge Summary indicated he was discharged home on 8/27/25. During interview on 9/23/25 at 12:45 p.m. the Administrator said he received a complaint from Resident #2 about the way Van Driver A was driving. The Administrator said Resident #2 said Van Driver A appeared more interested in his drink than what he was doing while driving. The Administrator said he had counseled with Van Drive A about driving safely and having food in the van. He said Van Driver A had worked at the facility since 2019 and within the last few weeks he had gotten complaints about his driving. The Administrator said he had talked to Van Driver A and gave him a stern warning after Resident #2's complaints. Resident #3 Record review of Resident #3's face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #3's MDS dated [DATE] she was cognitively intact with a BIMS score of 15. She was ambulatory with a wheelchair. She was dependent on staff to come to a standing position from sitting in a chair. She was dependent on staff for transfer from bed to chair or chair to bed. Record review of Resident #3's care plan dated 9/24/25 indicated she was at risk for pain and discomfort related to being admitted with a hip fracture with hemorrhage and underlying arthritis. One of the interventions was to position for comfort. Record review of Resident #3's Weekly Skin Date report dated 9/10/25 at 4:00 p.m. indicated she had a skin tear to the left lateral hand and bruise to the left anterior forearm during fall on facility transport. Record review of Resident #3's nursing notes dated 9/10/25 at 5:07 p.m. indicated Resident #3 sustained an unwitnessed fall while in the facility van for an appointment. Neuro checks were initiated. The Resident initially complained of a headache at 7 out of 10 for pain but increased to 8 out of 10. The patent request to be evaluated at the local emergency room. Record review of Resident #3's hospital CT (medical imaging test) of the spine and CT of the head revealed no findings. Record review of Van Driver A's employee file indicted he began work as a van driver on 6/4/2019. He had in service sign in sheets for the mobility company (the company responsible for training on transportation) indicated he received training on 10/11/22, 7/16/23, 4/4/24, 10/11/24 and 7/8/25. A Personnel Action Form dated 9/10/25 indicated Van Driver A was terminated due to violation of company's transportation policy and procedures. Review of the facility Provider Investigation Report dated 9/12/25 indicated on 9/10/25 Resident # 3 was transported at 10:30 a.m. to an appointment. Van Driver A failed to secure Resident #3 during transport. The report indicated the facility put measures in place to fix the noncompliance. The facility obtained a statement from Van Driver A and he was suspended. The van equipment was checked for proper operation with no issues noted. Transport training was conducted for the backup driver (Van Driver B), the Administrator did ride along for skills verification with the backup driver. An onsite training was scheduled with the mobility company for 9/29/25 for a new driver and backup drivers. The van driver was terminated. An Ad-Hoc QAPI meeting was conducted on 9/10/25. A written statement by Van Driver A dated 9/10/25 stated: I was transporting Resident # 3 and I forgot to hook the right hook to her chair. I was in a hurry and just forgot. I pulled out on the access road and the chair tipped backwards. During a telephone interview on 9/23/35 at 1:48 p.m. Van Driver A said Resident # 3 fell out of the wheelchair to the floor while he was transporting her to an appointment on 9/10/25. He said he pulled over and parked. He said picked Resident # 3 off the floor. He said he then asked her if she wanted to go back to the facility or go to her appointment. He said Resident # 3 said she wanted to go to her appointment. He said he did not notify anyone at that time, he took her to her appointment. Van Driver A said he had never had an incident like that happen before, so he did what he thought best at the time. Van Driver A said when he arrived back to the facility with Resident # 3, he told the Administrator what had occurred. During an interview on 9/24/25 at 9:20 a.m. Administrator said Van Driver A was in- serviced by an outside company that did the training for the van safety and resident security. He said someone from the corporate office came and provided the training on the van and transportation once or twice a year. The Administrator said at the current time the Maintenance Director/ Van Driver B was the only person conducting transport. He said they did use two other outside transport services when needed to transport residents. He said they only used ride along staff if the doctor requested, the resident was confused, and/ or the family was unable to attend the appointment. He said Van Driver A was in- serviced on the facility policy to not move a resident if they fall and to notify staff if a fall occurred. He said Van Driver A had been educated at least yearly since he had been driving the van over the facility policies several times. During an interview on 9/24/24 at 10:15 a.m. Resident #3 said on 9/10/25 Van Driver A put her in the van and buckled her down as far as she knew. She said Van Driver A stopped and when he pulled off, the wheelchair went backward, and she fell to the floor. She said she was still in the wheelchair ; he had buckled the waist and shoulder belts. She said her head hit the wheelchair belt holder and she hurt her hand. Resident # 3 said Van Driver A picked her up off the floor, and he apologized. She said he asked if she wanted to go back to the facility or her appointment. She said she told him she wanted to go to her appointment. She said she was not sent to the ER until she got back to the facility that afternoon. Resident # 3 said her head was still hurting so they sent her out, but everything was fine. During an interview on 9/24/25 at 11:00 a.m. the DON said on 9/10/25 Resident # 3's skin assessment showed she had a skin tear on left hand and bruise on her left forearm. She said the resident complained of head pain and was sent to the hospital. The DON said Van Driver A said he had never had anyone to fall on the van in the past and did not seem too concerned about the incident. She said he did not say much and did not provide much information. Corrective actions taken to correct the noncompliance on 9/10/25 through 9/12/25 included: Record review indicated an Ad-Hoc QAPI meeting was conducted on 9/10/25 with signatures of the Administrator, DON, ADON. Record review of the facility Transportation and Procedure policy indicated areas of how to secure the wheelchair for transport. If an emergency occurs and a resident fell during transport, call 911, for ambulance to transport the resident to the ER for evaluation. Do not move the resident or transport the resident yourself. Call the DON, ADON[ or Administrator. If they are not at the facility call cell phone numbers until you reach one of these individuals. If the resident sustains any injury other than a small skin tear or abrasion without a fall, still call 911 for transport to ER. Do not transport the resident yourself. If the resident sustains minor injuries while being transported to the appointment notify the physician office personnel of the injury on arrival. Transport drivers and passengers must always wear safety seat belts during transport. The training to be completed with all designated drivers, including PRN, by Administrator on policy and procedures on 9/11/25. Each driver would be provided with a copy of the policy and procedures related to safely securing residents, use of seatbelts, and emergency procedures. The training included a competency evaluation, transportation in-service. This training would be conducted with any newly hired drivers as part of the orientation process going forward. These training results will be kept in their files for future reference and verification of compliance. Record review of Van Driver B's mobility training record indicated he was in serviced on 7/6/23. Record review of Van Driver B's training record indicated he was trained on the facility Transportation Policy and Procedures for safety during transport and securing the chair on 9/10/25. He received the transportation monitoring on 9/11/25 and 9/12/25. The form indicated the driver was reviewed on his understating of the transportation policies, securing passengers, articulated the procedures for safely securing a passenger, how to handle a resident during an emergencies, injuries and emergency contacts. Record review of Van Driver B's Transportation monitoring form dated 9/12/25 indicated an understanding of transportation policy and procedures regarding safely securing passengers and emergency situations, property secure the passenger, drive articulate the procedures for safely, articulate the procedure on how to handle a resident during an emergency. The driver knew what he can and cannot do as it pertains to handling residents' injuries during transport. The driver knows who to notify in case of an emergency or resident injury. Record review of the facility Transportation Policy and Procedure Manual updated 4/1/20 and signed by the Administrator and Van Driver B on 9/10/25 contained information on: Driver requirements, vehicle lift safety, safety during transport, securing the chair, emergency procedures, use of seat belts, who can ride on transport, use of vehicle, safety maintenance checks, transport logbook, scheduling transports, standard items kept in vehicle, storage of resident property, transport vehicle paperwork, noise levels, food and beverages in vehicle, cleaning vehicle, safety responsibilities of the driver, transport safety program-defensive driving, policy and procedure acknowledgement form, transport driver job specific orientation, transport in-service, transport driver job description, and acknowledgment form and vehicle maintenance issues.' During an interview on 9/24/25 at 9:46 a.m. Van Driver B said he worked at the facility for 5 years. He said the corporate person completed the training on driving the van. He said he had the training to be an alternate driver on a few occasions over the past years. He said he was in- serviced on 9/10/25 again over the procedures on how to drive the van. He said he did not have to be told not to move a resident if they fall. He said if he was walking down the hall and saw a resident on the floor, he knew not to move them. He said if a resident were to fall on the van, he was to make sure he was in a safe location and call 911. He would call EMS to pick them up and report to the facility immediately. Van Driver B said it was the general rule of the whole facility if you are not licensed you are not allowed to pick a resident up. He said if a resident fell a nurse had to assess them, before they were moved. He said part of the job as the van driver, was to take time and make sure the resident was secure prior to transport. During an interview on 9/24/25 at 12:20 p.m. Resident # 4 said she rode the van to dialysis three times weekly. She said she did not have any issues with Van Driver A or Van Driver B. During an interview on 9/24/25 at 12:21 p.m. Resident # 5 said he rode the van to dialysis three times weekly. He said he did not have any issues with Van Driver A or Van Driver B. During an observation on 9/24/25 at 12:25 p.m. of Van Driver B securing a resident in a wheelchair in the van. The facility van showed it was just wide enough for one wheelchair. Observation revealed the back tie downs could be connected on the back of the van. However, to connect the front wheelchair tiedowns you had to stand on the ground with the door opened and buckle them from the outside of the van. Observation of Van Driver B showed he connected the resident wheelchair tiedowns on all four wheels of the wheelchair. He strapped the seat belts over the shoulder and around the waist of the resident. Once the resident was secured, he released the brakes of the wheelchair and tried to move the wheelchair from side to side and back and forth. He said that was an extra precaution to check and make sure the resident was secured. He then relocked the breaks. Observation of the right wheel of the wheelchair not tied down showed the wheelchair would only move to the right about 2 to 4 inches when tilted backward. Observations indicated for the wheelchair to fall backward both the right and the left wheelchair tiedowns would need to be unsecured. During an interview on 9/24/25 at 12:50 p.m. the Administrator said he felt they did the right thing by terminating Van Driver A. They had the company coming on 9/29/25 to train the new staff member on driving the van. He said the company was supposed to come on 9/22/25 but they got their times crossed up somehow. He said the new driver, Van Driver B, and himself as a backup driver would be given the training for safe and secure transportation of residents. He said they were already trained on the facility policy for transportation of residents and would be trained again as part of the company training procedures. On 9/24/25 at 3:50 p.m. the Administrator, DON, ADON, and MDS coordinator were informed of the PNC IJ verbally and emailed the IJ template.

Based on interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 3 residents reviewed for quality of care (Resident #289 and Resident #290). 1. The facility failed to ensure Resident #289 did not elope from the facility on [DATE]. 2. The facility failed to ensure Resident #290 did not elope from the facility on [DATE] and [DATE] . The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for injury or harm. The findings included: 1.Record review of Resident #289's face sheet dated [DATE] revealed he was a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of neurocognitive disorder with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning, and independent function) and Parkinson disease (a disorder of the central nervous system that affects movement, often including tremors). Record review of Resident #289's quarterly MDS assessment dated [DATE] revealed a BIMS of 06 which indicated severe cognitive impairment. Resident #289 required clean-up assistance for eating, showering and toileting. Resident #289 required moderate assistance to walk 10 feet. Record review of Resident #289's care plan revealed a care plan dated [DATE] titled cognitive deficit. Decision making monitor for any changes or decline in cognitive as evidenced by short-term memory loss and long-term memory loss. Resident #289 was a fall risk related to fall on [DATE] and a history of Parkinson's disease as evidenced by tremors, generalized weakness, left sided weakness, right sided weakness, and left upper extremities weakness. Resident #289 had behavioral changes dated [DATE] due to neurocognitive disorder. Record review of Resident #289's elopement risk assessment [DATE] revealed resident was a moderate elopement risk. Record review on 15 minute watch on Resident #289 dated [DATE]-[DATE]. Record review of Resident #289's incident accident report dated [DATE] 6:29 P.M., revealed Resident typically leaves on pass with [Family Member #1] on Thursdays for the weekend and returns on Monday. Resident stated to staff on ,d+[DATE] that he was getting ready to leave and he would see her on Monday which was not abnormal for this resident. Resident was seen by staff at facility at 6:00PM. Resident noted to be at a local restaurant at 6:29PM by facility staff. Upon interview resident stated that he was going to his family member #1's house . Resident was in fact headed in correct direction to arrive at family member #1 house. Investigation revealed that resident is concerned about marital issues. Resident alert and oriented with BIMS of 13 at time of incident. Resident repeatedly expressed his apologies for leaving facility without signing out stating that it would not happen again. Resident voiced that he thought he could leave whenever he wanted. Resident does have some impulse control deficits and acknowledges this deficit. Resident acknowledges that he did not consider the risk of leaving the facility unannounced and ambulating off facility grounds. Record review of Resident #289's skin data dated [DATE] revealed he had a skin tear to left knee approximately the size of a half dollar and skin tear to left elbow approximately the size of a nickel. Resident #289 had bruising to the top of right buttocks and left arm. During an interview on [DATE] at 5:31 P.M., Family Member #1 said Resident #289 and her had some problems when he stayed the weekend with her. She said she tried to bring him back to the facility that Saturday, but she was unsuccessful. She said she brought him back to the facility that Wednesday on [DATE], and he did not want to go back. She said he had been telling the facility she was sick and he was at home taking care of her, but she was not aware of that at the time. She said he had told a family member he could leave the facility any time he wanted to. She said when she brought Resident #289 back to the facility on [DATE], she made the facility aware that they had an argument and the facility staff told her to turn off her phone or block him from calling her. She said she was told that another resident's family member from the facility called the facility and told them they seen Resident #289 at a local restaurant on the interstate. She said the facility did not know he had left the facility. She said he was trying to get a ride to her house. She said one of the nurses that knew him finally convinced him to get in the car with her and she brought him back to the facility. She said [DATE] was the only time he ever tried to leave the facility. She said the facility would let him sit outside all the time without staff, because he loved to be outside. She said the facility said he was last seen outside in front of the facility at 6:,d+[DATE]:15 P.M. and a resident's family member called the facility from a local restaurant at about 6:27 P.M. and said he was there. She said Resident #289 fell in a local restaurant parking lot and skinned his left knee and left elbow, but they were not major injuries. She said the next morning the facility called her and said he was going to be transferred to a behavioral Unit. The facility said the state had got involved in the incident and said he was a high-risk resident. She said he was in another facility that was a locked down facility at that time. The facility told her when Resident #289 got back to the facility he was coherent and was trying to come home to check on her, because they had a bad argument. She said Resident #289 was not in the mental state to cross over a major highway that was very dangerous. During an interview on [DATE] at 9:11 A.M., LVN DD said she had just got to work at 6:00 P.M. on [DATE] and Resident #289 was sitting outside on the front porch . She said Resident #289 said he was waiting on, and they were going on a date. She said shortly after that, the Activity Director called the facility and said he was in the parking lot at a local restaurant. LVN DD said they tried to get him to come back to the facility, but he was adamant about going to see family member #1. LVN DD said RN U and CNA V, convinced him to get in the car with them and returned to the facility. LVN DD said it was normal for Resident #289 to sit outside on the porch without staff even though he was an elopement risk. LVN DD said Resident #289 thought family member #1 was cheating on him, so he was agitated. She said he was adamant about not getting in the car and said if he would have gone another route, he would have missed us. She said she knew Resident #289 had on a red button-down long sleeve shirt, blue jeans, and a white cowboy hat on [DATE]. She said she did not remember the shoes he had on. LVN DD said when Resident #289 got back to the facility, he was upset. LVN DD said he said he had fell at a local restaurant before staff got there and he was not hurt. LVN DD said Resident #289 had some confusion, but he said he did not hit his head. LVN DD said he knew where he was going. LVN DD said the facility did 15-minute checks on Resident #289 until he left the facility, but she was not sure if they did neuro checks. LVN DD said the road he traveled was very busy, he crossed a street, and the other staff said he had tried to get a ride from a stranger. LVN DD said when they got him back to the facility, it took her and other staff members a while to get him to calm down, then a family member came and they got into an argument and he was even more upset. During an interview on [DATE] at 9:42 A.M., Activity Director W she said she was leaving the facility on her way home about 6:00 P.M. She said something told her to look at a local restaurant and she seen Resident #289 standing there. She said Resident #289 was tired and she offered him to sit in the car with her and he refused. She said she called the nurse at the facility and when the nurse LVN DD arrived, she tried to get him in the car, but he still refused. Activity Director W said RN U and CNA V came to the scene. She said Resident #289 proceeded to walk with an unsteady gait. Activity Director W said a gentleman came to help and Resident #289 said he wanted to go home to family member #1. She said Resident #289 continued to walk to the bank with the RN U under his arm walking with him. She said Resident #289 gave in and got in the car with RN U and CNA V, because he was tired. During an interview on [DATE] at 3:50 P.M., the DON said she received a couple calls that Resident #289 had been found at a local restaurant. She said Resident #289 had a plan to go home, because family member #1 did not live far away from the facility. She said Resident #289 was concerned about family member #1 was cheating on him. She said at first Resident #289 did not want to get into the car with the staff members, but eventually he got in the car and came back to the facility. She said he did not take his wheelchair when he left; he used wheelchair as a walker. She said he fell during the elopement and scrapped his left leg and left elbow. She said he did not show any signs that he wanted to leave the facility. She said family member #1 came to the facility and got him often. She said he was worried about family member #1 because she was not answering the phone. She said Resident #289 and family member #1 had an argument a day before the elopement, because he thought she was cheating with the neighbor. She said he sat outside on the bench every day. She said there were two different ways he could get to a local restaurant from the facility, they were not sure which route he took. She said Resident #289 was a moderate elopement risk . She said when he returned to the facility staff did every 15-minute checks on him, then the facility started discussing the next plan for him. She said the facility sent him to a behavior unit . She said then the facility decided to send him to their sister facility, because it was a locked facility. During an interview on [DATE] at 4:18 P.M., CNA X said Resident #289 normally walked out of the facility and sat out on the front porch, but that day, he walked off the premises. She said usually he sat out there and came back in. She we got him back to the facility. She said when she last seen him, he was walking out the front door to sit on the porch. She said at supper time staff went to his room to pass his tray and he was not there; then we to the front porch and was not there. She said they expanded the search and she drove her personal car to a local restaurant after one of the staff members said he was going to meet family member #1; they had a dinner date. She said he did not look tired and did not appear to have had any injuries. CNA V was the aide that went to find them. He got in the car with the RN U and CNA U to go back to the facility. She said she wanted to say he was on one-on-one checks and the facility called family member # after the incident. She said Resident #289 had to crossed over 4 lanes of traffic before he made it to a local restaurant. During an interview on [DATE] at 5:18 P.M., the DON said since the elopement incident with Resident #289 the facility had put prevention steps in place . She said a licensed nurse did not complete the elopement risk assessment on [DATE] . She said an elopement risk assessment should be done on admission by a licensed nurse. She said previously nonclinical personnel completed elopement assessments. She said going forward nonclinical personnel was not someone that she would expect to complete an elopement assessment and the elopement assessments would to be filled out accurately under her management. 2. Record review of Resident #290's face sheet dated [DATE] revealed he was a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of dementia (a group of thinking and social symptoms that interferes with daily function), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities), altered mental status (a change in how well the brain is working), violent behavior and delirium due to known physiological condition (disrupts brain function). Record review of Resident #290's care plan dated [DATE] revealed the resident was a high elopement risk. His cognition decision-making skills were severely impaired. Record review of Resident #290's incident reported dated [DATE] revealed the resident had a fall and elopement outside of the facility. During an interview on [DATE] at 5:02 P.M., Family Member #2 said Resident #290 believed he was going to meet someone at a local restaurant . She Resident #290 turned over in his wheelchair off the curb in the parking lot. She said he was at the facility, and he did not leave the property. She said she was not sure how far he was from the front door. She said he tried to leave the facility several times, so the facility told her he needed to be in a secured unit. She said she tried to find placement for him. She said it was hard to find placement for him, because he had a history of violent and inappropriate behaviors in the past, but she found placement for him . She said the facility tried everything they could to keep him from eloping, but he was very persistent and head strong. During an interview on [DATE] at 3:35 P.M., LVN B said she remembered Resident #290 was arguing with staff, because they were trying to redirect him. She said he was trying to leave out the front door, because he was going out the front door to meet with a deceased family member to go eat at a local restaurant. She said she was unable to redirect him, so she had another staff member to help me with him . She said she believed the former Administrator helped get him back into the facility. She said the facility put Resident #290 on 15 minutes checks and she gave him a PRN Ativan for anxiety. She said Resident #290 tried more than once to leave the facility, but he never left the premises. During an interview on [DATE] at 3:41 P.M., the DON said she got a phone call , and she called the former DON and then called the former Administrator about Resident #290's elopement and him falling. She said a family member found him outside. She stated she could not remember if he hit his head. She stated the nurse assessed him outside and he had some scraps on his left knee and left elbow as if he was trying to get up by himself off the concrete. Resident #290 was confused. She said before Resident #290 became confused it was common for him to sit outside. She said Resident #290 was in the curb of the front entrance of the facility. She said she did not remember the incident on [DATE] when Resident #290 eloped. She said the facility requested for him to transferred him to another facility . During an interview on [DATE] at 2:27 P.M., Marketing Z said she covered multiple facilities and the only facilities that could take an elopement risk resident was a memory care unit. She said if the patient was an elopement risk, the patient could not be considered for the facility. During an interview on [DATE] at 2:34 P.M., Admissions Coordinator Y said the facility could not take residents that were an elopement risk. During an interview on [DATE] at 4:55 P.M., the RDO informed surveyor that former ADM was terminated on [DATE] due to elopement of Resident #289. Record review of the Nurse Practitioner progress note dated [DATE] revealed Resident #289 had been seen on [DATE]. This is a [AGE] year-old male who is seen today after he was found to have left the facility unannounced and was walking to his former home. He was found by nursing staff to be down the road quite a ways in the parking lot of a gas station. Initially, he was irrational and agitated and would not get in the car with the nursing staff to go back to the facility. He apparently told nursing staff that he thought since he had Medicaid he could leave whenever he wanted, and he told one nursing staff member that he was on his way to take his wife to the rodeo. However come on today's examination he states that he left to go check on his wife as he had not heard from her and he got very worried about her well-being. He was able to verbalize exactly what he did and why he did it. I do not believe that he was confused in the moment when he made the decision to leave the facility and to go home as he was headed in the correct direction and was able to verbalize that he should have told someone that he was leaving. However, I do believe that the action was very impulsive, and he verbalized that he did not think about the risks or repercussions of leaving the facility unannounced in walking down a busy road by himself considering his impaired gate from his Parkinson's. He admits that he has difficulty with impulse control. He verbalizes that he will never do this again and he is apologetic. He states overall that he has been feeling ok but has been having some freeze spells secondary to his Parkinson's. He has been taking his breakthrough carbidopa levodopa prn dose On most days, but he does state that it seems to help get him back moving. He denies any additional issues or needs at the time of exam. I did explain to him that depending on what the facility protocols are he may not be able to stay in this facility as it is not a locked facility considering he has had a previous attempt of leaving the facility. Record review of the facility policy, Elopement Risk Assessment, revised [DATE] revealed the licensed nurse documents in the nurse's notes and behavior monitoring in the HBR; any exit seeking behavior on an on-going basis and interventions are adjusted as needed. Record review of the facility policy, Elopement Management, dated [DATE] revealed an immediate investigation and search will be conducted if a resident is considered missing. The resident will be located and returned to a safe environment within standard practice guidelines. `The facility corrected the noncompliance on [DATE] by the following: Record review of Training In-Service Form, Elopement Policy and Procedure, dated [DATE]. Record review of Training In-Service Form, Door Alarms, undated. Record review of Training In-Service Form, Managing elopement risk when resident stated they were leaving. They discussed how they could have handled that differently and watching for signs of confusion. They also discussed disease process dated [DATE]. During an interview on [DATE] at 2:28 PM., Housekeeping AA said she was in serviced over elopement and door alarms. She said the green code was for staff to check everywhere for the resident. She said after 30 minutes if the resident was not found staff should contact the police and the family. She said if the resident was found check them from head to toe. She said let the DON and ADM know as soon as possible once staff were aware the resident was missing. Door alarms you look if anyone got out , see if all residents were there, check outside, check everything , the DON, and ADM first. During an interview on [DATE] at 2:31 P.M., the ADON said she was in serviced over elopement and door alarms. She said the facility should call a code green for a missing resident. She said go to the nurse's station and get details on the missing resident, what they were wearing, last seen, and plan to find the resident. She said two people go together to find the resident. She said make sure the ADM, DON and all staff are aware . She said if the door alarm went off, she would go check and assess why the alarm was going off and check to see if all the residents are accounted for. During an interview on [DATE] at 2:34 P.M., LVN N said She was in serviced over elopement and door alarms. She said notify Administration and search every room. She said a code green should be called. She said two people together look everywhere and if resident was not found call the police and the family. She said if the door alarm goes off to check for residents inside and outside. She said a full head count for the entire building should be performed immediately of the residents. During an interview on [DATE] at 2:37 P.M., Floor Tech EE said he had in-services over elopement and door alarms. He said he would stop doing the floors and follow instructions on finding a missing resident, he would help to find them. He said if he saw a resident in the parking lot, he would bring them back in and tell the DON, ADM, and charge nurse. He said if a door alarm went off he would make sure no resident was near the door and he would alert staff immediately. During an interview on [DATE] at 2:39 P.M., Admissions Y said she was in serviced over elopement and door alarms. She said if a resident was missing would get their face sheet, search the inside perimeter, and slowly move outside. She said she would tell the ADM and DON and they would call a code green and meet at the nurse's station for a plan. She said two people were to search outside and staff would search indoor, then everyone would keep looking until resident was found. She said if a door alarm went off staff should instantly look to see if a resident was trying to get out, alert ADM, DON, do a head count and find out why the alarm went off. She said staff should check all showers and any place a resident could be. During an interview on [DATE] at 2:42 P.M., CNA FF said she was in serviced over elopement and door alarms. She said if a resident was missing, code green should be called, if a resident said they wanted to leave she would tell the ADM and DON immediately. She said if a resident was missing search where last seen and let everyone know you cannot find them. She said all staff should meet at the front nurse's station and everyone looks for the resident. She said door alarms staff should run to the alarm to see what was going on, to see if anyone escaped. During an interview on [DATE] at 2:45 P.M., CNA CC said she was in serviced over elopement and door alarms. She said if a resident eloped a code green should be called, notify ADM, DON, charge nurse, and let everyone know and find the resident. She said staff should search perimeters first then go from there. She said call police if not found in 30 minutes. She said if a door alarm goes off, do not just turn it off make sure no one has gotten out, if no resident was there, get help, search elsewhere, across the street, down the back and everywhere. She said all staff meet at the front nurse's station for an elopement plan. During an interview on [DATE] at 2:48 P.M., CNA E said she was in serviced over elopement and door alarms. She said if a resident got out of the code green. They have a book at the desk will tell you about the resident. Will tell the ADM and DON and ADM will call the police if not found in a certain period. Meet at the nurse's station for a plan to find the resident. Door alarm - check immediately could be someone escaping. Make sure every resident is safe and secure. Even if you don't see a resident still have to notify everyone and go check and do a head count to make sure. During an interview on [DATE] at 3:07 P.M., WCLVN G said she was in-serviced on elopement and door alarms. She said if a resident had eloped or she suspected to elope; staff should try to determine the last place the resident was seen, the closest exit, meet at the front nurse's station, a code green should be called and a plan should be made to find the resident. She said when a resident was unaccounted for first thing, she would do would be tell the DON, ADM, and SW. She said after 30 minutes of searching and resident not found call the police, med director, fire dept, and family. She said when a door alarm goes off check the exits for a resident and look in that area to make sure a resident had not exited. During an interview on [DATE] at 2:48 P.M., DON said she in serviced all staff over the Elopement policy and procedure and alarms. She said during an elopement, look for the resident first. She said she discussed what to look for in a resident that might elope, look for triggers in residents that might elope, what make you think of a resident might try to go to the door. She said she made sure staff understood the measures taken for a resident at risk for elopement. She said informed all staff if a resident was missing contact the DON; so, she could call a code green. She said during an elopement she meet with all staff at the front nursing station and the facility had a 30-minute window to look for a missing resident before the police were called. She said when the door alarm in service was performed we did a live demonstration we had someone stand at the door to activate the alarm, so staff knew how the alarm sounds. She said staff were informed that they need to check for the resident before they assumed a resident was missing and checked outside of the door before the door alarms were turned off. She said the smoking area alarms were different. She said the side door alarms went off by closing the door and the alarm would go off. During an interview on [DATE] at 3:05 P.M., LVN BB said she in serviced over elopement and alarms. She said when an elopement occurred or suspected the facility called a code green. She said if staff were not unable to locate the resident within 30 minutes, then the police were called, figure out where the resident was last seen, search the building and perimeters for the resident. She said there was an elopement book that verified higher elopement risk residents. She said after an elopement an incident report should be completed, an updated the elopement risk assessment on the resident. She said once a resident was found a nurse should do a head-to-toe assessment, notify the DON/ADM/ MD and 15-minute checks on the resident for 72 hrs. She said when alarms went off check outside to see if a resident left through the door and check the area before the alarm was turned off. During an interview on [DATE] at 3:11 P.M., CNA F said she was in serviced over elopements and alarms with elopements, she said if a resident eloped the staff gather in the front at the nurse's station and all staff in the facility would be notified of the elopement. She said staff should look inside the facility then look outside the facility. Notify the police after 30 minutes of searching for a resident if they are not found. When alarms were heard then run to the end of the hall and see what was going on and check to see if someone has left out the door. During an interview on [DATE] at 2:41 P.M., ADM said the incident with Resident #289 was situational . He said the facility had guidelines in place to prevent this incident from reoccurring. He said he loved to see his residents sitting outside, but safety always came first. He said he was not working at the facility when the incident occurred. He said he did not have all the facts about the incident with the Resident #289 or Resident #290. He said safety would be an issue for a resident that eloped the facility and crossed 4 lanes of traffic. He said the risk for the Resident #289 and Resident #290 could have been anything from missing meds to an injury. The noncompliance was identified as PNC. The noncompliance began on [DATE] and ended on [DATE]. The facility corrected the noncompliance before the survey began.

Based on interview and record review the facility did not notify the physician of a significant change in the physical condition for 1 of 22 resident reviewed for notification of change. (Resident #151) The facility did not notify the physician when Resident #151, who had a history of Acute Respiratory Failure with hypercapnia (too much carbon dioxide in the body), had an oxygen saturation of 88% on [DATE] at approximately 6:30 p.m., had difficulty breathing, and would not keep on their Bipap (non-invasive ventilation breathing support administered through a face mask) mask . The resident was found unresponsive at 11:10 p.m. and expired at the facility. The facility failed to have a Physician Notification Policy. These failures resulted in the identification of an Immediate Jeopardy (IJ) on [DATE] at 5:21 p.m. While the IJ was removed on [DATE] at 4:02 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents who experience a change of condition at risk for harm, deteriorating health or death. Findings included: Record review of a face sheet dated [DATE] indicated Resident #151 was [AGE] years old. Resident #151 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including acute respiratory failure with hypercapnia (high levels of carbon dioxide in the body), heart failure, and chronic obstructive pulmonary disease (chronic lung disease). Record review of consolidated physician's orders dated [DATE] for Resident #151 indicated the resident was admitted on [DATE] to skilled care. An order dated [DATE] indicated Bipap as needed. As needed for SOB (shortness of breath), with naps. Notify provider with episodes of SOB . An order dated [DATE] indicated Bipap daily at bedtime . The orders indicated Resident #51 code status was full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). Record review of the MDS dated [DATE] indicated Resident #151 usually understood others and was usually understood. The MDS indicated a BIMS was not conducted due to the resident be rarely to never understood. The MDS indicated Resident #151 required oxygen care. The MDS did not indicate the use of Bipap. Record review of a care plan updated on [DATE] indicated Resident #151 had a care area for Breathing Pattern related to a diagnosis of chronic obstructive pulmonary disease. There was an intervention to administer medications, respiratory treatments, and oxygen as ordered. Record review of an After Visit Summary for Resident #151 from the hospital dated [DATE] indicated, .Other Instructions .continue BIPAP PRN (as needed) for shortness of breath, lethargy, hypercapnia .Last vital signs recorded .BP ,d+[DATE] (blood pressure), Pulse 81, Temp 97.8 (oral), Resp 22, SpO2 100% (oxygen saturation). Record review of hospital discharge records for Resident #151 with an admitted [DATE] and a discharge date d on [DATE] indicated, .Pt was admitted for acute hypercapnic respiratory failure, altered mental status, and resolving pneumonia .Recommendations .Continue Bipap/Avaps PRN (as needed) for shortness of breath, lethargy, hypercapnia . Record review of hospital records dated [DATE] indicate Resident #151 was evaluated in the emergency department. The reason for the visit was for chest pain and shortness of breath. The diagnosis was Atrial Fibrillation with rapid ventricular response (a cardiac rhythm when the rapid contractions of the atria make the ventricles beat to quickly. If the ventricles beat too fast, they cannot receive enough blood. So, they cannot meet the body's need for oxygenated blood). Record review of vital signs for Resident #51 indicated on [DATE] at 5:59 p.m. a blood pressure of ,d+[DATE], a heart rate of 88, respirations of 18, a temperature of 97.8, and an oxygen saturation of 97%. On [DATE] at 12:26 p.m. a heart rate of 78, respirations of 18, and an oxygen saturation on 98%. On [DATE] at 3:01 p.m. a blood pressure of ,d+[DATE], a heart rate of 78, respirations of 18, an oxygen saturation of 98%. On [DATE] at 8:44 a.m. a heart rate of 78, respirations of 18, and oxygen saturation of 98%. On [DATE] at 1:36 p.m. a heart rate of 78, respirations of 19, and an oxygen saturation of 98%. On [DATE] at 1:07 p.m. a blood pressure of ,d+[DATE] and a temperature of 98.3. There were no further vital signs documented. Record review of undated handwritten notes by LVN O indicated, at 18:30 p.m . Bipap on by nurse. The notes indicated at 8:50 p.m. went to pt. room, Bipap was off, pt had taken Bipap off, did explain to pt the need for keeping Bipap on, eyes closed, no response. The notes indicated at 10:25 p.m. went to pt. room, Bipap off, and was put back on pt. Bipap machine is working well. At 10.30 p.m. came to desk, called (family member) and explained to her that pt. will not keep Bipap on, that if pt's (family member) wanted to come and stay to help pt. with keeping Bipap on, it would be ok . At 11:10 p.m. Family member .here, nurse got up from desk and walked down to pt's room. Arrived in room, (family member) and I noticed pt not breathing and CPR (cardiopulmonary resuscitation) begin. At 11:23 p.m. CPR team arrived and CPR continued. There was one set of untimed vital signs that indicated pt pulse ox (oxygen saturation) was 88 then 90, B/P (blood pressure) ,d+[DATE], temp 96.2. The oxygen saturation, blood pressure and temperature were below Resident #151's baseline. Respirations or heart rate were not indicated. There was no documentation of the physician having been notified. Record review of nurse's notes on the electronic medical record for Resident #151 indicated a note made my LVN O on [DATE] and electronically signed at 11:12 p.m., 1850 (6:50 p.m.) .Bipap was applied .pt appears to be resting well. A note made by LVN O on [DATE] and electronically signed 11:31 p.m. indicated 2050 (8:50 p.m.) pt. has taken Bipap off and explained to pt. that this is to help remove the CO2 (carbon dioxide) d/t pt. needs help to get ride of the bad oxygen, was still trying to take mask out of nurse's hand. A nurse's note made by LVN O on [DATE] and electronically signed at 12:10 a.m. indicated, a note for [DATE] 2225 (10:25 p.m.) Pt had taken mask off and was replaced back on and ask pt to not remove, this mask help with your breathing. A nurse's note made by the DON dated [DATE] and was electronically signed at 7:37 a.m. indicated on [DATE] 2230 (10:30 p.m.) family member .was called and informed pt continues to taking off Bipap mask and refuses to keep it on, did inform her that nurse will continue to go back and check and put mask back on as needed, did ask if pt (family member) wanted to stay due to pt noncompliance . A nurse's note made by the DON dated [DATE] and electronically signed at 7:32 a.m. indicated, on [DATE] 2310 (11:10 p.m.) family member .here, him and nurse walked to the pt room, pt. had Bipap slid off to the right side top of head and was not breathing, cpr was done immediately while pt. (family member was screaming at nurse why somebody was not down here sitting with him, 2313 (11:13 p.m.) CPR team with crash cart arrived and began assisting nurse with CPR, board hard surface placed under patient, pads on, continuing CPR 2318 (11:18 p.m.), analyzing, shock not advised, paramedics arrived 2329 (11:29 p.m.) taking over CPR in progress, firefighters arrived 2340 (11:40 p.m.), IV (intravenous access to body) started, intubated (when a tube inserted for venilation) 2345 (11:45 p.m.) . continue cpr, 2354 (11:54 p.m.) pulse check continue cpr, 2357 (11:57 p.m.) pulse check continue cpr, 2359 (11:59 p.m.) pulse check continue cpr, 2403 (12:03 a.m.) continued cpr, paramedic spoke to nurse and stated pt. PEA (pulseless electrical activity, a type of irregular heart rhythm, meaning it is a malfunction of the heart's electrical system) was not active and only there because of continued compressions, last pulse check 2406 (12:06 a.m.). Police arrived, and also assisted with cpr. EMS called time of death. Family was present. There were no nurse's notes indicating the physician had been notified of Resident #151's condition on [DATE]. During an interview on [DATE] at 1:57 p.m., LVN O she was Resident #151's nurse the night of [DATE]. She said Resident #151 would not keep on his Bipap mask. She said she made notes on a piece of paper. She said when she came to work she checked on him right then. She said anytime she had a resident with a critical condition she checked on them first. She said she first checked on Resident #151 around 6:30 p.m. She said she took vital signs at this time. She said those vital signs were charted on the back of a handwritten note. She said she helped the aide clean him. She said she placed his Bipap mask back on him them. She said the aide reported to her that he had been taking his mask off that evening. She said she did call family and suggested that a family member might come sit with him to help keep his mask on. She said she walked in with the Family Member #2 and the resident was not breathing. She said the door was closed and no other staff were in the room. She said the mask was to the side of his head. She said she had previously taken care of the resident and he always has difficulty breathing. She said he could not breathe without some kind of assistance with his breathing. She said she did not call the physician at any time that evening . She said she did not notify the physician that Resident #151 would not keep on his Bipap mask. She said Resident #151 was not anxious and he did not need medication to calm him. She said she did not feel he needed medication so he would tolerate the Bipap better. She said she was checking on the resident every hour. She said she handwrote notes indicating when she had checked on him. She said at no time did staff sit with him to make sure he kept his mask on. She said, we just go in and do what we have to do and then leave. She said when she realized he was not breathing she checked his pulse and then started CPR. She said she only took one set of vital signs at 6:30 p.m. and this was documented on her handwritten note. She said she did not report the vital signs to the physician. She said at no time that evening did the resident open his eyes or talk to her. She said this was normal for him. She said she had had no specific trainings concerning the Bipap. She said she just knew how to use the Bipap from years of experience. During an interview on [DATE] at 2:20 p.m., Corporate Nurse AA said she was looking for, but did not think the facility had a physician notification policy. During an interview on [DATE] at 4:55 p.m., LVN O said she had only taken care of Resident #151 one previous shift. She said she was not that familiar with him. She said you could just tell he was critical. She said with CPR you check the airway, breaths, and circulations. She said the resident had no pulse. She said she did compressions in the middle of his sternum (the breastbone). She said she placed the heal of her hands in the middle of the sternum. During an interview on [DATE] at 9:06 a.m., Attending Physician Z said he would expect nursing staff in the facility to make sure residents with shortness of breath or difficulty breathing were compliant in wearing their Bipap mask appropriately. He said he would expect staff to monitor the resident and send them to the ER for any acute changes. He said he would have expected staff to have contacted Nurse Practitioner K for symptoms or non-compliance in wearing the Bipap mask. When asked if the resident not wearing his BiPap mask could have contributed to Resident #151's death he said, oh yeah. He said from what little he knew about the resident he had multiple conditions that could have led to his death but not being compliant with wearing his BiPap could be part of it. He said non-compliance with not wearing his mask could affect everything. During an interview on [DATE] at 9:25 a.m., Nurse Practitioner K said he would have expected staff to have contacted him for Resident #151 not wearing his mask or for increased shortness of breath. He said he had seen Resident #151 earlier in the day of [DATE] and the resident was a little short of breath. He said he told staff to call him for increased shortness of breath. He said he would have expected to have been notified for shortness of breath, not keeping his mask on and any acute changes. He said he might have tried a telehealth visit. He said he would have checked the resident's general condition. He said he probably would have had staff send the resident to the emergency room for further evaluation. During an interview on [DATE] at 2:40 p.m., the DON said a change in condition could be acute shortness of breath, skin changes such as sweat and temperature change, and cyanosis (a bluish discoloration of the skin resulting from poor circulation). She said any change in condition would need to be reported immediately to the provider. She said on [DATE], the resident was not acting any different than he had. She said the nurse told her she did not see him as in distress. During an interview on [DATE] at 10:54 a.m., the DON said she felt the nurse did not see Resident #151's vital signs and him taking his mask off as a change in condition. She said LVN O was a nurse a really long time. She said the resident had been fighting the mask and had been pulling it off. She said she did not feel the nurse recognized him as having a change in condition. She said when the resident was hypoxic (an absence of enough oxygen in the tissues to sustain bodily function. An oxygen saturation below 92% is considered hypoxic) the nurse should have checked the orders and notified the physician. The DON said she (the DON) had already discussed with the Nurse Practitioner K about the resident not keeping his mask on. She said he had advised that if Resident #151 would not keep the mask on to call family to the facility to keep the mask on. She said a provider not being notified for a change in condition could cause increased chance of harm. During an interview on [DATE] at 1:13 p.m., the Administrator said if a nurse felt that a resident was critical and having difficulty breathing she would have expected this to have been reported to the physician by the nurse. She said abnormal vital signs for any resident should have been reported to a physician. She said staff were in regular contact with Nurse Practitioner K that night. She said she was not sure if a oxygen saturation of 88% was ever communicated to the provider. She said the resident was not enrolled in Hospice, but there were family members that wanted him placed on hospice. There was a family member that wanted him to be a full code and wanted everything done. The administrator said she discussed with the family member that the resident would not keep on his mask and the facility was unable to restrain him as he was in the hospital at the facility could not force him to wear a mask. She said the family member said he was not restrained in the hospital but was sedated. She said the facility could not chemically restrain him. She said a medication such as Ativan could not be ordered because Resident #151 was so fragile. Review of a Change in Condition policy last revised on February 13, 2023 indicated, The primary goal of identifying Acute Changes of Condition (ACOCs) is to enable staff to evaluate and manage a patient at the community and avoid transfer to a hospital or emergency room (ER). To achieve this goal, the community's staff and practitioners must recognize an ACOC and identify it's nature, severity, and cause(s) changes in condition of the patient are determined by current and past medical conditions, medical orders, patient safety factors, and/or by assessments utilizing defined parameters .IMMEDIATE NOTIFICATION: Any symptom, sign, or apparent discomfort that is: acute or sudden in onset, and: a marked change (i.e. more severe) in relation to usually symptoms and sings, or Unrelieved by measures already prescribed . Review of an article title Hypoxia by The Cleveland Clinic, https://my.clevelandclinic.org/health/diseases/23063-hypoxia, and was accessed on [DATE] indicated, Hypoxia is low levels of oxygen in your body tissues. It causes symptoms like confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin. Many chronic heart and lung conditions can put you at risk for hypoxia. Hypoxia can be life-threatening. If you are experiencing symptoms of hypoxia, call 911 or go to the nearest ER . The treatment for hypoxia depends on the underlying cause. The cause might be a one-time event or it could be an ongoing condition. Treatments might include: . BiLevel positive airway pressure (often known under the trade name BiPAP(R)) . The Administrator was notified of an IJ on [DATE] at 5:21 p.m. and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on [DATE] at 1:40 p.m. and included the following: Plan of Removal Summary of Details which lead to outcomes On [DATE], during annual survey initiated at the facility, a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. F580 The notification of the alleged immediate jeopardy states as follows: F580-Physician Notification The resident was a 79 y/o male, admitted on [DATE] with a diagnosis of Acute Respiratory failure with hypercapnia (to much carbon dioxide in the body). The resident was sent to the hospital on [DATE] and readmitted to the facility on [DATE]. The facility failed to notify the physician of a low oxygen saturation of 88% and that the resident would not keep his bipap on. The facility failed to obtain and monitor the residents' vital signs. The facility does not have a physician notification policy. The facilities change of condition policy indicated to notify the physician when the resident is unrelieved by measures already prescribed. o How other residents with the potential to be affected by the same deficient practice will be identified; o Any resident with orders for bi-pap therapy and/or residents who have signs of respiratory distress o What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur; o The LVN was provided education by NP on [DATE]. Education includes: a.) Identification of change of condition. b.) Notification to provider for any change of condition. c.) Assessment and response to change of condition. d.) Increased monitoring at time of change of condition until recommendation received from physician. e.) Documentation of change of condition. f.) Ensuring physician orders are followed. o DON/ADON/MDS/WOUND NURSE were provided education by NP on [DATE]. Education includes: a) Identification of change of condition. b) Notification to provider for any change of condition. c)Assessment and response to change of condition. d) Increased monitoring at time of change of condition until recommendation received from physician. e) Documentation of change of condition. f ) Ensuring physician orders are followed. o DON/ADON will provide education to all licensed staff prior to start of next scheduled work shift to include: starting ,d+[DATE] and reported to QA committee monthly x 3 months a.) Identification of change of condition. b.) Notification to provider for any change of condition. c.) Assessment and response to change of condition. d.) Increased monitoring at time of change of condition until recommendation received from physician. e.) Documentation of change of condition. f.) Notification to DON/Designee of change of condition. g.) Ensuring physician orders are followed. o All residents requiring bipap therapy will have standing orders written on eMAR with parameters to notify physician per guidance on parameters for notification from physician. How the corrective action(s) will be monitored to ensure the deficient practice is being corrected and will not recur (i.e., what program will be put into place to monitor the continued effectiveness of the system changes); and o All new hire licensed staff are educated as above prior to completion of orientation. o All changes of condition will be communicated to DON/Designee and provider. o DON/Designee will review 24-hour reports and change of condition reports daily. o DON/Designee will review spo2 recordings for residents with bipap daily. Involvement of Medical Director The APRN Nurse Practitioner for Medical Director met with interdisciplinary team on [DATE]. Involvement of QA An Ad Hoc QAPI meeting will be held with the Medical Director, facility administrator, director of nursing, and social services director to review plan of removal. Administrator will forward results of audits monthly to the QAPI Committee for review and/or action times three months. Who is responsible for implementation of process? The Director of Nursing/designee will be responsible for implementation of New Process. The New Process/ system will be started on [DATE] and no employee be able to return to work until they complete the Inservice. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on [DATE]. The surveyor verification of the Plan of Removal from [DATE] was as follows: Record review of the current residents' electronic health records did not indicate any residents requiring breathing assistance with Bipap. Electronic health records were accessed from [DATE] - [DATE] . Record review of a Training In-Service Form indicated an in-service was held on [DATE]. The in-service was present by a Nurse Practitioner. The in-service covered change of condition, changes in level of consciousness, oxygen saturation, CPR hand placement, notifying providers, notifying DON/Family, Increased monitoring with change of condition, and following physician's orders. A total of 24 staff members attended the in-service. The in-service included a signature of LVN O, the ADON, the MDS and the wound care nurse. During an interview [DATE] at 2:00 p.m., the DON said the in-service training on [DATE] was verbal with mock CPR. She said staff completed a return demonstration on her. This in-service was completed on [DATE] at 8:00 p.m. The DON said a change in condition would be acute shortness of breath, skin changes such as sweat and temperature change, cyanosis. She said any change in condition would need to be reported immediately to the provider. She said she held a mock code using several different scenarios and with people with different body sizes. She said she instructed to never leave a resident unattended that was in distress. She said all staff performed all CPR correctly. She said she instructed staff when patients come in with physician's orders to verify the orders are in and all equipment is in the room and orders are on the chart. She was able to accurately describe neglect of a resident. She said she educated staff on change of condition, changes in level of consciousness, oxygen saturation, CPR hand placement, notifying providers, notifying DON/Family, Increased monitoring with change of condition, and following physician's orders. During an interview on [DATE] at 3:12 p.m., LVN O said she was in-serviced on identification of change of condition, notification to provider for any change of condition, assessment and response to change of condition., increased monitoring at time of change of condition until recommendation received from physician, documentation of change of condition and ensuring physician orders are followed. She was able to accurately describe how to do CPR and accurately describe neglect. During interviews conducted from on [DATE] beginning at 2:00 p.m. through 4:02 p.m., 20 of 24 of nursing staff in-serviced (including staff across all shifts that were the DON, ADON, MDS Nurse, the Wound Care Nurse, CNAs, LVNs and RNs) were interviewed. All staff said they received education on change of condition and were able to verbalize understanding, changes in level of consciousness, oxygen saturation, CPR hand placement, notifying providers, notifying DON/Family, Increased monitoring with change of condition, and following physician's orders. On [DATE] at 4:02 p.m., the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. 44933

Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 6 of 22 residents reviewed for respiratory care. (Resident #151, Resident #26, Resident #3, Resident #5, Resident #29, and Resident #67) The facility failed to monitor Resident #151 to ensure he kept his Bipap (non-invasive ventilation used for breathing support administered through a mask) mask on. The facility failed to notify the physician of a low oxygen saturation of 88% and the Resident #151 would not keep his Bipap mask on. The facility failed to obtain and monitor Resident #151's vital signs. The facility failed to follow Resident #151's readmission orders from the hospital for the use of Bipap. The facility did not ensure Resident #26's oxygen concentrator filter was free from gray like substances. The facility failed to ensure Resident#3, Resident#5, and Resident #29 oxygen concentrator (take air from your surroundings, extract oxygen and filter it into purified oxygen for you to breathe) did not have gray, fuzzy material in their filter (are used within the machine to remove particles and contaminants from entering your lungs for an improved therapy experience. They also prevent these same particles and contaminants from entering the machine to help it last longer and function properly) and filter compartment. The facility failed to ensure Resident #3, and Resident #5 had water in their humidification bottle (a plastic bottle designed to attached to oxygen machines and add moisture to the end users oxygen). The facility failed to ensure Resident #5 nasal cannula (is a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) and humidification bottle was not past due to be changed. The facility failed to ensure Resident #67 nebulizer mask (used to deliver aerosol medication to people with respiratory illnesses) was not past due to be changed. These failures resulted in the identification of an Immediate Jeopardy (IJ) on [DATE] at 5:21 p.m. While the IJ was removed on [DATE] at 4:02 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of respiratory complications or respiratory infection. Findings included: 1. Record review of a face sheet dated [DATE] indicated Resident #151 was [AGE] years old. Resident #151 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including acute respiratory failure with hypercapnia (increased levels of carbon dioxide in the body), heart failure, and chronic obstructive pulmonary disease (chronic lung disease). Record review of consolidated physician's orders dated [DATE] for Resident #151 indicated the resident was admitted on [DATE] to skilled care. An order dated [DATE] indicated Bipap (non-invasive ventilation used for breathing support administered through a mask) as needed. As needed for SOB (shortness of breath), with naps. Notify provider with episodes of SOB . An order dated [DATE] indicated Bipap daily at bedtime . The orders indicated Resident #51 code status was full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). Record review of the MDS assessment dated [DATE] indicated Resident #151 usually understood others and was usually understood. The MDS indicated a BIMS was not conducted due to the resident being rarely to never understood. The MDS indicated Resident #151 required oxygen care. The MDS did not indicate the use of Bipap. Record review of a care plan updated on [DATE] indicated Resident #151 had a care area for Breathing Pattern related to a diagnosis of chronic obstructive pulmonary disease. There was an intervention to administer medications, respiratory treatments, and oxygen as ordered. Record review of an After Visit Summary for Resident #151 from the hospital dated [DATE] indicated, .Other Instructions .continue BIPAP PRN (as needed) for shortness of breath, lethargy, hypercapnia .Last vital signs recorded .BP ,d+[DATE] (blood pressure), Pulse 81, Temp 97.8 (oral), Resp 22, SpO2 100% (oxygen saturation). Record review of hospital discharge records for Resident #151 with an admitted [DATE] and a discharge date d on [DATE] indicated, .Pt was admitted for acute hypercapnic respiratory failure, altered mental status, and resolving pneumonia .Recommendations .Continue Bipap/Avaps PRN (as needed) for shortness of breath, lethargy, hypercapnia . Record review of hospital records dated [DATE] indicate Resident #151 was evaluated in the emergency department. The reason for the visit was for chest pain and shortness of breath. The diagnosis was Atrial Fibrillation with rapid ventricular response (a cardiac rhythm when the rapid contractions of the atria make the ventricles beat too quickly. If the ventricles beat too fast, they cannot receive enough blood. So, they cannot meet the body's need for oxygenated blood). Record review of a Treatment Administration Record for Resident #151 indicated, Bipap daily at bedtime. There was a start date of [DATE] and an end date of [DATE]. There was no documentation of the Bipap being applied on [DATE], [DATE], or [DATE]. Record review of vital signs for Resident #151 indicated on [DATE] at 5:59 p.m. a blood pressure of ,d+[DATE], a heart rate of 88, respirations of 18, a temperature of 97.8, and an oxygen saturation of 97%. On [DATE] at 12:26 p.m. a heart rate of 78, respirations of 18, and an oxygen saturation on 98%. On [DATE] at 3:01 p.m. a blood pressure of ,d+[DATE], a heart rate of 78, respirations of 18, an oxygen saturation of 98%. On [DATE] at 8:44 a.m. a heart rate of 78, respirations of 18, and oxygen saturation of 98%. On [DATE] at 1:36 p.m. a heart rate of 78, respirations of 19, and an oxygen saturation of 98%. On [DATE] at 1:07 p.m. a blood pressure of ,d+[DATE] and a temperature of 98.3. There were no further vital signs documented. These were the baseline vital signs for Resident #151. Record review of undated handwritten notes by LVN O indicated, at 6:30 p.m. Bipap on by nurse. The notes indicated at 8:50 p.m. went to pt. room, Bipap was off, pt had taken Bipap off, did explain to pt the need for keeping Bipap on, eyes closed, no response. The notes indicated at 10:25 p.m. went to pt. room, Bipap off, and was put back on pt. Bipap machine is working well. At 10.30 p.m. came to desk, called (family member) and explained to her that pt. will not keep Bipap on, that if pt's (family member) wanted to come and stay to help pt. with keeping Bipap on, it would be ok . At 11:10 p.m. Family member .here, nurse got up from desk and walked down to pt's room. Arrived in room, (family member) and I noticed pt not breathing and CPR (cardiopulmonary resuscitation) begin. At 11:23 p.m. CPR team arrived and CPR continued. There was one set of untimed vital signs that indicated pt pulse ox (oxygen saturation) was 88 then 90, B/P (blood pressure) ,d+[DATE], temp 96.2. Respirations or heart rate were not indicated. The oxygen saturation, blood pressure and temperature were below Resident #151's baseline. There was no documentation of the physician having been notified. Record review of a nurse's note on the electronic medical record dated [DATE] and was entered and electronically signed by the DON on [DATE] at 8:01 a.m. indicated, .Bipap settings set by (respiratory company representative), per DC (discharge) order from (hospital), machine in place. Record review of nurse's notes on the electronic medical record for Resident #151 indicated a note made by LVN O on [DATE] and electronically signed 11:12 p.m., 1850 (6:50 p.m.) .Bipap was applied .pt appears to be resting well. A note made by LVN O on [DATE] and electronically signed 11:31 p.m. indicated 2050 (8:50 p.m.) pt. has taken Bipap off and explained to pt. that this is to help remove the CO2 (carbon dioxide) d/t pt. needs help to get ride of the bad oxygen, was still trying to take mask out of nurse's hand. A nurse's note made by LVN O on [DATE] and electronically signed at 12:10 a.m. indicated, a note for [DATE] 2225 (10:25 p.m.) Pt had taken mask off and was replaced back on and ask pt to not remove, this mask help with your breathing. A nurse's note made by the DON dated [DATE] and was electronically signed at 7:37 a.m. indicated on [DATE] 2230 (10:30 p.m.) family member .was called and informed pt continues to taking off Bipap mask and refuses to keep it on, did inform her that nurse will continue to go back and check and put mask back on as needed, did ask if pt (family member) wanted to stay due to pt noncompliance . A nurse's note made by the DON dated [DATE] and electronically signed at 7:32 a.m. indicated, on [DATE] 2310 (11:10 p.m.) family member .here, him and nurse walked to the pt room, pt. had Bipap slid off to the right side top of head and was not breathing, cpr was done immediately while pt. (family member was screaming at nurse why somebody was not down here sitting with him, 2313 (11:13 p.m.) CPR team with crash cart arrived and began assisting nurse with CPR, board hard surface placed under patient, pads on, continuing CPR 2318 (11:18 p.m.), analyzing, shock not advised, paramedics arrived 2329 (11:29 p.m.) taking over CPR in progress, firefighters arrived 2340 (11:40 p.m.), IV (intravenous access to body) started, intubated (when a tube inserted for ventilation) 2345 (11:45 p.m.) . continue CPR, 2354 (11:54 p.m.) pulse check continue CPR, 2357 (11:57 p.m.) pulse check continue CPR, 2359 (11:59 p.m.) pulse check continue CPR, 2403 (12:03 a.m.) continued CPR, paramedic spoke to nurse and stated pt. PEA (pulseless electrical activity, a type of irregular heart rhythm, meaning it is a malfunction of the heart's electrical system) was not active and only there because of continued compressions, last pulse check 2406 (12:06 a.m.). Police arrived, and also assisted with CPR. EMS called time of death. Family was present. There were no nurse's notes indicating the physician had been notified of Resident #151's condition on [DATE]. During an interview on [DATE] at 9:00 a.m., Family Member #1 of Resident #151 said the resident had been placed on Bipap while in the hospital between admission to the facility and when he was readmitted to the facility. Family Member #1 said there was a Bipap at the facility. Family Member #1 said the night Resident #151 died , a nurse called her and said he was having problems keeping the mask on. Family Member #1 said while he was in the hospital, they would put the Bipap on him as needed and then they would take it off so he could rest. Family Member #1 said there were times he would get confused and take the mask off of his face. Family Member #1 said a nurse at the facility told them that staff just put the mask on him and would leave him for the night. Family Member #1 said she did not know the name of this nurse. Family Member #1 said the nurse told them the facility did not have respiratory therapy present in the facility. Family Member #1 said they felt the resident was already dead when the nurse called her. Family Member #1 said Family Member #2 arrived at the facility, the door was closed, and no staff was in the room with him and the lights were out. Family Member #1 said the resident was admitted back to the facility on [DATE]. Family Member #1 said when they came into the facility on the morning of [DATE], Resident #151 was in distress. Family Member #1 said the Bipap was in the closet. Family Member #1 said they could not find a nurse and they told another staff member he was in distress, and they found a nurse. Family Member #1 said there was no Bipap machine in the room. Family Member #1 said when the nurse came to the room she seemed to not know that Resident #151 had an order for Bipap. While in the room they said the nurse said, I don't know what to do. Family Member #1 said Resident #151 had to be sent back to the ER. She said, I wish we had never brought him here. During an interview on [DATE] at 9:15 a.m., Family Member #2 of Resident #151 said the events that led to the resident's death began when the resident was sent out of the facility to theER on [DATE]. Family Member #2 said the doctor at the ER told him they could not hold him there. The ER doctor told the family the facility was not doing what they were supposed to be doing because the Bipap had not been placed on Resident #151 the night before. Family Member #2 said the resident was then sent back to the facility. Family Member #2 said they called the Administrator and had a long discussion with her about Resident #151's care. Family Member #2 said she promised them she would talk to staff about his care. Family Member #2 said on the evening of [DATE] Family Member #1 called them saying Resident #151 would not put on his Bipap mask. Family Member #2 said they then came to the facility. Family Member #2 said when they walked into the facility the resident's nurse was sitting at the nurse's station talking on a cellphone. Family Member #2 said LVN O walked down the hall with them with no sense of urgency about her. Family Member #2 said the resident's door was closed, the lights were out, and no staff were in the room with the resident. Family Member #2 said when the light was turned on the Bipap mask was on top of the resident's head. Family Member #2 said the nurse was trying to put the mask back on even though the resident was not breathing. Family Member #2 said they felt the nurse was suspicious because when walking in the room she did not turn on any lights or even speak a word to the resident. Family Member #2 said it was obvious she was not looking at him or talking to him. Family Member #2 said the nurse told the roommate to push the button, push the button. Family Member #2 said the roommate did not know which button she was talking about. Family Member #2 said they had to run out of the room and tell the other nurse's what was going on. Family Member #2 said the resident did not even have oxygen on him. Family Member #2 said he thought someone should have stayed in the room with him until family got there. Family Member #2 said earlier in the evening the resident had been awake and alert watching a TV show and talking about eating chicken and dressing. During an interview on [DATE] at 11:15 a.m., LVN EE said Resident #151 only had orders only to wear the Bipap at bedtime. She said this was how most of their residents do. She said she thought Resident #151 had a history of respiratory failure. She said family would sit with him during the day and request for the Bipap to be placed on the resident. She said she was unable to do so because the order was only for bedtime. She said she called the physician, and he told her the order was for bedtime and if he was in distress to send him to the hospital. She said his vital signs were stable when she took care of him. She said on [DATE] the Bipap was in the room. I am pretty sure he had it on the night before. She said he would pull on the mask and take it off. She said she had not received special training on using a BiPap at the facility. She said she just knew from experience from working at a respiratory company. She said she had no training specifically concerning the resident. During an interview on [DATE] at 1:57 p.m., LVN O she was Resident #151's nurse the night of [DATE]. She said Resident #151 would not keep on his Bipap mask. She said she made notes on a piece of paper. She said when she came to work she checked on him right then. She said anytime she had a resident with a critical condition she checked on them first. She said she first on Resident #151 around 6:30 p.m. She said she took one set of vitals at approximated 6:30 p.m. and they were charted on a handwritten note. She said she helped the aide clean him. She said she placed his Bipap mask back on him them. She said the aide reported to her that he had been taking his mask off that evening. She said she did call family and suggested that a family member might come sit with him to help keep his mask on. She said she walked in with Family Member #2 and the resident was not breathing. She said the door was closed and no other staff were in the room when they walked in the room. She said the mask was to the side of his head. She said she had previously taken care of the resident and he always has difficulty breathing. She said he could not breathe without some kind of assistance with his breathing. She said she did not call the physician at any time that evening. She said she did not notify the physician that Resident #151 would not keep on his Bipap mask. She said Resident #151 was not anxious and he did not need medication to calm him. She said she did not feel he needed medication so he would tolerate the Bipap better. She said she was checking on the resident every hour. She said she handwrote notes indicating when she had checked on him. She said at no time did staff sit with him to make sure he kept his mask on. She said, we just go in and do what we have to do and then leave. She said when she realized he was not breathing she checked his pulse and then started CPR. She said she only took one set of vital signs at 6:30 p.m. and this was documented on her handwritten note. She said she did not report the vital signs to the physician. She said at no time that evening did the resident open his eyes or talk to her. She said this was normal for him. She said she had had no specific trainings concerning the Bipap. She said she just knew how to use the Bipap from years of experience. During an interview on [DATE] at 2:16 p.m., CNA GG said she was Resident #151's CNA the evening of [DATE] along with CNA JJ. She said she came on duty at 10:00 p.m. She said she did one round. She said she saw the resident at 10:30 p.m. She said the resident was talking to her at that time. She said the Bipap mask was on top of his head at that time. She said she told the nurse, and the nurse called the family. She said Family Member #2 came to the facility and the next thing she heard was Family Member #2 screaming, he is already dead. She said when she walked in the room the nurse was standing there and looked shocked. She said at no time during the evening did the resident have staff sitting with him. She said she was not doing frequent checks on the resident. She said was only doing the normal 2-hour rounds. During an interview on [DATE] at 4:55 p.m., LVN O said she had only taken care of Resident #151 one previous shift. She said she was not that familiar with him. She said you could just tell he was critical. During an interview on [DATE] at 9:06 a.m., Attending Physician Z said he would expect nursing staff in the facility to make sure residents with shortness of breath or difficulty breathing were compliant for wearing their Bipap mask appropriately. He said he would expect staff to monitor the resident and send them to the ER for any acute changes. He said he would have expected staff to have contacted Nurse Practitioner K for symptoms or non-compliance in wearing the Bipap mask. When asked if the resident not wearing his BiPap mask could have contributed to Resident #151's death he said, oh yeah. He said from what little he knew about the resident he had multiple conditions that could have led to his death but not being compliant with wearing his BiPap could be part of it. He said non-compliance with not wearing his mask could affect everything. During an interview on [DATE] at 9:25 a.m., Nurse Practitioner K said he would have expected staff to have contacted him for Resident #151 not wearing his mask or for increased shortness of breath. He said he had seen Resident #151 earlier in the day of [DATE] and the resident was a little short of breath. He said he told staff to call him for increased shortness of breath. He said he would have expected to have been notified for shortness of breath, not keeping his mask on and any acute changes. He said he might have tried a telehealth visit. He said he would have checked the resident's general condition. He said he probably would have had staff send the resident to the emergency room for further evaluation. During an interview on [DATE] at 2:40 p.m., the DON said a change in condition could be acute shortness of breath, skin changes such as sweat and temperature change, and cyanosis (a bluish discoloration of the skin resulting from poor circulation). She said any change in condition would need to be reported immediately to the provider. She said on [DATE], the resident was not acting any different than he had. She said the nurse told her she did not see him as in distress. During an interview on [DATE] at 10:54 a.m., the DON said she felt the nurse did not see Resident #151's vital signs and him taking his mask off as a change in condition. She said LVN O was a nurse a really long time. She said the resident had been fighting the mask and had been pulling it off. She said she did not feel the nurse recognized him as having a change in condition. She said when the resident was hypoxic (an absence of enough oxygen in the tissues to sustain bodily function. An oxygen saturation below 92% is considered hypoxic) the nurse should have checked the orders and notified the physician. The DON said she (the DON) had already discussed with the Nurse Practitioner K about the resident not keeping his mask on. She said he had advised that if Resident #151 would not keep the mask on to call family to the facility to keep the mask on. She said a provider not being notified for a change in condition could cause increased chance of harm. The DON said she would have expected LVN O, after the first set of vitals, to have repeated the resident's vitals. She said but to LVN O thought he was at baseline the evening of [DATE]. She said the resident had a great day on [DATE] and had even eaten dinner. She said the resident would say he did not want to wear the BiPap. She said there was no one that could have kept that mask on his face because a staff at the bedside would have been forcing him to wear a mask. She said she would not have expected the nurse to do more frequent checks because the nurse felt like he was at his baseline. She said she felt the prior discharge from the hospital should not have played a part in the nurse's decisions that evening because he had been sent back from hospital with no new orders and he was fine. She said family did not want him sent back to the hospital. She said the family told her they could not keep the mask on his face in the hospital. She said the family had told them to call them for assistance. She said Family Member #2 wanted a sitter with the resident 24 hours a day. She said they had explained to family they do not provide sitters to their residents. She said there was a question about the recommendation for Bipap on the aftercare orders on [DATE]. She said there was some confusion on if he needed continuous Bipap or as needed Bipap. She said yes there should have been an order in on the day of admission. She said she cannot say if he had worn the Bipap the night of the 26th. She said she was aware that it was in the facility. She said the Bipap was not in the closet, it was a concentrator in the closet. She said she would have expected if the Bipap was placed on the resident the night of the [DATE] that it would have been charted. She said she did feel he had it was on the night of the [DATE] because if it had not been, he probably would have probably passed that night. During an interview on [DATE] at 11:55 a.m., CNA JJ said she was one of the aides caring for Resident #151 the night of [DATE]. She said she had provided Resident #151 care one previous time. She said he had seemed fine when she checked on him right after coming on duty at 10:00 p.m. She said he did not have his mask on when she checked on him. She said she reported this to the nurse and the nurse told her she had contacted the family and they were coming to sit with him. She said she was not sure where his mask was, but she thought it was on the nightstand. She said she was not in the room when the family got to the room. She said she was at the nurse's station. She said the family member came out and said, he's not breathing. During an interview on [DATE] at 1:13 p.m., the Administrator said if a nurse felt that a resident was critical and having difficulty breathing she would have expected this to have been reported to the physician by the nurse. She said abnormal vital signs for any resident should have been reported to a physician. She said staff were in regular contact with Nurse Practitioner K that night. She said herself and the DON had been in contact with Nurse Practitioner K. She said she was not sure if an oxygen saturation of 88% was ever communicated to the provider. She said the resident was not enrolled in Hospice, but there were family members that wanted him placed on hospice. There was a family member that wanted him to be a full code and wanted everything done. The administrator said she discussed with the family member that the resident would not keep on his mask and the facility was unable to restrain him as he was in the hospital at the facility could not force him to wear a mask. She said the family member said he was not restrained in the hospital but was sedated. She said the facility could not chemically restrain him. She said a medication such as Ativan could not be ordered because Resident #151 was so fragile. She said she did not know if LVN O knew Resident #151's baseline or not. She said being that his vital signs were out of the normal limits LVN O should have re-checked his vital signs to make sure they were accurate. She said she would have expected nursing staff to have increased supervision of Resident #151. She said any known history of any resident would play a part in any nurse's decision making. She said she did not know why the orders for the Bipap were not put in until [DATE]. She said she would have expected any orders should follow the patient from the hospital and should have been put into the system when the resident was admitted . She said she would have expected for Resident #151 to have worn his Bipap on the night of the [DATE]. Review of a Respirators, CPAP, Bipap, and AVAPS facility policy last revised on [DATE], indicated, .Staff will use standard methods of management of respiratory support devices categorized respirators with CPAP, BIPAP and AVAP settings in accordance with standard practice guidelines .The facility may provide care for residents in need of respirator therapies in the following cases .intermittent Bipap settings . Review of an article title Hypoxia by The Cleveland Clinic, https://my.clevelandclinic.org/health/diseases/23063-hypoxia, and was accessed on [DATE] indicated, Hypoxia is low levels of oxygen in your body tissues. It causes symptoms like confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin. Many chronic heart and lung conditions can put you at risk for hypoxia. Hypoxia can be life-threatening. If you are experiencing symptoms of hypoxia, call 911 or go to the nearest ER . The treatment for hypoxia depends on the underlying cause. The cause might be a one-time event or it could be an ongoing condition. Treatments might include: . BiLevel positive airway pressure (often known under the trade name BiPAP(R)) . The Administrator was notified of an IJ on [DATE] at 5:21 p.m. and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on [DATE] at 1:40 p.m. and included the following: Summary of Details which lead to outcomes On [DATE], during annual survey initiated at the facility, a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. F695 The notification of the alleged immediate jeopardy states as follows: F695-Respiratory Care The resident was a 79 y/o male, admitted on [DATE] with a diagnoses of Acute Respiratory failure with hypercapnia (to much carbon dioxide in the body). The resident was sent to the hospital on [DATE] and readmitted to the facility on [DATE]. The facility failed to monitor the resident to ensure he kept his bi-pap on. The facility failed to notify the physician of a low oxygen saturation of 88% and that the resident would not keep his bi-pap on. The facility failed to obtain and monitor the residents vital signs The facility failed to follow the readmission orders for the use of the bi-pap. o How other residents with the potential to be affected by the same deficient practice will be identified; Any resident with orders for bi-pap therapy and/or residents who experience respiratory distress o What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur; o The LVN was provided education by the NP on [DATE]. Education includes: a.) Identification of change of condition. b.) Notification to provider for any change of condition. c.) Assessment and response to change of condition. d.) Increased monitoring at time of change of condition until recommendation received from physician. e.) Documentation of change of condition. f.) Ensuring physician orders are followed as noted upon admission/readmission and verified by DON/designee. o DON/ADON/MDS/WOUND NURSE were provided education by the NP on [DATE]. Education includes: a) Identification of change of condition. b) Notification to provider for any change of condition. c) Assessment and response to change of condition. d) Increased monitoring at time of change of condition until recommendation received from physician. e) Documentation of change of condition. f) Ensuring physician orders are followed as noted upon admission/readmission and verified by DON/designee. o DON/ADON will provide education to all licensed staff prior to start of next scheduled work shift to include: a.) Identification of change of condition. b.) Notification to provider for any change of condition. c.) Assessment and response to change of condition. d.) Increased monitoring at time of change of condition until recommendation received from physician. e.) Documentation of change of condition. f.) Notification to DON/Designee of change of condition. g.) Ensuring physician orders are followed as noted upon admission/readmission and verified by DON/designee. o All residents requiring bi-pap therapy will have standing orders written on eMAR with parameters to notify physician per guidance on parameters for notification from physician. How the corrective action(s) will be monitored to ensure the deficient practice is being corrected and will not recur (i.e., what program will be put into place to monitor the continued effectiveness of the system changes); and o All new hire licensed staff are educated as above prior to completion of orientation. o All changes of condition will be communicated to DON/Designee and provider. o DON/Designee will review 24 hour reports and change of condition reports daily. o DON/Designee will review spo2 recordings for residents with bi-pap daily. Involvement of Medical Director The APRN Nurse Practitioner for Medical Director met with interdisciplinary team on [DATE]. Involvement of QA An Ad Hoc QAPI meeting will be held with the Medical Director, facility administrator, director of nursing, and social services director to review plan of removal. Administrator will forward results of audits and monthly to the QAPI Committee for review and/or action. Who is responsible for implementation

Based on interview and record review, the facility failed to provide basic life support, including cardiopulmonary resuscitation (CPR) to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 1 resident reviewed for CPR. (Resident #151) The facility failed to ensure that staff provided appropriate CPR when LVN O performed CPR on the Resident #151's abdomen and not his chest as indicated by the American Heart Association. This failure resulted in the identification of an Immediate Jeopardy (IJ) on [DATE] at 5:21 p.m. While the IJ was removed on [DATE] at 4:02 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents who had a full code status at risk of death. Findings included: Record review of a face sheet dated [DATE] indicated Resident #151 was [AGE] years old. Resident #151 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including acute respiratory failure with hypercapnia (increased levels of carbon dioxide in the body), heart failure, and chronic obstructive pulmonary disease (chronic lung disease). Record review of consolidated physician's orders dated [DATE] for Resident #151 indicated the resident was admitted on [DATE] to skilled care. An order dated [DATE] indicated Bipap (non-invasive ventilation used for breathing support administered through a mask) as needed. As needed for SOB (shortness of breath), with naps. Notify provider with episodes of SOB . An order dated [DATE] indicated Bipap daily at bedtime . The orders indicated Resident #51 code status was full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). Record review of the MDS assessment dated [DATE] indicated Resident #151 usually understood others and was usually understood. The MDS indicated a BIMS was not conducted due to the resident being rarely to never understood. The MDS indicated Resident #151 required oxygen care. The MDS did not indicate the use of Bipap. Record review of a care plan updated on [DATE] indicated Resident #151 had a care area for Breathing Pattern related to a diagnosis of chronic obstructive pulmonary disease. There was an intervention to administer medications, respiratory treatments, and oxygen as ordered. The care plan did not indicate Resident #151's code status. Record review of undated handwritten notes by LVN O indicated, at 6:30 p.m. Bipap on by nurse. The notes indicated at 8:50 p.m. went to pt. room, Bipap was off, pt had taken Bipap off, did explain to pt the need for keeping Bipap on, eyes closed, no response. The notes indicated at 10:25 p.m. went to pt. room, Bipap off, and was put back on pt. Bipap machine is working well. At 10.30 p.m. came to desk, called (family member) and explained to her that pt. will not keep Bipap on, that if pt's (family member) wanted to come and stay to help pt. with keeping Bipap on, it would be ok . At 11:10 p.m. Family member .here, nurse got up from desk and walked down to pt's room. Arrived in room, (family member) and I noticed pt not breathing and CPR (cardiopulmonary resuscitation) begin. At 11:23 p.m. CPR team arrived and CPR continued. There was one set of untimed vital signs that indicated pt pulse ox (oxygen saturation) was 88 then 90, B/P (blood pressure) ,d+[DATE], temp 96.2. Respirations or heart rate was not indicated. The oxygen saturation, blood pressure and temperature were below Resident #151's baseline. Respirations or heart rate were not indicated. There was no documentation of the physician having been notified. Record review of nurse's notes on the electronic medical record for Resident #151 indicated a note made by LVN O on [DATE] and electronically signed 11:12 p.m., 1850 (6:50 p.m.) .Bipap was applied .pt appears to be resting well. A note made by LVN O on [DATE] and electronically signed 11:31 p.m. indicated 2050 (8:50 p.m.) pt. has taken Bipap off and explained to pt. that this is to help remove the CO2 (carbon dioxide) d/t pt. needs help to get ride of the bad oxygen, was still trying to take mask out of nurse's hand. A nurse's note made by LVN O on [DATE] and electronically signed at 12:10 a.m. indicated, a note for [DATE] 2225 (10:25 p.m.) Pt had taken mask off and was replaced back on and ask pt to not remove, this mask help with your breathing. A nurse's note made by the DON dated [DATE] and was electronically signed at 7:37 a.m. indicated on [DATE] 2230 (10:30 p.m.) family member .was called and informed pt continues to taking off Bipap mask and refuses to keep it on, did inform her that nurse will continue to go back and check and put mask back on as needed, did ask if pt (family member) wanted to stay due to pt noncompliance . A nurse's note made by the DON dated [DATE] and electronically signed at 7:32 a.m. indicated, on [DATE] 2310 (11:10 p.m.) family member .here, him and nurse walked to the pt room, pt. had Bipap slid off to the right side top of head and was not breathing, cpr was done immediately while pt. (family member was screaming at nurse why somebody was not down here sitting with him, 2313 (11:13 p.m.) CPR team with crash cart arrived and began assisting nurse with CPR, board hard surface placed under patient, pads on, continuing CPR 2318 (11:18 p.m.), analyzing, shock not advised, paramedics arrived 2329 (11:29 p.m.) taking over CPR in progress, firefighters arrived 2340 (11:40 p.m.), IV (intravenous access to body) started, intubated (when a tube inserted for ventilation) 2345 (11:45 p.m.) . continue CPR, 2354 (11:54 p.m.) pulse check continue CPR, 2357 (11:57 p.m.) pulse check continue CPR, 2359 (11:59 p.m.) pulse check continue CPR, 2403 (12:03 a.m.) continued CPR, paramedic spoke to nurse and stated pt. PEA (pulseless electrical activity, a type of irregular heart rhythm, meaning it is a malfunction of the heart's electrical system) was not active and only there because of continued compressions, last pulse check 2406 (12:06 a.m.). Police arrived, and also assisted with CPR. EMS called time of death . Family was present. There were no nurse's notes indicating the physician had been notified of Resident #151's condition on [DATE]. Record review of a Basic Life Support certification card with an expiration date of ,d+[DATE] indicated LVN O was certified at the local college. Record review of a Basic Life Support certification card with an expiration date of ,d+[DATE] indicated LVN D was certified at the local college. Record review of a Basic Life Support certification card with an expiration date of ,d+[DATE] indicated LVN FF was certified at a training center . During an interview on [DATE] at 9:15 a.m., Family Member #2 of Resident #151 said the events that led to the resident's death began when the resident was sent out of the facility to theER on [DATE]. Family Member #2 said the doctor at the ER told him they could not hold him there. The ER doctor told the family the facility was not doing what they were supposed to be doing because the Bipap had not been placed on Resident #151 the night before. Family Member #2 said the resident was then sent back to the facility. Family Member #2 said they called the Administrator and had a long discussion with her about Resident #151's care. Family Member #2 said she promised them she would talk to staff about his care. Family Member #2 said on the evening of [DATE] Family Member #1 called them saying Resident #151 would not put on his Bipap mask. Family Member #2 said they then came to the facility. Family Member #2 said when they walked into the facility the resident's nurse was sitting at the nurse's station talking on a cellphone. Family Member #2 said LVN O walked down the hall with them with no sense of urgency about her. Family Member #2 said the resident's door was closed, the lights were out, and no staff were in the room with the resident. Family Member #2 said when the light was turned on the Bipap mask was on top of the resident's head. Family Member #2 said the nurse was trying to put the mask back on even though the resident was not breathing. Family Member #2 said they felt the nurse was suspicious because when walking in the room she did not turn on any lights or even speak a word to the resident. Family Member #2 said it was obvious she was not looking at him or talking to him. Family Member #2 said the nurse told the roommate to push the button, push the button. Family Member #2 said the roommate did not know which button she was talking about. Family Member #2 said they had to run out of the room and tell the other nurse's what was going on. Family Member #2 said the LVN O did start compressions, but they were on the resident's stomach not on the resident's chest. Family Member #2 said the resident did not even have oxygen on him. Family Member #2 said he thought someone should have stayed in the room with him until family got there. Family Member #2 said earlier in the evening the resident had been awake and alert watching a TV show and talking about eating chicken and dressing. During an interview on [DATE] at 1:08 p.m., LVN D said she was not Resident #151's nurse. She said his nurse on the night of [DATE] was LVN O. She said herself and other staff were at the front nurse's station and was alerted by a CNA that they needed help on the rehabilitation hall. She said CPR was in progress when she entered the room. She said she thought but was not sure LVN FF was doing chest compressions . She said she did not see LVN O doing chest compressions on Resident #151. She said the resident was not her resident. She said she did not know anything about the resident before entering the room. During an interview on [DATE] at 1:15 p.m., LVN FF said she just knew the family came in because the Resident #151 was not taking his medications. She said she was alerted by a CNA that the resident was not breathing, and they needed her help with CPR. She said when she got to the room CPR was in progress. She said she was not familiar with the resident's history, and she had not previously provided care to the resident. During an interview on [DATE] at 1:57 p.m., LVN O she was Resident #151's nurse the night of [DATE]. She said Resident #151 would not keep on his Bipap mask. She said she made notes on a piece of paper. She said when she came to work she checked on him right then. She said anytime she had a resident with a critical condition she checked on them first. She said she first checked on Resident #151 around 6:30 p.m. She said she helped the aide clean him. She said she placed his Bipap mask back on him then. She said the aide reported to her that he had been taking his mask off that evening. She said she did call family and suggested that a family member might come sit with him to help keep his mask on. She said she walked in with Family Member #2 and the resident was not breathing. She said the door was closed and no other staff were in the room when they walked in the room. She said the mask was to the side of his head. She said she had previously taken care of the resident and he always has difficulty breathing. She said he could not breathe without some kind of assistance with his breathing. She said she did not call the physician at any time that evening. She said she did not notify the physician that Resident #151 would not keep on his Bipap mask. She said Resident #151 was not anxious and he did not need medication to calm him. She said she did not feel he needed medication so he would tolerate the Bipap better. She said she was checking on the resident every hour. She said she handwrote notes indicating when she had checked on him. She said at no time did staff sit with him to make sure he kept his mask on. She said, we just go in and do what we have to do and then leave. She said when she realized he was not breathing she checked his pulse and then started CPR. She said she only took one set of vital signs at 6:30 p.m. and this was documented on her handwritten note. She said she did not report the vital signs to the physician. She said at no time that evening did the resident open his eyes or talk to her. She said this was normal for him. She said she had had no specific trainings concerning the Bipap. She said she just knew how to use the Bipap from years of experience. During an interview on [DATE] at 2:16 p.m., CNA GG said she was Resident #151's CNA the evening of [DATE] along with CNA JJ. She said she came on duty at 10:00 p.m. She said she did one round. She said she saw the resident at 10:30 p.m. She said the resident was talking to her at that time. She said the Bipap mask was on top of his head at that time. She said she told the nurse, and the nurse called the family. She said Family Member #2 came to the facility and the next thing she heard was Family Member #2 screaming, he is already dead. She said when she walked in the room the nurse was standing there and looked shocked. She said she did not want to get anyone in trouble, but she wanted to tell the truth. She said when LVN O began CPR she was not doing compressions on the chest. She was doing compressions below the chest and did not have a board under him. She said herself and LVN FF attached the AED and did CPR and placed a board under the resident. She said at no time during the evening did the resident have staff sitting with him. She said she was not doing frequent checks on the resident. She said was only doing the normal 2 hour rounds. During an interview on [DATE] at 4:55 p.m., LVN O said she had only taken care of Resident #151 one previous shift. She said she was not that familiar with him. She said you could just tell he was critical. She said with CPR you check the airway, breaths, and circulations. She said the resident had no pulse. She said she did compressions in the middle of his sternum (the breastbone). She said she placed the heel of her hands in the middle of the sternum. She said she took her CPR class at the local college. She said she did have to demonstrate how to perform CPR in front of an instructor to receive her certification. During an interview on [DATE] at 10:15 a.m., LVN FF said when she came in the room LVN O was performing CPR on the Resident #151. She said she could only see LVN O's back and could not see her hand placement on the resident. During an interview on [DATE] at 10:54 a.m., the DON said doing chest compressions on anyone's abdomen would not be effective CPR. She said she did not feel like LVN O did chest compressions on Resident #151's abdomen. She said ineffective chest compressions could lead to ineffective circulation of oxygen in the body. During an interview on [DATE] at 11:41 a.m., CNA HH said she was not the aide for Resident #151 the evening of [DATE]. She said an aide ran to the front and told her there was a code. She said she grabbed the AED and ran to help. She said when she walked into the room CPR was in progress. She said CNA GG was doing chest compressions. She said she never saw LVN O doing chest compressions. She said she never saw anyone do compressions on the abdomen. She said prior to the night on [DATE] she had not provided care to Resident #151 and was not familiar with him. During an interview on [DATE] at 11:55 a.m., CNA JJ said she was one of the aides caring for Resident #151 the night of [DATE]. She said she had provided Resident #151 care one previous time. She said he had seemed fine when she checked on him after she came on duty at 10:00 p.m She said she was not in the room when the family got to the room. She said she was at the nurse's station. She said the family member came out and said, he's not breathing. She said when she got to the room CNA JJ was doing chest compressions on the resident. She said she was not doing compressions on the abdomen. During an interview on [DATE] at 1:13 p.m., the Administrator said if a staff performed chest compressions on the abdomen, this would not be effective CPR. She said if CPR was necessary and was not done correctly there would not be a positive resuscitation effort. Review of a Cardiopulmonary Resuscitation (CPR): Basic Life Support (BLS)/Hands-Only CPR facility policy last revised on February 12, 2020, indicated, .Cardiopulmonary Resuscitation (CPR) - is a group of emergency treatments that are executed when someone's breathing or heartbeat has stopped. The treatments consist of rescue breathing and chest compressions. CPR allows oxygenated blood to circulate to vital organs such as the brain and heart .if an individual is found unresponsive by an employee of the community the employee will initiate CPR .begin chest compressions . Review of an online article titled, What is CPR? by the American Heart Association, https://cpr.heart.org/en/resources/what-is-cpr and was accessed on [DATE], indicated, .CPR - or Cardiopulmonary Resuscitation - is an emergency lifesaving procedure performed when the heart stops beating. Immediate CPR can double or triple chances of survival after cardiac arrest . Keeping the blood flow active - even partially - extends the opportunity for a successful resuscitation once trained medical staff arrive on site .Early CPR with an emphasis on chest compressions . Ensure proper hand placement . Review of an online article titled, Hands-only CPR for Adults by the American Red Cross Training Services, https://www.redcross.org/take-a-class/cpr/performing-cpr/hands-only-cpr and was accessed on [DATE], indicated, .Use correct hand placement. Place the heel of one hand in the center of their chest, with your other hand on top, interlace your fingers and make sure they are up off the chest . The Administrator was notified of an IJ on [DATE] at 5:21 p.m. and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on [DATE] at 1:40 p.m. and included the following: Summary of Details which lead to outcomes On [DATE], during annual survey initiated at the facility, a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. F678 The notification of the alleged immediate jeopardy states as follows: The resident was a 79 y/o male, admitted on [DATE] with a diagnoses of Acute Respiratory failure with hypercapnia (to much carbon dioxide in the body). The resident was sent to the hospital on [DATE] and readmitted to the facility on [DATE]. The facility failed to ensure that staff provided appropriate CPR (cardiopulmonary resuscitation) for the resident who was a full code. The facility LVN performed CPR on the resident's abdomen and not his chest as indicated by the American Heart Association standards. o How other residents with the potential to be affected by the same deficient practice will be identified; o Any resident with full code status have potential to be affected by the alleged deficient practice o What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur; o CPR certified Nurse Practitioner will in-service DON/ADON/MDS/Wound Nurse on correct hand placement for chest compressions during CPR on [DATE]. o DON who is CPR certified by American Heart Association will in-service all licensed nurses on correct hand placement for chest compressions during CPR by 10:00 P.M. on [DATE]. No nurses will be allowed to work until training has been completed. Any nurses who did not receive training before 10:00 P.M. on [DATE] will receive training prior to the start of their next shift. Return demonstration of proper hand placement will be required as part of the licensed nurse education. How the corrective action(s) will be monitored to ensure the deficient practice is being corrected and will not recur (i.e., what program will be put into place to monitor the continued effectiveness of the system changes); and o Proof of the education will be submitted to QA committee Involvement of Medical Director The APRN Nurse Practitioner for Medical Director met with interdisciplinary team on [DATE]. Involvement of QA An Ad Hoc QAPI meeting will be held with the Medical Director, facility administrator, director of nursing, and social services director to review plan of removal. Administrator will forward results of audits and monthly to the QAPI Committee for review and/or action. Who is responsible for implementation of process? The Director of Nursing/designee will be responsible for implementation of New Process. The New Process/ system will be started on [DATE] and no employee be able to return to work until they complete the Inservice. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on [DATE]. The surveyor verification of the Plan of Removal from [DATE] was as follows: Record review of the current residents' electronic health records did not indicate any residents requiring breathing assistance with Bipap. Electronic health records were accessed from [DATE] - [DATE]. Record review of a Training In-Service Form indicated an in-service was held on [DATE]. The in-service was presented by a Nurse Practitioner. The in-service covered change of condition, changes in level of consciousness, oxygen saturation, CPR hand placement, notifying providers, notifying DON/Family, Increased monitoring with change of condition, and following physician's orders. A total of 24 staff members attended the in-service. The in-service included a signature of LVN O, the ADON, the MDS and the wound care nurse. During an interview on [DATE] at 2:00 p.m., the DON said the in-service training on [DATE] was verbal with mock CPR. She said staff completed a return demonstration on her. This in-service was completed on [DATE] at 8:00 p.m. The DON said a change in condition would be acute shortness of breath, skin changes such as sweat and temperature change, cyanosis. She said any change in condition would need to be reported immediately to the provider. She said she held a mock code using several different scenarios and with people with different body sizes. She said she instructed to never leave a resident unattended that was in distress. She said all staff performed all CPR correctly. She said she instructed staff when patients come in with physician's orders to verify the orders are in and all equipment is in the room and orders are on the chart. She was able to accurately describe neglect of a resident. She said she educated staff on change of condition, changes in level of consciousness, oxygen saturation, CPR hand placement, notifying providers, notifying DON/Family, Increased monitoring with change of condition, and following physician's orders. During an interview on [DATE] at 3:12 p.m., LVN O said she was in-serviced on identification of change of condition, notification to provider for any change of condition, assessment and response to change of condition, increased monitoring at time of change of condition until recommendation received from physician, documentation of change of condition and ensuring physician orders are followed. She was able to accurately describe how to do CPR and accurately describe neglect. During interviews conducted from [DATE] beginning at 2:00 p.m. through 4:02 p.m., 20 of 24 of nursing staff in-serviced (including staff across all shifts that were the DON, ADON, MDS Nurse, the Wound Care Nurse, CNAs, LVNs and RNs) were interviewed. All staff said they received education and were able to verbalize understanding on change of condition, changes in level of consciousness, oxygen saturation, CPR hand placement, notifying providers, notifying DON/Family, Increased monitoring with change of condition, and following physician's orders. On [DATE] at 4:02 p.m., the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 2 of 6 residents (Resident #27 and Resident #361) reviewed for pressure injury. The facility failed to ensure Resident #27 low air loss mattress (is designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was on the correct settings. The facility failed to ensure Resident #27 had dressing on his back wounds. The facility failed to ensure the WCN loosening Resident #27's dressing, before removing, from his heel wound to prevent bleeding. The facility failed to ensure Resident #27 was turned and repositioned every 2 hours. The facility failed to ensure Resident #27 was positioned correctly when using his positioning aides. The facility failed to treat Resident #361's unstageable (the base of the wound was covered by a layer of dead tissue that was yellow, grey, green, brown, or black and unable to determine the stage of the wound) sacral pressure ulcer for 3 days after admission. These failures could place residents at risk for deterioration of wound. Findings included: 1. Record review of Resident #27's face sheet dated 10/30/23 indicated Resident #27 was a [AGE] year-old male and admitted on [DATE] with diagnoses including cerebral infarction ((also known as a stroke) refers to damage to tissues in the brain due to a loss of oxygen to the area), pressure ulcer of buttock (also known as bedsores, are an injury that breaks down the skin and underlying tissue), stage 3, skin changes and pain. Record review of Resident #27's annual MDS assessment dated [DATE] indicated Resident #27 was usually understood and usually understood others. The MDS indicated Resident #27 had a BIMS score of 09 which indicated moderately impaired cognition and required limited assistance with dressing, extensive assistance with bed mobility, toilet use, personal hygiene, and bathing. The MDS indicated Resident #27 had 2 Stage 4 pressure ulcers and were present upon admission/entry or reentry. The MDS indicated Resident #27 had skin and ulcer/injury treatments of pressure reducing device for bed, nutrition or hydration intervention, pressure ulcer/injury care, application of ointments/medications other than to feet, and application of dressing to feet. The MDS indicated Resident #27 received an anticoagulant (are medicines that help prevent blood clots) for 3 days during the 7 days assessment period. Record review of Resident #27's care plan dated 09/21/23 indicated anticoagulant/antiplatelet (medications that prevent blood clots from forming) related to diagnosis of atrial fibrillation (is an irregular and often very rapid heart rhythm) and history of cerebrovascular accident (stroke) as evidence by Apixaban (is used to prevent serious blood clots from forming due to a certain irregular heartbeat) 5mg tablet 1 tablet by mouth 2 times a day. Interventions included handle resident carefully when turning, positioning, or transferring and maintain pressure on skin tears, blood draws sites, and IV sites for at least five minutes. Record review of Resident #27's care plan dated 10/24/23 indicated Resident #27 was at risk for/actual of skin breakdown related to skin failure and history of pressure injury as evidence by pressure reducing/redistribution mattress (redistribute a patient's weight so as to relieve pressure points), pressure ulcer risk: high score 10-12, confined to bed most of time, wound (pressure, diabetic or stasis), open lesions. Interventions assist resident to turn and reposition frequently, report refusals, off load heels, position resident properly; use pressure reducing or pressure relieving devices if indicated, and treatments and dressings as ordered per physician. Record review of Resident #27's Consolidated Physician Orders dated 04/06/23 Pressure reducing/redistributing mattress, night shift. Record review of Resident #27's Consolidated Physician Orders dated 06/02/23 Air Mattress to bed, every 2 shifts. Check every shift for function. Record review of Resident #27's Consolidated Physician Orders dated 10/12/23 indicated cleanse wound on day shift, cleanse wound to left upper back with normal saline, pat dry, apply calcium alginate with silver (Assist with infection reduction. Primary dressing for wounds with moderate to heavy exudate (drainage)), cover with silicone bordered dressing (is highly conformable with a thin, low-profile edge to help minimize the rolling and lifting that can impact adhesion) daily. Record review of Resident #27's Consolidated Physician Orders dated 10/27/23 indicated cleanse wound on day shift, right back with normal saline, pat dry, apply alginate calcium when blister breaks and cover with silicone foam bordered dressing daily. Record review of Resident #27's TAR dated 10/01/23-10/31/23 indicated Pressure reducing/redistributing mattress, night shift. Diagnosis: Benign Prostate Hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty) with lower urinary tract symptoms. Start date: 04/06/23. Documentation noted every day, night shifts. Record review of Resident #27's TAR dated 10/01/23-10/31/23 indicated Air Mattress to bed, every 2 shifts. Check every shift for function. Diagnosis: skin changes. Start date: 06/02/23. Documentation noted every day, 2 shifts. Record review of Resident #27's TAR dated 10/01/23-10/31/23 indicated cleanse wound on day shift, cleanse wound to left upper back with normal saline, pat dry, apply calcium alginate with silver, cover with silicone bordered dressing daily. Diagnosis: skin changes. Start date: 10/12/23. Documentation noted 10/12/23-10/31/23 on day shift. Record review of Resident #27's TAR dated 10/01/23-10/31/23 indicated cleanse wound on day shift, right back with normal saline, pat dry, apply alginate calcium when blister breaks and cover with silicone foam bordered dressing daily. Diagnosis: skin changes. Start dated: 10/27/23. Documentation noted 10/27/23-10/31/23 on day shift. Record review of Resident #27's wound evaluation and management summary dated 10/25/23 indicated .wounds on his sacrum .left first finger .right lateral (outside of your foot) heel .right upper lateral foot .left upper back .left back .right back .stage 4 pressure wound (There is full-thickness skin loss extending through the fascia with considerable tissue loss) of the right, upper, lateral foot full thickness .2.4cmx1.8cmx0.2cm (Lx W x D) .at goal for wound progress .stage 4 pressure wound of the right, lateral heel, full thickness .3.4cm.3.4cmx0.1cm .stage 4 pressure wound sacrum full thickness .6.8cmx10cmx2cm .at goal .recommendation off-load wound .reposition per facility protocol .group-2 mattress .stage 3 pressure wound of the left upper back full thickness .1.2cmx0.9cmx0.1cm .improved evidence by decreased surface area .non-pressure wound of the left back partial thickness .9cmx2.5cmx0.1cm .abrasion/sheer .non-pressure wound of the right back .6cmx1.5cmxnot measurable cm .blister fluid filled . Record review of Resident #27's wound evaluation and management summary dated 11/01/23 indicated .wounds on his right lateral heel .left upper back .sacrum .right upper lateral foot .left back .right back .left first finger . stage 4 pressure wound the right, upper, lateral foot full thickness .8cmx10cmx0.2cm .objective palliation .wound progress at goal . stage 4 pressure wound of the right, lateral heel, full thickness .3.5cmx4.0cmx0.1cm .wound progress at goal . stage 4 pressure wound sacrum full thickness .9cmx12.5cmx2.0cm .wound progress at goal . stage 3 pressure wound of the left upper back full thickness .19cmx12.5cmx0.1cm .wound progress at goal .unavoidable due to generalized decline .non-pressure wound of the left back .signoff-wounds has merged with another site on 11/01/23 . non-pressure wound of the right back .signoff-wounds has merged with another site on 11/01/23 Record review of the facility's weight log dated 10/04/23 indicated Resident #27 was 6'3 and 215.6 pounds. During an interview and observation on 10/30/23 at 11:24 a.m., Resident #27 was on a bariatric (a person is classified as having obesity), low air loss mattress, lying on his back. Resident #27 feet were covered but appeared to be elevated. Resident #27 low air loss mattress setting was 50 pounds. Resident #27 said he had wounds on his right foot and bottom. He said he came to the facility with the wounds. Resident #27 said he did not feel like the staff turned him enough. During an observation on 10/30/23 at 3:41 p.m., Resident #27 was lying on his back with head of his bed elevated. During an observation on 10/31/23 at 9:46 a.m., Resident #27 was lying on his right side with an elongated, balloon shaped pillow in front of him. He said he did not know what the pillow was used for, and it had not been used before. Resident #27's low air loss mattress setting was on 50 pounds. During an observation on 10/31/23 at 11:37 a.m., Resident #27 was lying on his right side with an elongated, balloon shaped pillow in front of him. During an observation on 10/31/23 at 2:08 p.m., Resident #27 was lying on his left side and the low air loss mattress setting was on 50 pounds. During an observation and interview on 10/31/23 at 3:02 p.m., Resident #27 was lying on his left side with triangular shaped positioning aide behind his back. When WCN NN removed the covers from Resident #27's legs, 2 small rectangular shaped positioning wedges were beneath his heels, but no pillow or wedge observed underneath the knees and Resident #27's calf was laying on the edge of the rectangular wedges which caused an indentation to his calf. During wound care provided by WCN NN, WCN NN removed a dressing from Resident #27's left heel. The dressing from Resident #27's left heel was slightly stuck to the skin and when removed, small amounts of [NAME] blood dripped onto the positioning wedges. When Resident #27 was turned on his left side, one dressing was noted to the left side of his back but two other wounds were noted to the back without dressing. Resident #27's low air loss mattress setting was on 50 pounds. Resident #27 said he was 6'3 and 380 lbs. During an observation on 11/01/23 at 3:08 p.m., Resident #27's low air loss mattress setting was on 300 pounds. During an interview on 11/02/23 at 10:26 a.m., WCN NN said she started as the wound care nurse August 2023. She said everyone was responsible for checking the low air loss mattress settings. She said Resident #27's low air low mattress setting was on 50 pounds. She said when she went to do wound care with the wound care doctor today (11/02/23), they noticed the mattress looked low. She said she did not know how to unlock the bed settings, so the wound care doctor fixed the settings on Resident #27's bed. She said she thought the wound care doctor set the bed to 180 pounds. She said she only looked at the machine lights to make sure they were green, after the wound care doctor set the settings. She said she did not know why the wound care doctor set the low air loss mattress settings at 180 pounds because Resident #27 weighed more than 180 pounds. She said she normally tried to glance at the low air loss mattress machine when she did his daily dressings changes. She said she because there was no specific order on what weight to set the mattress settings on, she would look up the resident's weight to determine the settings. She said the floor nurses should check the mattress setting every shift to make sure it was working and on the right settings. She said the nurse's charted on the TAR every shift, they checked the mattress. She said correct inputted weight on the low air loss mattress was important to prevent wounds from happening and current wounds from getting worse. She said the wrong settings negatively affected the resident by worsening the wounds and be in pain. She said that could cause the need for pain medication and contributed to the slow healing of Resident #27's sacrum wounds. The WCN NN said CNAs were responsible for turning and repositioning residents every 2 hours when they made rounds. She said the hall nurse should ensure the CNAs were turning and repositioning residents every 2 hours. She said she did not know how the hall nurse monitored if every 2-hour turning happened. She said she looked into resident's rooms when she walked the halls to monitor turning and repositioning. She said turning and repositioning every 2 hours prevents further deterioration of wounds, removed pressure to prevent wounds, and reduced pressure on bony areas. She said she had not noticed Resident #27 not been tuned and repositioned every 2 hours. The WCN NN said she was responsible for dressing changes and wound care Monday-Friday and floor nurse did dressing changes on the weekend. She said the nurses were responsible for the resident's dressing staying on and changing the dressing when soiled. She said when she did Resident #27's wound care on Monday (10/30/23), he had 3 dressing to his back. She said no one notified her two of the dressing had fallen off on Tuesday (10/31/23) prior to the observed dressing change. She said the CNAs are supposed to let the nurses know when a dressing comes off. She said the wounds needed dressing to stop bacteria from getting in and help with healing. She said if no dressing is on the wounds, it could get infected and deteriorate. She said this would cause Resident #27 to need antibiotics and different treatment orders. She said she did not know if the CNAs had been instructed or in-serviced to notify nursing staff when wound dressing come off. The WCN NN said she did not know if CNAs had training on how to use and place positioning aides. She said she did not know if the positioning wedges came in different size and lengths since Resident #27 was tall and bariatric. She said she did not remember on Tuesday (10/31/23) during the dressing change if Resident #27 had a pillow underneath his knees. She said but Resident #27 should have a pillow underneath his knees to prevent pressure and give knee support. She said no knee support could cause blisters, wounds, and decreased range of motion. She said the facility was in the process of starting training on turning and repositioning. The WCN NN said Resident #27 was on a blood thinner and the Xeroform gauze dried out and stuck to the wound. She said she could have moistened the dressing to help prevent the wound from bleeding. She said Resident #27 being on a blood thinner cause him to bleed easier than other residents. During an interview on 11/02/23 at 11:35 a.m., CNA H said she had been a CNA for [AGE] years but started back working at the facility around August 2023. She said she worked 6am-2pm shift on the 100-hall. She said she worked with Resident #27. She said resident were supposed to be turned every 2 hours to prevent skin break down and pressure sores. She said she knew how to correctly position resident using position aides and knew why it was important. She said pillows or position aides were important because they kept the skin from touching, prevented skin breakdown, and relieved pressure areas. She said she always found Resident #27 with a pillow underneath his knees. She said she let nurses know when wound dressing came off. She said Resident #27's back dressing normally stayed on, but his butt dressing came loose often. She said the wounds needed dressings because they were pressure sores, and they needed the dressing to heal. During an interview on 11/02/23 at 2:06 p.m., LVN N said she had worked at the facility for 4 years and worked the 6am-6pm shift. She said she primarily worked the 300-hall and 400-hall but also worked the others hall too. She said residents should be turned. She said the resident should be turned and repositioned every 2 hours by the aides. She said LVN should check what position the resident are in throughout the day. She said if residents refused to be turned and repositioned, the aides needed to notify the nurse so it could be charted. She said turning and repositioning ensured resident did not develop wounds. LVN N said it was the nurse's responsibility to make sure the low air loss mattress was working every time you entered the room. She said all nurses should make sure the setting was on the correct weight by checking the weight in the computer system. She said the correct settings helped distribute the correct amount for the wounds and if the mattress is flat, it could cause more wounds or make current wounds worse. LVN N said all nurses should make sure dressings stayed on. She said if the wounds are left open, bacteria could be introduced and cause an infection. She said the infection could cause the resident to need antibiotics, develop sepsis (is a serious condition in which the body responds improperly to an infection) and c-diff ((also known as Clostridioides difficile or C. difficile) is a germ (bacterium) that causes diarrhea and colitis (an inflammation of the colon)), and death. During an interview on 11/02/23 at 3:04 p.m., the DON said the CNAs should be turning and repositioning residents every 2 hours and as needed. She said LVNs and the DON should ensure it happened by making rounds. She said the facility used to have a system in place to have residents face a certain way a specific time of the day. She said that process did not work. She said she picked a different hall a week and monitored turning and repositioning. She said turning and repositioning was important to prevent skin breakdown. She said it was always uncomfortable to the resident to stay in the same position. The DON said the WCN was responsible for making sure low air loss mattress were on the right settings or weight. She said the WCN should at least be checking weekly, if not every time she was in the room doing dressing changes. She said unfortunately, CNAs can accidently change the setting and family members. She said the wrong setting could cause pressure and effect the resident's skin integrity. She said she did not know if the low air loss mattress being on the incorrect weight could cause pressure ulcer delayed healing. She said the floor nurse were responsible to make sure the low air loss mattress was working and on the ordered type of mattress. The DON said the WCN did dressing changes and the aides should notify the LVN when the dressing came off. She said the aides know to notify the nurses when a dressing comes off. She said wounds without ordered dressing risked infection and delayed healing. She said wound dressing were important for adequate healing. The DON said she did not know if all the aides knew how the use positioning aide/wedges. She said the facility had a large turnover in aides and was in the process of training the staff. She said pillow or wedge should be between or under the knees to provide support. She said correct use of positioning aides was important for comfort, proper body alignment, and reduced pressure wounds. During an interview on 11/02/23 at 4:30 p.m., the WC MD said Resident #27 was under his care for several wounds. He said Resident #27 had recently been placed on hospice and his wound care was palliation, so not directly trying to heal the wounds. He said he had also clustered some wounds after his last visit (11/01/23) to decrease the amount of treatment needing to be performed. He said he vaguely remembered Resident #27 mattress setting being on the wrong weight. He said the low air loss mattress should be close the resident's weight and if tolerated, alternating every 15 minutes. He said Resident #27 was about 250 pounds so 50 pounds was far from what he needed. He said Resident #27 had a decline in health, decreasing the healing of his wounds. He said Resident #27 being on 50 pounds settings instead of about 250 pounds could feasibly have contributed to the increased size of the pressure and non-pressure wounds. He said he did not know the facility's policy on how often the low air loss mattress setting should be checked but they should be checked when wound care was provided. 2. Record review of Resident #361's face sheet dated 10/30/23 revealed Resident #361 was admitted to the facility initially on 2/17/17 and readmitted on [DATE] with diagnoses including lymphedema (swelling in an arm or leg caused by a blockage in the lymphatic system, part of the immune and circulatory systems), pneumonia (infection in lungs), weakness, abnormalities of gait and mobility, heart failure, and diabetes (high sugar levels in blood). Record review of Resident #361's admission MDS dated [DATE] indicated Resident #361 was understood and understood others. The MDS indicated a BIMS score of 15 which indicated Resident #361 was cognitively intact. Resident #361 required extensive assistance of 2 persons for most ADLs. Resident #361 was always incontinent of urine and frequently incontinent of bowel. The MDS said Resident #361 did not have pressure ulcers. Record review of Resident #361's undated care plan revealed he was at risk for/actual skin breakdown with onset date of 8/07/23. Record review of hospital records dated 8/3/23 revealed Resident #361 had a sacral decubital ulcer (wound caused from pressure to the lower back at the bottom of the spine) and was being treated with Santyl (ointment used to remove damaged tissue from skin ulcers). Record review of Resident #361 's admission assessment revealed there was no documentation of an admission assessment upon admission. Record review of Resident #361 's initial skin assessment revealed there was no documentation of an initial skin assessment completed. Record review of Resident #361 's nurses' notes revealed there was no documentation until 8/18/23 and it did not address Resident #361 's pressure ulcer to his sacrum/coccyx. Record review of Resident #361 's order summary report dated 10/31/23 revealed there was no orders to treat Resident #361 's pressure ulcer to his sacrum/coccyx until 8/07/23, however, the order did not match what APRN QQ had documented in his 8/07/23 note. The 8/07/23 order was to cleanse the coccyx wound every other day with wound cleanser, pat dry, apply medihoney, wet/dry dressing, and cover with mepilex. Record review of Resident #361 's physician visit note dated 8/07/23 completed by APRN QQ revealed during the visit Resident #361 complained of pain to his coccyx. APRN QQ documented Resident #361 to have an unstageable sacral wound that covered his sacrum and his left and right buttocks. APRN QQ documented the wound to have slough and eschar to the wound base with serous drainage present. APRN QQ ordered wound care to cleanse the wound with wound cleanser, pat dry, apply Santyl to moist fluffed gauzes covering the entire wound, cover with dry gauze and secure with a silicone foam dressing every other day. During an interview on 11/01/23 at 10:31 AM, APRN QQ said he did not recall being notified about Resident #361 's wound to his bottom upon his admission. APRN QQ said he would have expected the admitting nurse to notify him with abnormal findings for orders. APRN QQ said Resident #361 admitted on Friday 8/04/23 and he saw Resident #361 on Monday 8/07/23. APRN QQ said he remembered there was little mention of the pressure ulcer to Resident #361 's bottom in the hospital records during his review. APRN QQ said the wound was covered with slough (wet dead tissue) and eschar (dried out dead tissue) and he was unable to stage the pressure injury. APRN QQ said it was a pretty bad wound and he gave orders for wound care, and he made a referral for the wound care physician to see him that usually came to the facility on Wednesdays. APRN QQ said after the wound care physician saw Resident #361 and debrided the wound (cut away dead tissue), then they were able to see the extent of the wound. APRN QQ said the resident had osteomyelitis (bone infection) in his foot and he suspected that it could have come through the bone and settled in the sacrum/coccyx. APPRN QQ said he did an x-ray of the sacral area, and it was suspicious of osteomyelitis, then they decided it was best to send him to the hospital for further treatment. APRN QQ said depending on how the wound looked upon admission on 8/04/23, he most likely would have given the same orders and made a referral to wound care. APRN QQ said it was possible the wound could have deteriorated without appropriate care from 8/04/23 until 8/07/23, but unlikely that it would have deteriorated to the point of needing emergent intervention in that time frame. During an interview on 11/01/23 at 11:18 AM, LVN KK had worked at the facility for six months and normally worked on 600 hall on the 6am-6pm shift. LVN KK said the nurse on the floor was primarily responsible for completing the admission assessment, obtaining and entering orders, initial skin assessments upon the resident's arrival/admission. LVN KK said the first nurse to lay eyes on resident was responsible for all the admission stuff. LVN KK said if a resident was admitted during the week, he preferred to have the wound care nurse go with him and do the skin assessment with him. LVN KK said by completing the admission assessment that included the skin assessment, it would find a pressure wound and it was important to find pressure wounds on admission, so it would show it was acquired at hospital and not at the facility. He would document LVN KK said if he found any new wounds during his skin assessment, he would notify the physician for orders, and he let wound care nurse and the DON know. LVN KK said the nurses were responsible for doing the wound care on the weekends if there was no treatment nurse on the weekend. LVN KK reviewed Resident 361's chart at surveyor request and he none of Resident #361's admission assessments, including the skin assessment was not completed upon admission and still did not show to be completed. LVN KK said it appeared there was no orders to treat the pressure ulcer to Resident #361's bottom until 8/07/23. LVN KK said he could not tell what nurse had admitted Resident #361 due to there was no notes documented. During an interview on 11/01/23 at 11:49 AM, MD RR said he remembered Resident #361 and he had a really nasty coccyx wound. MD RR said he saw Resident #361 on 8/16/23 and that was the only time he saw him in August. MD RR said he debrided the wound and then staged it as a stage 4 pressure ulcer (extends to muscle, tendon, and bone). MD RR said he believed he received the referral to see Resident #361 on 8/16/23 and remembered APRN QQ asking him to see Resident #361. MD RR said any wound that did not receive the appropriate care over three days would most likely deteriorate. During an interview on 11/01/23 at 11:57 AM, LVN NN said she began working at the facility sometime in August 2023. LVN NN said she did not recall seeing Resident #361 for wound care because he may have admitted before she began working at the facility as the wound care nurse. LVN NN said the nurses were responsible for completing the admission skin assessments and if she was at the facility, she would do them with the admitting nurse. During an interview on 11/01/23 at 6/02 PM LVN O said she had worked at the facility for five years and normally worked the 600 hall on 6pm-6am shift. LVN O said on new resident admissions, the nurse had to complete a head-to-toe assessment to include weight, vital signs, assess lungs, heart, feet, and look at everywhere on their skin. LVN O said findings during the assessment should be documented in the admission assessment and skin assessment questionnaire. LVN O said if she found a pressure wound and did not have orders to treat it, then she would notify the physician for orders for treatment immediately. LVN O said Resident #361 did not admit to 600 hall, he was on the 100 hall when he came back from the hospital in August after his amputation. LVN O said she thought an agency nurse admitted him. LVN O said if a pressure ulcer did not receive appropriate care for three days, then the wound could get worse. During an interview on 11/02/23 at 8:36 AM, ADON P said she had worked at the facility since 7/26/23. ADON P said she was responsible for reviewing the 24-hour reports, reviewing nurses' notes, making sure labs were done, along with making sure the nurses were doing what they were supposed to do and helping the DON and ADM. ADON P said she also reviewed new admissions to ensure all the medications were reconciled correctly and available. ADON P said the admitting nurse was responsible for completing the admission assessments and skin assessments as soon as possible, but within 24 hours. ADON P said there was no admission assessment documented on Resident #361 and there were only two nurses' notes on Resident #361. ADON P said if the admission assessment, skin assessments, nurse's notes or anything were not documented, it affected Resident #361's care. ADON P said if it was not documented, then it was not done. ADON P said not receiving needed care to Resident #361's pressure ulcer for three days could have negatively affected the healing of his wound. During an interview on 11/02/23 at 10:05 AM, the DON said the admission assessment, skin assessment, medication review, orders, bed rail evaluation, consents, and baseline care plans should be completed by the admitting nurse. The DON said the admission assessments should be completed by the admitting nurse within 24 hours of admission. The DON said the documentation on Resident #361 was terrible and just awful due to there was no admission assessment with skin assessment and only two nurses' notes during Resident #361's 8/04/23-8/18/23 stay. The DON said she could not determine who the admitting nurse was that did not complete the admission and skin assessments on Resident #361, but she said she believed it had to be an agency nurse. The DON said she was responsible for making sure the nurses were completing the admission assessments. The DON said they had an admission audit form that was started by ADON P, and the DON was the second check. The DON said at time of Resident #361's admission, she did not have an ADON to help her and was having to work the floor frequently and at night and was not able to follow on things like she needed to. The DON said due to the admission assessments not being completed and Resident #361's pressure to his sacrum/coccyx was not discovered on admission, then his needed care was delayed and that was not good. The DON said not receiving care to Resident #361's sacrum/coccyx pressure ulcer could have negatively impacted the healing of the pressure ulcer, however, since it was not documented on his admission assessment, there was no way of determining how much or if any deterioration occurred to his pressure ulcer. During an interview on 11/02/23 at 10:52 AM, the ADM said the receiving nurse would be responsible for completing an admission assessment and the DON or her designee checks over it. The ADM said if the admission assessment was not completed, then they could miss resident care needs. The ADM said a complete admission assessment should be completed to identify any resident issues and provide interventions to prevent decline. The ADM said she would have expected Resident #361 to have been provided care to his pressure ulcer to his coccyx to prevent further breakdown. Record review of the facility's policy titled Prevention of Pressure Ulcers/Injuries dated July 2018 indicated . residents would receive care to maintain skin integrity and prevent pressure ulcers/injuries . residents will be repositioned on a routine basis based on the individual needs of the resident, risk associated with skin disorder such as pressure ulcers/injuries (PU/PI) and/or risk thereof, and other factors that may affect skin integrity . the comprehensive assessment should provide the basis for defining approaches to address residents at risk of developing or already having a pressure ulcer o [TRUNCATED]

Based on interview and record review the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 resident reviewed (Resident #1.) for transfers. The facility failed to transfer a non-weight bearing resident with a Hoyer as directed by her care plan which resulted in a fracture. This failure resulted in the resident receiving fractures, having pain and suffering harm. Findings include: Record review of Resident #1's face sheet indicated a [AGE] year old female resident admitted to the facility on [DATE]. Record review of consolidated physician's orders, dated 7/1/22, indicated Resident #1 had diagnoses which included [CONDITION(S)] of the left lower limb, pain in the left ankle and joints of the left foot, age related [CONDITION(S)] without current pathological fracture (when force or impact did not cause the break), pressure ulcer of other site, unspecified stage, depressive disorder, and [CONDITION(S)]. Record review of Resident #1 MDS, dated [DATE], indicated her BIMS score was 11, which indicated she had moderately impaired cognition. Resident #1's functional status indicated she was totally dependent on staff for transfers, and she did not walk in the room, corridor, or on the unit. The MDS indicated the resident did not walk, turn around or move from surface to surface. She had impairment of both sides of her lower extremities. There was no indication of mobility devices needed. Record review of the CNA ADL Self Performance Care Plan, dated 8/14/21, indicated Resident #1 required caution during transfers due to a wound on her right leg. She required special equipment of a Hoyer lift and her physical functioning was total dependent with two staff assistance. Record review of Resident #1's Care Plan, dated 5/6/22, indicated Resident #1 had a problem area of preferred to stay in the bed most of the time. (no interventions listed.) A problem of total dependence for transfers, mobility, and non-weight bearing all with an onset date of 11/15/21. One of the interventions was assist the resident with ADLs as needed. Record review of the provider investigation report, dated 6/14/22, indicated Resident #1 had an injury of unknown origin. She had a closed fracture of the left ankle. She could verbalize events and could not recall how she would have injured her ankle. She said possibly folding it back under her chair. The Investigation report contained statements taken by the DON. There were statements from the two aides that transferred the resident out of bed and put her back to bed. However, the statements did not provide any descriptive information. They indicated the resident was transferred on 6/6/22. Record review of the incident report, dated 6/7/22, indicated Resident #1's ability to stand was impaired, and balance for transfer was total dependence. She was described as none weight bearing. The incident report indicated there was no change in her physical functioning. Record review of nursing notes, dated 6/7/22 at 7:45 p.m., indicated Resident #1 complained of ankle pain that radiated throughout her toes and lower leg. Pain medications were given and an order for an Xray was completed. Record review of physician's progress note dated 6/7/22 at 11:14 a.m., indicated Resident #1 reported over the weekend she had gotten up from bed to her wheelchair and her left ankle rolled up under her. She stated at that time the pain was very mild but last night it got exceedingly worse she denied hearing a pop or feeling a tear at the time of the injury. The note indicated Resident #1 was non ambulatory, range of motion limited upper extremity with bilateral lower extremities weakness noted. She was primarily bed bound. Record review of an Xray report, dated 6/7/22, indicated Resident #1 had a mildly displaced impacted fracture, moderate degree of osteopenia (low bone density) and moderate degree of [CONDITION(S)] (degeneration of joint cartilage.) Record review of hospital physician orders, dated 6/8/22, indicated Resident #1 had a closed fracture to the left ankle. She was ordered Tylenol #3, to take one tablet every 4 hours as needed for pain. The air splint was in place for comfort. Record review of a training in service form, dated 6/8/22, indicated the staff were trained on safe transfers and plan of care. Record review of physician progress note, dated 6/14/22 at 10:35 a.m., indicated Resident #1 was admitted from the hospital with, orders for an air split. Daily skin checks underneath the air splint, observation for swelling, and skin color of the toes every shift, and for the provider to assess the left ankle weekly. We will continue these orders and I will follow up on her ankle weekly. Orthopedic surgery stated she is not a surgical candidate . Continue to monitor vascular status . Record review of hospital records, dated 6/22/22, indicated Resident #1 recently suffered a left ankle fracture as she was being transferred from one chair to another in the nursing home. During an interview on 6/21/22 at 8:50 a.m. Resident #1's family member said the facility staff broke Resident #1's leg. The resident told them when the staff put her back to bed her foot got caught under the chair. The family member said Resident #1 was non-weight bearing and had been for about two years. She had a car accident in 2020 and had both legs broken. She had several surgeries and the doctor said at that time she would never be able to walk. The family member said they were supposed to transfer her with a Hoyer and did not. During an interview on 6/22/22 at 1:00 p.m., CNA Q said she did not transfer Resident #1 when she hurt her ankle. She said Resident #1 was a two person Hoyer lift transfer. They had a care plan in the system for a long time that said Resident #1 was a Hoyer lift transfer. She said the incident happened when the two staff put her back to bed. She heard the aides stood her up and transferred Resident #1 without a Hoyer. During an interview on 6/22/22 at 1:33 p.m. CNA P said they used a body lift to transfer Resident #1. She said she did not know they were supposed to use a Hoyer. The DON told her they were supposed to use a Hoyer to transfer the resident. The DON took them and showed them how to look at the care plans. CNA P said she did not know it was there. She said they (she and CNA O) transferred her back to bed the same way they transferred her in the chair. During an interview on 6/22/22 at 2:03 p.m., CNA CC said Resident #1 did not get out of bed. The day after she was gotten out of bed, she complained about ankle pain. She was told the aides that transferred Resident #1 did not use a Hoyer. CNA CC said Resident #1 was care planned for a Hoyer lift transfer. She said Resident #1 could not bear any weight and she would not transfer her without a Hoyer. During an interview on 6/22/22 at 2:10 p.m., CNA O said Resident #1 was transferred by a body lift, they did not use a Hoyer for the transfer. Resident #1 was gotten out of bed and put back to bed the same way. The DON showed her in the care plan a few days later. The care plan indicated Resident #1 was a Hoyer lift transfer. During an interview on 6/22/22 at 2:23 p.m., the DON said the staff did not tell her they did not use a Hoyer for the transfer. She said Resident #1 never got up. During an observation and interview on 7/1/22 at 9:21 a.m., Resident #1 was observed to be lying in bed with several layers of cover. She had a metal bracket across the bottom of the bed to keep the covers from touching her feet. Her right and left legs had bandages and the resident had on socks. Her left foot was turned completely to the right. Resident #1 was somewhat confused and answered most questions with, I do not remember. Resident #1 said she did not remember wearing a splint or why she was in the hospital. She said she did remember how her ankle was broken. She said, two staff drug her across the floor. The resident said she was always in pain and did not know when she would try to get up again. During an interview on 7/1/22 at 11:22 a.m., LVN F (the MDS nurse) said they did not document on the MDS Resident #1's transfer needs because she did not get out of bed during the look back period for the MDS. She said Resident #1 was total dependent on two people for transfers. She said the aides used a CNA Care Plan to provide care to the residents. During an interview on 7/1/22 at 11:56 a.m., CNA DD said as far as she knew Resident #1 had not been out of bed in over a year. She said Resident #1 could not stand and she could not help with a transfer at all. She was a Hoyer transfer for a long time but was basically bed bound. During an interview on 7/1/22 at 1:11 p.m., the DON said there was nothing wrong with Resident #1's transfer. She required two people for transfer, and she was transferred by two people. She said Resident #1 was not a non -weight bearing resident. If she was then she would require a Hoyer lift transfer. She said she was the person that did the official interviews with the aides after the incident and did not find any issues. Record review of the facility policy on ADL Care and transfer techniques, revised 2/12/20, indicated staff will provide safe and effective transfer techniques for residents in accordance with standard practice guidelines. The procedures were for transfer pivot techniques, lateral transfer to a stretcher and mechanical lift (Hoyer.) There were no other techniques listed.

Based on interview and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing prevent infection and prevent new pressure ulcers from developing for 2 of 5 residents (Resident #1 and Resident #3) reviewed for pressure ulcers. 1. The facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. The facility failed to prevent the development or worsening of pressure injuries on the coccyx of Resident #3. These failures could place residents at risk for developing avoidable pressure injuries and the worsening of existing pressure injuries. Findings include: 1.Record review of Resident #1's face sheet indicated [AGE] year-old a female resident who was admitted to the facility on [DATE]. Record review of consolidated physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .) She had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's MDS, dated [DATE], indicated her BIMS score was 11 which indicated moderately impaired cognition. Resident #1's functional status indicated she was totally dependent on staff for transfers, and she did not walk in the room, corridor, or on the unit. She had impairment of both sides of her lower extremities. The MDS indicated the resident did not walk, turn around or move from surface to surface. She had impairment of both sides of her lower extremities. There was no indication of mobility devices needed. She had 2 stage 3 pressure ulcers (MDS identified a stage 3 as full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the dept of tissue loss. May include undermining and tunneling). Record review of the care plan, dated 5/6/22, indicated Resident #1 had a problem area of prefers to stay in the bed most of the time. (no interventions listed.) A problem of total dependence for transfers, mobility, and non-weight bearing all with an onset date of 11/15/21. One of the interventions was assist the resident with ADLs as needed. A Problem area of skin breakdown last updated 6/15/22 indicated she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Measures taken to prevent skin breakdown were to apply protective or barrier lotion after incontinent care, assist the resident to turn and reposition frequently, cleanse wound to the right calf, dietitian referral, and inspect skin a complete body head to toe assessment each week and document results. Record review of Resident #1's pressure ulcer risk assessment, dated 5/9/22, indicated she was at high risk with a score of 11. Record review of nursing notes, dated 6/7/22 at 7:45 p.m., indicated Resident #1 complained of ankle pain that radiated throughout her toes and lower leg. Pain medications were given and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of an Xray report, dated 6/7/22, indicated Resident #1 had a mildly displaced impacted fracture, moderate degree of osteopenia (low bone density) and moderate degree of [CONDITION(S)] (degeneration of joint cartilage.) Record review of Hospital physician orders, dated 6/8/22, indicated Resident #1 had a closed fracture to the left ankle. She was ordered Tylenol #3, to take one table every 4 hours as needed for pain. The air splint was in place for comfort. The order stated to check the skin under splint daily and observe for swelling and skin color of toes every shift. The order indicated facility provider assess the left ankle weekly. Record review of Resident #1's physician orders, dated 6/8/22, indicated Cold Packs 3 times per day for 7 days. Apply ice pack three times a day for 20 minutes daily for 7 days and as needed for [CONDITION(S)]. Elevate the left foot as much as possible due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . No other orders were noted regarding the left ankle/foot. Record review of a care plan with an onset date of 6/8/22, indicated Resident #1 had a recent fracture. Interventions were to give pain medications as ordered and keep the resident comfortable. Position the with pillows as needed. Record review of Treatment Administration Records indicated, from 6/8/22 through 6/15/22, Resident #1 received a Cold Pack 3 times daily for 20 minutes applied to her left leg. From 6/9/22 through 6/19/22 one time per day leave left foot elevated as much as possible. Resident #1 also had treatment to right calf. Record Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Daily skin checks underneath the air splint, observation for swelling, and skin color of the toes every shift, and for the provider to assess the left ankle weekly. We will continue these orders and I will follow up on her ankle weekly. Orthopedic surgery stated she is not a surgical candidate .Continue to monitor vascular status. Continue wound care to right lower extremity arterial wound. We will monitor left foot and ankle closely secondary to recent fracture given her history of poor peripheral perfusion (decreased arterial blood flow to the extremities) she is at a high higher likelihood of tissue ischemia (deficiency of blood supply). She currently shows no signs or symptoms of tissue ischemia noted to her left foot. Record review of Resident #1's Weekly Wound Assessments indicated, on 6/15/22, pressure to the right leg at a stage 3 the wound measured 7.9 x 2.4 cm w and 0.1 cm depth, the wound base was red with moderate color and serous drainage. The right leg was noted with a second wound a stage 3 that measured 3.0 x 1.5 cm w and 0.1 cm dept. the wound base was pink in color with a small amount of serous drainage. There was no mention of the left foot or ankle. Record review of a Skin Data form, dated 6/16/22, indicated Resident #1's skin status was a rash and redness to both right and left legs. She had skin desensitization (reduced sensitivity) to the right and left leg. (completed by LVN Z.) Record review of Resident #1's nursing notes, from 6/8/22 through 6/19/22, revealed there was no documentation of the splint being removed or the skin being checked. Record review of a nursing note dated 6/19/22 at 6:23 p.m. indicted Resident #1 was not responding. Her vital signs were taken and she was sent to the hospital. Record review of hospital records, dated 6/19/22, indicated Resident #1 recently suffered a left ankle fracture. The patent was deemed a poor surgical candidate and had an air splint placed on her left lower extremity. The placement of the splint led to the wound on the left lower extremity. The patient presented with open wounds to the bilateral lower extremities with purulent (sign of infection) discharge. The assessment of the wounds indicated the resident had multiple open lower extremity wounds to left and right lower extremities. Record Review of Resident #1's Hospital Discharge Summary dated 6/22/22 indicated the wound culture growing out multiple gram-negative organisms, enterococcus species, and [CONDITION(S)], of note, the patients white count was normal, and the wounds show no signs of infection. Record review of a hospital wound care consult report, dated 6/19/22 at 11:11 p.m., indicated the reason for the [NAME] was purulent pressure ulcers. Discharge, dated 6/22/22, continue wound care to bilateral lower extremity ulcers as follows. Recommended treating with [MEDICATION(S)] AG foam, Kerlix and elevation. The wounds show no signs of infection. Record review of a picture of Resident #1's wound to her left ankle, dated 6/19/22, revealed the skin around the wound was macerated (macerated skin looks lighter in color and wrinkly. It may feel soft, wet, or soggy to touch.) The surrounding tissue of the wound bed had dark purple discoloration. The inside of the wound bed was dark red in color with no top layer of skin. The wound bed was open. The wound had and irregular shaped border. It did not have defined edges. Record review of a nursing note, dated 6/23/22 at 3:04 p.m., indicated Resident # 1 was admitted back to the facility on [DATE]. Discharge orders were received for wound care to both lower extremity ulcers. Recommended treating with Meplilex AG foam, kerlix, elevation. The NP at bedside for skin assessment. The resident had a half soft splint in place to the left lower extremity. Consulted with wound doctor. She did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .) Record review of Resident #1's Skin Data Sheet, dated 6/23/22, indicated she had a wound to the left and right legs with treatment in place. She had skin desensitization to the left and right leg with dry flaky skin to both. Record review of a Wound Report dated 6/29/22, (first) indicated Resident #1 had a Stage 3 wound to her left leg that measured 3.8 x 2.5 with a dept of 0.1 wound margins open. The comments said left posterior calf 100 percent granulation tissue. Medical device injury. The from said the resident was admitted with the wound on 8/14/21 and it had improved. There was no prior documentation of the wound. Record review of consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound to the left lower extremity was to be cleaned daily, hydrogel wafer applied, and wrapped with Kerlix. During an interview on 6/21/22 at 12:45 p.m., LVN D/ Treatment Nurse said the last skin assessment she completed on Resident #1 was on Tuesday, 6/15/22, with the wound care doctor. She said at that time she took the splint off and looked at the left foot and the skin looked fine. The Treatment Nurse said she was not aware there were orders to check under the splint every day. She said the family member contacted her with concerns after Resident #1 was admitted to the hospital with a pressure sore under the splint. During an interview on 06/22/22 at 1:10 p.m., the DON said the admitting nurse ( LVN Z) should transcribe the orders into the system. She said Resident #1 was readmitted on [DATE]. She completed a skin assessment on 06/09/22 and there was no wound. She said LVN D did a skin assessment on 06/15 and 06/16 and there were no wounds under the splint. During an interview on 7/1/22 at 8:31 a.m., LVN F/treatment nurse said she worked at the facility for two years. She said Resident #1 was back at the facility. She did have pressure sores on her left ankle, and they changed the treatment orders several times since her re admission. She appeared to be doing well but she still complained about pain. She said she did the initial note on Resident #1. She was admitted in the middle of the night and the nurse may not have known she was to complete and initial assessment on admission. She said she completed the first skin assessment on Resident #1 on 6/29/22, she saw her on 6/23/22 but did not complete an assessment. During an interview on 7/1/22 at 8:38 a.m., LVN Z said she had worked at the facility for two months she said Resident # 1 was back at the facility from the hospital and the resident was doing well. LVN Z said she was the nurse that sent Resident #1 to the hospital on 6/19/22. The resident would open her eyes but would not respond. Resident #1 was often in extreme pain. The LVN said she never took the splint off Resident #1's left ankle, because if Resident #1's foot was barely moved it was very painful for her. LVN Z said she completed the skin data sheet on 6/23/22 but had not removed the splint. The LVN said it was her fault the order was not transcribed for the splint to be removed. She was a new nurse and had not transcribed the order correctly. She had been counseled regarding the incident. She said she noted on the Skin Data Sheet, dated 06/23/22, Resident #1 had a rash on both legs. She had a reoccurring rash between her upper thighs. During an interview on 7/1/22/22 at 9:26 a.m., CNA CC said she provided care to Resident #1. When the resident wore the splint, she never took it off her foot, that was not something she as an aide would do. The nurse or the treatment nurse would be the ones to remove the splint. During an interview on 7/1/22 at 11:56 a.m., CNA DD said she provided care to Resident #1 when she had the splint. She said she never removed it to provide any care. She said the nurse would be the one who removed the splint. During an interview on 7/1/22 at 1:11 p.m., the DON said there was an initial nursing assessment that should have been completed. She said Resident #1 did not have a pressure sore she had a statis ulcer and it was not caused by pressure. The splint would not have made a difference due to the resident's poor circulation. 2.) Record review of Resident #3's face sheet, dated 06/23/22, indicated a [AGE] year old male who was admitted to the facility on [DATE]. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's MDS, dated [DATE], indicated a BIMS score of 99, which indicated the resident was not able to complete the interview. Resident #3 had severe cognitive impairment, required extensive 1-person assist for most ADLS, used a wheelchair for a mobility, had an indwelling catheter, and was frequently incontinent of bowel. He was at risk of pressure ulcers. He had no pressure ulcers. Record review of Resident #3's pressure ulcer risk assessment, dated 10/22/21, indicated he was at high risk with a score of 13. Record review of Resident #3's care plan, dated 10/22/21, indicated he was at risk for skin break down and interventions included assist resident to turn and reposition frequently and inspect skin every week and document results. Record review of nurse note, dated 10/25/22, completed by LVN BB indicated Resident #3 was transferred to the hospital due to abnormal labs and left pleural effusion. Resident #3 was stable at the time of transfer. There was no documentation of pressure ulcers. Record review of Resident #3's Skin Data sheet dated 10/23/22 indicated no pressure wounds or rashes. Record review of Resident #3's hospital records indicated he was in the emergency roiagnom on [DATE] at 11:49 p.m., he was admitted on [DATE] at 4:38 a.m. and included the following: -Infectious Disease Consult .urine culture grew out to Pseudomonas aeruginosa organisms (type of bacteria (germ) that is found commonly in the environment, like in soil and in water . which can cause infections in the blood, lungs (pneumonia), or other parts of the body after surgery). coccyx wound culture grew out Pseudomonas aeruginosa, Escherichia coli (bacteria that normally lives in the intestines of both healthy people) and Enterococcus facialis (bacteria spread from person to person through poor hygiene) . MRI 10/26/22 5:00 a.m. Impression: 1. Negative for [CONDITION(S)]. 2. Left perineum subcutaneous infection continuous through the skin ulceration left superolateral to the anus is concerning for Fournier's gangrene (an acute necrotic infection of the scrotum; penis; or perineum) .10/26/21 5:41 p.m .Examination of the backside shows a malodorous nonunstageable decubitus ulcer of the coccyx with an overlying black eschar and several stage II ulcerations of bilateral sacral/buttock skin . 10/28/21 Present on admit/arrival - decubital ulcer to coccyx, dressing in place . 11/02/21 . present on admit/arrival: decubitus ulcer with necrosis. During an interview on 07/1/22 at 8:31 a.m., LVN D (treatment nurse) said she had worked at the facility for two years. She said she was the treatment nurse when Resident #3 was at the facility. She looked at his records. She said she remembered him and he did not have anything on his buttocks when he was discharged from the facility. Record review of Resident #3's clinical record did not include a skin assessment prior to discharge to hospital on 10/25/22. Record review of the facility's Pressure Ulcer policy, revised 07/2018, indicated Pressure ulcers/injuries will be identified, evaluated and treated in accordance with generally accepted guidelines. Record review of a Pressure Sores article, https://medlineplus.gov/pressuresores.html, last revised May 2, 2016 and accessed on 07/01/22, indicated .Pressure sores are areas of damaged skin caused by staying in one position for too long. They commonly form where your bones are close to your skin, such as your ankles, back, elbows, heels and hips. You are at risk if you are bedridden, use a wheelchair, or are unable to change your position. Pressure sores can cause serious infections, some of which are life-threatening. They can be a problem for people in nursing homes. You can prevent the sores by keeping skin clean and dry, changing position every two hours, and using pillows and products that relieve pressure

Based on observation, interview, and record review, the facility failed to provide or arranged services as outlined by the comprehensive care plan that meet met professional standards of quality of care for 1 of 15 residents (Resident #2) reviewed for professional standards. The facility failed to ensure LVN C immediately evaluated and treated Resident #2's open and uncovered finger amputation. These failures could place residents at risk for decline in health status. Findings included: Record review of Resident #2's face sheet date 06/29/22 indicated she a female resident who was initially admitted to the facility on [DATE]. She was and readmitted on [DATE] from the hospital. She was [AGE] years old and her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's MDS, dated [DATE], indicated she was admitted from the hospital, had a BIMS score of 7 and which indicated she had severe cognitive impairment. She was inattentive and had disorganized thinking, had daily behaviors not directed at others, rejected care, was total dependent for most ADLS of care and mobility, utilized a wheelchair for mobility, and was incontinent of bladder and bowel. She had 1 unhealed pressure stage 4 ulcers/injuries, 1 unstageable and 1 deep issue injury, 1 venous and arterial ulcer, and a surgical wound. She required pressure ulcer/injury care, surgical care, and application of dressings to feet. Record review of Resident #2's physician order, dated 06/17/22, indicated every AM shift (6 a.m. -2 p.m.) -cleanse left heal with NS, apply Santyl followed by calcium alginate, cover with dry dressing, -cleanse wound to right lateral foot with NS, apply collagen sheet, cover with dry dressing, -skin prep to left distal second finger for unspecified open wound of unspecified finger with damage to nail, -skin prep to left fourth distal finger for unspecified open wound of unspecified finger with damage to nail, and -apply [MEDICATION(S)] to right posterior heel every day. Record review of Resident #2's physician order, dated 06/12/22, indicated every AM shift (6 a.m. -2 p.m.) - 1 time per day to right heel-cleanse with NS, pat dry, apply [MEDICATION(S)] wet to dry dressing- D/C 06/17/22, -cleanse right outer foot with NS, pat dry, apply calcium alginate and cover with dry dressing, D/C 06/17/22, -cleanse left heel area with NS, pat dry, apply [MEDICATION(S)] wet to dry dressing, D/C 06/17/22, -cleanse left outer foot with NS, pat dry, apply calcium alginate and cover with dry dressing, and -cleanse right 1st finger amputation site with NS, pat dry, apply steri strips, cover with dry dressing daily as resident allows or tolerates. Record review of Resident #2's care plan, dated 06/12/22, indicated she was at risk for skin break down as evidenced by surgical wound (onset date 06/12/22) and heel discoloration (onset date 06/12/22). Interventions included inspect skin daily with care and bathing and report any changes to charge nurse and treatments and dressing as ordered by physician. Record review of a nurse note, dated 06/20/22 at 9:12 a.m., completed by LVN C, indicated Resident #2 was sitting on the side of the bed. Family members were in the room. Police were called by the family to have Resident #2 transferred to the hospital. LVN C was not aware of any complaints due to Resident #2 siting on the side of the bed. Resident #2 was confused and disoriented. Resident #2 had blood on gown, had taken off all wound dressings, fingers had blood where Resident #2 had bit dressings off. Record review of Resident #2's hospital records, dated 06/19/22, indicated on 06/20/22 indicated . she was admitted for a non-healing wound. [Resident #2] has a history of chewing her fingernails off, biting her fingers, picking her skin, and visual hallucinations of bugs on her skin. According to the nursing home, family came to visit and felt she was not being care for as her wounds were not dressed, they saw blood on her clothes .Resident #2 has multiple excoriations to her lower legs, missing distal tip of her left index finger that is still red, missing nail on her left ring finger with flesh colored nail bed, multiple sores atop her toes of bilateral feet. [Resident #2] has history of amputation to right index finger and right 4th finger .has multiple pressure wounds but nursing home staff stated they have been attempting to keep these dressed but [Resident #2] will often take the dressing off and pick at the wounds.right MCP (metacarpophalangeal) has moist, pale wound base but no discharge to be expressed. Does appear bone may be exposed. Left index finger from DIP (distal interphalangeal) to tip is erythematous with missing nail bed and missing nail tip. Left ring finger has a missing nail that appears chronic. Several wounds linearly spaced on bilateral shins. Right first toe amputation. Several small, scabbed, circumferential wounds on dorsum of second toe. There is an unstageable ulcer approximately 3 x 3 cm on left heel. There is an approximately 2 x 2 cm wound with moist base on right heel. Problems: surgical wound, non-healing. Plan: Resident #2 presents with a non-healing surgical site from right index finger amputation 2 weeks ago. Has failed outpatient treatment with 2 antibiotics. Will admit for further treatment .Decubitus ulcer of heel, bilateral, unstageable, chronic, wound care consulted . has nonhealing surgical wound and [CONDITION(S)] .will be admitted for IV antibiotics . During an interview on 06/20/22 at 2:13 p.m., Police Officer G said he observed Resident #2 with blood on her gown and around her head. He said an aide came in to clean up the blood. He said there was blood splatters on the floor. He said Resident #2's feet were bleeding and looked infected. He said LVN C did not check on Resident #2. During an interview on 06/22/22 at 8:25 a.m., CNA B said she arrived to work at approximately 7:00 p.m. on 06/19/22. She said she arrived on hall 600 and went to Resident #2's room and found her sitting on the side of the bed covered in blood. She said Resident #2 was trying to get off the bed. She said she gave her a drink and snack and then told LVN C Resident #2 was covered in blood. She said LVN C said there was nothing to be done because Resident #2 takes off her bandages. She said LVN C said she (LVN C) and CNA B were not miracle workers. She said Resident #2's family asked her to take pictures, so she took pictures and sent the pictures to the family. She said the family said they needed proof because they were coming after the facility. She said she could not recall what time the family and police arrived. She said she realized she was not supposed to take pictures of Resident #2 and send them via her phone to family. During an interview on 06/23/22 at 8:30 a.m., Resident #2 was lying in a hospital bed eating breakfast. She had no bandage on her right hand. The amputation wound of her right ring finger was open to the bone. She said she was fine when asked how she was feeling. She did not respond when asked about her bandages. During an interview on 06/23/22 at 3:00 p.m., LVN C said she came on shift on 06/19/22 at 6:00 p.m. She said she started her rounds and was checking residents'; BS and passing medications. She said she arrived at Resident #2's room and checked her BS and gave her medications. She said Resident #2 did not have on her bandages and the bandages were all on the floor. She said Resident #2's gown had some blood on the right shoulder. She said she did not see where the blood was coming from. She said she directed Resident #2 to remain sitting on the bed and she would return and fix the bandages after she completed checking other residents' blood sugars and administering medications. She said she was at the nurse station desk and did not get back to Resident #2's room because she was calling a physician regarding another resident's fall. She said she looked up from the phone and saw the police and family going into Resident #2's room. She said it was approximately 30 minutes between when she first noticed Resident #2's bandages were off and the blood on her gown and when the police and family arrived at the facility. She said she did not call any nurse from the other halls for assistance. She said there were two aides on shift while she was completing her medication pass. She said CNA B did not report Resident #2 had taken off her bandages or was bleeding. She said she did not document until the morning of 06/20/22 in the nurse note. During an interview on 06/23/22 at 12:04 p.m., MDS F said the staff should have followed Resident #2's care plan and assessed and addressed Resident #2's wound and dressings when she became aware Resident #2's dressings were not in place and had blood on her gown. During an interview on 06/23/22 at 4:25 p.m., the Administrator said she was not aware of any complaints of Resident #2's care. During an interview on 06/24/22 at 9:30 a.m., NP H said he was made aware of Resident #2's non-healing wound from the amputation of the right ring finger. He said she received ABT but would remove the bandages. He said the bandages should have been re-applied as Resident #2 would tolerate. He said he was aware she would take the banges off and chew on her fingers and nails. He said she was admitted to the facility with the same behaviors. Record review of the facility's Care Plan Process policy dated 02/12/20 indicated . The Plan of Care identifies the date, problem, goals, measurable and realistic, timeframe for achievement, interventions, discipline specific services, and frequency .

Based on interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment which included both the comprehensive and quarterly review assessments for 1 of 15 residents (Resident #2) reviewed for comprehensive assessments. The facility failed to ensure Resident #2's comprehensive care plan included specific behaviors which included skin picking, chewing fingernails and fingers, taking off bandages, and chewing sutures and skin of amputated fingers. This failure could place residents at risk for not receiving needed care and services. Findings include: Record review of Resident #2's face sheet, dated 06/29/22, indicated female, resident who was initially admitted to the facility on [DATE] and readmitted on [DATE], from hospital. She was [AGE] years old and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's MDS, dated [DATE], indicated she was admitted from the hospital and, had a BIMS score of 7, which indicated she had severe cognitive impairment. She was inattentive and had disorganized thinking, hallucinated, and delusions, had daily behaviors not directed at others, rejected care, was total dependent for most ADLS of care and mobility, utilized a wheelchair for mobility, and was incontinent of bladder and bowel. Care areas triggered included behavioral symptoms. Record review of Resident #2's care plan, dated 06/12/22, indicated she was at risk of behavioral changes related to a [CONDITION(S)]. The goal was identified as will demonstrate improvements in behavior over the next 90 days. Interventions included analyze key times, places, circumstances, triggers and de-escalates behaviors. Record review of a nurse note, dated 06/20/22 at 9:12 a.m., completed by LVN C, indicated Resident #2 was sitting on the side of the bed. Family members were in the room. Police were called by the family to have Resident #2 transferred to the hospital. LVN C was not aware of any complaints due to Resident #2 siting on the side of the bed. Resident #2 was confused and disoriented. Resident #2 had blood on her gown, had taken off all wound dressings, fingers had blood where Resident #2 had bit dressings off. Record review of Resident #2's hospital records, dated 06/19/22, and 06/20/22 indicated . she was admitted for a non-healing wound. Resident #2 has a history of chewing her fingernails off, biting her fingers, picking her skin, and visual hallucinations of bugs on her skin. Resident #2 has history of amputation to right index finger and right 4th finger .has multiple pressure wounds but nursing home staff stated they have been attempting to keep these dressed but [Resident #2] will often take the dressing off and pick at the wounds.right MCP (metacarpophalangeal) has moist, pale wound base but no discharge to be expressed. Does appear bone may be exposed. Left index finger from DIP (distal interphalangeal) to tip is erythematous with missing nail bed and missing nail tip. Left ring finger has a missing nail that appears chronic. Several wounds linearly spaced on bilateral shins. Right first toe amputation. Several small, scabbed, circumferential wounds on dorsum of second toe. There is an unstageable ulcer approximately 3 x 3 cm on left heel. There is an approximately 2 x 2 cm wound with moist base on right heel. During an interview on 06/20/22 at 2:13 p.m., Police Officer G said he observed Resident #2 with blood on her gown and around her head. He said an aide came in to clean up the blood. He said there were blood splatters on the floor. He said Resident #2's feet were bleeding and looked infected. He said LVN C did not check on Resident #2. During an interview on 06/21/22 at 3:59 p.m., a family member said Resident #2 was found sitting on a bed covered in blood. She said a staff member took some pictures at the request of the family and sent the pictures to another family member. She said the family arrived about 25 minutes after they received the pictures. She said the family called the police because of the blood and roaches in the room. She said the nurse came in and told Resident #2 she said to leave that on and then walked out of the room and did not assess Resident #2 or clean and put the bandages back on. She said the family wanted Resident #2 transferred to the hospital. She said the hospital told the family Resident #2 was septic from her wounds. During an interview on 06/22/22 at 8:25 a.m., CNA B said she arrived to work at approximately 7:00 p.m. on 06/19/22. She said she arrived on hall 600 and went to Resident #2's room and found her sitting on the side of the bed covered in blood. She said Resident #2 was trying to get off the bed. She said she gave her a drink and snack and then told LVN C Resident #2 was covered in blood. She said LVN C said there was nothing to be done because Resident #2 took off her bandages. She said LVN C said she (LVN C) and CNA B were not miracle workers. She said Resident #2's family asked her to take pictures, so she took pictures and sent the pictures to the family. She said the family said they needed proof because they were coming after the facility. She said she could not recall what time the family and police arrived. She said she realized she was not supposed to take pictures of Resident #2 and send them via her phone to family. During an observation and interview on 06/23/22 at 8:30 a.m., Resident #2 was lying in a hospital bed eating breakfast. She had no bandage on her right hand. The amputation wound of her right ring finger was open to the bone. She said she was fine when asked how she was feeling. She did not respond when asked about her bandages. During an interview on 06/23/22 at 3:00 p.m., LVN C said she came on shift on 06/19/22 at 6:00 p.m. She said she started her rounds , administered residents' BS, and passed medications. She said she arrived at Resident #2's room and checked her BS and gave her medications. She said Resident #2 did not have on her bandages on and the bandages were all on the floor. She said Resident #2's gown had some blood on the right shoulder. She said she did not see where the blood was coming from. She said she directed Resident #2 to remain sitting on the bed and she would return and fix the bandages after she completed checking other residents' blood sugars and administering medications. She said she was at the nurse station desk and did not get back to Resident #2's room because she called a physician regarding another resident's fall. She said she looked up from the phone and saw the police and family going into Resident #2's room. She said that it was approximately 30 minutes between when she first noticed Resident #2's bandages were off and the blood on her gown and when the police and family arrived at the facility. She said she did not call any nurse from the other halls for assistance. She said there were two aides on shift while she completed her medication pass. She said CNA B did not report Resident #2 had taken off her bandages or was bleeding. She said she did not document until the morning of 06/20/22 in the nurse note. She said the behaviors of picking and taking off bandages were documented in the nurse notes. During an interview on 06/23/22 at 12:04 p.m. LVN F said she was not able to figure out what happened to the behavior care plan. She said when Resident #2 was discharged and then returned to the facility, a whole new care plan was developed. She said she was sure Resident #2's care plan included the amputations and her behaviors. She said she was not able to locate Resident #2's care plan for behaviors. She said RN X was responsible for Resident #2's most current care plan. She said RN X was not available for interview. During an interview on 06/23/22 at 4:25 p.m., the Administrator said she was not aware the care plan did not include behaviors. She said care plans were completed by the MDS LVN. During an interview on 06/24/22 at 9:30 a.m., NP H said he was made aware of Resident #2's non-healing wound from the amputation of the right ring finger. He said she received ABT but would remove the bandages. He said the bandages should have been re-applied as Resident #2 would tolerate. He said he was aware she would take the bandages off and chew on her fingers and nails. He said she was admitted to the facility with the same behaviors. Record review of the facility's Care Plan Process, policy dated 02/12/20 indicated . The Plan of Care identifies the date, problem, goals, measurable and realistic, timeframe for achievement, interventions, discipline specific services, and frequency .

Based on interview and record review, the facility failed to ensure the physician was consulted regarding a significant change in the physical, mental, psychosocial status for 3 of 6 residents reviewed for laboratory services and change of condition. (Resident #s 1, 2, and 3) The facility did not consult with the physician on [DATE] when Resident #1 was bleeding from the penis, had a decrease in appetite, and was no longer able to feed himself. The facility did not followup to ensure they received the C&S following an abnormal urinalysis on [DATE]. The resident was sent to the emergency roiagnom on [DATE] with active bleeding from the penis, low blood pressure, and was diagnosed with [REDACTED].#1 was placed on hospice and died three days later. The facility did not follow up on laboratory tests to ensure C & S tests were received and did not promptly treat Residents #2 and #3 with antibiotics when they had abnormal laboratory results. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern and of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the census of 108 residents at risk of neglect due to changes in condition and abnormal laboratory results not being addressed. Findings included: 1. Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. A hospice discharge summary report dated [DATE] indicated Resident #1 admitted to the hospice facility on [DATE] with a [DIAGNOSES REDACTED].#1 expired in the hospice facility on [DATE] at 4:40 a.m. The most recent MDS dated [DATE] indicated Resident #1 made himself understood and understood others. He had severely impaired cognition and required extensive assistance with bed mobility, transfers, dressing, and hygiene. Resident #1 required supervision with setup help only for eating. A nursing note dated [DATE] indicated Resident #1 appeared lethargic. The nurse practitioner (NP) was notified and ordered a complete blood count (CBC) and a Basic Metabolic Panel. (BMP) The 24 hour nursing report dated [DATE] indicated a UA with a C&S was also ordered for Resident #1. A nursing note dated [DATE] indicated the laboratory results for Resident #1 returned with a potassium level of 5.8. (normal range is 3.7 to 5.2 mEq/L ( milliequivalents per liter) The NP gave a new order for [MEDICATION NAME] (used to treat too much potassium in the body) and to re-check potassium level on [DATE]. A laboratory report dated [DATE] indicated the tests for Resident #1 included abnormal results for protein, blood/UA, bacteria, leukocyte esterase, and mucus. Resident #1 had blood in his urine. ADON H noted on the bottom of the laboratory report .awaiting C&S noted [DATE] . A laboratory report dated [DATE] indicated the laboratory tests for Resident #1 included abnormal results for blood, protein, [MEDICATION NAME], and leukocyte esterase. Resident #1 had blood in his urine. ADON H noted on the bottom of the laboratory report .awaiting C&S noted [DATE] . During an interview on [DATE] at 11:24 a.m., the DON said C&S results were usually expected to return to the facility in 72 hours. She said the pending laboratory reports were discussed daily in the morning meeting, and if a laboratory result was pending it should be located on the 24 hour report. She said no one person was designated to follow up on laboratory tests. She said the ADON's and charge nurses were all responsible to follow-up and ensure laboratory tests were done. The DON said she was not aware the facility had not received the results for the C&S ordered for Resident #1 on [DATE]. The DON said she was not aware of any change in condition for Resident #1, and was not aware of why Resident #1 was sent to the hospital because she was out of the facility for personal reasons during that time. During an interview on [DATE] at 2:01 p.m., LVN D, who worked with Resident #1 on [DATE], [DATE], [DATE], and [DATE], said Resident #1 was lethargic on [DATE], so she notified the NP on [DATE], who ordered a CBC, BMP, and a UA with a C&S. She said ADON H was responsible for following up with the laboratory tests and ensuring the C&S was returned and the results were reported to the NP. LVN D said sometimes, if she remembered, she called the laboratory company herself for the results of the C&S if it was not returned within 3 days. She said the only way for a charge nurse to track whether they were awaiting laboratory results, was if it was put on the 24 hour nursing report. She said when she noted Resident #1's UA with C&S on the 24 hour nursing report on [DATE], it should have been carried over on the following days so it could be tracked. She said when she cared for Resident #1, he was able to feed himself, but required assistance with other ADLs. She said it was never reported to her that Resident #1 had blood in his urine or was bleeding from his penis. She said Resident #1 was lethargic each time she worked with him after [DATE]. LVN D said she reported to the NP when she first noted Resident #1's lethargy, but not in the days after because she had not noticed a worsened decline. There were no nursing notes for Resident #1 between [DATE] and [DATE]. The 24 hour nursing report dated [DATE] did not include any notes for Resident #1. The 24 hour nursing report dated [DATE] indicated Resident #1 was stable. The 24 hour nursing report dated [DATE] noted by LVN E indicated the .C&S pending . for Resident #1. During an interview on [DATE] at 2:16 p.m., LVN E said he was approached on [DATE] by Resident #1's wife who inquired about the laboratory results for Resident #1. He said he checked the scanned documents and saw ADON H noted on the laboratory report they were awaiting the C&S. He said the C&S typically arrived in 3 to 5 days, so he included C&S pending on the 24 hour report to ensure follow up was done. He said a charge nurse the following day should have followed up on the C&S or included it on the 24 hour report to be carried over the following day. He said ADON H was responsible for follow ups to ensure laboratory results were received via fax. He said he was told prior to working with Resident #1 that Resident #1 was able to feed himself, but Resident #1 required assistance being fed when he worked with him. LVN E said he did not report that Resident #1 required assistance being fed, as a change in condition, to the physician because he had not personally observed the resident to feed himself prior. The 24 hour nursing report dated [DATE] indicated Resident #1 had signs and symptoms of bleeding. LVN F noted Resident #1 had .red blood in urine . There were several attempts made to contact LVN F, but they were unsuccessful. During an interview on [DATE] at 11:21 a.m., CNA A said she was not assigned to provide care for Resident #1 on [DATE], but did assist CNA B with changing Resident #1 on that day. She said Resident #1 was bleeding from his penis, and had blood in his urine and on his brief. She said she noted that to be a change from when she assisted with changing Resident #1 on previous occasions. CNA A said she asked CNA B if she reported the bleeding to the nurse, and CNA B told her she already had. CNA A said she did not report the bleeding to the charge nurse. During an interview on [DATE] at 11:48 a.m., CNA C said about three days before Resident #1 discharged to the hospital, she noticed Resident #1 had really dark urine with blood in it. She did not recall if she was working with Resident #1 or assisting with Resident #1. She said she did report the blood to the charge nurse, but did not recall which charge nurse she reported to. She said several other CNAs asked her if she noticed the blood in Resident #1's urine, and she told them she had. She said Resident #1 did not have blood in his urine when he was first admitted . During a telephone interview on [DATE] at 3:45 p.m., CNA B said she was assigned to provide care for Resident #1 on [DATE]. She said CNA A assisted her with changing Resident #1, and Resident #1 had blood in his urine that day, blood on his penis, and a lot of blood on the pad beneath Resident #1. CNA B said Resident #1 was not talking as much as he had been previously, was no longer able to feed himself, and was not eating as much. CNA B said when Resident #1 first admitted , he ate between 50% and 100% of his food, and around [DATE], he was only eating a couple bites of his meals. CNA B said she reported those changes, including Resident #1 bleeding from his penis, to LVN F and was not sure what was done about it. The 24 hour report dated [DATE] indicated LVN G noted Resident #1 had a urinary tract infection. [MEDICAL CONDITION] The staffing schedule indicated LVN G worked with Resident #1 on [DATE] and [DATE]. During an interview on [DATE] at 12:14 p.m., LVN G said she did not recall Resident #1, did not know why she noted Resident #1 had a UTI, and did not recall anyone reporting blood in Resident #1's urine. She said if blood in Resident #1's urine was reported to her and was not normal for him, she would have reported it to the NP. During an interview on [DATE] at 1:21 p.m., ADON H said the laboratory company usually sent the C&S results within 3 days. She said if a C&S was not received after it was ordered, she or the floor nurses were responsible for ensuring the laboratory company was called and the C&S results were obtained. ADON H did not know what happened and why the C&S results were not sent to the facility. The 24 hour report dated [DATE] did not include any documentation for Resident #1. During an interview on [DATE] at 2:38 p.m., the NP said she ordered a C&S for Resident #1 after his laboratory results were questionable on [DATE]. She did not recall why a second UA was done on [DATE]. She said she was doing a chart review for Resident #1, when she saw the two laboratory tests were awaiting a C&S results and she questioned why the facility was still waiting on a C&S after that many days. She said the nurse could not provide a C&S and told her Resident #1 was not any better, but was not any worse. She said since the C&S results could not be located, she went ahead and ordered Resident #1 to be started on antibiotics. The NP said Resident #1 was not on her list to see that day and she did not recall anyone reporting Resident #1 bleeding from his penis until it was reported on [DATE] and Resident #1 was sent to the hospital. A nursing note dated [DATE] for Resident #1 indicated the NP [MEDICATION NAME] (antibiotic) milligrams (mg) twice a day for 10 days related to a UTI. During an interview on [DATE] at 5:36 p.m., the laboratory technician said when stat (urgent)laboratory tests were ordered, the urine was split into two separate cups and one UA was done along with other stat laboratory tests. He said the results were provided on the same day. He said a second cup of urine was usually taken at the same time for a second UA because bacteria sometimes took time to grow. He said on [DATE], there was not enough urine to collect a second specimen for the culture to grow, so when the laboratory returned on [DATE], they took another UA specimen. The laboratory technician said the C&S results were faxed to the facility on [DATE] and on [DATE]. He said someone from the facility must have called to request the results again on [DATE], but there was no way to tell who made the request. During an interview on [DATE] at 4:02 p.m., the administrator said they discussed and tracked laboratory tests and results during the morning meeting. He said ADON H was responsible for following up on the laboratory tests and results for Halls 100 and 600. (Halls where Resident #s 1, 2, and 3 resided) A nursing note dated [DATE] indicated Resident #1 was sent to the hospital after the CNA reported Resident #1 was bleeding from his penis. An incident report dated [DATE] indicated Resident #1 was sent to the hospital after the CNA reported Resident #1 was bleeding from his penis at 5:30 a.m. The hospital emergency department records indicated Resident #1 admitted to the hospital on [DATE] was actively bleeding from his penis and had blood in his urine. The records indicated Resident #1's .diaper and pad soaked and diaper changed and still bleeding in new one . Resident #1 was hypotensive (low blood pressure) on arrival. The records indicated after discussion with the family, Resident #1 was admitted to hospice. A hospice discharge summary report dated [DATE] indicated Resident #1 expired in the hospice facility on [DATE] at 4:40 a.m. A C&S report, recieved [DATE], dated [DATE] indicated Resident #1 had a presence of pseudomonas aeruginosa bacteria. (infection) The C&S report indicated the preliminary report was completed on [DATE], and the final report was completed on [DATE]. 2. Physician orders [REDACTED].#2 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #2 made herself understood and understood others. She had moderately impaired cognition and required limited assistance with bed mobility, transfers, dressing, toileting, and hygiene. A nursing note dated [DATE] indicated Resident #2 said she had discomfort with urination. The NP gave a new order for a UA. A laboratory report dated [DATE] indicated the laboratory results for Resident #2 included abnormal results for protein, blood, urobilinogen, and leukocyte esterase. Resident #2 had blood noted in his urine. ADON H noted on the bottom of the laboratory report awaiting C&S and signed the report on [DATE]. The 24 hour report dated [DATE], [DATE], [DATE], and [DATE] did not note anything related to Resident #2's UA or C&S. During an interview on [DATE] at 7:00 p.m., the laboratory technician said Resident #2's C&S was faxed to the facility on [DATE]. He said he was not notified by the facility that the C&S's were not received until today. (after surveyor intervention) During an interview on [DATE] at 7:36 p.m., ADON H said the laboratory technician reported today that Resident #2's C&S results were faxed to the facility on [DATE]. ADON H said she could not find the original C&S that was faxed to the facility. She said she could not find where Resident #2's C&S had been reported to the NP or followed up on. During an interview on [DATE] at 8:00 p.m., the NP said she was not aware the facility had not received or acted on the C&S for Resident #2 until today. (after surveyor intervention) The NP said if a C&S was not received within 3 days, the facility should ask the laboratory if the results were in yet. The nursing note dated [DATE] (after surveyor intervention) indicated Resident #2's C&S laboratory results were reported to the NP, and a new order was given to start [MEDICATION NAME] (antibiotic) 250 mg for seven days related to a UTI. A C&S report, recieved [DATE], dated [DATE] indicated Resident #2 had a presence of Escherichia coli and [MEDICATION NAME] gallinarum bacterias. (infection) The C&S report indicated the preliminary report was completed on [DATE], and the final report was completed on [DATE]. 3. Physician orders [REDACTED].#3 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #3 made herself understood and understood others. Her cognition was intact and she required extensive assistance with bed mobility, transfers, dressing, toileting, and hygiene. A nursing note dated [DATE] indicated a UA with C&S was ordered for Resident #3 related to dysuria (painful urination). A laboratory report dated [DATE] indicated the laboratory results for Resident #3 included abnormal results for blood, urobilinogen, [MEDICATION NAME], and leukocyte esterase. Resident #1 had blood noted in his urine. ADON H noted on the bottom of the laboratory report .awaiting C&S per the NP . ADON H signed signed the laboratory report on [DATE]. The 24 hour nursing report dated [DATE], [DATE], [DATE], and [DATE] did not note anything related to Resident #3's UA or C&S. During an interview on [DATE] at 7:00 p.m., the laboratory technician said Resident #3's C&S was faxed to the facility on [DATE]. He said he was not notified by the facility that the C&S was not received until today. (after surveyor intervention). During an interview on [DATE] at 7:36 p.m., ADON H said the laboratory technician reported today that Resident #3's C&S results were faxed to the facility on [DATE]. ADON H said she could not find the original C&S that was faxed to the facility. She said she could not find where Resident #3's C&S had been reported to the NP or followed up on. During an interview on [DATE] at 8:00 p.m., the NP said she was not aware the facility had not received or acted on the C&S for Resident #3 until today. (after surveyor intervention) The NP said if a C&S was not received within 3 days, the facility should ask the laboratory if the results were in yet. The nursing note for Resident #3 dated [DATE] (after surveyor intervention) indicated C&S laboratory results were reported to the NP. A new order was given to start Bactrim (antibiotic) twice a day for 10 days related to a UTI. A C&S report, recieved [DATE], dated [DATE] indicated Resident #3 had a presence of morganella morgana bacteria. (infection) The C&S report indicated the preliminary report was completed on [DATE], and the final report was completed on [DATE]. A Test Results policy revised [DATE] indicated .1. Results of laboratory, radiological, and diagnostic tests shall be reported in writing to the resident's Attending Physician or to the facility. 2. Should the test result be provided to the facility, the Attending Physician shall be promptly notified of the results. 3. The Director of Nursing Services, ADONs, or Charge Nurse receiving the rest results, shall be responsible for notifying the Physician of such test results. 4. Signed and dated reports of all diagnostic services shall be made a part of the resident's medical record An Acute Condition Changes - Clinical Protocol revised [DATE] indicated before contacting a physician about someone with an acute change of condition, the nursing staff will make pertinent observations and collect appropriate information to report the Physician .the Attending Physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. The administrator, DON, and two ADONs were notified on [DATE] at 4:02 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 7:25 p.m., and included: PLAN OF REMOVAL Date: [DATE] for Lab Services Change of Condition 1. Action- Notification to Medical Director completed with abbreviated QA by phone ,[DATE] at 6:47 PM. Formal QA scheduled. Person responsible -Medical Director/IDT. D(NAME)- [DATE]. 2. Action- All residents with lab work ordered will be reviewed and all lab will have proof of results and proof of follow up noted. All residents with pending results will be evaluated to ensure no adverse effects have occurred. Person responsible-DON/ADONs. D(NAME)- [DATE]. 3. Action - Lab policy reviewed. Facility will be implementing a daily lab log tool attached. Person responsible - DON. D(NAME) - [DATE]. 4. Action - All nurses will be in-serviced and provide return demonstration regarding the procedure of maintaining the daily lab log prior to their next working shift. Person responsible - DON/ADON. D(NAME) - [DATE]. 5. Action - All nurses will be in-serviced and provide competency based review regarding reporting of changes of condition, shift to shift report and physician notification. CNAs will be in-serviced regarding reporting of changes of condition to the nurse. If C.N.A. feels appropriate follow up is not done, report will be made to nurse management and/or Administrator. Person responsible - DON. D(NAME) - [DATE]. 6. Action - All residents are being assessed head to toe to ensure no change of condition is present. Any changes are to be noted and reported to physician for follow up. Person responsible - Treatment Nurse. D(NAME) - [DATE]. 7. Action - Daily email with follow up to C&S results to be sent to Admin/DON/ADONs by close of business. Person responsible - Lab representative. Action - Call to Lab rep if email not received. Person responsible - DON. D(NAME) - [DATE]. On [DATE] the surveyor confirmed the facility implemented their plan of removal to sufficiently remove the Immediate Jeopardy by: During an interview the administrator said the laboratory policy was reviewed and the facility implemented a daily laboratory log tool for the charge nurses to track when laboratory tests were ordered, when laboratory tests were conducted, when laboratory results were obtained, and when the physician or NP was notified of the laboratory results. She said the charge nurses were in-serviced on the new laboratory log tool and on reporting changes in condition. She said the CNAs were in-serviced on reporting changes in condition, and if the CNA felt appropriate follow-up was not done to their notification, they would be responsible for reporting the change of condition to nurse management or the administrator. The administrator said the facility held a quality assurance (QA) meeting with the medical director and went over laboratory services, changes in condition, and physician notification of laboratory results and changes in condition. She said a daily laboratory log was implemented for both nurses station, and was discussed in the QA meeting. She said all residents with laboratory work ordered were reviewed and all laboratory tests had proof of results and follow up noted. She said there were no residents with pending results. The administrator said all residents were assessed from head to toe to ensure no change of condition was present. She said the head to toe assessment was documented in each resident's clinical record, and no changes in condition were identified. The administrator said the laboratory company was contacted and ensured they would send a daily email with follow up to C&S results to the administrator, DON, and both ADONs by the close of business day until the C&S's were made available for review on the computer system (that feature was projected to be completed within 7 days and DON and ADONs would be responsible for checking the computer system Monday through Friday and the weekend RN would be responsible for checking the computer system on the weekend). She said the laboratory technician was at the facility today doing a laboratory audit and reported there were no C&S results for [DATE], and therefore an email was not required. Three resident charts indicated each resident was assessed from head to toe with no changes in condition and no current issues related to their laboratory services. During interviews on [DATE] between 4:24 p.m. and 4:37 p.m., four CNAs said they received an in-service regarding resident change of condition. They said they were in-serviced on what a change of condition was, and understood changes of condition were to be reported to the charge nurse, who was then to report the change of condition to the physician or nurse practitioner to determine appropriate follow up. The CNAs said if they felt the charge nurses did not respond to the change in condition, they would report the change of condition to the DON, ADON's, or administrator. During interviews on [DATE] between 4:17 p.m. and 4:48 p.m., four charge nurses said they were in-serviced regarding the procedures for laboratory. They said each new laboratory that was ordered was put in the laboratory book and indicated the date ordered, the date the laboratory was due, the resident name, room number, and the laboratory test that was ordered. They said they were to initial when they received a laboratory order, and initial when the results were received, when the physician was notified, and when the results were documented. They said the log would be checked daily, and if results for a C&S were still pending after 3 days, they would call the laboratory company to see if the results were sent to the facility. The nurses said the laboratory would now call them before they faxed over laboratory results, and the laboratory would note which nurse was informed the laboratory results were being faxed. On [DATE] at 5:54 p.m., the administrator and clinical consultant were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated [DATE] indicated a census of 108 residents.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent neglect for 3 of 6 residents reviewed for change of condition and laboratory results. (Residents #s1, 2 and 3) The facility did not consult with the physician on [DATE] when Resident #1 was bleeding from the penis, had a decrease in appetite, and was no longer able to feed himself. The facility did not followup to ensure they received the C&S following an abnormal urinalysis on [DATE]. The resident was sent to the emergency roiagnom on [DATE] with active bleeding from the penis, low blood pressure, and was diagnosed with [REDACTED].#1 was placed on hospice and died three days later. The facility did not follow up on laboratory tests to ensure C & S tests were received and did not promptly treat Residents #2 and #3 with antibiotics when they had abnormal laboratory results. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern and of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the census of 108 residents at risk of neglect due to changes in condition and abnormal laboratory results not being addressed. Findings included: 1. Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. A hospice discharge summary report dated [DATE] indicated Resident #1 admitted to the hospice facility on [DATE] with a [DIAGNOSES REDACTED].#1 expired in the hospice facility on [DATE] at 4:40 a.m. The most recent MDS dated [DATE] indicated Resident #1 made himself understood and understood others. He had severely impaired cognition and required extensive assistance with bed mobility, transfers, dressing, and hygiene. Resident #1 required supervision with setup help only for eating. A nursing note dated [DATE] indicated Resident #1 appeared lethargic. The nurse practitioner (NP) was notified and ordered a complete blood count (CBC) and a Basic Metabolic Panel. (BMP) The 24 hour nursing report dated [DATE] indicated a UA with a C&S was also ordered for Resident #1. A nursing note dated [DATE] indicated the laboratory results for Resident #1 returned with a potassium level of 5.8. (normal range is 3.7 to 5.2 mEq/L ( milliequivalents per liter) The NP gave a new order for [MEDICATION NAME] (used to treat too much potassium in the body) and to re-check potassium level on [DATE]. A laboratory report dated [DATE] indicated the tests for Resident #1 included abnormal results for protein, blood/UA, bacteria, leukocyte esterase, and mucus. Resident #1 had blood his urine. ADON H noted on the bottom of the laboratory report .awaiting C&S noted [DATE] . A laboratory report dated [DATE] indicated the laboratory tests for Resident #1 included abnormal results for blood, protein, [MEDICATION NAME], and leukocyte esterase. Resident #1 had blood his urine. ADON H noted on the bottom of the laboratory report .awaiting C&S noted [DATE] . During an interview on [DATE] at 11:24 a.m., the DON said C&S results were usually expected to return to the facility in 72 hours. She said the pending laboratory reports were discussed daily in the morning meeting, and if a laboratory result was pending it should be located on the 24 hour report. She said no one person was designated to follow up on laboratory tests. She said the ADON's and charge nurses were all responsible to follow-up and ensure laboratory tests were done. The DON said she was not aware the facility had not received the results for the C&S ordered for Resident #1 on [DATE]. The DON said she was not aware of any change in condition for Resident #1, and was not aware of why Resident #1 was sent to the hospital because she was out of the facility for personal reasons during that time. During an interview on [DATE] at 2:01 p.m., LVN D, who worked with Resident #1 on [DATE], [DATE], [DATE], and [DATE], said Resident #1 was lethargic on [DATE], so she notified the NP on [DATE], who ordered a CBC, BMP, and a UA with a C&S. She said ADON H was responsible for following up with the laboratory tests and ensuring the C&S was returned and the results were reported to the NP. LVN D said sometimes, if she remembered, she called the laboratory company herself for the results of the C&S if it was not returned within 3 days. She said the only way for a charge nurse to track whether they were awaiting laboratory results, was if it was put on the 24 hour nursing report. She said when she noted Resident #1's UA with C&S on the 24 hour nursing report on [DATE], it should have been carried over on the following days so it could be tracked. She said when she cared for Resident #1, he was able to feed himself, but required assistance with other ADLs. She said it was never reported to her that Resident #1 had blood in his urine or was bleeding from his penis. She said Resident #1 was lethargic each time she worked with him after [DATE]. LVN D said she reported to the NP when she first noted Resident #1's lethargy, but not in the days after because she had not noticed a worsened decline. There were no nursing notes for Resident #1 between [DATE] and [DATE]. The 24 hour nursing report dated [DATE] did not include any notes for Resident #1. The 24 hour nursing report dated [DATE] indicated Resident #1 was stable. The 24 hour nursing report dated [DATE] noted by LVN E indicated the .C&S pending . for Resident #1. During an interview on [DATE] at 2:16 p.m., LVN E said he was approached on [DATE] by Resident #1's wife who inquired about the laboratory results for Resident #1. He said he checked the scanned documents and saw ADON H noted on the laboratory report they were awaiting the C&S. He said the C&S typically arrived in 3 to 5 days, so he included C&S pending on the 24 hour report to ensure follow up was done. He said a charge nurse the following day should have followed up on the C&S or included it on the 24 hour report to be carried over the following day. He said ADON H was responsible for follow ups to ensure laboratory results were received via fax. He said he was told prior to working with Resident #1 that Resident #1 was able to feed himself, but Resident #1 required assistance being fed when he worked with him. LVN E said he did not report that Resident #1 required assistance being fed, as a change in condition, to the physician because he had not personally observed the resident to feed himself prior. The 24 hour nursing report dated [DATE] indicated Resident #1 had signs and symptoms of bleeding. LVN F noted Resident #1 had .red blood in urine . There were several attempts made to contact LVN F, but they were unsuccessful. During an interview on [DATE] at 11:21 a.m., CNA A said she was not assigned to provide care for Resident #1 on [DATE], but did assist CNA B with changing Resident #1 on that day. She said Resident #1 was bleeding from his penis, and had blood in his urine and on his brief. She said she noted that to be a change from when she assisted with changing Resident #1 on previous occasions. CNA A said she asked CNA B if she reported the bleeding to the nurse, and CNA B told her she already had. CNA A said she did not report the bleeding to the charge nurse. During an interview on [DATE] at 11:48 a.m., CNA C said about three days before Resident #1 discharged to the hospital, she noticed Resident #1 had really dark urine with blood in it. She did not recall if she was working with Resident #1 or assisting with Resident #1. She said she did report the blood to the charge nurse, but did not recall which charge nurse she reported to. She said several other CNAs asked her if she noticed the blood in Resident #1's urine, and she told them she had. She said Resident #1 did not have blood in his urine when he was first admitted . During a telephone interview on [DATE] at 3:45 p.m., CNA B said she was assigned to provide care for Resident #1 on [DATE]. She said CNA A assisted her with changing Resident #1, and Resident #1 had blood in his urine that day, blood on his penis, and a lot of blood on the pad beneath Resident #1. CNA B said Resident #1 was not talking as much as he had been previously, was no longer able to feed himself, and was not eating as much. CNA B said when Resident #1 first admitted , he ate between 50% and 100% of his food, and around [DATE], he was only eating a couple bites of his meals. CNA B said she reported those changes, including Resident #1 bleeding from his penis, to LVN F and was not sure what was done about it. The 24 hour report dated [DATE] indicated LVN G noted Resident #1 had a UTI. The staffing schedule indicated LVN G worked with Resident #1 on [DATE] and [DATE]. During an interview on [DATE] at 12:14 p.m., LVN G said she did not recall Resident #1, did not know why she noted Resident #1 had a UTI, and did not recall anyone reporting blood in Resident #1's urine. She said if blood in Resident #1's urine was reported to her and was not normal for him, she would have reported it to the NP. During an interview on [DATE] at 1:21 p.m., ADON H said the laboratory company usually sent the C&S results within 3 days. She said if a C&S was not received after it was ordered, she or the floor nurses were responsible for ensuring the laboratory company was called and the C&S results were obtained. ADON H did not know what happened and why the C&S results were not sent to the facility. The 24 hour report dated [DATE] did not include any documentation for Resident #1. During an interview on [DATE] at 2:38 p.m., the NP said she ordered a C&S for Resident #1 after his laboratory results were questionable on [DATE]. She did not recall why a second UA was done on [DATE]. She said she was doing a chart review for Resident #1, when she saw the two laboratory tests were awaiting a C&S results and she questioned why the facility was still waiting on a C&S after that many days. She said the nurse could not provide a C&S and told her Resident #1 was not any better, but was not any worse. She said since the C&S results could not be located, she went ahead and ordered Resident #1 to be started on antibiotics. The NP said Resident #1 was not on her list to see that day and she did not recall anyone reporting Resident #1 bleeding from his penis until it was reported on [DATE] and Resident #1 was sent to the hospital. A nursing note dated [DATE] for Resident #1 indicated the NP [MEDICATION NAME] (antibiotic) milligrams (mg) twice a day for 10 days related to a UTI. During an interview on [DATE] at 5:36 p.m., the laboratory technician said when stat (urgent) laboratory tests were ordered, the urine was split into two separate cups and one UA was done along with other stat laboratory tests. He said the results were provided on the same day. He said a second cup of urine was usually taken at the same time for a second UA because bacteria sometimes took time to grow. He said on [DATE], there was not enough urine to collect a second specimen for the culture to grow, so when the laboratory returned on [DATE], they took another UA specimen. The laboratory technician said the C&S results were faxed to the facility on [DATE] and on [DATE]. He said someone from the facility must have called to request the results again on [DATE], but there was no way to tell who made the request. During an interview on [DATE] at 4:02 p.m., the administrator said they discussed and tracked laboratory tests and results during the morning meeting. He said ADON H was responsible for following up on the laboratory tests and results for Halls 100 and 600. (Halls where Resident #s 1, 2, and 3 resided) A nursing note dated [DATE] indicated Resident #1 was sent to the hospital after the CNA reported Resident #1 was bleeding from his penis. An incident report dated [DATE] indicated Resident #1 was sent to the hospital after the CNA reported Resident #1 was bleeding from his penis at 5:30 a.m. The hospital emergency department records indicated Resident #1 admitted to the hospital on [DATE] was actively bleeding from his penis and had blood in his urine. The records indicated Resident #1's .diaper and pad soaked and diaper changed and still bleeding in new one . Resident #1 was hypotensive (low blood pressure) on arrival. The records indicated after discussion with the family, Resident #1 was admitted to hospice. A hospice discharge summary report dated [DATE] indicated Resident #1 expired in the hospice facility on [DATE] at 4:40 a.m. A C&S report, recieved [DATE], dated [DATE] indicated Resident #1 had a presence of pseudomonas aeruginosa bacteria. (infection) The C&S report indicated the preliminary report was completed on [DATE], and the final report was completed on [DATE]. 2. Physician orders [REDACTED].#2 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #2 made herself understood and understood others. She had moderately impaired cognition and required limited assistance with bed mobility, transfers, dressing, toileting, and hygiene. A nursing note dated [DATE] indicated Resident #2 said she had discomfort with urination. The NP gave a new order for a UA. A laboratory report dated [DATE] indicated the laboratory results for Resident #2 included abnormal results for protein, blood, urobilinogen, and leukocyte esterase. Resident #2 had blood noted in his urine. ADON H noted on the bottom of the laboratory report awaiting C&S and signed the report on [DATE]. The 24 hour report dated [DATE], [DATE], [DATE], and [DATE] did not note anything related to Resident #2's UA or C&S. During an interview on [DATE] at 7:00 p.m., the laboratory technician said Resident #2's C&S was faxed to the facility on [DATE]. He said he was not notified by the facility that the C&S's were not received until today. (after surveyor intervention) During an interview on [DATE] at 7:36 p.m., ADON H said the laboratory technician reported today that Resident #2's C&S results were faxed to the facility on [DATE]. ADON H said she could not find the original C&S that was faxed to the facility. She said she could not find where Resident #2's C&S had been reported to the NP or followed up on. During an interview on [DATE] at 8:00 p.m., the NP said she was not aware the facility had not received or acted on the C&S for Resident #2 until today. (after surveyor intervention) The NP said if a C&S was not received within 3 days, the facility should ask the laboratory if the results were in yet. The nursing note dated [DATE] (after surveyor intervention) indicated Resident #2's C&S laboratory results were reported to the NP, and a new order was given to start [MEDICATION NAME] (antibiotic) 250 mg for seven days related to a UTI. A C&S report, recieved [DATE], dated [DATE] indicated Resident #2 had a presence of Escherichia coli and [MEDICATION NAME] gallinarum bacterias. (infection) The C&S report indicated the preliminary report was completed on [DATE], and the final report was completed on [DATE]. 3. Physician orders [REDACTED].#3 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #3 made herself understood and understood others. Her cognition was intact and she required extensive assistance with bed mobility, transfers, dressing, toileting, and hygiene. A nursing note dated [DATE] indicated a UA with C&S was ordered for Resident #3 related to dysuria. (painful urination) A laboratory report dated [DATE] indicated the laboratory results for Resident #3 included abnormal results for blood, urobilinogen, [MEDICATION NAME], and leukocyte esterase. Resident #1 had blood noted in his urine. ADON H noted on the bottom of the laboratory report .awaiting C&S per the NP . ADON H signed signed the laboratory report on [DATE]. The 24 hour nursing report dated [DATE], [DATE], [DATE], and [DATE] did not note anything related to Resident #3's UA or C&S. During an interview on [DATE] at 7:00 p.m., the laboratory technician said Resident #3's C&S was faxed to the facility on [DATE]. He said he was not notified by the facility that the C&S was not received until today. (after surveyor intervention). During an interview on [DATE] at 7:36 p.m., ADON H said the laboratory technician reported today that Resident #3's C&S results were faxed to the facility on [DATE]. ADON H said she could not find the original C&S that was faxed to the facility. She said she could not find where Resident #3's C&S had been reported to the NP or followed up on. During an interview on [DATE] at 8:00 p.m., the NP said she was not aware the facility had not received or acted on the C&S for Resident #3 until today. (after surveyor intervention) The NP said if a C&S was not received within 3 days, the facility should ask the laboratory if the results were in yet. The nursing note for Resident #3 dated [DATE] (after surveyor intervention) indicated C&S laboratory results were reported to the NP. A new order was given to start Bactrim (antibiotic) twice a day for 10 days related to a UTI. A C&S report, recieved [DATE], dated [DATE] indicated Resident #3 had a presence of morganella morgana bacteria. (infection) The C&S report indicated the preliminary report was completed on [DATE], and the final report was completed on [DATE]. A Test Results policy revised [DATE] indicated .1. Results of laboratory, radiological, and diagnostic tests shall be reported in writing to the resident's Attending Physician or to the facility. 2. Should the test result be provided to the facility, the Attending Physician shall be promptly notified of the results. 3. The Director of Nursing Services, ADONs, or Charge Nurse receiving the rest results, shall be responsible for notifying the Physician of such test results. 4. Signed and dated reports of all diagnostic services shall be made a part of the resident's medical record An Acute Condition Changes - Clinical Protocol revised [DATE] indicated before contacting a physician about someone with an acute change of condition, the nursing staff will make pertinent observations and collect appropriate information to report the Physician .the Attending Physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. A Resident Abuse, Neglect, and Exploitation and Misappropriation of Resident Property policy dated [DATE] indicated .Residents must not be subjected to abuse, neglect, exploitation, misappropriation of resident's property . The policy defined neglect as .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 administrator, DON, and two ADONs were notified on [DATE] at 4:02 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 7:25 p.m., and included: PLAN OF REMOVAL Date: [DATE] for Lab Services Change of Condition 1. Action- Notification to Medical Director completed with abbreviated QA by phone ,[DATE] at 6:47 PM. Formal QA scheduled. Person responsible -Medical Director/IDT. D(NAME)- [DATE]. 2. Action- All residents with lab work ordered will be reviewed and all lab will have proof of results and proof of follow up noted. All residents with pending results will be evaluated to ensure no adverse effects have occurred. Person responsible-DON/ADONs. D(NAME)- [DATE]. 3. Action - Lab policy reviewed. Facility will be implementing a daily lab log tool attached. Person responsible - DON. D(NAME) - [DATE]. 4. Action - All nurses will be in-serviced and provide return demonstration regarding the procedure of maintaining the daily lab log prior to their next working shift. Person responsible - DON/ADON. D(NAME) - [DATE]. 5. Action - All nurses will be in-serviced and provide competency based review regarding reporting of changes of condition, shift to shift report and physician notification. CNAs will be in-serviced regarding reporting of changes of condition to the nurse. If C.N.A. feels appropriate follow up is not done, report will be made to nurse management and/or Administrator. Person responsible - DON. D(NAME) - [DATE]. 6. Action - All residents are being assessed head to toe to ensure no change of condition is present. Any changes are to be noted and reported to physician for follow up. Person responsible - Treatment Nurse. D(NAME) - [DATE]. 7. Action - Daily email with follow up to C&S results to be sent to Admin/DON/ADONs by close of business. Person responsible - Lab representative. Action - Call to Lab rep if email not received. Person responsible - DON. D(NAME) - [DATE]. On [DATE] the surveyor confirmed the facility implemented their plan of removal to sufficiently remove the Immediate Jeopardy by: During an interview the administrator said the laboratory policy was reviewed and the facility implemented a daily laboratory log tool for the charge nurses to track when laboratory tests were ordered, when laboratory tests were conducted, when laboratory results were obtained, and when the physician or NP was notified of the laboratory results. She said the charge nurses were in-serviced on the new laboratory log tool and on reporting changes in condition. She said the CNAs were in-serviced on reporting changes in condition, and if the CNA felt appropriate follow-up was not done to their notification, they would be responsible for reporting the change of condition to nurse management or the administrator. The administrator said the facility held a quality assurance (QA) meeting with the medical director and went over laboratory services, changes in condition, and physician notification of laboratory results and changes in condition. She said a daily laboratory log was implemented for both nurses station, and was discussed in the QA meeting. She said all residents with laboratory work ordered were reviewed and all laboratory tests had proof of results and follow up noted. She said there were no residents with pending results. The administrator said all residents were assessed from head to toe to ensure no change of condition was present. She said the head to toe assessment was documented in each resident's clinical record, and no changes in condition were identified. The administrator said the laboratory company was contacted and ensured they would send a daily email with follow up to C&S results to the administrator, DON, and both ADONs by the close of business day until the C&S's were made available for review on the computer system (that feature was projected to be completed within 7 days and DON and ADONs would be responsible for checking the computer system Monday through Friday and the weekend RN would be responsible for checking the computer system on the weekend). She said the laboratory technician was at the facility today doing a laboratory audit and reported there were no C&S results for [DATE], and therefore an email was not required. Three resident charts indicated each resident was assessed from head to toe with no changes in condition and no current issues related to their laboratory services. During interviews on [DATE] between 4:24 p.m. and 4:37 p.m., four CNAs said they received an in-service regarding resident change of condition. They said they were in-serviced on what a change of condition was, and understood changes of condition were to be reported to the charge nurse, who was then to report the change of condition to the physician or nurse practitioner to determine appropriate follow up. The CNAs said if they felt the charge nurses did not respond to the change in condition, they would report the change of condition to the DON, ADON's, or administrator. During interviews on [DATE] between 4:17 p.m. and 4:48 p.m., four charge nurses said they were in-serviced regarding the procedures for laboratory. They said each new laboratory that was ordered was put in the laboratory book and indicated the date ordered, the date the laboratory was due, the resident name, room number, and the laboratory test that was ordered. They said they were to initial when they received a laboratory order, and initial when the results were received, when the physician was notified, and when the results were documented. They said the log would be checked daily, and if results for a C&S were still pending after 3 days, they would call the laboratory company to see if the results were sent to the facility. The nurses said the laboratory would now call them before they faxed over laboratory results, and the laboratory would note which nurse was informed the laboratory results were being faxed. On [DATE] at 5:54 p.m., the administrator and clinical consultant were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern and of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated [DATE] indicated a census of 108 residents.

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for 3 of 6 residents reviewed for laboratory services. (Resident #s 1, 2 and 3) The facility did not consult with the physician on [DATE] when Resident #1 was bleeding from the penis, had a decrease in appetite, and was no longer able to feed himself. The facility did not followup to ensure they received the C&S following an abnormal urinalysis on [DATE]. The resident was sent to the emergency roiagnom on [DATE] with active bleeding from the penis, low blood pressure, and was diagnosed with [REDACTED].#1 was placed on hospice and died three days later. The facility did not follow up on laboratory tests to ensure C & S tests were received and did not promptly treat Residents #2 and #3 with antibiotics when they had abnormal laboratory results. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the census of 108 residents at risk of neglect due to changes in condition and abnormal laboratory results not being addressed. Findings included: 1. Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. A hospice discharge summary report dated [DATE] indicated Resident #1 admitted to the hospice facility on [DATE] with a [DIAGNOSES REDACTED].#1 expired in the hospice facility on [DATE] at 4:40 a.m. The most recent MDS dated [DATE] indicated Resident #1 made himself understood and understood others. He had severely impaired cognition and required extensive assistance with bed mobility, transfers, dressing, and hygiene. Resident #1 required supervision with setup help only for eating. A nursing note dated [DATE] indicated Resident #1 appeared lethargic. The nurse practitioner (NP) was notified and ordered a complete blood count (CBC) and a Basic Metabolic Panel. (BMP) The 24 hour nursing report dated [DATE] indicated a UA with a C&S was also ordered for Resident #1. A nursing note dated [DATE] indicated the laboratory results for Resident #1 returned with a potassium level of 5.8. (normal range is 3.7 to 5.2 mEq/L ( milliequivalents per liter) The NP gave a new order for [MEDICATION NAME] (used to treat too much potassium in the body) and to re-check potassium level on [DATE]. A laboratory report dated [DATE] indicated the tests for Resident #1 included abnormal results for protein, blood/UA, bacteria, leukocyte esterase, and mucus. Resident #1 had blood in his urine. ADON H noted on the bottom of the laboratory report .awaiting C&S noted [DATE] . A laboratory report dated [DATE] indicated the laboratory tests for Resident #1 included abnormal results for blood, protein, [MEDICATION NAME], and leukocyte esterase. Resident #1 had had blood in his urine. ADON H noted on the bottom of the laboratory report .awaiting C&S noted [DATE] . During an interview on [DATE] at 11:24 a.m., the DON said C&S results were usually expected to return to the facility in 72 hours. She said the pending laboratory reports were discussed daily in the morning meeting, and if a laboratory result was pending it should be located on the 24 hour report. She said no one person was designated to follow up on laboratory tests. She said the ADON's and charge nurses were all responsible to follow-up and ensure laboratory tests were done. The DON said she was not aware the facility had not received the results for the C&S ordered for Resident #1 on [DATE]. The DON said she was not aware of any change in condition for Resident #1, and was not aware of why Resident #1 was sent to the hospital because she was out of the facility for personal reasons during that time. During an interview on [DATE] at 2:01 p.m., LVN D, who worked with Resident #1 on [DATE], [DATE], [DATE], and [DATE], said Resident #1 was lethargic on [DATE], so she notified the NP on [DATE], who ordered a CBC, BMP, and a UA with a C&S. She said ADON H was responsible for following up with the laboratory tests and ensuring the C&S was returned and the results were reported to the NP. LVN D said sometimes, if she remembered, she called the laboratory company herself for the results of the C&S if it was not returned within 3 days. She said the only way for a charge nurse to track whether they were awaiting laboratory results, was if it was put on the 24 hour nursing report. She said when she noted Resident #1's UA with C&S on the 24 hour nursing report on [DATE], it should have been carried over on the following days so it could be tracked. She said when she cared for Resident #1, he was able to feed himself, but required assistance with other ADLs. She said it was never reported to her that Resident #1 had blood in his urine or was bleeding from his penis. She said Resident #1 was lethargic each time she worked with him after [DATE]. LVN D said she reported to the NP when she first noted Resident #1's lethargy, but not in the days after because she had not noticed a worsened decline. There were no nursing notes for Resident #1 between [DATE] and [DATE]. The 24 hour nursing report dated [DATE] did not include any notes for Resident #1. The 24 hour nursing report dated [DATE] indicated Resident #1 was stable. The 24 hour nursing report dated [DATE] noted by LVN E indicated the .C&S pending . for Resident #1. During an interview on [DATE] at 2:16 p.m., LVN E said he was approached on [DATE] by Resident #1's wife who inquired about the laboratory results for Resident #1. He said he checked the scanned documents and saw ADON H noted on the laboratory report they were awaiting the C&S. He said the C&S typically arrived in 3 to 5 days, so he included C&S pending on the 24 hour report to ensure follow up was done. He said a charge nurse the following day should have followed up on the C&S or included it on the 24 hour report to be carried over the following day. He said ADON H was responsible for follow ups to ensure laboratory results were received via fax. He said he was told prior to working with Resident #1 that Resident #1 was able to feed himself, but Resident #1 required assistance being fed when he worked with him. LVN E said he did not report that Resident #1 required assistance being fed, as a change in condition, to the physician because he had not personally observed the resident to feed himself prior. The 24 hour nursing report dated [DATE] indicated Resident #1 had signs and symptoms of bleeding. LVN F noted Resident #1 had .red blood in urine . There were several attempts made to contact LVN F, but they were unsuccessful. During an interview on [DATE] at 11:21 a.m., CNA A said she was not assigned to provide care for Resident #1 on [DATE], but did assist CNA B with changing Resident #1 on that day. She said Resident #1 was bleeding from his penis, and had blood in his urine and on his brief. She said she noted that to be a change from when she assisted with changing Resident #1 on previous occasions. CNA A said she asked CNA B if she reported the bleeding to the nurse, and CNA B told her she already had. CNA A said she did not report the bleeding to the charge nurse. During an interview on [DATE] at 11:48 a.m., CNA C said about three days before Resident #1 discharged to the hospital, she noticed Resident #1 had really dark urine with blood in it. She did not recall if she was working with Resident #1 or assisting with Resident #1. She said she did report the blood to the charge nurse, but did not recall which charge nurse she reported to. She said several other CNAs asked her if she noticed the blood in Resident #1's urine, and she told them she had. She said Resident #1 did not have blood in his urine when he was first admitted . During a telephone interview on [DATE] at 3:45 p.m., CNA B said she was assigned to provide care for Resident #1 on [DATE]. She said CNA A assisted her with changing Resident #1, and Resident #1 had blood in his urine that day, blood on his penis, and a lot of blood on the pad beneath Resident #1. CNA B said Resident #1 was not talking as much as he had been previously, was no longer able to feed himself, and was not eating as much. CNA B said when Resident #1 first admitted , he ate between 50% and 100% of his food, and around [DATE], he was only eating a couple bites of his meals. CNA B said she reported those changes, including Resident #1 bleeding from his penis, to LVN F and was not sure what was done about it. The 24 hour report dated [DATE] indicated LVN G noted Resident #1 had a UTI. The staffing schedule indicated LVN G worked with Resident #1 on [DATE] and [DATE]. During an interview on [DATE] at 12:14 p.m., LVN G said she did not recall Resident #1, did not know why she noted Resident #1 had a UTI, and did not recall anyone reporting blood in Resident #1's urine. She said if blood in Resident #1's urine was reported to her and was not normal for him, she would have reported it to the NP. During an interview on [DATE] at 1:21 p.m., ADON H said the laboratory company usually sent the C&S results within 3 days. She said if a C&S was not received after it was ordered, she or the floor nurses were responsible for ensuring the laboratory company was called and the C&S results were obtained. ADON H did not know what happened and why the C&S results were not sent to the facility. The 24 hour report dated [DATE] did not include any documentation for Resident #1. During an interview on [DATE] at 2:38 p.m., the NP said she ordered a C&S for Resident #1 after his laboratory results were questionable on [DATE]. She did not recall why a second UA was done on [DATE]. She said she was doing a chart review for Resident #1, when she saw the two laboratory tests were awaiting a C&S results and she questioned why the facility was still waiting on a C&S after that many days. She said the nurse could not provide a C&S and told her Resident #1 was not any better, but was not any worse. She said since the C&S results could not be located, she went ahead and ordered Resident #1 to be started on antibiotics. The NP said Resident #1 was not on her list to see that day and she did not recall anyone reporting Resident #1 bleeding from his penis until it was reported on [DATE] and Resident #1 was sent to the hospital. A nursing note dated [DATE] for Resident #1 indicated the NP [MEDICATION NAME] (antibiotic) milligrams (mg) twice a day for 10 days related to a UTI. During an interview on [DATE] at 5:36 p.m., the laboratory technician said when stat (urgent)laboratory tests were ordered, the urine was split into two separate cups and one UA was done along with other stat laboratory tests. He said the results were provided on the same day. He said a second cup of urine was usually taken at the same time for a second UA because bacteria sometimes took time to grow. He said on [DATE], there was not enough urine to collect a second specimen for the culture to grow, so when the laboratory returned on [DATE], they took another UA specimen. The laboratory technician said the C&S results were faxed to the facility on [DATE] and on [DATE]. He said someone from the facility must have called to request the results again on [DATE], but there was no way to tell who made the request. During an interview on [DATE] at 4:02 p.m., the administrator said they discussed and tracked laboratory tests and results during the morning meeting. He said ADON H was responsible for following up on the laboratory tests and results for Halls 100 and 600. (Halls where Resident #s 1, 2, and 3 resided) A nursing note dated [DATE] indicated Resident #1 was sent to the hospital after the CNA reported Resident #1 was bleeding from his penis. An incident report dated [DATE] indicated Resident #1 was sent to the hospital after the CNA reported Resident #1 was bleeding from his penis at 5:30 a.m. The hospital emergency department records indicated Resident #1 admitted to the hospital on [DATE] was actively bleeding from his penis and had blood in his urine. The records indicated Resident #1's .diaper and pad soaked and diaper changed and still bleeding in new one . Resident #1 was hypotensive (low blood pressure) on arrival. The records indicated after discussion with the family, Resident #1 was admitted to hospice. A hospice discharge summary report dated [DATE] indicated Resident #1 expired in the hospice facility on [DATE] at 4:40 a.m. A C&S report, recieved [DATE], dated [DATE] indicated Resident #1 had a presence of pseudomonas aeruginosa bacteria. (infection) The C&S report indicated the preliminary report was completed on [DATE], and the final report was completed on [DATE]. 2. Physician orders [REDACTED].#2 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #2 made herself understood and understood others. She had moderately impaired cognition and required limited assistance with bed mobility, transfers, dressing, toileting, and hygiene. A nursing note dated [DATE] indicated Resident #2 said she had discomfort with urination. The NP gave a new order for a UA. A laboratory report dated [DATE] indicated the laboratory results for Resident #2 included abnormal results for protein, blood, urobilinogen, and leukocyte esterase. Resident #2 had blood in his urine. ADON H noted on the bottom of the laboratory report awaiting C&S and signed the report on [DATE]. The 24 hour report dated [DATE], [DATE], [DATE], and [DATE] did not note anything related to Resident #2's UA or C&S. During an interview on [DATE] at 7:00 p.m., the laboratory technician said Resident #2's C&S was faxed to the facility on [DATE]. He said he was not notified by the facility that the C&S's were not received until today. (after surveyor intervention) During an interview on [DATE] at 7:36 p.m., ADON H said the laboratory technician reported today that Resident #2's C&S results were faxed to the facility on [DATE]. ADON H said she could not find the original C&S that was faxed to the facility. She said she could not find where Resident #2's C&S had been reported to the NP or followed up on. During an interview on [DATE] at 8:00 p.m., the NP said she was not aware the facility had not received or acted on the C&S for Resident #2 until today. (after surveyor intervention) The NP said if a C&S was not received within 3 days, the facility should ask the laboratory if the results were in yet. The nursing note dated [DATE] (after surveyor intervention) indicated Resident #2's C&S laboratory results were reported to the NP, and a new order was given to start [MEDICATION NAME] (antibiotic) 250 mg for seven days related to a UTI. A C&S report, recieved [DATE], dated [DATE] indicated Resident #2 had a presence of Escherichia coli and [MEDICATION NAME] gallinarum bacterias. (infection) The C&S report indicated the preliminary report was completed on [DATE], and the final report was completed on [DATE]. 3. Physician orders [REDACTED].#3 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #3 made herself understood and understood others. Her cognition was intact and she required extensive assistance with bed mobility, transfers, dressing, toileting, and hygiene. A nursing note dated [DATE] indicated a UA with C&S was ordered for Resident #3 related to dysuria (painful urination). A laboratory report dated [DATE] indicated the laboratory results for Resident #3 included abnormal results for blood, urobilinogen, [MEDICATION NAME], and leukocyte esterase. Resident #1 had blood in his urine. ADON H noted on the bottom of the laboratory report .awaiting C&S per the NP . ADON H signed signed the laboratory report on [DATE]. The 24 hour nursing report dated [DATE], [DATE], [DATE], and [DATE] did not note anything related to Resident #3's UA or C&S. During an interview on [DATE] at 7:00 p.m., the laboratory technician said Resident #3's C&S was faxed to the facility on [DATE]. He said he was not notified by the facility that the C&S was not received until today. (after surveyor intervention). During an interview on [DATE] at 7:36 p.m., ADON H said the laboratory technician reported today that Resident #3's C&S results were faxed to the facility on [DATE]. ADON H said she could not find the original C&S that was faxed to the facility. She said she could not find where Resident #3's C&S had been reported to the NP or followed up on. During an interview on [DATE] at 8:00 p.m., the NP said she was not aware the facility had not received or acted on the C&S for Resident #3 until today. (after surveyor intervention) The NP said if a C&S was not received within 3 days, the facility should ask the laboratory if the results were in yet. The nursing note for Resident #3 dated [DATE] (after surveyor intervention) indicated C&S laboratory results were reported to the NP. A new order was given to start Bactrim (antibiotic) twice a day for 10 days related to a UTI. A C&S report, recieved [DATE], dated [DATE] indicated Resident #3 had a presence of morganella morgana bacteria. (infection) The C&S report indicated the preliminary report was completed on [DATE], and the final report was completed on [DATE]. A Test Results policy revised [DATE] indicated .1. Results of laboratory, radiological, and diagnostic tests shall be reported in writing to the resident's Attending Physician or to the facility. 2. Should the test result be provided to the facility, the Attending Physician shall be promptly notified of the results. 3. The Director of Nursing Services, ADONs, or Charge Nurse receiving the rest results, shall be responsible for notifying the Physician of such test results. 4. Signed and dated reports of all diagnostic services shall be made a part of the resident's medical record An Acute Condition Changes - Clinical Protocol revised [DATE] indicated before contacting a physician about someone with an acute change of condition, the nursing staff will make pertinent observations and collect appropriate information to report the Physician .the Attending Physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. The administrator, DON, and two ADONs were notified on [DATE] at 4:02 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 7:25 p.m., and included: PLAN OF REMOVAL Date: [DATE] for Lab Services Change of Condition 1. Action- Notification to Medical Director completed with abbreviated QA by phone ,[DATE] at 6:47 PM. Formal QA scheduled. Person responsible -Medical Director/IDT. D(NAME)- [DATE]. 2. Action- All residents with lab work ordered will be reviewed and all lab will have proof of results and proof of follow up noted. All residents with pending results will be evaluated to ensure no adverse effects have occurred. Person responsible-DON/ADONs. D(NAME)- [DATE]. 3. Action - Lab policy reviewed. Facility will be implementing a daily lab log tool attached. Person responsible - DON. D(NAME) - [DATE]. 4. Action - All nurses will be in-serviced and provide return demonstration regarding the procedure of maintaining the daily lab log prior to their next working shift. Person responsible - DON/ADON. D(NAME) - [DATE]. 5. Action - All nurses will be in-serviced and provide competency based review regarding reporting of changes of condition, shift to shift report and physician notification. CNAs will be in-serviced regarding reporting of changes of condition to the nurse. If C.N.A. feels appropriate follow up is not done, report will be made to nurse management and/or Administrator. Person responsible - DON. D(NAME) - [DATE]. 6. Action - All residents are being assessed head to toe to ensure no change of condition is present. Any changes are to be noted and reported to physician for follow up. Person responsible - Treatment Nurse. D(NAME) - [DATE]. 7. Action - Daily email with follow up to C&S results to be sent to Admin/DON/ADONs by close of business. Person responsible - Lab representative. Action - Call to Lab rep if email not received. Person responsible - DON. D(NAME) - [DATE]. On [DATE] the surveyor confirmed the facility implemented their plan of removal to sufficiently remove the Immediate Jeopardy by: During an interview the administrator said the laboratory policy was reviewed and the facility implemented a daily laboratory log tool for the charge nurses to track when laboratory tests were ordered, when laboratory tests were conducted, when laboratory results were obtained, and when the physician or NP was notified of the laboratory results. She said the charge nurses were in-serviced on the new laboratory log tool and on reporting changes in condition. She said the CNAs were in-serviced on reporting changes in condition, and if the CNA felt appropriate follow-up was not done to their notification, they would be responsible for reporting the change of condition to nurse management or the administrator. The administrator said the facility held a quality assurance (QA) meeting with the medical director and went over laboratory services, changes in condition, and physician notification of laboratory results and changes in condition. She said a daily laboratory log was implemented for both nurses station, and was discussed in the QA meeting. She said all residents with laboratory work ordered were reviewed and all laboratory tests had proof of results and follow up noted. She said there were no residents with pending results. The administrator said all residents were assessed from head to toe to ensure no change of condition was present. She said the head to toe assessment was documented in each resident's clinical record, and no changes in condition were identified. The administrator said the laboratory company was contacted and ensured they would send a daily email with follow up to C&S results to the administrator, DON, and both ADONs by the close of business day until the C&S's were made available for review on the computer system (that feature was projected to be completed within 7 days and DON and ADONs would be responsible for checking the computer system Monday through Friday and the weekend RN would be responsible for checking the computer system on the weekend). She said the laboratory technician was at the facility today doing a laboratory audit and reported there were no C&S results for [DATE], and therefore an email was not required. Three resident charts indicated each resident was assessed from head to toe with no changes in condition and no current issues related to their laboratory services. During interviews on [DATE] between 4:24 p.m. and 4:37 p.m., four CNAs said they received an in-service regarding resident change of condition. They said they were in-serviced on what a change of condition was, and understood changes of condition were to be reported to the charge nurse, who was then to report the change of condition to the physician or nurse practitioner to determine appropriate follow up. The CNAs said if they felt the charge nurses did not respond to the change in condition, they would report the change of condition to the DON, ADON's, or administrator. During interviews on [DATE] between 4:17 p.m. and 4:48 p.m., four charge nurses said they were in-serviced regarding the procedures for laboratory. They said each new laboratory that was ordered was put in the laboratory book and indicated the date ordered, the date the laboratory was due, the resident name, room number, and the laboratory test that was ordered. They said they were to initial when they received a laboratory order, and initial when the results were received, when the physician was notified, and when the results were documented. They said the log would be checked daily, and if results for a C&S were still pending after 3 days, they would call the laboratory company to see if the results were sent to the facility. The nurses said the laboratory would now call them before they faxed over laboratory results, and the laboratory would note which nurse was informed the laboratory results were being faxed. On [DATE] at 5:54 p.m., the administrator and clinical consultant were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated [DATE] indicated a census of 108 residents.

Based on interview and record review, the facility failed to provide laboratory services to meet the needs of its resident in a timely manner for 3 of 6 residents reviewed for laboratory services. (Resident #s 1, 2 and 3) The facility did not followup to ensure Resident #1's culture and sensitive (C&S) test ordered [DATE] was received in order to appropriately treat an abnormal urinalysis indicative of a urinary tract infection. On [DATE] the resident was bleeding from the penis, had a decrease in appetite, and was no longer able to feed himself and the nurse practitioner (NP) who was aware of the abnormal urinalysis was not notified. The resident was sent to the emergency roiagnom on [DATE] with active bleeding from the penis, low blood pressure, and was diagnosed with [REDACTED].#1 was placed on hospice and died three days later. The facility did not follow up on laboratory tests to ensure C & S tests were received and did not promptly treat Residents #2 and #3 with antibiotics when they had abnormal laboratory results. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the census of 108 residents at risk of neglect due to changes in condition and abnormal laboratory results not being addressed. Findings included: 1. Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. A hospice discharge summary report dated [DATE] indicated Resident #1 admitted to the hospice facility on [DATE] with a [DIAGNOSES REDACTED].#1 expired in the hospice facility on [DATE] at 4:40 a.m. The most recent MDS dated [DATE] indicated Resident #1 made himself understood and understood others. He had severely impaired cognition and required extensive assistance with bed mobility, transfers, dressing, and hygiene. Resident #1 required supervision with setup help only for eating. A nursing note dated [DATE] indicated Resident #1 appeared lethargic. The nurse practitioner (NP) was notified and ordered a complete blood count (CBC) and a Basic Metabolic Panel. (BMP) The 24 hour nursing report dated [DATE] indicated a UA with a C&S was also ordered for Resident #1. A nursing note dated [DATE] indicated the laboratory results for Resident #1 returned with a potassium level of 5.8. (normal range is 3.7 to 5.2 mEq/L ( milliequivalents per liter) The NP gave a new order for [MEDICATION NAME] (used to treat too much potassium in the body) and to re-check potassium level on [DATE]. A laboratory report dated [DATE] indicated the tests for Resident #1 included abnormal results for protein, blood/UA, bacteria, leukocyte esterase, and mucus. Resident #1 had blood in his urine. ADON H noted on the bottom of the laboratory report .awaiting C&S noted [DATE] . A laboratory report dated [DATE] indicated the laboratory tests for Resident #1 included abnormal results for blood, protein, [MEDICATION NAME], and leukocyte esterase. Resident #1 had blood in his urine. ADON H noted on the bottom of the laboratory report .awaiting C&S noted [DATE] . During an interview on [DATE] at 11:24 a.m., the DON said C&S results were usually expected to return to the facility in 72 hours. She said the pending laboratory reports were discussed daily in the morning meeting, and if a laboratory result was pending it should be located on the 24 hour report. She said no one person was designated to follow up on laboratory tests. She said the ADON's and charge nurses were all responsible to follow-up and ensure laboratory tests were done. The DON said she was not aware the facility had not received the results for the C&S ordered for Resident #1 on [DATE]. The DON said she was not aware of any change in condition for Resident #1, and was not aware of why Resident #1 was sent to the hospital because she was out of the facility for personal reasons during that time. During an interview on [DATE] at 2:01 p.m., LVN D, who worked with Resident #1 on [DATE], [DATE], [DATE], and [DATE], said Resident #1 was lethargic on [DATE], so she notified the NP on [DATE], who ordered a CBC, BMP, and a UA with a C&S. She said ADON H was responsible for following up with the laboratory tests and ensuring the C&S was returned and the results were reported to the NP. LVN D said sometimes, if she remembered, she called the laboratory company herself for the results of the C&S if it was not returned within 3 days. She said the only way for a charge nurse to track whether they were awaiting laboratory results, was if it was put on the 24 hour nursing report. She said when she noted Resident #1's UA with C&S on the 24 hour nursing report on [DATE], it should have been carried over on the following days so it could be tracked. She said when she cared for Resident #1, he was able to feed himself, but required assistance with other ADLs. She said it was never reported to her that Resident #1 had blood in his urine or was bleeding from his penis. She said Resident #1 was lethargic each time she worked with him after [DATE]. LVN D said she reported to the NP when she first noted Resident #1's lethargy, but not in the days after because she had not noticed a worsened decline. There were no nursing notes for Resident #1 between [DATE] and [DATE]. The 24 hour nursing report dated [DATE] did not include any notes for Resident #1. The 24 hour nursing report dated [DATE] indicated Resident #1 was stable. The 24 hour nursing report dated [DATE] noted by LVN E indicated the .C&S pending . for Resident #1. During an interview on [DATE] at 2:16 p.m., LVN E said he was approached on [DATE] by Resident #1's wife who inquired about the laboratory results for Resident #1. He said he checked the scanned documents and saw ADON H noted on the laboratory report they were awaiting the C&S. He said the C&S typically arrived in 3 to 5 days, so he included C&S pending on the 24 hour report to ensure follow up was done. He said a charge nurse the following day should have followed up on the C&S or included it on the 24 hour report to be carried over the following day. He said ADON H was responsible for follow ups to ensure laboratory results were received via fax. He said he was told prior to working with Resident #1 that Resident #1 was able to feed himself, but Resident #1 required assistance being fed when he worked with him. LVN E said he did not report that Resident #1 required assistance being fed, as a change in condition, to the physician because he had not personally observed the resident to feed himself prior. The 24 hour nursing report dated [DATE] indicated Resident #1 had signs and symptoms of bleeding. LVN F noted Resident #1 had .red blood in urine . There were several attempts made to contact LVN F, but they were unsuccessful. During an interview on [DATE] at 11:21 a.m., CNA A said she was not assigned to provide care for Resident #1 on [DATE], but did assist CNA B with changing Resident #1 on that day. She said Resident #1 was bleeding from his penis, and had blood in his urine and on his brief. She said she noted that to be a change from when she assisted with changing Resident #1 on previous occasions. CNA A said she asked CNA B if she reported the bleeding to the nurse, and CNA B told her she already had. CNA A said she did not report the bleeding to the charge nurse. During an interview on [DATE] at 11:48 a.m., CNA C said about three days before Resident #1 discharged to the hospital, she noticed Resident #1 had really dark urine with blood in it. She did not recall if she was working with Resident #1 or assisting with Resident #1. She said she did report the blood to the charge nurse, but did not recall which charge nurse she reported to. She said several other CNAs asked her if she noticed the blood in Resident #1's urine, and she told them she had. She said Resident #1 did not have blood in his urine when he was first admitted . During a telephone interview on [DATE] at 3:45 p.m., CNA B said she was assigned to provide care for Resident #1 on [DATE]. She said CNA A assisted her with changing Resident #1, and Resident #1 had blood in his urine that day, blood on his penis, and a lot of blood on the pad beneath Resident #1. CNA B said Resident #1 was not talking as much as he had been previously, was no longer able to feed himself, and was not eating as much. CNA B said when Resident #1 first admitted , he ate between 50% and 100% of his food, and around [DATE], he was only eating a couple bites of his meals. CNA B said she reported those changes, including Resident #1 bleeding from his penis, to LVN F and was not sure what was done about it. The 24 hour report dated [DATE] indicated LVN G noted Resident #1 had a UTI. The staffing schedule indicated LVN G worked with Resident #1 on [DATE] and [DATE]. During an interview on [DATE] at 12:14 p.m., LVN G said she did not recall Resident #1, did not know why she noted Resident #1 had a UTI, and did not recall anyone reporting blood in Resident #1's urine. She said if blood in Resident #1's urine was reported to her and was not normal for him, she would have reported it to the NP. During an interview on [DATE] at 1:21 p.m., ADON H said the laboratory company usually sent the C&S results within 3 days. She said if a C&S was not received after it was ordered, she or the floor nurses were responsible for ensuring the laboratory company was called and the C&S results were obtained. ADON H did not know what happened and why the C&S results were not sent to the facility. The 24 hour report dated [DATE] did not include any documentation for Resident #1. During an interview on [DATE] at 2:38 p.m., the NP said she ordered a C&S for Resident #1 after his laboratory results were questionable on [DATE]. She did not recall why a second UA was done on [DATE]. She said she was doing a chart review for Resident #1, when she saw the two laboratory tests were awaiting a C&S results and she questioned why the facility was still waiting on a C&S after that many days. She said the nurse could not provide a C&S and told her Resident #1 was not any better, but was not any worse. She said since the C&S results could not be located, she went ahead and ordered Resident #1 to be started on antibiotics. The NP said Resident #1 was not on her list to see that day and she did not recall anyone reporting Resident #1 bleeding from his penis until it was reported on [DATE] and Resident #1 was sent to the hospital. A nursing note dated [DATE] for Resident #1 indicated the NP [MEDICATION NAME] (antibiotic) milligrams (mg) twice a day for 10 days related to a UTI. During an interview on [DATE] at 5:36 p.m., the laboratory technician said when stat (urgent)laboratory tests were ordered, the urine was split into two separate cups and one UA was done along with other stat laboratory tests. He said the results were provided on the same day. He said a second cup of urine was usually taken at the same time for a second UA because bacteria sometimes took time to grow. He said on [DATE], there was not enough urine to collect a second specimen for the culture to grow, so when the laboratory returned on [DATE], they took another UA specimen. The laboratory technician said the C&S results were faxed to the facility on [DATE] and on [DATE]. He said someone from the facility must have called to request the results again on [DATE], but there was no way to tell who made the request. During an interview on [DATE] at 4:02 p.m., the administrator said they discussed and tracked laboratory tests and results during the morning meeting. He said ADON H was responsible for following up on the laboratory tests and results for Halls 100 and 600. (Halls where Resident #s 1, 2, and 3 resided) A nursing note dated [DATE] indicated Resident #1 was sent to the hospital after the CNA reported Resident #1 was bleeding from his penis. An incident report dated [DATE] indicated Resident #1 was sent to the hospital after the CNA reported Resident #1 was bleeding from his penis at 5:30 a.m. The hospital emergency department records indicated Resident #1 admitted to the hospital on [DATE] was actively bleeding from his penis and had blood in his urine. The records indicated Resident #1's .diaper and pad soaked and diaper changed and still bleeding in new one . Resident #1 was hypotensive (the use of restrictive fluid therapy, specifically in the trauma patient, that increases systemic blood pressure without reaching normal blood pressures) on arrival. The records indicated after discussion with the family, Resident #1 was admitted to hospice. A hospice discharge summary report dated [DATE] indicated Resident #1 expired in the hospice facility on [DATE] at 4:40 a.m. A C&S report, recieved [DATE], dated [DATE] indicated Resident #1 had a presence of pseudomonas aeruginosa bacteria. (infection) The C&S report indicated the preliminary report was completed on [DATE], and the final report was completed on [DATE]. 2. Physician orders [REDACTED].#2 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #2 made herself understood and understood others. She had moderately impaired cognition and required limited assistance with bed mobility, transfers, dressing, toileting, and hygiene. A nursing note dated [DATE] indicated Resident #2 said she had discomfort with urination. The NP gave a new order for a UA. A laboratory report dated [DATE] indicated the laboratory results for Resident #2 included abnormal results for protein, blood, urobilinogen, and leukocyte esterase. Resident #2 had blood in his urine. ADON H noted on the bottom of the laboratory report awaiting C&S and signed the report on [DATE]. The 24 hour report dated [DATE], [DATE], [DATE], and [DATE] did not note anything related to Resident #2's UA or C&S. During an interview on [DATE] at 7:00 p.m., the laboratory technician said Resident #2's C&S was faxed to the facility on [DATE]. He said he was not notified by the facility that the C&S's were not received until today. (after surveyor intervention) During an interview on [DATE] at 7:36 p.m., ADON H said the laboratory technician reported today that Resident #2's C&S results were faxed to the facility on [DATE]. ADON H said she could not find the original C&S that was faxed to the facility. She said she could not find where Resident #2's C&S had been reported to the NP or followed up on. During an interview on [DATE] at 8:00 p.m., the NP said she was not aware the facility had not received or acted on the C&S for Resident #2 until today. (after surveyor intervention) The NP said if a C&S was not received within 3 days, the facility should ask the laboratory if the results were in yet. The nursing note dated [DATE] (after surveyor intervention) indicated Resident #2's C&S laboratory results were reported to the NP, and a new order was given to start [MEDICATION NAME] (antibiotic) 250 mg for seven days related to a UTI. A C&S report, recieved [DATE], dated [DATE] indicated Resident #2 had a presence of Escherichia coli and [MEDICATION NAME] gallinarum bacterias. (infection) The C&S report indicated the preliminary report was completed on [DATE], and the final report was completed on [DATE]. 3. Physician orders [REDACTED].#3 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #3 made herself understood and understood others. Her cognition was intact and she required extensive assistance with bed mobility, transfers, dressing, toileting, and hygiene. A nursing note dated [DATE] indicated a UA with C&S was ordered for Resident #3 related to dysuria (painful urination). A laboratory report dated [DATE] indicated the laboratory results for Resident #3 included abnormal results for blood, urobilinogen, [MEDICATION NAME], and leukocyte esterase. Resident #1 had blood in his urine. ADON H noted on the bottom of the laboratory report .awaiting C&S per the NP . ADON H signed signed the laboratory report on [DATE]. The 24 hour nursing report dated [DATE], [DATE], [DATE], and [DATE] did not note anything related to Resident #3's UA or C&S. During an interview on [DATE] at 7:00 p.m., the laboratory technician said Resident #3's C&S was faxed to the facility on [DATE]. He said he was not notified by the facility that the C&S was not received until today. (after surveyor intervention). During an interview on [DATE] at 7:36 p.m., ADON H said the laboratory technician reported today that Resident #3's C&S results were faxed to the facility on [DATE]. ADON H said she could not find the original C&S that was faxed to the facility. She said she could not find where Resident #3's C&S had been reported to the NP or followed up on. During an interview on [DATE] at 8:00 p.m., the NP said she was not aware the facility had not received or acted on the C&S for Resident #3 until today. (after surveyor intervention) The NP said if a C&S was not received within 3 days, the facility should ask the laboratory if the results were in yet. The nursing note for Resident #3 dated [DATE] (after surveyor intervention) indicated C&S laboratory results were reported to the NP. A new order was given to start Bactrim (antibiotic) twice a day for 10 days related to a UTI. A C&S report, recieved [DATE], dated [DATE] indicated Resident #3 had a presence of morganella morgana bacteria. (infection) The C&S report indicated the preliminary report was completed on [DATE], and the final report was completed on [DATE]. A Test Results policy revised [DATE] indicated .1. Results of laboratory, radiological, and diagnostic tests shall be reported in writing to the resident's Attending Physician or to the facility. 2. Should the test result be provided to the facility, the Attending Physician shall be promptly notified of the results. 3. The Director of Nursing Services, ADONs, or Charge Nurse receiving the rest results, shall be responsible for notifying the Physician of such test results. 4. Signed and dated reports of all diagnostic services shall be made a part of the resident's medical record An Acute Condition Changes - Clinical Protocol revised [DATE] indicated before contacting a physician about someone with an acute change of condition, the nursing staff will make pertinent observations and collect appropriate information to report the Physician .the Attending Physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. The administrator, DON, and two ADONs were notified on [DATE] at 4:02 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 7:25 p.m., and included: PLAN OF REMOVAL Date: [DATE] for Lab Services Change of Condition 1. Action- Notification to Medical Director completed with abbreviated QA by phone ,[DATE] at 6:47 PM. Formal QA scheduled. Person responsible -Medical Director/IDT. D(NAME)- [DATE]. 2. Action- All residents with lab work ordered will be reviewed and all lab will have proof of results and proof of follow up noted. All residents with pending results will be evaluated to ensure no adverse effects have occurred. Person responsible-DON/ADONs. D(NAME)- [DATE]. 3. Action - Lab policy reviewed. Facility will be implementing a daily lab log tool attached. Person responsible - DON. D(NAME) - [DATE]. 4. Action - All nurses will be in-serviced and provide return demonstration regarding the procedure of maintaining the daily lab log prior to their next working shift. Person responsible - DON/ADON. D(NAME) - [DATE]. 5. Action - All nurses will be in-serviced and provide competency based review regarding reporting of changes of condition, shift to shift report and physician notification. CNAs will be in-serviced regarding reporting of changes of condition to the nurse. If C.N.A. feels appropriate follow up is not done, report will be made to nurse management and/or Administrator. Person responsible - DON. D(NAME) - [DATE]. 6. Action - All residents are being assessed head to toe to ensure no change of condition is present. Any changes are to be noted and reported to physician for follow up. Person responsible - Treatment Nurse. D(NAME) - [DATE]. 7. Action - Daily email with follow up to C&S results to be sent to Admin/DON/ADONs by close of business. Person responsible - Lab representative. Action - Call to Lab rep if email not received. Person responsible - DON. D(NAME) - [DATE]. On [DATE] the surveyor confirmed the facility implemented their plan of removal to sufficiently remove the Immediate Jeopardy by: During an interview the administrator said the laboratory policy was reviewed and the facility implemented a daily laboratory log tool for the charge nurses to track when laboratory tests were ordered, when laboratory tests were conducted, when laboratory results were obtained, and when the physician or NP was notified of the laboratory results. She said the charge nurses were in-serviced on the new laboratory log tool and on reporting changes in condition. She said the CNAs were in-serviced on reporting changes in condition, and if the CNA felt appropriate follow-up was not done to their notification, they would be responsible for reporting the change of condition to nurse management or the administrator. The administrator said the facility held a quality assurance (QA) meeting with the medical director and went over laboratory services, changes in condition, and physician notification of laboratory results and changes in condition. She said a daily laboratory log was implemented for both nurses station, and was discussed in the QA meeting. She said all residents with laboratory work ordered were reviewed and all laboratory tests had proof of results and follow up noted. She said there were no residents with pending results. The administrator said all residents were assessed from head to toe to ensure no change of condition was present. She said the head to toe assessment was documented in each resident's clinical record, and no changes in condition were identified. The administrator said the laboratory company was contacted and ensured they would send a daily email with follow up to C&S results to the administrator, DON, and both ADONs by the close of business day until the C&S's were made available for review on the computer system (that feature was projected to be completed within 7 days and DON and ADONs would be responsible for checking the computer system Monday through Friday and the weekend RN would be responsible for checking the computer system on the weekend). She said the laboratory technician was at the facility today doing a laboratory audit and reported there were no C&S results for [DATE], and therefore an email was not required. Three resident charts indicated each resident was assessed from head to toe with no changes in condition and no current issues related to their laboratory services. During interviews on [DATE] between 4:24 p.m. and 4:37 p.m., four CNAs said they received an in-service regarding resident change of condition. They said they were in-serviced on what a change of condition was, and understood changes of condition were to be reported to the charge nurse, who was then to report the change of condition to the physician or nurse practitioner to determine appropriate follow up. The CNAs said if they felt the charge nurses did not respond to the change in condition, they would report the change of condition to the DON, ADON's, or administrator. During interviews on [DATE] between 4:17 p.m. and 4:48 p.m., four charge nurses said they were in-serviced regarding the procedures for laboratory. They said each new laboratory that was ordered was put in the laboratory book and indicated the date ordered, the date the laboratory was due, the resident name, room number, and the laboratory test that was ordered. They said they were to initial when they received a laboratory order, and initial when the results were received, when the physician was notified, and when the results were documented. They said the log would be checked daily, and if results for a C&S were still pending after 3 days, they would call the laboratory company to see if the results were sent to the facility. The nurses said the laboratory would now call them before they faxed over laboratory results, and the laboratory would note which nurse was informed the laboratory results were being faxed. On [DATE] at 5:54 p.m., the administrator and clinical consultant were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated [DATE] indicated a census of 108 residents.

Based on observation, interview, and record review, the facility failed to ensure necessary treatment and services was provided, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development and worsening of pressure ulcers for 3 of 4 residents reviewed for pressure ulcers. (Residents #1, #2, and #3) The facility did not provide Resident #1 pressure relief with a low air loss mattress until 25 days after it was ordered, did not assess the resident's pressure ulcers after they developed, and did not notify the physician of the worsening of the wounds. Resident #1 developed a facility acquired stage 2 pressure ulcer on her right buttock that worsened to a stage 3 and a facility acquired stage 2 on her sacral area that worsened to an unstageable. The sacral area pressure ulcer and the right buttock pressure ulcer developed an odor and an infection that required debridement and antibiotics. The facility did not provide Resident #2 with nutritional interventions after he developed a facility acquired stage 2 pressure ulcer and had a 12 pound weight loss since admission (27days). The facility did not provide accurate and thorough assessments of the resident's pressure ulcer once it developed. Resident #2 developed a facility acquired stage 2 that worsened to having slough and a dark purple center in the wound bed. The facility did not provide accurate and timely skin assessments for Resident #3 after he developed a facility acquired stage 2 pressure ulcer on his right buttock. This failure could place 9 residents with pressure ulcers at risk for developing new pressure ulcers and decline in existing pressure ulcers. Findings included: 1. A face sheet dated 5/15/17 indicated Resident #1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The initial nursing assessment dated [DATE] did not indicate Resident #1 had any skin issues. A pressure ulcer risk assessment dated [DATE] indicated Resident #1 was at moderate risk for developing pressure ulcers. The most recent MDS dated [DATE] indicated Resident #1 was usually understood and understood others. She required total assistance of two staff for transfers, dressing, toileting, and hygiene and was always incontinent of bowel and bladder. The MDS indicated Resident #1 had two stage 2 pressure ulcers. A care plan related to skin breakdown updated 7/13/17 indicated Resident #1 was at risk for/actual skin breakdown. The goal indicated measures would be taken to prevent skin breakdown over the next 90 days. Interventions included: Inspect skin head to toe every week and document results. The care plan also included: Inspect skin daily with care, bathing, and report any changes to charge nurse. A Wound Report dated 7/12/17 indicated Resident #1 developed a (new) stage 2 pressure ulcer on the sacrum measuring 2.0 cm x 2.0 cm with a red wound bed. The wound was described with no drainage. There were no other documented skin assessments for Resident #1 until 8/8/17. A physician telephone order, written by the treatment nurse, dated 7/13/17 indicated to clean Resident #1's sacral pressure ulcer (area #1) with normal saline, pat dry, apply Santyl (topical debridement) to the ulcer, and cover with Allevyn every three days. This order was electronically signed by the physician on 8/4/17. A physician telephone order dated 7/14/17 indicated an order for [REDACTED]. A nursing note dated 7/14/17 indicated a new order was received for Resident #1 to use a low air loss mattress to relieve pressure due to pressure ulcer wound. A nursing note dated 7/29/17 indicated Resident #1 had a new facility acquired pressure ulcer noted on her right lower buttock (area #2). The note indicated the treatment nurse was to assess the next day. The notes did not include measurements or a description of the new pressure ulcer. A treatment order dated 7/29/17 indicated to cleanse Resident #1's pressure ulcer on her right lower buttock (area #2) with normal saline, apply barrier cream, and leave open to air. The order was signed by the physician on 8/2/17. A skin assessment was not documented on 7/29/17 for Resident #1's new right buttock pressure ulcer (area #2). A physician telephone order dated 7/30/17 indicated to clean Resident #1's sacral pressure ulcer (area #1) that developed on 7/12/17 with normal saline, pat dry, apply Santyl (topical debridement) to wound bed, and cover with Allevyn as needed due to deterioration and drainage. A nursing note dated 8/1/17 indicated Resident #1's daughter was concerned about the pressure ulcer on the resident's buttock. The note indicated the NP would be consulted in the morning for possible order to obtain a wound culture and sensitivity (C&S). A nursing note dated 8/2/17 indicated the NP assessed Resident #1's pressure ulcers on 8/2/17 and ordered the following: Wound culture, laboratory panels, Santyl to both wounds, wet to dry dressing every day and as needed, and a wound care consult. A physician order [REDACTED].#1's sacral pressure ulcer (area # 1) and right upper leg -buttock (area #2). The orders included a wound care consult. The wound care consultant report dated 8/2/17 indicated Resident #1 had an unstageable pressure ulcer on her right buttock and sacral area. The wounds had 100 percent eschar (dead tissue) with mild odor. There was no granulation tissue (healing tissue) in either wound. The right buttock pressure ulcer (area #2) had a serous drainage and the sacral pressure ulcer (area #1) had a small amount of brownish drainage. The wound care consult report did not include measurements of the wounds. A physician order [REDACTED].#1's final wound C&S report indicated a wound infection (in both wounds). [MEDICATION NAME] 500 mg (antibiotic) was ordered once a day for ten days. A treatment sheet dated 8/8/17 indicated a low air loss mattress (ordered for Resident #1 on 7/12/17) was not applied to the resident's bed until 8/8/17. During an interview on 8/10/17 at 3:48 pm, the administrator said Resident #1 was ordered a low air loss mattress several weeks ago and it was just recently placed on the resident's bed. A Wound Report dated 8/8/17 indicated Resident #1 had the following pressure ulcers: *Area #1 - Unstageable on her sacrum (coccyx area) measuring 7.0 cm x 5.0 cm x1.5 cm. Surrounding skin-slough. There was a heavy amount yellow colored purulent drainage and a strong odor was noted. *Area #2 - Stage 3 on her right buttock measuring 3.3 cm x 2.3 cm with a red wound base, surrounding skin with slough present. There was a small amount of tan colored drainage. The wound was described as deteriorated. During an observation on 8/10/17 at 4:25 p.m., the treatment nurse provided wound care for Resident #1's pressure ulcers. Resident # 1 was lying on a low air loss mattress. The following was noted: *Area #1-sacral area The treatment nurse removed the soiled dressing from Resident #1's sacral area pressure ulcer and removed the packing from the wound bed. There was a moderate amount of dark drainage noted. The wound had approximately 25% yellow slough at the wound edges and the wound bed had red tissue with some eschar noted around the sides within the wound. There was a noticeable dying flesh odor within the wound (area #2). *Area #2 - right ischium (buttock) The treatment nurse removed the old dressing from Resident #1's right ischium pressure ulcer. There was scant slough noted at the wound's edges and the wound bed was pink with a scant amount of drainage. During an interview on 8/10/17 at 11:27 a.m., the treatment nurse said she had just started working back at the facility on 8/8/17. She said she completed Resident #1's skin assessment on 8/8/17 and the physician was notified. She said new treatments were ordered and started on 8/3/17. The treatment nurse said the treatment for [REDACTED].#2) included: cleanse once a day with normal saline, apply Santyl to wound bed, and cover with Allevyn border dressing. She said the treatment for [REDACTED].#1) treatment included: cleanse with Dakin's solution (bleach solution), apply Santyl to the wound bed, pack wound with Dakin's wet to dry dressing, and change daily. During an interview on 8/10/17 at 4:40 p.m., the DON said she had not seen Resident #1's pressure ulcers in a while and she did not know the treatment at the time. She said the wound care specialist saw the resident's pressure ulcers and treated them. She said she did not know why the low air loss mattress was not placed on Resident #1's bed when it was ordered. She said the nurses were supposed to be completing skin assessments since the treatment nurse was not working. During an interview on 8/11/17 at 3:00 p.m. the NP said she had not seen Resident #1's pressure ulcers in a couple of weeks (she was unsure of the date). She said the last time she saw Resident #1's sacral pressure ulcer (area #1), it was an abrasion that was almost healed. She said no staff called her to report the resident's wounds had worsened. The NP said she would have ordered a wound consult sooner if she had been made aware of the worsening wounds and the wounds would not be as bad. She described the resident's pressure ulcers as the sacral area having tunneling with a very foul odor and the right buttock with slough present. During an interview on 8/15/17 at 2:25 p.m., the wound care consultant said he first saw Resident #1's pressure ulcers around 8/2/17. He said the sacral area pressure ulcer (area #1) was covered with brownish-colored eschar and had a mild odor. The wound care consultant said the skin surrounding the wound was irritated. He said he ordered Santyl for debridement and he was hoping to stabilize the wound before he debrided it. He said he saw Resident #1 last week (8/11/17) and removed a big oyster piece of eschar out of the sacral area pressure ulcer (area #1) which removed most of the odorous part of the wound. The wound care consultant said the resident's right buttock pressure ulcer (area #2) was red and yellow with around 20 percent slough present. During an interview on 8/15/17 at 4:15 p.m., Resident #1's daughter said she requested her mother's dressing (area #1) to be changed on 8/5/17 because it was soiled with an odor. She said the staff were changing Resident#1's dressing every three days until a week or so ago and the NP was consulted after the wound started smelling. She said the dressing on (area #1) was now changed once a day. She said Resident #1 had been on a regular mattress and did not receive an air loss mattress until after her wound had an odor. 2. Physician orders [REDACTED].#2 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. A skin data sheet dated 7/17/17 indicated Resident #2 did not have any skin issues including pressure ulcers. A dietary consult completed on 7/17/17 indicated Resident #2 required assistance with eating and he was to be monitored for skin issues. A nutrition therapy assessment dated [DATE] indicated to start Resident #2 on [MEDICATION NAME] 15 mg once every day at bedtime. A care plan related to skin breakdown updated 7/17/17 indicated Resident #2 was at risk for/actual skin breakdown. Interventions included: Inspect skin head to toe every week and document results. The care plan also included: Inspect skin daily with care, bathing, and report any changes to charge nurse. Weekly treatment documentation to include measurement of skin breakdown, type of tissue, and if there was drainage. It indicated Resident #2 was at a moderate risk for skin breakdown. The most recent MDS dated [DATE] indicated Resident #2 was sometimes understood and understood others and was incontinent of bowel and bladder. He required total assistance of two staff for transfers, dressing, toileting, and hygiene. The MDS did not indicate Resident #2 had any pressure ulcers. A nursing note dated 7/29/17 indicated Resident # 2 was found to have a stage 2 facility acquired pressure ulcer on his right heel and the wound base was red. The notes indicated treatment orders included: cleanse wound to right heel with normal saline and apply Allevyn dressing once a day until healed. During an interview on 8/10/17 at 2:02 p.m., the weekend treatment nurse said she had provided the residents wound care for the past several months on the weekends. She said on 7/29/17 she noted Resident #2's right heel pressure ulcer. She said it was a blister that busted open with the loose skin intact and draining clear fluid. She said she notified the NP on 7/29/17, whom said she saw the wound on the resident's heel on 7/28/17. There was not a skin assessment dated [DATE] or 7/29/17 for Resident #2's stage 2 pressure ulcer on his right heel. During an interview on 8/10/17 at 3:33 pm, the DON said CNA B worked the night of 7/28/17 and discovered the pressure ulcer on Resident #2's right heel. During an interview on 8/10/17 at 3:38 pm, CNA B said on the night of 7/28/17, she was doing bed checks and noticed Resident #2 pulled his sheet off the bed. She said there was a wet spot at his feet, when she turned him she noticed the pressure ulcer on his right heel. She said she placed a pillow beneath his feet and reported to the charge nurse. CNA B said the wound looked like a blister had busted. She said this was the first time she had seen the pressure ulcer on Resident #2's heel. A weight record 8/08/17 indicated Resident #2 had lost 12 pounds since he was admitted on [DATE]. He weighed 220 pounds on admission and his current weight was 208 pounds. Resident #2 received [MEDICATION NAME] 40 mg once a day (initiated on 8/03/17). During an observation on 8/10/17 at 11:28 a.m., Resident #2 was alert, but confused and unable to answer questions. He was attempting to eat his lunch, but was slumped over in his chair and unable to feed himself. After approximately 20 minutes into the meal service, staff assisted him and he ate 100 percent of his meal. His feet were on the floor with no foot pedals on his wheelchair. His heels were not offloaded and he was unable to propel himself in his wheelchair. During an interview on 8/10/17 at 1:13 p.m., the DON said Resident #2 had a weight loss due to too much fluid and they were giving him [MEDICATION NAME] to pull it off. She said the resident still had swelling in his hands and feet. The DON said she was unaware when Resident #2's pressure ulcer developed, but the treatment nurse probably knew. She said they had not consulted the dietician regarding his weight loss and they did not think he needed nutritional interventions to prevent skin breakdown because they related the weight loss to fluid. During an interview on 8/10/17 at 1:15 p.m., the treatment nurse said she returned to work as treatment nurse on 8/7/17. She said she did not know when the Resident #2's right heel pressure ulcer developed. She said it should be documented in the nursing notes. Treatment orders for Resident #2's right heel pressure ulcer dated 8/10/17 indicated the following: cleanse wound as needed with normal saline, apply moisture barrier of choice to peri-wound, apply Santyl to wound bed and cover with normal saline moistened gauze, and wrap with kerlix (gauze wrap) daily and as needed. During an observation and interview on 8/10/17 at 1:17 p.m., the treatment nurse removed the dressing from Resident #2's right heel. The pressure ulcer measured 2.7 cm x 4.3 cm with a dark purple center measuring 1 cm x 1.8 cm. There was a scant amount of slough tissue in the center of the wound bed, around the dark purple area. The treatment nurse said when she provided Resident #2 with wound care earlier that morning, the wound bed was very dry. The treatment nurse said she notified the physician and received an order change to use Santyl. She said Resident #2's heels were to be offloaded at all times. 3. A face sheet dated 8/10/17 indicated Resident #3 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. A pressure ulcer risk assessment dated [DATE] indicated Resident #3 was at moderate risk for developing pressure ulcers. The most recent MDS dated [DATE] indicated Resident #3 was understood and could understand others and was incontinent of bowel and bladder. He required total assistance of two staff for transfers, dressing, toileting, and hygiene. The MDS did not indicate Resident #3 had any pressure ulcers. A care plan related to skin breakdown updated 7/14/17 indicated Resident #3 was at risk for/actual skin breakdown. Interventions included: Inspect skin head to toe every week and document results. The care plan also included: Inspect skin daily with care, bathing, and report any changes to charge nurse. He was incontinent of bowel and bladder. Physician orders [REDACTED].#3 had an air mattress on his bed and was to have heel protectors on at all times while in bed. The Treatment orders dated 8/8/17 included: apply barrier cream or spray to Resident #3's buttocks daily and as needed. A wound report dated 8/9/17 indicated Resident #3 had a facility acquired stage 2 pressure ulcer on his right buttock (found on 7/14/17) measuring 2.5 cm x1 cm. The report indicated the wound had deteriorated. There were no documented assessments from 7/14/17 through 8/08/17. During an observation on 8/10/17 at 4:00 p.m., Resident# 3 was in bed lying on his back on a low air loss mattress. He did not have on heel protectors. He was able to turn with the treatment nurse's assistance. Resident #3 had a stage 2 on his right buttock. During an interview on 8/10/17 at 4:40 p.m., the DON said they had several fill ins doing the treatments until the treatment nurse came back to work on 8/7/17. During an interview on 8/10/17 at 3:48 pm, the administrator said upon admission, residents were supposed to be assessed by the LVN charge nurse. The administrator said the treatment nurse completed a full head to toe skin assessment on the resident within 24 hours. She said weekly skin assessments were to be done on all residents at risk for skin breakdown. She said if there was a skin issue, the resident should be evaluated for treatment, if a specialty mattress was needed, and other measures should be put into place to prevent the worsening of the pressure ulcers. The administrator said every Thursday the residents with treatments were discussed and reevaluated to determine if a change in the treatment was needed or measures put into place to prevent further deterioration. The administrator said she thought the issues with pressure ulcers occurred due to the inconsistency of resident skin assessments and different nurses doing resident treatments. She said their full time treatment nurse had been out for multiple weeks and other nurses were filling in. She said she had been on maternity leave and was unaware of the pressure ulcers until recently when she returned. The policy titled Pressure Sores dated 04/2012 indicated the following: According to the NPUAP website, http://www.npuap.org/resources/educational-and-clinical-resources, accessed 8/22/17, the following was noted about pressure ulcers (injuries): Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). --Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. --Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. The CMS form 672 dated 08/10/17 indicated 9 residents had pressure ulcers.

Based on observation, interview, and record review, the facility failed to provide assistance to prevent accidents for 2 of 6 residents reviewed for accidents. (Residents #1 and #6) The facility did not provide Resident #1 and Resident #6 a safe transfer. Resident #1 sustained a fractured arm when CNA A and CNA B used an unsafe method of transfer. This failure could place 13 residents who were dependent on staff for assistance with transfers at risk for injuries. Findings included: 1. A face sheet dated 11/22/16 indicated Resident #1 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 was in a persistent vegetative state/no discernible consciousness. The MDS indicated Resident #1 required total dependence for ADLs, and transfers had not occurred. Resident #1 had range of motion limitations to both upper and lower extremities. The most recent care plan updated on 11/22/16 indicated Resident #1 had impaired physical mobility and required total assistance. The care plan indicated Resident #1 was totally dependent on staff for transfers and required the assistance of 2 persons. A mechanical lift was checked on the resident caution section of the care plan. During an observation on 11/21/16 at 11:03 a.m., Resident #1 was lying in bed with a sling on her right arm. Resident #1 was nonverbal and non-responsive. During an interview on 11/21/16 at 11:00 a.m., LVN C said Resident #1 was in a vegetative state since her admission. LVN C said she had not witnessed the CNAs transferring Resident #1, but the resident should be transferred with a mechanical lift. She said the CNAs should check the Plan of Care if they are unsure of how a resident should be transferred. During an interview on 11/21/16 at 12:52 p.m., CNA B said she helped transfer Resident #1 on the day the resident's arm was fractured. She said it was her first day of work at this facility. CNA B said she and CNA A assisted Resident #1 back to bed. CNA B said they put the gait belt around Resident #1 and she stood on one side of the resident and grasped the gait belt with one hand and placed her other arm under Resident #1's arm. CNA B said when they lifted the resident she heard a pop. They continued with the transfer and put Resident #1 in bed. She said the pop was immediately reported to the charge nurse. CNA B said she did not feel comfortable transferring Resident #1 with a gait belt. CNA B said if she was unsure of how a resident should be transferred she would ask the CNA supervisor or other staff on the hall. She said she was not aware of any other way to find out how a resident should be transferred. During an interview on 11/22/16 at 7:48 a.m., CNA A said she and CNA B transferred Resident #1 on the day her arm was fractured. CNA A said she and CNA B got Resident #1 up for a shower and left her up for approximately 2 hours. She said she was on one side of Resident #1, and CNA B was on the other. She said she grasped the gait belt with one hand and under Resident #1's arm with the other. She said they heard a pop and felt Resident #1's arm break when they lifted her. She said they continued with the transfer, put Resident #1 into bed and immediately reported the incident. CNA A said she always transferred Resident #1 with a gait belt and 2 persons. She said she did not check the Plan of Care before transferring Resident # 1. CNA A said she knew the Plan of Care said Resident #1 should be transferred with the mechanical lift but she always transferred her with the gait belt. CNA A said Resident #1 was out of bed 3 times a week. She said she got her up on Monday, Wednesday, and Friday, and always transferred her the same way. An incident report dated 11/11/16 indicated CNA A heard and felt a pop in Resident #1's right arm during a transfer. The physician was notified and an order was received for an x-ray to be obtained. A nursing note dated 11/11/16 indicated Resident #1 was transferred to a local ER due to a suspected right arm fracture. Report was received of spiral fracture to right arm and an immobilizer was applied. A radiology report dated 11/11/16 from a local hospital indicated Resident #1 had a minimally displaced fracture of the right humerus near the elbow joint with severe osteoporosis present. During an observation and interview on 11/21/16 at 1:16 p.m., LVN D said the CNAs should check the ADL Plan of Care to determine how to transfer a resident. LVN D said she monitored the CNAs transferring residents occasionally to ensure residents were being transferred properly. LVN D said she was unsure how Resident #1 was to be transferred. LVN D was unsure of how to bring the ADL Plan of Care up on the computer so she asked CNA E to show her. LVN D and CNA E both said according to the Plan of Care Resident #1 was to be transferred using a mechanical lift. This ADL Plan of Care was last updated on 12/2014. During an interview on 11/21/16 at 1:23 p.m., CNA E said she would ask a charge nurse or go to the resident's ADL Plan of Care to learn how a resident should be transferred. CNA E said she had worked at this facility approximately 9 months and Resident #1 was always transferred with a mechanical lift. She said she would never attempt to transfer her with a gait belt and 2 persons because Resident #1 could not bear weight or assist with any body movements. During an interview on 11/22/16 at 8:14 a.m., CNA F said she asked the charge nurse or looked in the Plan of Care to see how a resident should be transferred. She said she had transferred Resident #1 multiple times. CNA F said Resident #1 was gotten out of bed 3 times a week. She said she always used the mechanical lift or sheet transfer. She said she never used a gait belt with 2 persons, because that would not be safe. During an interview on 11/22/16 at 8:22 a.m., CNA G said she looked on the Plan of Care or asked the charge nurse if she didn't know how to transfer a resident. CNA F said she transferred Resident #1 multiple times. She said she used the sheet transfer for Resident #1. She said she never used a gait belt and 2 persons and never witnessed anyone transfer Resident #1 with a gait belt. During an interview on 11/22/16 at 8:27 a.m., the DON said staff should check the Plan of Care system to determine how a resident should be transferred. She said they have access to handheld devices and the desktop computer for this information. She said the ADON and CNA supervisor were responsible for monitoring the CNAs. The DON said she was aware Resident #1 was being transferred with a gait belt and 2 person assist. She said she did not believe the mechanical lift was safe because Resident #1 was too stiff. The DON said she thought the care plan indicated Resident #1 could be transferred with 2 person assist or mechanical lift. The DON said she was not aware the Plan of Care indicated mechanical lift transfer. During an interview on 11/22/16 at 8:47 a.m. ADON H said Resident #1 should be transferred with a sheet or the mechanical lift. She said Resident #1 should never be transferred with a gait belt and 2 person assist. She said she was not aware staff transferred Resident #1 with a gait belt. ADON H said after Resident #1's arm was fractured she discussed the incident with CNA A. She said CNA A was upset and began crying because she knew better than to transfer the resident with a gait belt. ADON H said Resident #1's Plan of Care indicated she was transferred with the mechanical lift. She said CNAs should look on the Plan of Care or ask a charge nurse or herself if they were unsure of how to transfer a resident. ADON H said CNAs were trained by the CNA supervisor. ADON H said she conducted care rounds daily to monitor care of the residents. During an interview on 11/22/16 at 9:01 a.m., the administrator said staff should check the ADL Plan of Care to determine how to transfer a resident. She said they could access this information on the handheld device or the desktop computer. The administrator said she had a lead CNA who checked the CNAs off routinely and at random. The administrator said there was not a good way to transfer Resident #1. She said the mechanical lift was unsafe because Resident #1 was too stiff and she could slide out. She said she believed transferring Resident #1 with a gait belt and 2 person assist was the safest way for her situation. She said after Resident #1's fractured arm, the family requested Resident #1 not be gotten out of bed anymore, so her care plan was updated and now reflected the resident was bedfast. During an interview on 11/22/16 at 9:50 a.m., the OT(occupational therapist) said a non- weight bearing individual should be transferred with a sliding board or mechanical lift. She said she was familiar with Resident #1. The OT said Resident #1 should be transferred with the mechanical lift as it would be unsafe to transfer Resident #1 with a gait belt and 2 person assist because the resident could not bear weight. During an interview on 11/22/16 at 9:58 a.m., CNA J said she never transferred Resident #1, but she observed her being transferred by CNA A and CNA F. She said the CNAs sat the resident up and transferred her with the gait belt. During an interview on 11/22/16 at 10:15 a.m., the regional nurse said Resident #1's ADL Plan of Care needed to be updated. She said the mechanical lift was checked on the resident caution section but not on the transfer section. The regional nurse said she was auditing all ADL Plans of Care to make sure the CNA alerts and means of transfer match. During an interview on 11/22/16 at 10:26 a.m., the rehab manager said Resident #1 was a total assist. She said to safely transfer Resident #1 she would recommend the mechanical lift or sheet transfer. She said transferring Resident #1 with just a gait belt and 2 persons was not safe because she could not bear weight. During an interview on 11/22/16 at 12:45 p.m., the physical therapist said she was familiar with Resident #1. She said she would recommend the mechanical lift or sheet transfer. She said a 2 person transfer with a gait belt would not be considered safe for any resident who could not bear weight. Quarterly therapy screenings dated 6/27/16 and 8/23/16 indicated Resident #1 had both upper and lower extremity contractures and required extensive assistance for all aspects of daily living. 2. A face sheet dated 11/22/16 indicated Resident #6 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #6 was rarely able to make himself understood and rarely understood by others. The MDS indicated Resident #6 required extensive assistance of 2 persons for ADLs and transfers. Resident #6 had range of motion limitations to both upper and lower extremities. The most recent care plan updated on 10/26/16 indicated Resident #6 had a self-care deficit and required total assistance with transfers. During an observation on 11/22/16 at 10:46 a.m., Resident #6 was sitting upright in bed. Resident # 6 was nonverbal. During an observation on 11/22/16 at 12:27 p.m., CNA A and CNA J transferred Resident #6 from his bed to the Geri-chair. ADON H was present. Resident #6 was assisted to a sitting position on the side of the bed and the gait belt was applied. CNA A was on one side and CNA J was on the other. A towel was placed under Resident #6's legs close to the knees. The CNA's grasped the gait belt with one hand and the towel with the other. Resident #6 was lifted off the bed and into the chair. During an interview on 11/22/16 at 9:58 a.m., CNA J said Resident #6 was non-weight bearing and was assisted out of bed daily. She said she transferred him routinely. CNA J said she never used the gait belt with Resident #6. She said she sat him up on the side of the bed and put a towel under his legs and grabbed him under the arms. CNA J said she thought he should be transferred with the mechanical lift. During an interview on 11/22/16 at 1010 a.m., LVN K said Resident #6 was out of the bed every day. She said he was a full body transfer. LVN K said he was non-weight bearing so he was not a candidate for a gait belt transfer. During an interview on 11/22/16 at 11:14 a.m., CNA A said she was familiar with Resident #6 and transferred him several times. She said she normally transferred him with 2 people and a towel under his legs. She said she did not always use a gait belt. During an interview on 11/22/16 at 12:40 p.m., the rehab manager said Resident #6 was a total assist for all transfers. She said the mechanical lift or sheet transfer would be safe for Resident #6. During an interview on 11/22/16 at 12:45 p.m., the physical therapist said she was familiar with Resident #6. She said she would recommend the mechanical lift or sheet transfer. She said a 2 person transfer with a gait belt would not be considered safe. A Patient Safe Handling and Movement Policy dated 10/01/07 indicated .it is the policy to care for residents safely while maintaining a safe work environment for employees .direct care staff should assess residents in advance to determine the safest way to accomplish lifting, transferring, and movement needs .mechanical lifting equipment and/or other handling aides should be used to prevent the manual lifting and handling of residents except when absolutely necessary . The CMS 672 dated 11/21/16 indicated 13 residents were dependent for transfers.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and interventions to prevent accidents for 5 of 18 residents reviewed for accidents. (Resident #s 1, 3, 12, 14, and 17) Staff did not re-evaluate the effectiveness of interventions and implement new interventions to prevent/reduce Resident #12's falls. Resident #12 fell 19 times from 2/6/16 to 3/4/16. (28 days) Resident #12 was hospitalized after falling on 3/4/16 and sustained a subdural hematoma. Staff did not implement new interventions, re-evaluate the effectiveness of interventions, modify or replace interventions as needed and did not follow through with interventions that were in place to help reduce Resident #14's falls. Staff did not evaluate Resident #1's falls and implement interventions to prevent further falls surrounding incontinence. Resident #1 had 5 falls related to the need to toilet. Staff did not implement care planned interventions to prevent Resident #17 from further falls. Resident #17 had 15 falls in 6 months. Staff did not implement new fall interventions when Resident #3 fell six times February through April 2016. This failure could place 50 residents, who are high fall risk, at an increased risk for injuries. Findings included: 1. Consolidated physician order [REDACTED].#12 was [AGE] years old, readmitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #12 was understood and understood others. He required extensive assistance with ADLs. He was always incontinent of bowel and bladder. The assessment indicated he had falls prior to re-entry and two or more falls with no injury, one fall with injury, and one fall with major injury. The incident/accident reports for Resident #12 included the following: *2/6/16 at 1:30 p.m., Resident #12 was found on the floor of Hall 400. Actions taken: physical exam, sent to emergency room , MD notified, well lit/non cluttered room, bed in low position, wheelchair, and redirected. No interventions were implemented to prevent falls. *2/8/16 at 5:25 p.m., Alarm was sounding and Resident #12 stood up out of his wheelchair and fell to the floor next to ADON office. Actions taken: physical exam, MD notified, wheelchair, chair cushion, one on one (does not state for how long), and redirected. He was assessed and put back in wheelchair and taken to Hall 400 where resident was noted to have slid out of his wheelchair again. There was not an incident report for the second fall. No interventions were implemented to prevent falls. There was no medication review, no lab review, and no PT recommendation. *2/10/16 at 2:25 p.m., Resident #12 was found at the nursing station with his alarm sounding when an LVN on duty came in from outside. The fall was unwitnessed. Actions taken: physical exam, MD notified, place resident in an open area for maximum observation opportunities, chair alarm, wheelchair, chair cushion, one on one, and redirected. *2/13/16 at 9:40 p.m., Resident #12 was heard yelling and found lying in front of his bathroom, grimacing in pain. A second time he was brought out into hallway and the alarm was heard again and he was found on the floor on his left side. A third fall was noted when staff heard Resident #12 yell out in pain and he was found on the floor again, and the location was not included. Actions taken: physical exam, sent to emergency room , MD notified, well lit/ non cluttered room, call light in reach, place resident in an open area for maximum observation opportunities, mat at bedside, chair alarm, wheelchair, chair cushion, leg pedals, and redirected. Only one incident report was made for all three falls. *2/27/16 at 8:30 p.m., Resident #12 was found in the floor with his back against the bathroom door and he received a skin tear to his right lower arm. Action taken: physical exam, call light in reach, place resident in open area for maximum observation opportunities, and chair alarm. No new interventions were implemented. *2/28/16 at 6:00 a.m., Resident #12 was found in the floor in front of his air conditioner, on his back with his head against the appliance. He had struck his head and he complained of pain to his left foot and left leg. Action taken: physical exam, neuro checks, MD notified, PT/OT to evaluate and treat as indicated. Well lit/non cluttered room, bed in low position, chair alarm, wheelchair, one on one, redirected, music and headphones. *2/28/16 at 2:20 p.m., Resident #12 was found in the floor on his right side in front of the bathroom and he complained of pain to his right elbow and right leg. His pajama bottoms and bed were wet. Actions taken: physical exam, neuro checks, MD notified, well lit/non cluttered room, call light in reach, place resident in open area for maximum observation opportunities, bed in low position, mat at bedside, chair alarm, wheelchair, and redirected. No new interventions were implemented. *2/29/16 at 6:00 p.m., Resident #12 was found once on Hall 400, a second time in his room and a third time at the entrance of Hall 100 where he hit his head and right elbow and yelled out in pain. Actions taken: physical exam, well lit, non-cluttered room, chair alarm, redirected. There is only one incident report for all three falls and no details of how resident was found. *3/1/16 at 8:00 p.m., the report was noted to be the same report dated 2/29/16 with all the same information. *3/4/16 at 7:55 a.m., Resident #12 got up out of wheelchair and fell to floor. Action taken: physical exam, MD notified. *3/4/16 at 11:00 p.m., Resident #12 stood up out of wheelchair at the nursing station, lost his balance, fell backwards, and hit his head on the wall. The reports indicated he was assisted back in to the wheelchair and the brakes were locked. Action taken: MD notified, well/lit non cluttered room, place resident in open area for maximum observation opportunities, chair alarm, wheelchair, redirected. A nursing note dated 3/4/16 indicated Resident #12 fell three times. He fell twice at the nursing station on Hall 400, and was found on the ground in the fetal position with an abrasion to his right shoulder, elbow, and knee. He was sent to the emergency room for altered mental status and decreased oxygen saturation of 82 percent. Resident #12's closed clinical record did not contain an incident report or investigation of the fall on 3/4/16. A fall risk assessment dated [DATE] indicated Resident #12 was a high risk for falls. Hospital records dated 3/5/16 indicated Resident #12 was admitted with chronic right sided subdural hematoma per CT scan of the head, altered mental status secondary to fall, hyperkalemia, normocytic chronic anemia, acute or chronic kidney injury. The history of present illness indicated Resident #12 stepped outside while at the nursing facility, and fell and hit the back of his head. Over the course of the day, he showed signs of confusion and unusual behavior. The report also indicated metabolic [DIAGNOSES REDACTED], a new onset of seizures, [DIAGNOSES REDACTED] with levels in the 30s and 40s, a urinary tract infection, and chronic anemia with hemoglobin of 8.3 and hematocrit of 27.1. Hospital records indicated that Resident #12's daughter did not want Resident #12 discharged back to the facility. A care plan printed 4/20/16 indicated Resident #12 had a potential for falls due to his history of falls. Interventions included: assist resident with toileting as needed, assess contributing factors related to fall history, assist resident with ADLs as needed, keep call light and most frequently used personal items within reach, wheelchair, and maintain record of falls and evaluate for patterns. A face sheet printed 4/20/16 indicated Resident #12 discharged from the facility to theER on [DATE] for altered mental status and a decreased oxygen saturation of 82 percent after several falls on this date. There was no indication in the clinical record Resident #12's medications or lab work were ever assessed or a therapy evaluation was ever ordered to help determine the reason for his frequent falls. During an interview on 4/20/16 at 11:18 a.m., ADON B said an incident report should be completed for every incident/accident and said she is responsible for reading the nursing notes and ensuring all incident/accident reports were completed correctly and interventions were put in place. She said Resident #12 went to live with his daughter because the facility could not manage him. 2. Consolidated physician orders [REDACTED].#14 was [AGE] years old, readmitted [DATE], with [DIAGNOSES REDACTED]. A fall risk assessment dated [DATE] indicated Resident #14 was a high risk for falls. The most recent MDS dated [DATE] indicated Resident #14 was understood and understood others. He required extensive assistance with his ADLs, and was a one person assist with transfers. He was continent of bowel and bladder. The assessment indicated he had falls prior to entry and two or more falls since readmission with injury and one fall with major injury. The incident/accident reports for Resident #14 included the following: *2/29/16 at 1:30 p.m., Resident #14 sat in the floor next to his air conditioner when he attempted to sit in a chair next to the window. Actions taken: he was assessed for injury, an abrasion was noted to his back, he was assisted by two persons to his chair and then assisted with ambulating to the bed, and neurological checks were initiated. *3/11/16 at 9:15 p.m., Resident #14 had a fall while coming out of the bathroom. Actions taken: neurological checks were started and he was placed back in bed. Falling star was placed on resident's door. At 3:38 a.m., resident complained of severe back pain, rating it a 10, and he was transferred to the emergency room . The incident report indicated he was found to have a nondisplaced fracture of the pelvis. *3/16/16 at 1:00 p.m., another resident reported Resident #14 was coming out his bathroom and fell on the floor at the entrance of his doorway and hit his head. Resident #14 complained of severe head, neck, back, and hip pain and yelled out when assessed and was sent to emergency room . The report indicated bed alarm was to be placed on bed/chair, but he fell before we could get it in place. Actions taken: room closer to nurses' station, chair alarm, bed alarm every shift ensure alarm is in place and functioning properly and add a two hour toileting program. A physician order [REDACTED].#14's bed alarm was to be used every shift. Staff were to ensure alarm was in place and functioning properly. An incident/accident reports for Resident #14 dated 4/9/16 at 10:30 a.m., indicated Resident #14 vomited in the floor and stood up to transfer himself and slipped in the emesis, falling in the floor next to the bed, and he received a skin tear to his right elbow. Actions taken: He was assisted back in to bed by three person transfer, wound care was performed, and a floor mat was placed next to bed. Incident reports indicated that a chair alarm and two hour toileting schedule would be put into place for Resident #14, but there was no evidence to indicate staff followed through with those interventions. A physician order [REDACTED].#14 was in bed. A care plan dated 4/20/16 indicated Resident #14 had potential for falls due to his history of falls. Interventions included: anticipate residents needs, check frequently, assess contributing factors related to fall history, assist resident with ADLs as needed, bed alarm-sensor, ensure bed in lowest position, falling star symbol on door, keep call light and personal items in reach, make sure staff members are aware that resident is at high risk for falls, and place floor mat next to bed. During an observation on 4/20/16 at 9:36 a.m., Resident #14 was lying in bed sleeping. The fall mat was folded up between the right side of his bed and the exterior wall. His bed alarm was not plugged in to the alarm box and he did not have a chair alarm. During an interview on 4/20/16 at 9:45 a.m., LVN D said Resident #14 was not on a toileting program and did not have a chair alarm. She said nurses and nurse aides were responsible for ensuring bed/chair alarms were functioning properly and in place and that the fall mats were in place. She said the fall mat should be placed next to the bed in the floor and did not know why it was folded up next to his bed. She said the bed alarm was not plugged in and did not know why. During an interview on 4/20/16 at 9:52 a.m., CNA A said Resident #14 did not have a chair alarm and was not on a toileting program. She said nurses were responsible for checking bed/chair alarms and fall mat placement. She said she did not know Resident #14 was supposed to have a fall mat at his bedside and she did not know that he was a fall risk or had a history of [REDACTED]. During an interview on 4/20/16 at 10:20 p.m., ADON C said everyone was responsible for checking bed/chair alarms and fall mats. She said the interventions put in place for Resident #14 were a bed alarm, and a fall mat, and indicated the facility does not have a toileting program. During an interview on 4/20/16 at 1:05 p.m., Resident #14 said it took staff ten to thirty minutes to answer his call light. He said he often felt he had to use the restroom before he could get assistance, and did not feel pressing the call light would get him any assistance. 3. A face sheet generated on 4/20/16 indicated Resident #1 was [AGE] years old, admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 was rarely understood and rarely understood others. He required extensive assistance of one staff for bed mobility, transfers, locomotion, eating, toileting, and personal hygiene. Resident #1 was always incontinent of bowel and bladder. Incident and accident reports indicated: *10/16/15 at 8:30 p.m., Resident #1 was trying to get up to go to the bathroom, fell on a bedside mat reopening a skin tear received at the hospital. Resident #1 was assisted back to bed and incontinent care was provided. *10/30/15 at 4:45 p.m. Resident #1 slid off his bed and landed in the floor and he continued to try to do his own ADLs. *11/16/15 at 1:40 a.m. Resident #1 was on the floor mat beside the bed. He had an abrasion to the right side of the head. He was sent to the emergency room . *11/25/15 at 9:20 p.m. Resident #1 was found with his brief pulled off, sitting on the bathroom floor. The report indicated Resident #1 was incontinent less than daily. *12/01/15 at 1:00 p.m. Resident #1 had a delayed injury from a fall on 11/25/15. Resident #1 had a large bruised area to his left flank area and to his mid lower back. *12/06/15 at 1:35 p.m. Resident #1 slid off his wheelchair while going to the bathroom. Resident #1 sustained a skin tear to his right hand. *2/29/16 at 7:10 p.m. Resident #1 was sitting on the floor scooting toward the doorway. The incident/accident report stated Safety mat down and alarm was intact. He had alarm in his hand attached. He was very agitated and combative. He had bowel movement on his bottom so I asked did he want us to change him and was that what he was trying to tell us. He shook his head yes. He cannot verbalize what he needs or wants. Teaching done with CNAs when he gets agitated to first start by asking about pain, bathroom and hydration, because those are usually the things he's trying to tell us. A fall risk assessment dated [DATE] indicted a fall score of 12 (high). The assessment indicated Resident #1 was always incontinent and was a poor candidate for scheduled retraining. The assessment indicated Resident #1 had a usual urinary pattern upon arising and before going to bed. The most recent care plan electronically generated on 4/20/16 indicated Resident #1 had fall risk as a care area. There were no new interventions after his most recent fall. All preventions were initiated in 2015. The goal indicated the resident was to be free from complications related to falls for the next 3 days, and would verbalize the need for assistance over the next 90 days (resident was non-verbal). Dated interventions were: adequate lighting (9/22/15), anticipate needs and check frequently (6/05/15), administer first aid as needed (9/22/15), assess contributing factors related to fall history (6/05/15), assess medications (6/05/15), assist with ADLs as needed (5/29/15), assist with toileting as needed (6/05/15), bed alarm (10/16/15), chair alarm (11/15/16), call light within reach (6/05/15), glasses clean (11/25/15), staff members aware he was at risk to fall (11/25/15), padded floor mat next to bed(10/16/15), redirected (10/30/15) and therapy referral (5/29/15). During an interview on 4/20/16 at 8:55 a.m., CNA F said when Resident #1 was taken to the toilet before and after meal times he stayed dry and was much calmer. During an interview on 4/20/16 at 9:03 a.m., LVN E said Resident #1 would at times respond to being toileted. During an interview on 4/20/15 at 11:15 a.m., the DON said she and the ADONs evaluated all the falls. The DON said Resident #1 did not qualify for a toileting plan even though his falls occurred while he tried to toilet himself. 4. A face sheet generated on 4/20/16 indicated Resident #17 was [AGE] years old, and admitted on [DATE] with the [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #17 was sometimes understood and sometimes understood others. The MDS indicated he had poor recall, and inattention. Resident #17 required extensive assistance with bed mobility and total assistance with transfers, locomotion, dressing, eating, toileting, personal hygiene and bathing. Resident #17 was always incontinent. The MDS indicated Resident #17 had 1 fall with no injury and 1 fall with injury and no major injury falls. Incident and accidents reviewed for Resident #17 indicated: *10/02/15 at 10:25 a.m., Resident #17 had an unwitnessed fall in his room while trying to get out of his chair. The report indicated he should be in observed areas to prevent falls. *10/11/15 at 11:10 a.m., Resident #1 attempted to transfer himself and lost his balance, which caused the fall. The report indicated continued education with the staff to keep Resident #17 in open areas where he can be observed frequently. *10/14/15 at 3:55 p.m., indicated a fall in the Hall 400 while he was trying to get up unassisted. Resident #17 was sent to the emergency room . *11/08/15 at 3:00 a.m., Resident #17 had an unwitnessed fall in the lobby. He was sent to the ER. *11/09/15 at 5:00 a.m., Resident #17 had a witnessed fall in the hallway. *11/15/15 at 4:45 p.m., Resident #17 had a witnessed fall in the dining room *11/23/15 at 12:20 p.m., Resident #17 had a witnessed fall at the nursing station. *11/24/15 at 1:45 p.m., Resident #17 had a witnessed fall by the nursing station. The report indicated the personal alarm did not detach until the after fall occurred. The report also indicated Resident #17 continued to try and get up unassisted, and when asked to sit down he became angry and agitated. *12/15/15 at 1:50 p.m., Resident #17 was in his room and fell from his wheelchair. The report indicted reinstructed staff not to leave Resident #17 in his room alone without direct supervision. *12/30/15 at 7:50 a.m., Resident #17 fell in his room when the CNA stepped out to gather supplies. *1/16/16 at 1:00 p.m., a witnessed fall from wheelchair in sitting area *1/16/15 at 6:20 p.m., Resident #17 was found crawling off the safety mat on the floor. Resident #17 reported unspecified pain then later aching legs. *2/08/16 at 8:40 a.m., Resident #17 was combative during morning care and had been attempting to stand all morning. The report indicated administered Ativan had no effect. Resident was sitting in the hallway while staff was passing medications. Resident #17 stood when staff was away and fell . *3/30/16 at 12:45 p.m., Resident #17 fell while leaning on another resident's wheelchair. The fall risk care plan updated 4/20/16 indicated Resident #17's fall score on 8/25/15 was high risk. The goal indicated Resident #17 would be free from complications related to falling over the next 3 days (8/26/15), he would verbalize the need for assistance over the next 90 days (2/21/16), and safety to be maintained over the next 90 days (8/25/15). The interventions were activities one on one (8/25/15), activity board (11/9/15), adequate lighting (9/28/15), anticipate resident needs checks frequently (8/25/15), assess contributing factors related to fall history (8/25/15), assess medications (8/25/15), assist with ADLs as needed (8/25/15), assist with toileting as needed (8/25/15), bed alarm clip (8/26/15), chair alarm clip (8/27/15), complete physical exam for injuries (8/26/15), falling star (8/28/15), keep call light within reach (8/25/15), low bed (9/29/15), maintain record of falls and evaluate for patterns (12/14/15), make sure staff are aware of fall risk (8/27/15), one to one observation (9/28/15), padded floor mat to left side of bed (9/29/15), place resident in open area for maximum observation opportunities (9/3/15), refer to psychologist (12/15/15), therapy referral (8/25/15), wheelchair with tilt back (9/3/15). A nursing note dated 4/17/16 indicated Resident #17 fell from his wheelchair at the nursing station and sustained lacerations that required suturing to the middle finger and ring finger of his right hand. During an observation and an interview on 4/20/16 at 8:45 a.m., Resident #17 was resting in bed. There was no pressure bed or a personal alarming device. The treatment nurse said Resident #17 had a wheelchair alarm and fall mats beside his bed but no bed alarm. During an interview on 4/20/16 at 9:45 a.m., LVN D said Resident #17 was at risk to fall. She said Resident #17 had a history of [REDACTED]. LVN D said there was no bed alarm on Resident #17's bed. During an observation and interview on 4/20/16 at 1:10 p.m., LVN D said she was unsure how to access Resident #17's care plan. LVN D said she was unaware Resident #17 required a bed alarm. Following surveyor intervention, LVN D said she would apply a bed alarm. During an interview on 4/20/16 at 1:30 p.m., CNA O said Resident #17 did not have a bed alarm; only a chair alarm. She said he was at risk to fall. During an interview on 4/20/16 at 2:15 p.m., RN B said Resident #17 required a bed alarm. A physician order [REDACTED].#3 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #3's most recent MDS dated [DATE] indicated she made herself understood and was able to understand others; had poor memory recall; and required limited assistance of one person most of her ADLs, including transfers. The resident's balance for moving from a seated position to standing, moving on and off toilet, and for surface to surface transfers was not steady and could only stabilize with staff assistance; and she had fallen three times since admission - one time without injury and two times with injury that was not major (skin tears, abrasions, bruises or any fall that caused the resident to complain of pain). An incident/accident report dated 2/28/16 at 6:00 a.m. indicated Resident #3 was found on the floor facing her commode with her back against her wheelchair, legs in front of her beside commode. Resident was sent to the emergency room for follow-up due to complaint of pain in her head, left shoulder and left foot. Interventions: Physical Therapy evaluation indicated and initial neurological check. Resident #3's fall assessment dated [DATE] indicated she was a high fall risk, needed assistance for mobility and balance, had three or more health issues (osteoarthritis, high blood pressure, pain in knees, muscle weakness, dizziness, dementia and memory loss, and more) that contributed to her high fall risk. April 2016 incident/accident reports indicated Resident #3 had fallen four additional times: *4/04/16 - 4:00 a.m. - seated on floor between her wheelchair and the toilet. The wheelchair wheels were not locked. Resident denied pain/injury. Interventions: call light in reach, bed in low position, redirect and provide patient teaching on proper use of W/C brakes. No Physical Therapy notes were found for the year 2016. *4/04/16 - 8:00 a.m. - Resident stated she was trying to get off the toilet when she lost balance and fell . She stated she hit her head on the floor in the bathroom and felt dizzy and her back hurt real bad. Resident #3 was confused and did not know where she was when the ambulance arrived to take her to the ER. Interventions: Assist X 1 at all times, neurological checks every 2 hours for 6 hours then every 8 hours for 4 days. To evaluate resident for a two hour toileting program to reduce falls. There were no orders or assessments found to indicate the facility implemented a 2 hour toileting program for the resident. *4/05/16 - 10:00 p.m. - Resident #3 stated she was getting into the W/C and it rolled out from under her. She was found sitting on the floor next to the bed and she denied pain. Interventions: non-skid and well-fitting shoes, educated resident on use of the wheel chair brakes and to lock them prior to getting in or out of W/C and to alert staff prior to any transfers. *4/08/16 - 2:30 a.m. - Resident #3 called out and had fell fallen on her knees while attempting to transfer herself from her commode back to her wheelchair. A 2 cm x 2 cm skin tear was noted on her right knee, and bilateral knees and her right great toe had dark discoloration; the resident complained of pain to her bilateral knees and legs. Interventions: encouraged resident to not transfer without assistance, orders for wound care for the skin tear and referred to therapy. No Physical Therapy notes were found for the year 2016. A follow-up order on dated 04/09/16 indicated the resident's x-rays of her left knee and left hip. X-rays did not indicate any dislocations or fractures. No other interventions were done. A care plan updated 03/31/16 indicated Resident #3 was at risk for falls as evidenced by history of falls, problem with balance, had several general health conditions, mild/moderately impaired cognition, needed extensive assistance for transfers, and had vision deficits with a need for glasses. Interventions included: remind resident to ask for assistance, call light in reach, therapy evaluation, anticipate needs, assist with ADLs and toileting, bed in lowest position, educate in safety awareness, bed in lowest position, and assess for contributing factors related to fall history (medications, toileting needs, ADL needs and wheelchair use). An untimed nursing note on 4/18/16, indicated Resident #3 had a fall when her wheelchair went out from under her and she sat on the floor. No injury was found. No interventions were listed. This was her sixth fall since 2/28/16. During an interview on 4/20/16 at 8:48 a.m., Resident #3 said she had fallen in the past because she forgot to call the nurse for assistance. She said her falls usually occurred when she was getting up to go to the bathroom or when she was getting on or off the commode. She said her knees were bad and would buckle on her sometimes. During observations the following were noted for Resident #3: *4/18/16 at 10:40 a.m., the resident was in her bathroom on the commode by herself, no staff was present. There was no wheelchair alarm on the resident's chair. No fall mats were next to Resident #3's bed. *4/19/16 at 8:41 a.m., Resident #3 was sitting up in her wheelchair, pushing herself back and forth next to her bed, awaiting the CNA to come for her morning shower. No chair alarms were noted. No fall mats were next to bed. *4/20/16 at 8:48 a.m., Resident #3 was sitting up in her wheelchair, pushing herself back and forth next to her bed. No chair alarms were noted. No fall mats were next to bed. During an interview on 04/20/16 at 12:55 p.m., CNA H said Resident #3 had fall precautions that included being assisted by one person with transfers and toileting, to remind the resident to call staff for assistance when she wanted to go to the bathroom, and said the resident should have a bed/wheelchair alarm on to prevent falls. CNA H did not know if the resident had the bed or wheelchair alarms on. During an interview on 04/20/16 at 1:01 p.m., ADON C said Resident #3 had falls because she had to be redirected frequently and was impulsive. She said the staff were to follow the care plan interventions to prevent falls and the resident did not have a bed or chair alarm, but the team was discussing the need to implement this in the near future. She said the facility did not have a specific policy for fall prevention at this time. An undated Fall Prevention and Management Program indicated the process of addressing falls prevention was similar to that for other problems, and should include the following elements: assessment; [DIAGNOSES REDACTED]. During an interview on 4/20/16 at 2:00 p.m., the MDS Nurse said 50 residents were at high risks for falls.

Based on observation, interview, and record review, the facility failed to ensure 1 of 7 residents reviewed for pain received the necessary care and services to maintain the highest practicable, physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. (Resident #7) The facility did not provide pain relief or pain assessments for Resident # 7, who had a healing [MEDICAL CONDITION], vascular insufficiency with necrotic areas to 4 of the toes to his right foot, and a Stage II pressure sore on his buttocks. This failure could place 44 residents who received PRN pain medication at risk of unresolved pain relief, depression and lack of quality of life. Findings included: Electronic physician orders [REDACTED].#7 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. His orders did not include any routine anti-[MEDICAL CONDITION], Tylenol or pain medications. His orders included a PRN (as needed), [MEDICATION NAME]-[MEDICATION NAME] 5 mg -325 mg (2) every four hours as needed for pain. Orders further indicated: Wound to sacrum to be cleansed with normal saline, apply hydrogel, cover with Allevyn dressing every 3 days until resolved; and cleanse right great toe every evening, second toe and right heel with [MEDICATION NAME] and leave, open to air. The most recent MDS dated [DATE] indicated Resident #7 had clear comprehension, and was able to make himself understood. He required extensive assistance with all of his ADLs except he was independent for eating. His pain assessment indicated he was not on a routine pain medication regimen, but received PRN pain medication and received non-medication intervention for pain. He said the worst pain he had experienced in the last 5 days was a 4. (ie. pain scale 1-10; 1 minimal to 10 being excruciating pain). A care plan entry for pain last updated 3/11/16 indicated interventions were to assess Resident #7 for pain, discuss with his physician for maximum pain relief, and indicated pain medications are best given around the clock, and PRNs for breakthrough pain. Notify the physician of any changes to his level or frequency of pain. During an observation and interview on 4/18/16 at 2:00 p.m., Resident #7 was lying in bed. He was constantly rolling back and forth, on his right side and then back. He also moved his lower legs, back and forth, crossing and uncrossing his legs. The toes on his right foot were bright red, and necrotic areas were visible to his great, second, and third toes. He said he had daily pain, currently his back and buttocks were hurting, and said his pain was about an 8 (on a scale of 1-10). He said he did not ask for pain medication as it did not help much, he just tried to block it. CNA Q was notified of his discomfort and she told LVN R. During an interview on 4/18/16 at 3:25 p.m., CNA Q said Resident #7 slid down in bed a lot, and his foot and back hurt him all the time. She said LVN K gave him something for pain about 30-45 minutes ago. Resident #7's EMAR (electronic medication administration record) indicated his last PRN pain medication ([MEDICATION NAME] 5mg-325) was dated 4/17/16. During an interview on 4/18/16 at 3:05 p.m., LVN R said Resident #7's pain assessment indicated: 4/11-18- day shift 4/13- pain was an 8, all other days were a 0; evening 4/11 and 4/12 his pain was a 7, 4/13 and 4/14 his pain was a 6 and his pain on 4/17 it was a 3. LVN R said Resident #7 did not get routine pain medication. She said she did not think he was having a lot of pain. After discussion about the necrotic areas to his feet, the pressure sore to his buttocks, and the fracture to his leg LVN R, said she would contact the physician. During an observation on 4/18/16 at 4:00 p.m., the treatment nurse asked CNA Q if Resident #7 was given pain medication and she said the MA gave him something about 2:30 p.m. (after surveyor intervention). Resident #7 rolled on his right side and a small light pink open area (0.3 cm) was noted to his gluteal fold. His right foot had a black area on his heel that measured approximately 6 cm x 4 cm. The treatment nurse said it was mostly firmed, and when she pressed on his heel he gasped. His outer foot had a 1 cm x 1 cm black area, his great toe area was approximately 2 cm x 1 cm (black), second toe 0.5 x 0.5 cm, third toe had a small 0.3 cm dark area. During an observation and interview on 4/19/16 at 8:15 a.m., Resident #7 was eating breakfast sitting in his wheelchair; he said his pain was about a 7. Resident #7 said the nurse told him they were working on alternatives for his pain. During an interview on 4/19/16 at 10:30 a.m., CNA L said Resident #7 did not complain about pain much. She said she had to ask him if he was hurting or he would not complain. She said he often showed non-verbal signs of pain and rolled around a lot. She said she tried to position him for comfort. She said she encouraged him to verbalize pain to the nurses. She said he rolled around with pain 3-4 days a week. During an interview on 4/19/16 at 10:50 a.m., LVN J said he had to ask Resident #7 if he was hurting. He said when Resident #7 was first admitted to the facility, he verbalized his pain and requested pain medications. LVN J said the resident recently had some TIAs ([MEDICAL CONDITION]) and had some changes in his cognition, and did not verbalize his pain needs. LVN J said the resident's pain should be assessed by non-verbal symptoms. LVN J said Resident #7 received a new order on 4/18/16, (after surveyor intervention ) to receive pain medication prior to skin treatment. During an interview on 4/20/16 at 2:00 p.m., the MDS nurse said 44 residents received PRN pain medication.

Based on observation, interview, and record review, the facility failed to ensure residents received necessary treatment and services based on comprehensive assessment to promote healing, prevent infection, and prevent the worsening of pressure sores for 1 of 8 residents reviewed for pressure sores. (Resident #11) Resident #11 was admitted with a Stage 2 pressure sore on his coccyx. The facility did not measure or assess the pressure ulcer until 15 days later. The facility did not prevent Resident #11 ' s pressure sore from becoming infected and provide treatments as required. These failures contributed to the deterioration of Resident #11's pressure sore and placed 8 residents with pressure sores at risk for worsening of pressure sores and further skin breakdown. Findings included: 1. An undated electronic face sheet indicated Resident #11 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. An initial care plan dated 4/6/15 indicated Resident #11 had Stage 2 pressure sore to his coccyx and interventions included, to apply protective barrier after incontinence, assist resident to reposition frequently, document the condition of the skin breakdown with every treatment/dressing change, inspect skin head to toe weekly, keep skin clean and dry, notify physician of worsening of skin breakdown, position with pads and cushion to prevent pressure, treatments and dressings as ordered per physician. An MDS dated [DATE] indicated Resident #11 had clear comprehension and made himself understood and required extensive assistance with his ADLs, but was independent for eating. He had impairment in one lower extremity, was occasionally incontinent of urine, but was continent of bowel. The resident had a Stage 2 pressure sore with pink granulation tissue. Resident #11 was 72 inches in height (6 foot) and weighed 171 lbs. During an interview on 5/11/15 at 10:00 a.m., the MDS coordinator said Resident #11 had a Stage II pressure sore to his coccyx which was declining. She said the resident was on a low air loss mattress and was on his back often. During an interview on 5/13/15 at 2:45 p.m., the treatment nurse said she assessed Resident #11's skin after his admission on 4/6/15, but she could not find any documentation of the wound assessment. She said she found the nursing note entry dated 4/13/15, but not any wound measurement. She said the wound originally was kind of macerated, but slightly yellow with some serous drainage. Nursing notes for Resident #11 indicated the following: *4/6/15- (admission) noted he had a wound on his coccyx. (No measurements, no color nor description was noted.) *4/13/15- (nursing note 4/13/15 at 12:20 p.m.)- Denuded area and possibly Stage II pressure sore to gluteal cleft (coccyx wound from admission) draining serous fluid. Received orders from NP (nurse practitioner) for [MEDICATION NAME] two times a day until resolved. (no measurements noted.) Skin assessment sheets for Resident #11 indicated the following: *4/20/15 - Stage II pressure sore on coccyx measuring 6 centimeter (cm) x 5 cm (first measurement since admission), with - granulating red tissue, non-granulating pink wound margins. Exudate (drainage) small, yellow, and mild odor. Treatment [MEDICATION NAME] to Stage 2 pressure sore and surrounding denuded area. There was no nurse practitioner order for [MEDICATION NAME] on the electronic orders from 4/6/15 through 4/20/15. The undated electronic physician orders [REDACTED].#11 had a wound culture of his coccyx pressure sore dated 4/28/15 and it was positive [MEDICAL CONDITION]. The resident was started on Bactrim DS one by mouth two times daily. A physician's orders [REDACTED]. An electronic treatment administration record dated April 2015 indicated Santyl (removes slough, dead tissue) was applied to Resident #11 ' s pressure sore from 4/29-5/4/15. There was no skin assessment for Resident #11 from 4/20/15 until 5/4/15. Skin assessment sheets for Resident #11 indicated the following: *5/4/15- Unstageable pressure sore measuring 4.5 cm x 3 cm with 1.5 cm depth; tissue- granulating red, non-granulating pink wound margins, exudate heavy tan, purulent strong odor. Treatment calcium alginate and bordered dressing to on coccyx due to unstageable pressure ulcer until resolved. A physician's orders [REDACTED]. The Wound Care Consultant progress note dated 5/5/15 noted Resident #11's pressure sore on his coccyx was 1.5 cm x 1.5 cm by 1.5 cm (depth) with 4 cm of undermining from 7 o ' clock -5 o'clock No granulation tissue, no eschar, no odor, was noted and peri-wound was intact with small amount of serous drainage. The comments indicated to clean the base of the wound and continue to treat with Alginate, utilize a Roho (dry floatation air cushion) cushion while the resident was up in a chair and use a low air loss mattress while in the bed. Skin assessment sheets for Resident #11 indicated the following: * 5/7/15- Unstageable pressure sore measuring 4.5 cm x 3 cm with 1.5 cm depth; tissue- granulating red, non-granulating pink wound margins, exudate heavy tan, purulent strong odor. Treatment calcium alginate and bordered dressing to coccyx due to unstageable pressure sore until resolved. No tunneling was documented. During an observation and interview on 5/11/15 at 12:30 p.m., Resident #11 was sitting in his wheelchair on a Roho cushion. He had a trapeze bar on his bed, and said staff assisted him with positioning, due to his fractured right leg, but he could shift his weight with the trapeze bar. During an observation and interview on 5/11/15 at 2:12 p.m., Resident #11 was lying in bed on his left side on a low air loss mattress. The treatment nurse turned him on his right side and removed a dressing from his coccyx that had a moderate amount of serous/yellow drainage. There was a Stage 3 pressure sore on his coccyx that was approximately 3 cm x 2.5 cm in size. The treatment nurse said the depth of the wound was 1.5 cm with 4 cm tunneling at 12 o'clock. The wound bed was beefy red, but the wound edges were macerated (white, wet looking tissue) from 12 o'clock to 6 o'clock, with two open areas. The treatment nurse said the macerated areas were new, since she had seen him last, and she had not worked in a few days. One macerated area measured approximately 5 o'clock was 1 cm x 0.5 cm, and the second macerated open area at 12 o'clock was approximately 0.5 cm. The peri-wound of the coccyx was blanchable dark red approximately 6 cm around the circumference of the wound.The. The treatment nurse rinsed the wound with normal saline and placed a piece of Calcium Alginate on top of the wound (not in the wound bed) and covered it with a bordered gauze dressing. The treatment nurse said when Resident #11 admitted from the hospital he had a Stage 2 pressure sore on his coccyx, and the wound had recently " opened " to a Stage 3 pressure sore, and had deteriorated. The treatment nurse said she thought an unstageable pressure sore was " sort of " whitish and macerated looking. She said she wasn ' t sure, and had been trying to learn and ask question about pressure sores on her own. The treatment nurse said she the current drainage was purulent, sort of yellow/brown in color. She said the wound odor was worse than last week. The treatment nurse said she had been placing the Calcium Alginate on top of the wound rather than in the wound because it would "gel up" and then she would not be able to remove it. The treatment nurse said the resident was placed on the low air loss mattress when his wound deteriorated (5/4/15 per wound note). She said because of his fractured leg, he could not get comfortable and often stayed on his back, and she felt this had caused the decline of his wound. The treatment nurse said she had not been a treatment nurse before. During an interview on 5/12/15 at 2:35 p.m., the WCC said the Calcium Alginate should be packed inside of Resident #11's pressure sore, and he did not instruct it be placed on top of the sore. He was unaware of the resident's pressure sore having any odor. During an interview on 5/12/15 at 2:45 p.m., the DON said the treatment nurse had not received any formal wound care instruction, but oriented with the previous wound care nurse for several weeks. The DON said the treatment nurse was responsible for skin treatments and all residents' weekly skin assessments. She said the NP came weekly and was available for wound care consultation, and they had a WCC that would come when they called him. The DON said if the treatment nurse wanted her to look at a resident's skin she would, but she randomly checked the residents' skin/wounds. She said she, the treatment nurse and the administrator met weekly to discuss pressure sores and skin issues and was aware his pressure sore had declined. The Policy of Wound Nurse Orientation updated 4/2012 included mandatory trainings that included the following: Skin and wound care-skills checklist, Licensed nurse skin evaluation checks, nurse assistant skin evalutation checks and negative pressure wound therapy. This also included application of dressings and etc. The orientation included resource sites, nutritional needs and documentation guidelines. This orientation had not been done per the treatment nurse. http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/> This web page was accessed on 5/14/15. Category/ Stage II: partial thickness Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister.Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation. Category/Stage III: Full thickness skin loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. http://www.pdrhealth.com/drugs/[MEDICATION NAME], web page was accessed on 5/14/15. [MEDICATION NAME] is a topical ointment (applied directly on the skin) used to promote healing and treat decubitus ulcers or bedsores, ulcers due to varicose veins, or open wounds. [MEDICATION NAME] increases blood flow to your wound, helps fight bacteria, helps reduce pain, and removes unhealthy tissue from your wound. The CMS 672 dated 5/11/15 indicated 8 residents had pressure sores.

Based on observation, interview, and record review, the facility failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently to maintain the residents' highest physical well-being for 1 of 7 residents (Resident #11) reviewed for pressure sore care and 1 of 2 residents reviewed for peripherally inserted central catheter line care. (Resident # 23). The administrator and DON failed to ensure the the treatment nurse was trained appropriately, the pressure sore policy and procedures were available, and failed to ensure she was given a competency check prior to providing wound care and skin assessments. The administrator and DON failed to ensure LVNs received appropriate training and were competent to provide peripherally inserted central catheter (PICC) line care. No competency check offs had been completed. This failure could place 8 residents with pressure sores at risk for wound care decline, inappropriate treatment, infections and pain and could place 2 residents with PICC lines at risk for infections, complications of the PICC line and inappropriate dressing care. Findings included: 1. Resident #11 was admitted with a Stage 2 pressure sore on his coccyx. The facility did not measure or assess the pressure ulcer until 15 days later. The facility did not prevent Resident #11 ' s pressure sore from becoming infected and provide treatments as required. During an interview on 5/12/15 at 2:45 p.m., the DON said the treatment nurse had not received any formal wound care instruction, but had been oriented with the previous wound care nurse for 2-3 weeks. The DON said the treatment nurse was responsible for skin treatments and all residents' weekly skin assessments. She said the NP came weekly and was available for wound care consultation, and they had a WCC that would come when they called him. The DON said if the treatment nurse wanted her to look at a resident's skin she would, but she randomly checked the residents' skin/wounds. During an interview on 5/13/15 at 11:00 a.m., the DON said the reason for Resident #11's pressure sore decline was due to the treatment nurse's knowledge deficit, and not providing the appropriate treatment. She said she was unaware of Resident #11 not receiving the appropriate treatment. The DON said the treatment nurse needed a competency check, the weekend treatment nurse as well as the other nurses. During an interview on 5/13/15 at 11:20 a.m., the administrator said every employee hired received a general orientation and the DON made weekly rounds with the wound care nurse, but was unsure if she had been checked off for wound care skills. The administrator said the wound care nurse was trained by the former wound care nurse for a full two weeks. She said the DON, the treatment nurse and herself met weekly to discuss pressure sores and skin. The administrator said she was unaware of Resident #11's pressure sore was declining. 2. During an observation on 5/12/15 at 9:15 a.m., LVN L provided antibiotics to Resident #23 via his peripherally inserted central catheter (PICC) line. No competency checks for LVN L for intravenous (IV) therapy were done. During an interview on 5/12/15 at 10:00 a.m., the staffing coordinator said the ADON was attending a class on PICC lines so he could become a trainer to teach the staff on PICC lines. She said there was not any paperwork in the LVN files to verify if they were IV certified and they currently did not have an IV check off for competency. During an interview on 5/12/15 at 1:40 p.m., the ADON said he thought he had watched all of the nurses provide IV fluids/care, including LVN L. He said he thought there was a 10 p.m.- 6 a.m., he still needed to watch. The ADON said they did not have a competency check off but was hoping to have a more formal program soon. The CMS 672 dated 5/11/15 indicated 8 residents had pressure sores and 2 residents had PICC lines/IVs.

Based on interview and record review, the administrator and DON failed to ensure: the facility's resources were managed effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 of 1 residents reviewed for life sustaining equipment. (Resident #11) The administrator failed to ensure staff was trained to notify the administrator and the DON of a non-functioning emergency electrical power system (generator) and the DON failed to ensure arrangements were made to provide life sustaining equipment and interventions for residents requiring life sustaining equipment in the event of a non- functioning emergency electrical power system (generator). Resident #11 required suctioning via a [MEDICAL CONDITION]. The facility emergency power generator had not been functioning as of 7/11/14 at 4:45 p.m. The maintenance man did not notify nursing staff. The facility did not have an alternate plan for provision of suctioning for Resident #11. This failure created an Immediate Jeopardy situation identifed on 7/15/14 at 2:30 p.m. that had existed since 7/11/14 at 4:45 p.m. The Immediate Jeopardy was removed on 7/16/14 at 11:25 a.m. The facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 1 resident who received endotracheal suctioning at risk for respiratory complications including death. Findings included: During an interview on 7/15/14 at 3:00 p.m., the DON said she was just informed the emergency power system had been malfunctioning since 7/11/14 at 4:45 p.m. She said she had not made plans for emergency care for Resident #11. After surveyor intervention the DON said, Resident #11 would go to the local emergency room for life sustaining care due to the generator malfunction. She said ambulance could take up to 5 minutes to arrive. During a telephone interview on 7/15/14 at 3:33 p.m., the corporate maintenance man said he was aware on 7/11/14 the emergency generator was not functioning. He said he did not advise the facility maintenance man to notify the administrator or the DON. He said he did not inform the corporate clinical nursing of the malfunction of the generator. During an interview on 7/15/14 at 4:00 p.m., the RDO (administrator on vacation) said he was made aware of the generator malfunction by the life safety code surveyor. He said he would expect the facility maintenance man to inform him and the DON of such failures. During an interview on 7/15/14 at 4:20 p.m., the DON facility had no emergency plan in place for Resident #11. Electronic physician orders [REDACTED].#11 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #11 was in a persistent vegetative state, required total care for all ADLs, oxygen therapy and suctioning. The comprehensive care plan dated 6/12/14 indicated Resident #11 had a [MEDICAL CONDITION] and would have an effective airway. A nursing note dated 7/10/14 indicated Resident #11 was having thick yellow green colored sputum. A nursing note dated 7/5/14 indicated Resident #11 had thick yellow green sputum. During an observation on 7/14/14 at 10:35 a.m., Resident #11 was in bed. Humidified oxygen was being administered via the [MEDICAL CONDITION]. Resident #11 had expectorated (eject or expel matter, as phlegm, from the throat or lungs by coughing or hawking and spitting) thick yellow green colored sputum through the [MEDICAL CONDITION]. During an observation on 7/15/14 at 2:20 p.m., the emergency generator did not automatically start when the main power was shut off. The life sustaining equipment did not work. During an interview on 7/15/14 at 3:30 p.m., the maintenance man said on 7/11/14 at 4:45 p.m., he discovered the emergency generator was not functioning. He said he the contracted emergency power company said a part would be at the facility on Tuesday 7/15/14. He said he informed the corporate maintenance supervisor of the non- functioning emergency generator, but did not notify the administrator or the DON of the mal-function. He said he was un-aware of the risks it posed for the residents. He said he checks the generator weekly. During an interview on 7/16/14 at 9:20 a.m., the maintenance man said he had not been in-serviced on notification process for emergency power outages. He said he could not locate the contracted agreement with the generator company. The RDO and DON were notified on 7/15/14 at 2:30 p.m.,that an Immediate Jeopardy situation was identified due to the above failures. The plan of removal was accepted on 7/15/14 at 4:06 p.m. and included: *A 55 KW rental generator was delivered to the facility as back up to the facility 45 KW generator. *Power systems company on site on 7/15/14 to make repairs to the facility generator and provide connections to the rented back-up generator. *In the event of an emergency power was disrupted for any reason, the facility will take steps to immediately transfer any resident who require electricity to maintain any of their life support systems. *The nurses will be in-serviced on the required notifications they will need to make including, but not limited to Administrator, Director of Nurses, Assistant director of nurses, maintenance director, attending physician, responsible party and hospital emergency room staff. *Two nurses on each shift will be trained on how to manually start the generator in the event the generator fails to start automatically, or when power to the facility is interrupted. *The maintenance director will be responsible for training those two staff members. The surveyor confirmed the POR had been implemented sufficiently to remove the IJ by: *4 nurses were interviewed on manually starting the generator in the event the generator fails to start automatically, or when power to the facility is interrupted. *maintenance director was in-serviced on facility disaster plan and current electrical outage policy; and *observation of the generator functioning after the facility power system was turned off. On 7/16/14 at 11:25 a.m., the RDO and the DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated 7/14/14 indicated 1 resident required [MEDICAL CONDITION] care and suctioning.

Based on observation, interview, and record review, the facility failed to provide an emergency electrical power system to maintain life support systems in the event the normal electrical supply was interrupted for 1 of 1 resident reviewed for life sustaining equipment. (Resident #11) Resident #11 required suctioning via a [MEDICAL CONDITION]. The facility emergency electrical power system (generator) was not functioning as of 7/11/14 at 4:45 p.m. The maintenance man did not notify nursing. The facility did not have an alternate plan for provision of suctioning for Resident #11. This failure created an Immediate Jeopardy situation identifed on 7/15/14 at 2:30 p.m. that had existed since 7/11/14 at 4:45 p.m. The Immediate Jeopardy was removed on 7/16/14 at 11:25 a.m. The facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 1 resident who received endotracheal suctioning at risk for respiratory complications including death. Findings included: Electronic physician orders [REDACTED].#11 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #11 was in a persistent vegetative state, required total care for all ADLs, oxygen therapy and suctioning. The comprehensive care plan dated 6/12/14 indicated Resident #11 had a [MEDICAL CONDITION] and would have an effective airway. A nursing note dated 7/10/14 indicated Resident #11 was having thick yellow green colored sputum. A nursing note dated 7/5/14 indicated Resident #11 had thick yellow green tracheal secretions. During an observation on 7/14/14 at 10:35 a.m., Resident #11 was in bed. Humidified oxygen was being administered via the [MEDICAL CONDITION]. Resident #11expectorated (eject or expel matter, as phlegm, from the throat or lungs by coughing or hawking and spitting) thick yellow green colored secretions through her [MEDICAL CONDITION]. During an observation on 7/15/14 at 2:20 p.m., the emergency generator did not automatically start when the main power was shut off. The life sustaining equipment had no power supply while the main power was off. During an interview on 7/15/14 at 3:00 p.m., the DON said she was just informed the emergency power system had not functioned since 7/11/14 at 4:45 p.m. She said there was not a plan for emergency care for Resident #11. The DON said she would have to send Resident #11 to the local emergency room for life sustaining care due to the generator malfunction. She said the ambulance could take up to 5 minutes to arrive. During an interview on 7/15/14 at 3:30 p.m., the maintenance man said on 7/11/14 at 4:45 p.m., he discovered the emergency generator was not functioning. He said the emergency power company said a part would be at the facility on Tuesday 7/15/14. He said he informed the corporate maintenance supervisor of the nonfunctioning emergency generator, but did not notify the administrator or the DON of the malfunction. He said he was unaware of the risks it posed for the residents. He said he checks the generator weekly. During a telephone interview on 7/15/14 at 3:33 p.m., the corporate maintenance man said he was aware on 7/11/14 the emergency generator was not functioning. He said he did not tell the facility maintenance man to notify the administrator or the DON. He said he did not inform the corporate clinical nursing of the malfunction of the generator. During an interview on 7/15/14 at 4:00 p.m., the RDO said he was made aware of the generator malfunction by the life safety code surveyor. He said he would expect the maintenance staff to inform him and the DON of such failures. During an interview on 7/15/14 at 4:20 p.m., the DON said the facility still had no emergency plan in place for Resident #11. During an interview on 7/16/14 at 9:20 a.m., the maintenance man said he had not been in-serviced on a notification process for emergency power outages. He said he could not locate the contracted agreement with the generator company. The RDO and DON were notified on 7/15/14 at 2:30 p.m., that an Immediate Jeopardy situation had existed since 7/11/14 at 4:45 p.m. due to the above failures. The plan of removal (POR) was accepted on 7/15/14 at 4:06 p.m. and included: "*A 55 KW rental generator was delivered to the facility as back up to the facility 45 KW generator. *Power systems company on site on 7/15/14 to make repairs to the facility generator and provide connections to the rented back-up generator. *In the event of an emergency power was disrupted for any reason, the facility will take steps to immediately transfer any resident who require electricity to maintain any of their life support systems. *The nurses will be in-serviced on the required notifications they will need to make including, but not limited to Administrator, Director of Nurses, Assistant director of nurses, maintenance director, attending physician, responsible party and hospital emergency room staff. *Two nurses on each shift will be trained on how to manually start the generator in the event the generator fails to start automatically, or when power to the facility is interrupted. *The maintenance director will be responsible for training those two staff members." The survey team confirmed on 7/16/14 at 11:20 a.m. the POR had been implemented sufficiently to remove the Immediate Jeopardy by: *4 nurses were interviewed on manually starting the generator in the event the generator fails to start automatically, or when power to the facility is interrupted. *the maintenance director was interviewed and had been in-serviced on the facility disaster plan and current electrical outage policy *the generator was observed to function after the facility power system was turned off On 7/16/14 at 11:25 a.m., the RDO and the DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated 7/14/14 indicated 1 resident required [MEDICAL CONDITION] suctioning.