Every finding on record at Rio Rancho Center

Based on observation, record review, and interviews, the facility failed to ensure residents received the necessary treatment and services to promote healing of a wound for 1 (R #1) of 1 (R #1) resident reviewed, when the facility staff failed to:Provide consistent wound care per physician orders for R #1.Implement interventions to address repeated refusals of wound care.Ensure R #1's wound care was completed by facility nursing staff and not by R #1.These deficient practices led to R #1 having maggots (a soft bodied, legless larva of a fly or other insect, found in decaying matter) present causing the wound on R #1's right foot to worsen. If wound care is not provided as ordered by a physician, then the residents are likely at risk for wound deterioration, infection, delayed healing, and other complications. The findings are: A. Record review of the facility's treatment policy, revised on [DATE], revealed the following: Licensed nurses or medical technicians performed ordered treatments according to state regulations. If a resident refused treatment, staff attempted the treatment again later and notified the physician or advanced practice provider when the resident refused a second attempt.Staff evaluated the resident's comfort during treatment and notified the physician or advanced practice provider of significant changes in the treatment area.Staff documented treatment administration on the Treatment Administration Record (TAR), the resident's response, any treatment refusal, and physician or advanced practice provider notification, as applicable. B. Record review of the facility's skin integrity and wound management policy, dated [DATE], revealed the following:Staff completed comprehensive skin and wound assessments upon admission, weekly, with significant changes in condition, and as clinically indicated. Staff documented performance of skin inspections and wound evaluations for newly identified or existing skin and wound impairments.Staff performed daily monitoring and documentation of wounds and dressings, including assessment of dressing integrity, surrounding tissue changes, wound related pain, and signs of wound deterioration or complications. The facility implemented physician ordered wound care treatments, notified the physician or advanced practice provider of changes in wound condition, and communicated significant changes to the interdisciplinary team.Staff revised the resident's care plan to reflect findings from the comprehensive skin and wound assessment and changes in the resident's condition. C. Record review of R #1's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) revealed R #1 was admitted on [DATE] with a diagnosis of bilateral lower-extremity atherosclerosis with gangrene (a condition in which narrowed or blocked arteries reduce blood flow to both legs and feet, resulting in tissue death due to inadequate circulation) and paraplegia (paralysis of both legs). R #1's Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) showed a score of 14, cognitively intact. D. Record review of R #1's care plan, dated [DATE], revealed R #1 was admitted with multiple skin issues and concerns, including right and left foot wounds, and staff were instructed to provide wound treatments as ordered. R #1's care plan, updated on [DATE], instructed staff to complete a change in condition (CIC; any noticeable shift in a resident's health, behavior, or functional status from their established baseline) for all wound care treatment refusals, notify the provider, and notify the family. E. Record review of R #1's physician orders revealed the following: Dated [DATE], R #1 was admitted to Hospice with a diagnosis of bilateral foot gangrene, and R #1 was not allowed to administer his own medications. Dated [DATE], wound care to both feet. Cleanse the wounds with soap and water, apply Betadine (an antiseptic solution used to prevent and treat infections in minor cuts, scrapes, burns, and surgical wounds), add metronidazole powder (used to treat bacterial infections), cover with an ABD (thick gauze dressing) pad, wrap with Kerlix (woven gauze dressing used primarily for wound care, known for its absorbency, cushioning, and versatility), secure the dressing with tape, and change dressings twice weekly every Monday and Thursday and as needed when. Discontinued on [DATE]. Dated [DATE], weekly head-to-toe skin assessments and document all skin findings. If staff identified new or worsening skin issues, obtained a wound photograph, complete the required documentation, and ensure current wound treatment orders were in place.Dated [DATE], perform wound care to both feet. Cleanse the wounds with soap and water, apply Betadine, add metronidazole powder, cover with an ABD pad, wrap with Kerlix, secure the dressing with tape, and change dressings twice weekly every Tuesday and Thursday and as needed when soiled. Discontinued on [DATE].Dated [DATE], complete a head-to-toe skin evaluation every Tuesday during the day shift.Dated [DATE], perform wound care to both feet. Cleanse with wound cleanser, apply Betadine to gangrenous toes and open areas, apply metronidazole powder to the right foot and toes, cover with an ABD pad, wrap with Kerlix, secure the dressing with tape, and change dressings daily and as needed when soiled. Discontinued on [DATE]. Dated [DATE], perform a daily skilled nursing assessment of the wound dressings and surrounding tissue for changes in dressing integrity, drainage, bleeding, edema (swelling), odor, pain, and other signs of wound deterioration. Staff to document significant findings, notify the Physician and Wound Care Specialist of complications, and implemented new orders as indicated.Dated [DATE], to perform wound care to both feet. Cleanse with wound cleanser, apply Betadine to gangrenous toes and open areas, apply metronidazole powder to the right foot and toes, apply hydrogel (a gel in which the liquid component is water) and Xeroform (a sterile, non-adherent wound dressing made of gauze used to protect wounds and promote healing) to the exposed bone and tendon, cover with an ABD pad, wrap with Kerlix, secure the dressing with tape, and change dressings daily and as needed when soiled. F. Record review of R #1's TAR, dated [DATE] through [DATE], revealed the following: Dated [DATE] through [DATE], staff documented they completed R #1's wound care as ordered for four out of nine opportunities. Staff documented the physician placed the wound care on hold four times. Dated [DATE] through [DATE], staff documented they completed R #1's wound care as ordered for two out of nine opportunities. Staff documented the physician placed the wound care on hold four times, and R #1 refused wound care treatment once. Dated [DATE] through [DATE], staff documented they completed R #1's wound care as ordered for zero out of nine opportunities. Staff documented R #1 refused the wound care treatment eight times, and staff did not document anything for one day. Dated [DATE] through [DATE], staff documented they completed R #1's wound care as ordered for one out of three opportunities. Staff documented R #1 refused the wound care treatment once, and staff documented see nurses' notes for one treatment.Dated [DATE] through [DATE], staff documented they completed R #1's wound care as ordered for five out of seven opportunities. Staff documented R #1 refused the wound care treatment twice. G. Record review of R #1's skin issues assessment documentation, revealed the following: Dated [DATE], right foot wound - frostbite (injury to body tissues caused by exposure to extreme cold, typically affecting the nose, fingers, or toes and often resulting in gangrene) involving the entire foot, with eschar (dark, crusty tissue that forms on top of a wound) present. The wound measured 9.21 centimeters (cm) in length, 7.74 cm in width, and 0 cm in depth.Dated [DATE], right foot - frostbite involving the entire foot, with eschar present. The wound measured 12.1 cm in length, 11.32 cm in width, and 0 cm in depth. Staff documented maggots were not present in the wound as of [DATE].The record did not contain any other skin issue assessments dated [DATE] through [DATE]. H. Record review of R #1's nursing progress notes, revealed the following:Dated [DATE], staff completed wound care for R #1 on [DATE], and the facility's Wound Care Nurse (WCN) would complete wound care on [DATE].Dated [DATE], a provider documented nursing staff reported R #1 frequently refused wound dressing changes. The WCN stated R #1 refused dressing changes on [DATE] through [DATE] but agreed to a dressing change on [DATE]. Upon removal of the wound dressing, there was a heavy amount of malodorous drainage (bodily fluid or discharge that has a strong, unpleasant, or foul smell, often indicating infection or tissue breakdown) on the right foot, with maggots present on the wet gangrenous toes. Staff irrigated R #1's right foot with wound cleanser solution and Betadine solution until maggots were no longer visible and the drainage was clear, although an odor remained. R #1's primary nurse and the facility WCN were at the bedside. Staff contacted the hospice provider regarding the presence of maggots in R #1's foot wound. The hospice supervisor stated she would notify the hospice nurse and provider and would call back with any new orders. I. Record review of R #1's nursing progress notes, dated [DATE], revealed the hospice physician provided updated wound care orders and told the facility WCN that amputation (the action of surgically cutting off a limb) of R #1's right foot would be the only available treatment option. J. On [DATE] at 9:51 AM, during an interview and observation, R #1 stated he performed his own wound care since admission because different nurses used different wound care techniques. R #1 stated some nurses removed dry gauze without first moistening the dressing, which caused pain and removal of skin. R #1 stated he occasionally refused wound care because he had already completed the dressing change himself or believed it had already been completed. R #1 stated the facility's WCN was the staff member he trusted to perform wound care and was usually the one who provided the wound care. R #1 stated the facility WCN discovered maggots during a dressing change and, after this discovery, began performing daily wound care instead of every other day. R #1 stated he felt sad about the planned amputation of his right foot, and losing his foot would mean he would no longer be able to feel sand, grass, or water with his foot. R #1 was observed to be upset and became tearful when discussing the amputation. Wound care supplies were also observed stored in R #1's room. K. On [DATE] at 12:37 PM, during an interview, the facility WCN stated the Nurse Practitioner (NP) assessed R #1's right foot wound on [DATE] and identified approximately 30 maggots in the wound. The WCN stated staff last completed R #1's wound care on [DATE], before maggots were found on [DATE]. The WCN stated the NP revised the wound care orders on [DATE] and increased R #1's wound care to daily treatments because of the condition of R #1's right foot wound. The WCN stated floor nurses performed wound care on weekends, and the WCN provided wound care Monday through Friday. The WCN stated R #1 refused wound care with facility nurses and often requested the WCN to complete the wound care, but the WCN did not know why R #1 refused wound care treatments. L. On [DATE] at 2:51 PM, during an interview, Licensed Practical Nurse (LPN) #1 stated she had never performed wound care on R #1 because the resident preferred to perform his own wound care. LPN #1 stated staff did not identify why the resident preferred to perform wound care independently. LPN #1 stated refusals of wound care should be documented in the medical record. LPN #1 stated R #1 generally allowed the WCN to provide wound care because the WCN had established a trusting relationship with him. LPN #1 stated she observed R #1 covering his lower extremities with plastic bags and was aware staff had complained about the odor from the wounds. LPN #1 stated the WCN and the NP discovered maggots in R #1's foot wound during a wound assessment. M. On [DATE] at 12:21 PM, during an interview, the Hospice Registered Nurse (HRN) stated she had cared for R #1 since [DATE] but had never assessed the resident's wounds or performed wound care because the facility's WCN was responsible for providing wound care. The HRN stated wound care was initially performed approximately three times per week and later increased to daily treatments after maggots were discovered in R #1's right foot wound. The HRN stated R #1 was admitted to hospice with gangrene and originally elected hospice services because he did not want to undergo an amputation surgery. The HRN stated she educated R #1 regarding the seriousness of the infection and discussed the option of amputation on multiple occasions. The HRN stated she ordered the wound care supplies but followed the facility WCN's treatment orders. The HRN stated her understanding was R #1 had also refused wound care from the facility WCN for a period of time. The HRN stated she routinely communicated with the WCN regarding R #1's wounds and was informed when he refused treatment. The HRN stated approximately two to three weeks before the maggots were discovered, R #1 began allowing the WCN to perform wound care. The HRN stated the WCN initially performed wound care approximately three times per week and later performed wound care daily. The HRN stated she did not personally observe the maggots, and the facility WCN discovered the maggots during a dressing change and notified her of the finding. The HRN stated she immediately contacted the hospice provider and provided the WCN's telephone number so the provider could speak directly with the WCN regarding treatment orders. The HRN stated she had been told R #1's wounds appeared fine the day before the maggots were discovered and was surprised by the report. The HRN stated the WCN reported not knowing how the maggots developed. N. On [DATE] at 3:06 PM, during an interview, Registered Nurse (RN) #1 stated she had not recently observed R #1's foot wounds because the facility's WCN typically performed wound care. RN #1 stated R #1 sometimes refused wound care and performed his own dressing changes. RN #1 stated refusals of wound care should be documented in the medical record. RN #1 stated facility nurses were responsible for providing wound care, with the WCN performing most of the advanced wound care treatments. RN #1 stated R #1 allowed the WCN to perform dressing changes because they had developed a good rapport. O. On [DATE] at 3:35 PM, during an interview, LPN #2 stated wound care treatment refusals should be documented in the medical record and hospice should be notified. LPN #2 stated the facility's WCN informed her maggots had been discovered in R #1's right foot wound, and she assisted while the WCN removed the maggots. LPN #2 stated the facility's wound care team was primarily responsible for R #1's wound care, with the WCN performing most of the treatments. LPN #2 stated if the WCN was unavailable, the nurse assigned to the resident was responsible for providing wound care treatments. P. On [DATE] at 3:57 PM, during an interview, the Wound Care Nurse Practitioner (WCNP) stated [DATE] was the first time she had assessed R #1's wounds. The WCNP stated R #1 reported during this assessment that the last dressing change had been completed on [DATE]. The WCNP stated the dressings were heavily saturated, and maggots were present in R #1's right foot wound, along with a large amount of drainage and odor. The WCNP stated the wound was cleansed, the maggots were removed, an antibiotic was ordered, and wound care orders were updated. The WCNP stated the maggot infestation likely developed because dressing changes had not been completed consistently by facility nursing staff and the dressings had become saturated. The WCNP stated nursing staff were expected to document repeated wound care treatment refusals and notify the provider, so the next step could be addressed in providing resident wound care, but this did not occur. Q. On [DATE] at 12:34 PM, during an interview, the Director of Nursing (DON) stated R #1 had performed his own wound care at times and should have been assessed to determine whether he was competent to safely perform his own wound care. The DON stated wound care supplies should never be left in a resident's room and should be stored in the treatment cart in accordance with facility policy. The DON stated the resident's care plan should have been updated to reflect his performance of wound care and current care needs. The DON stated the WCN, WCNP, hospice, and facility nurses were all responsible for R #1's wound care and were expected to assess his wounds, communicate changes in condition, and ensure physician ordered wound care and documentation were completed. The DON stated all licensed nurses shared responsibility for visualizing the resident's wounds and performing skin assessments and should not rely solely on the WCN. The DON stated when a resident refused wound care, staff were expected to educate the resident regarding risks and benefits of refusing treatment, continue attempts to provide ordered wound care, document the refusal, and update the resident's care plan. The DON stated if physician ordered wound care and wound assessments were not completed, the resident's wounds could worsen. The DON stated her expectation was for physician ordered wound care, wound assessments, skin checks, and documentation to be completed.

Based on observation, record review, and interviews, the facility failed to maintain a sanitary environment to prevent the transmission risk of infectious agents for 2 (R #1, and R #4) of 2 (R #1, and R #4) residents, when:Facility staff stored wound care treatment supplies in unsanitary locations in R #1's and R #4's rooms.Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) guidelines were not followed when staff failed to wear Personal Protective Equipment (PPE; protective clothing, face masks, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) while providing care to R #4, who required PPE use during care. These deficient practices have the potential to expose staff and other residents to infectious diseases. The findings are:A. Record review of the facility's treatment policy, revised on 06/01/21, revealed the following: Licensed nurses or medical technicians performed ordered treatments according to state regulations. If a resident refused treatment, staff attempted the treatment again later and notified the physician or advanced practice provider when the resident refused a second attempt. Staff are required to maintain standard precautions (basic level of infection control practices designed to reduce the risk of transmission of bloodborne and other pathogens from both recognized and unrecognized sources) during treatments. Staff evaluated the resident's comfort during treatment and notified the physician or advanced practice provider of significant changes in the treatment area.Staff documented treatment administration on the Treatment Administration Record (TAR), the resident's response, any treatment refusal, and physician or advanced practice provider notification, as applicable. B. Record review of the facility's skin integrity and wound management policy, dated 09/15/25, revealed the following:Staff completed comprehensive skin and wound assessments upon admission, weekly, with significant changes in condition, and as clinically indicated. Staff documented performance of skin inspections and wound evaluations for newly identified or existing skin and wound impairments.Staff performed daily monitoring and documentation of wounds and dressings, including assessment of dressing integrity, surrounding tissue changes, wound related pain, and signs of wound deterioration or complications. The facility implemented physician ordered wound care treatments, notified the physician or advanced practice provider of changes in wound condition, and communicated significant changes to the interdisciplinary team.Staff revised the resident's care plan to reflect findings from the comprehensive skin and wound assessment and changes in the resident's condition. R #1: C. Record review of R #1's face sheet revealed R #1 was admitted on [DATE] with a diagnosis of Atherosclerosis of the native arteries of the extremities with gangrene (hardening and narrowing of the arteries that reduces blood flow to the extremities, resulting in tissue death), and a pressure ulcer (PU; an injury to skin and underlying tissue resulting from prolonged pressure on the skin). D. Record review of R #1's care plan, dated 03/08/26, revealed R #1 was at risk for skin breakdown related to a history of foot wounds and a documented pressure ulcer to the sacrum (a large flat bone in the lower part of the spine, forming the rear section of the pelvis). Staff were instructed to provide wound treatment as ordered, change wound dressings every one to three days, and provide preventive skin care while applying barrier cream (a cream used to protect the skin from damage or infection) with each cleansing. E. On 07/22/26 at 1:15 PM, during an observation, R #1's room contained one 16-ounce bottle of wound cleanser, gauze, medical tape, bandage gauze, Optifoam (an advanced foam wound dressing designed to promote optimal healing, reduce infection risk, and enhance patient comfort), and abdominal pads (large wound dressing) stored throughout the room in locations that were not sanitary. F. On 07/23/26 at 12:37 PM, during an interview, the Wound Care Nurse (WCN) stated, in accordance with facility policy, wound care supplies should not be kept in R #1's room because they could become contaminated and increase the risk of infection. G. On 07/27/26 at 10:49 AM, during an interview, the Unit Manager (UM) #1 stated wound care supplies should be kept in a sanitary location and not in R #1's room. UM #1 stated when wound care supplies are not maintained in a sanitary location, the resident is at risk for wound contamination, infection, and delayed healing. R #4: H. Record review of R #4's face sheet revealed R #4 was admitted on [DATE] with a diagnosis of a pressure ulcer of the sacral region (a localized injury to the skin and underlying tissue over the tailbone caused by prolonged pressure or pressure with shear), and Type 2 diabetes mellitus (DM2; a disease in which the body cannot make or properly use insulin). I. Record review of R #4's care plan, dated 12/29/25, revealed R #4 had a pressure ulcer and required EBP. Staff were directed to follow EBP guidance and use gowns and gloves for all personal care. J. On 07/27/26 at 10:35 AM, during an observation, R #4 was lying in bed wearing a T shirt and a brief, with soiled bed linen. Signage was posted outside R #4's room indicating R #4 was on EBP. K. On 07/27/26 at 10:41 AM, during an observation, Licensed Practical Nurse (LPN) #3 and UM #1 were observed providing care to R #4 without wearing required PPE gowns. R #4's room contained one 16 ounce bottle of wound cleanser, medical tape, gauze pads, and abdominal pads stored throughout the room in locations that were not sanitary. L. On 07/27/26 at 10:51 AM, during an interview, LPN #3 stated proper PPE, including gowns and gloves, should be worn while providing resident care. LPN #3 stated infections can spread when proper EBP is not followed. M. On 07/30/26 at 3:42 PM, during an interview, the Director of Nursing (DON) stated wound care supplies should never be left in a resident's room and should be stored in the treatment cart in accordance with facility policy. The DON stated it was her expectation for staff to know a resident's required EBP before providing care and to follow facility policy, including wearing appropriate PPE while providing care.

Based on record review and interviews, the facility failed to ensure residents were able to receive mail on Saturdays for all 110 residents residing at the facility. This deficient practice is likely to result in residents not receiving timely communication which could result in feelings of isolation. The findings are: A. Record review of the facility's admission Packet, undated, revealed residents' incoming or outgoing correspondence will not be opened, delayed, held, or censored. B. On 06/02/26 at 2:00 pm, during the Resident Council Meeting, the residents stated mail was not delivered on Saturdays, and they wanted to receive their mail when it arrived at the facility. R #33 stated mail was not delivered on Saturdays and any mail the facility received was held until Monday. C. On 06/04/26 at 12:11 pm, during an interview, the Receptionist stated the residents' mail was not delivered on Saturdays, because the Business Office Manager did not work on weekends. The receptionist stated the residents' mail was held until the Business Office Manager returned on Monday.

Based on record review, observations and interviews, the facility failed to ensure beverage items used for resident meal service were labeled and dated. This deficient practice is likely to affect all 110 residents in the facility. If staff do not store food according to food handling standards, then residents could acquire foodborne illnesses. The findings are: A. Record review of the facility's food and nutrition services policy, dated 05/01/23, revealed the following: 1. Food and nutrition employees prepared, labeled, and dated evening snacks including the use by date. 2. Labels are affixed to each item, which included the resident's name, the current date, and the use by date. 3. The use by date was either added to the tray card label or on an additional label is used to indicate the use by date. 4. Food and Nutrition Services employees inventoried the nurses' station pantries at least daily and stocked them with enough covered, labeled, and dated items, including use by dates. B. On 05/31/26 at 11:10 am, an observation of the kitchen revealed the following: 1. Eight pitchers filled with a yellow-colored liquid were not labeled or dated and were stored in the refrigerator. 2. Three pitchers filled with brown-colored liquid were not labeled or dated and were stored in the refrigerator. C. On 05/31/26 at 12:06 pm, during an observation of the resident lunch service, staff served the residents the brown liquid from the refrigerator. D. On 05/31/26 at 12:06 pm, during an interview, the Registered Nurse Supervisor stated the brown liquid was not labeled or dated. She stated it should have been labeled and dated prior to being served to the residents. E. On 05/31/26 at 12:17 pm, during an interview, the Dietary Manager (DM), he stated the pitchers were not labeled. He stated all food and beverage items should be labeled and dated. The DM stated it was his expectation for staff to follow facility polices. He stated staff were trained and required to label and date food items prior to storage or service to the residents.

Based on observation, record review, and interviews, the facility failed to maintain a sanitary environment to prevent the transmission risk of infectious agents when staff failed to:- Ensure enhanced barrier precautions signage (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) was posted outside of R #4's room.- Wear personal protective equipment (PPE) when providing direct care and administering medications through a gastric feeding tube for R #90.- Ensure nasal cannulas (flexible tube with two prongs inserted into the nostrils to deliver supplemental oxygen) and humidifiers (concentrator component; bottle filled with distilled water that adds moisture to the oxygen to prevent the user's nasal passages from drying out) were dated and labeled for R #7, R #10, R #83, R #90, and R #122.These deficient practices have the potential to spread infectious diseases. The findings are: Enhanced Barrier Precautions R #4 A. Record review of R #4's Face Sheet revealed R #4 was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: 1. End stage renal disease (ESRD; chronic irreversible kidney failure), 2. Chronic kidney disease (CKD; is the gradual, long-term loss of the kidney's ability to filter waste and excess fluid from your blood), 3. Dependence on renal dialysis (ongoing dialysis therapy). B. Record review of R #4's physician orders revealed the following orders: 1. An order, dated 04/29/26, for hemodialysis (a medical treatment that filters waste and excess fluid from the blood). Dressing changes may be performed if the dressing was accidentally removed or come off. 2. An order, dated 04/29/26, staff to monitor the hemodialysis catheter (an indwelling device used to access a major vein) site for signs and symptoms of complications. C. Record review of R #4's care plan, dated 04/29/26, revealed interventions directed staff to monitor hemodialysis catheter site for catheter integrity, excessive redness, swelling, paint at the site, and signs and symptoms of infection or bleeding. Staff were instructed to report any concerns to the physician as indicated. D. On 06/01/26 at 9:36 am, during an observation, R #4 did not have an enhanced barrier precaution sign posted on or around his door. E. On 06/04/26 at 12:19 pm, during an interview, Licensed Practical Nurse (LPN) #1 stated R #4 had a hemodialysis catheter, which was an indwelling device. She stated R #4 should have an EBP sign posted on his door, but he did not have one. She stated that delete all nursing staff were responsible to ensure EBP is responsible for ensuring signs are posted. She stated nurses were trained to identify needs that required EBP. Personal Protective Equipment R #90 F. Record review of R #90's annual Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 02/25/26, revealed the following: 1. R #90 was admitted to the facility on [DATE]. 2. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) was not completed because R #90 was rarely or never understood. 3. R #90 utilized a feeding tube (a tube surgically inserted through the abdomen into the stomach and used to provide fluids, nourishment and medications). G. Record review of R #90's care plan, dated 12/04/25, revealed R #90 was on enhanced barrier precautions due to having a feeding tube. H. On 05/31/26 at 8:51 am, during an observation, Licensed Practical Nurse (LPN) #3 walked into R #90's room, removed the resident's blanket, replaced the resident's nasal cannula, checked the resident's oxygen saturation (the amount of oxygen in the blood), and replaced the resident's blanket. Further observation revealed LPN #3 did not wear PPE while providing direct care to R #90. I. On 06/03/26 at 11:30 am, during observation, CMA #1 administered medication to R #90 through a feeding tube. CMA #1 wore gloves but did not wear a gown prior to accessing the resident's feeding tube and administering medications. Further observation revealed an EBP sign was posted on the wall outside of R #90's room and directed staff to use a gown and gloves for high contact activities, including device care. J. On 06/03/26 at 11:30 am, during an interview, Certified Medical Assistant (CMA) #1 stated she did not have to wear a gown during medication administration through a feeding tube. K. On 06/04/26 at 1:58 pm, during an interview, the Market Resources Clinician (MRC; regional corporate staff sitting in for the DON) stated it was expected for all staff to wear gloves and a gown for feeding tube related tasks, including flushing, dressing changes, and medication administration. The MRC stated all staff should wear PPE when providing direct care to R #90, because EBP was in place for the resident. Oxygen Equipment L. Record review of the facilities Respiratory Equipment/Supply Cleaning/Disinfecting policy, dated 07/15/21, revealed the following: 1. Staff to change oxygen delivery devices every seven days and as needed (PRN) for soiling, 2. Staff to change oxygen humidifiers every seven days and PRN for soiling. R #7 M. Record review of R #7's Face Sheet revealed R #7 was admitted to the facility on [DATE] with the following diagnoses: 1. Dysphagia (difficulty or discomfort in swallowing, as a symptom of disease), 2. Hypertension (HTN; high blood pressure). N. Record review of R #7's physician orders revealed the following: 1. An order, dated 03/26/26, supplemental oxygen to be administered at 2 liters per minute (lpm) via nasal cannula at bedtime and as needed. 2. An order, dated 03/12/26, staff to change the oxygen tubing weekly and label each component with the date and their initials. O. On 05/31/26 at 1:20 pm, during an observation and interview, an oxygen concentrator (a medical device that concentrates oxygen and delivers it to someone that needs supplemental oxygen) sat on the floor on the left side of R #7's bed. Further observation revealed the nasal cannula was attached to the concentrator. There was not a date on the nasal cannula or the humidifier. R #7 stated he did not wear his oxygen all the time. P. On 05/31/26/26 at 2:08 pm, during an interview, Certified Nurse Aide (CNA) #1 stated the nasal cannula and humidifier were not labeled or dated for R #7. She stated she could not state when the last time the tubing was changed. R #10 Q. Record review of R #10's Face Sheet revealed R #10 was admitted to the facility on [DATE] with the following diagnoses: 1. Quadriplegia (paralysis of all four limbs), 2. Persistent vegetative state (PVS; a person who is awake but lacks cognitive function), 3. Chronic Respiratory Failure (a life-term condition where the lungs cannot maintain adequate oxygen levels). R. Record review of R #10's physician orders, dated 09/18/24, revealed an order for supplemental oxygen to be administered at 1 to 5 liters lpm via nasal cannula as needed. S. On 05/31/26 at 1:03 pm, during an observation, R #10 lay in his bed and wore a nasal cannula connected to an oxygen concentrator. Further observation revealed the nasal cannula and humidifier were not dated. T. On 05/31/26 at 2:12 pm, during an interview, CNA #1 stated the nasal cannula and humidifier were not labeled and dated for R #10. She stated she could not state when the last time the tubing was changed. R #83 U. Record review of R #83's admission Record revealed R #83 was admitted to the facility on [DATE] with the following diagnoses: - Sepsis (a serious condition in which the body responds improperly to an infection), - Metabolic encephalopathy (a brain dysfunction caused by metabolic disturbances in the body, leading to symptoms such as confusion, memory loss, and altered consciousness), - Traumatic brain injury (TBI; injury to the brain caused by an outside force, usually a violent blow to the head). V. Record review of R #83's quarterly MDS assessment, dated 04/23/26, revealed R #83 was to receive oxygen therapy while at facility. W. Record review of R #83's comprehensive care plan, dated 04/28/26, revealed staff were to administer oxygen as ordered, via nasal cannula, to maintain an oxygen saturation of 89%. X. Record review of R #83's physician orders revealed the following: - An order, dated 6/17/25, staff to change oxygen tubing weekly and to label and date it every Sunday on the night shift. - An order, dated 6/17/25, staff to administer oxygen at 2 to 5 liters per minute by nasal cannula continuously. Y. On 05/31/26 at 2:15 pm, during an observation, R #83 wore a nasal cannula connected to an oxygen concentrator. Further observation revealed the oxygen tubing was not labeled or dated. Z. On 5/31/26 at 2:20 pm, during an interview, LPN #4 stated R #83's oxygen tubing did not have a label or a date after it was changed, but it should have. She stated she was designated responsible for changing O2 tubing weekly. She stated she recently changed the tubing but did not date or label the tubing. R #90 AA. Record review of R #90's annual Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 02/25/26, revealed the following: 1. R #90 was admitted to the facility on [DATE]. 2. R #90 utilized oxygen therapy (a therapy treatment which provides extra oxygen). BB. Record review of R #90's Electronic Health Record (EHR) revealed it did not contain an order for oxygen use. CC. On 05/31/26 at 8:40 am, during an observation, R #90 lay in her bed with a nasal cannula resting around her neck and chest area. Further observation revealed the nasal cannula was attached to an oxygen concentrator sitting on the floor near R #90's bed. The nasal cannula tubing did not have a label or date. DD. On 05/31/26 at 8:51 am, during an interview, Licensed Practical Nurse (LPN) #3 stated R #90 wore supplemental oxygen. LPN #3 stated the nasal cannula tubing did not have a date indicating when it was last changed. EE. On 06/04/26 at 1:50 pm, during an interview, the MRC stated it was his expectation for staff to follow policies to include all oxygen tubing to be replaced weekly and labeled with the date the tubing was changed. R #122 FF. Record review of R #122's Face Sheet revealed she was admitted to the facility on [DATE] with the following diagnoses: 1. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar) with hyperglycemia (abnormally high levels of sugar in the blood), 2. Atherosclerotic heart disease (the build-up of fats, cholesterol, and other substances in and on the artery walls). GG. Record review of R #122's physician orders, dated 02/14/26, revealed an order 1 to 5 liters of oxygen via nasal cannula continuously. HH. On 06/01/26 at 9:10 am, during an observation, R #122 lay in her bed. Further observation revealed R #122 wore a nasal cannula attached to an oxygen concentrator sitting on the floor near the bed. Further observation revealed the nasal tubing not initialed or dated. II. On 06/04/26 at 2:00 pm, during an interview, the MRC stated staff should change the oxygen tubing every seven days as ordered. He stated staff should label the oxygen tubing to indicate the date it was changed.

Based on observation, record review, and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) accurately reflected residents' clinical status for 3 (R #7, R #79, and R #117) of 6 (R #2, R #7, R #79, R #111, R #117, and R #122) residents reviewed for assessments. If staff do not accurately assess residents, then the resident may not receive the care needed to obtain optimal health. The findings are: R #7 A. Record review of R #7's MDS, dated [DATE], revealed the following: 1. R #7 was admitted to the facility on [DATE]. 2. R #7 had the following diagnoses: - Hypertension (HTN; high blood pressure), - Type 2 diabetes mellitus (DM2, a disease in which the body cannot make or properly use insulin), - Post traumatic stress disorder (PTSD; a mental health condition triggered by a terrifying event, causing flashbacks, nightmares, and severe anxiety), - Benign prostatic hyperplasia (BPH; enlarged prostate). 3. R #7 did not take hypnotic medications. 4. R #7 did not receive oxygen therapy. 5. R #7 took anticoagulant medications. B. Record review of R #7's physician orders revealed the following: 1. An order, dated 03/26/26, for Ramelteon (hypnotic; medication to induce and maintain sleep), 8 milligrams (mg) at bedtime for insomnia. 2. An order, dated 03/26/26, for supplemental oxygen to be administered at 2 liters per minute (lpm) at bedtime and as needed. 3. An order, dated 03/13/26, for aspirin (antiplatelet medication), 81 mg to be given daily. This order was discontinued and started again on 04/17/26. 4. The record did not contain an order for an anticoagulant medication. C. On 06/01/26 at 1:57 pm, during an interview and observation, R #7 sat in his room with an oxygen concentrator (a medical device used to deliver additional oxygen) on the floor next to his bed. Further observation revealed R #7 did not use the oxygen concentrator. R #7 stated he only used supplemental oxygen when needed. R #7 did not know the types of medications he took. D. On 06/04/26 at 2:49 pm, during an interview, the MDS Coordinator (MDSC) stated the following: 1. The MDS assessment did not indicate that R #7 took Ramelteon, a hypnotic medication. 2. R #7 received supplemental oxygen, but staff did not document it on the resident's MDS assessment. 3. R #7 did not take anticoagulants during the look back period (The time period over which staff observe a resident to capture the resident's condition or status for the MDS assessment. Unless otherwise stated, the look back period is seven days, and only those occurrences during the look back period will be captured on the MDS.) 4. R #7's MDS assessment was not accurate. R #79 E. Record review of R #79's admission MDS assessment, dated 03/03/26, revealed the following: 1. R #79 was admitted to the facility on [DATE]. 2. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 11, cognitively intact. 3. R #79 did not exhibit wandering behavior. 4. R #79 did not have any restraints or alarms including a wander guard (wearable technology used to keep residents from wandering or leaving the facility). F. On 05/31/26 at 1:31 pm, during an observation and interview, R #79 lay in his bed. Further observation revealed a wander guard hung on the resident's wheelchair. R #79 stated he used a wander guard. G. Record review of R #79's physician orders, dated 02/26/26, revealed an order for R #79 to use a wander guard. Staff were instructed to check the placement of the wander guard daily. H. Record review of R #79's comprehensive care plan, dated 03/02/2, revealed R #79 was at risk for elopement and had a wander guard in place. I. Record review of R #79's Medication Administration Record (MAR; a tool facility staff used to document administering medications), dated March, April, and May 2026, revealed the facility staff documented R #79's use of the wander guard daily as ordered. J. On 06/04/26 at 2:30 pm, during an interview, the MDSC stated R #79's MDS assessment was not accurate, because staff did not document R #79 used a wander guard. The MDSC stated she expected all alarms, including wander guards, to be indicated in the MDS assessment. R #117 K. Record review of R #117's MDS assessments revealed the following: 1. A MDS assessment, dated 03/20/26, revealed the following: - R #117 was admitted to the facility on [DATE]. - R #117 had the following diagnoses: -Paranoid personality disorder (includes conditions marked by odd or eccentric thinking and behavior), -Epilepsy (a seizure disorder), -Anxiety (feelings of fear or apprehension) disorder, -Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), -Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) with severe, psychotic features (refers to a loss of contact with reality). - R #117 did not take any hypnotic medications. 2. A discharge MDS assessment, dated 05/21/26, revealed R #117 did not take any hypnotic medications. L. Record review of R #117's physician orders, dated 02/01/26, revealed an order for Ramelteon, 8 mg. M. On 06/04/26 at 2:30 pm, during an interview, the MDSC stated R #117's MDS assessments were not accurate, because staff did not document R #117 received hypnotic medication. The MDSC stated the resident's assessment should indicate all types of medication the residents took during the look back period.

Based on observation, record review, and interviews, the facility failed to create a baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 4 (R #3, R #7, R #13 and R #80) of 5 (R #3, R #7, R #11, R #13 and R #80) residents reviewed for baseline care plans. This deficient practice is likely to result in residents not receiving the appropriate care needed, causing harm or worsening of their current conditions. The findings are:R #3 A. Record review of R #3's Face Sheet revealed she was admitted to the facility on [DATE] with the following diagnoses: 1. Cellulitis (deep inflammation of the tissues just under the skin; caused by infection) of the right lower limb, 2. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar), 3. Kidney transplant (a section of tissue or a complete organ that is removed from its original natural site and transferred to a new position in the same person or in a separate individual), 4. Hypertension (HTN; high blood pressure). B. Record review of R #3's Progress Note, dated 05/15/26, revealed R #1 had a diagnosis of cellulitis in the right lower limb. C. On 06/01/26 at 9:09 am, during an interview, R #3 stated that she was admitted to the facility because she fell and hurt her leg at home, and it became infected. D. Record review of R #3's comprehensive care plan, dated 05/18/26, revealed the resident's care plan was not created within 48 hours of admission. Further review revealed the care plan did not include interventions for the resident's cellulitis infection. E. On 06/04/26 at 1:37 pm, during an interview, the Market Resources Clinician (MRC; regional corporate staff sitting in for the DON) stated the following: 1. The facility used a comprehensive care plan in place of a baseline care plan. 2. Staff did not create or implement interventions for R #3's nutritional risk within 48 hours of admission. 3. The care plan did not include interventions for R #3's cellulitis infection. 4. R #3's comprehensive care plan did not meet his expectations for the development and implementation of a 48-hour baseline care plan to address R #3's immediate needs. 5. His expectations were for facility staff to develop and implement a baseline care plan that included the resident's immediate care needs within 48 hours of admission to the facility. R #80 F. Record review of R #80's Face Sheet revealed she was admitted to the facility on [DATE] with a diagnosis of a pressure ulcer (PU; an injury to skin and underlying tissue resulting from prolonged pressure on the skin) on his right heel. G. Record review of R #80's Skin Check (a skin assessment completed by facility staff), dated 04/24/26, revealed R #80 had a pressure ulcer on his right heel that was present on admission. H. Record review of R #80's care plan, dated 05/01/26, revealed the resident's care plan was not created within 48 hours of admission. I. On 06/01/26 at 10:08 am, during an interview and observation, R #80 had a bandage on his right heel. R #80 stated he had a pressure ulcer under the bandage. J. On 06/04/26 at 2:15 pm, during an interview, the MRC stated the following: 1. The facility used a comprehensive care plan in place of a baseline care plan. 2. Staff did not create or implement the focus, goals, and interventions for R #80's nutritional needs within 48 hours of admission. 3. R #80's comprehensive care plan did not meet his expectations for the development and implementation of a 48-hour baseline care plan to address R #80's immediate needs. 4. His expectations were for facility staff to develop and implement a baseline care plan that included the residents' immediate care needs within 48 hours of admission to the facility. R #7 K. Record review of R #7's Face Sheet revealed R #7 was admitted to the facility on [DATE] with the following diagnoses: 1. Type 2 diabetes mellitus, 2. Hypertension. L. Record review of R #7's comprehensive care plan, dated 07/21/26, revealed the resident's care plan was not created within 48 hours of admission. M. On 06/01/26 at 1:13 pm, during an observation and interview, R #7 wore a bandage on his left foot. R #7 stated he was diabetic and used insulin. R #7 stated he did not have any wounds. N. On 06/04/26 at 1:37 pm, during an interview, the MRC stated the following: 1. The facility used a comprehensive care plan in place of a baseline care plan. 2. Staff did not create or implement intervention for R #7's pressure ulcers and diabetic care within 48 hours of admission. 3. R #7's comprehensive care plan did not meet his expectations for developing and implementing a 48-hour baseline care plan to address R #7's immediate needs. 4. His expectations were for facility staff to develop and implement a baseline care plan that included the residents' immediate care needs within 48 hours of admission to the facility. R #13 O. Record review of R #13's Face Sheet revealed R #13 was admitted to the facility on [DATE] with the following diagnoses: 1. Paraplegia (impairment in motor or sensory function of lower portions of the body), 2. Palliative care (medical care for anyone living with a serious illness, focused on providing relief from symptoms and stress). P. Record review of R #13's medical orders, dated 03/05/26, revealed an order to perform catheter care two times a day for foley care. Q. Record review of R #13's comprehensive care plan, dated 03/08/26, revealed the resident's care plan was not created within 48 hours of admission. R. On 06/01/26 at 10:26 am, an interview and observation, R #13 lay in his bed covered with a blanket. A plastic tube ran from under the blanket and connected to a catheter collection bag (also called a drainage bag; a device connected to the catheter tubing and collects urine), which hung on R #13's bed rail. R #13 stated he was on hospice care and used an indwelling foley catheter. S. On 06/04/26 at 1:37 pm, during an interview, the MRC stated the following: 1. The facility used a comprehensive care plan in place of a baseline care plan. 2. Staff did not create or implement the interventions for R #13's hospice care, indwelling foley catheter, and assistance with ADLs within 48 hours of admission. 3. R #13's comprehensive care plan did not meet his expectations for developing and implementing a 48-hour baseline care plan to address R #13's immediate needs. 4. His expectations were for facility staff to develop and implement a baseline care plan that included the residents' immediate care needs within 48 hours of admission to the facility.

Based on observation, record review, and interview, the facility failed to fully and accurately develop the care plan for 2 (R #89 and R #90) of 6 (R #13, R #14, R #81, R #89, R #90, and R #117) residents reviewed for care plan, when staff failed to: Update R #89's care plan to include interventions for oxygen use that matched the physician's order.Update R #90's care plans to include interventions for oxygen use.Update R #117's care plan to reflect a change in the fluid restriction.These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are:R #89 A. Record review of R #89's significant change Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 05/13/26, revealed the following:1. R #89 was admitted to the facility on [DATE].2. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 06, severe impairment.3. R #89 utilized oxygen therapy (treatment that provides extra oxygen). B. Record review of R #89's comprehensive care plan, revised on 03/24/26, revealed the following:1. R #89 was at risk for respiratory complications and required the use of oxygen to keep oxygen saturation (the amount of oxygen in the blood) above 90 percent (%).2. Staff monitored and reported abnormal oxygen saturation levels to the physician.3. R #89 was to have 25 liters of oxygen delivered via nasal cannula. C. Record review of R #89's medical orders, dated 02/20/25, revealed an order for 1-5 liters of oxygen to maintain oxygen saturation above 89%. This order did not have an end date. D. On 06/01/26 at 8:37 am, during an observation, R #89 lay in her bed and wore a nasal cannula (a small, flexible tube that delivers oxygen to the nose through soft prongs) connected to an oxygen concentrator (a medical device that delivered supplemental oxygen). E. On 06/04/26 at 1:50 pm, during an interview, the Market Resources Clinician (MRC; regional corporate staff sitting in for the DON) stated R #89's care plan was not accurate because it did not match the oxygen order. He stated that his expectation is for facility staff to revise the person's care plan as their needs and medical orders change. R #90F. Record review of R #90's annual MDS, dated [DATE], revealed the following:1. R #90 was admitted to the facility on [DATE].2. R #90 was rarely or never understood.3. R #90 used oxygen therapy. G. Record review of R #90's comprehensive care plan, initiated on 02/19/25, revealed it did not contain interventions for R #90's oxygen use. H. Record review of R #90's Electronic Health Record (EHR), revealed it did not contain an order for oxygen use. I. On 05/31/26 at 8:40 am, during an observation, R #90 lay in her bed with a nasal cannula resting on her neck and chest. Further observation revealed the nasal cannula was attached to an oxygen concentrator that sat on the floor near R #90's bed. J. On 05/31/26 at 8:51 am, during an interview, Licensed Practical Nurse (LPN) #3 stated R #90 was supposed to be wearing the oxygen and replaced R #90's nasal cannula. K. On 06/04/26 at 1:50 pm, during an interview, the MRC stated the facility failed to include interventions for R #90's oxygen use in the care plan. The MRC stated his expectations were for all residents who used oxygen to have interventions for its use in their care plan.

Based on observation, record review, and interview, the facility failed to provide quality of care that met professional standards for 2 (R #79 and R #89) of 3 (R #2, R #79, and R #89) residents reviewed when staff failed to:- Assess R #79 prior to implementing the use of a wander guard. - Follow physician orders for pain relief cream for R #89. If staff do not follow professional standards of care, then residents may have a decreased quality of life. The findings are: R #79A. Record review of the facility's Patient Security Bracelet policy, revised on 07/01/24, revealed staff evaluated residents in the facility for the need for a wandering security bracelet such as a wander guard. B. Record review of R #79's physician orders, dated 02/26/26, revealed an order for R #79 to use a wander guard (wearable technology used to keep residents from wandering or eloping from the facility unattended), and staff were to check the placement of the wander guard daily. C. Record review of R #79's comprehensive care plan, dated 03/02/26, revealed R #79 was at risk for elopement and had a wander guard in place. D. Record review of R #79's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 03/03/26, revealed the following:1. R #79 was admitted to the facility on [DATE].2. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 11, cognitively intact.3. R #79 did not exhibit wandering behavior. 4. R #79 did not have any restraints or alarms, including a wander guard in use. E. Record review of R #79's elopement evaluation, dated 05/26/26, revealed R #79 was not at risk for elopement. F. On 05/31/26 at 1:31 pm, during an interview, R #79 stated he had an alarm on his wheelchair that sounded when he got too close to the door. G. On 06/04/26 at 1:45 pm, during an interview, the MRC stated the first elopement evaluation the facility completed for R #79 was on 05/26/26. The MRC stated this did not meet his expectations because facility staff should have completed an elopement evaluation before the facility implemented the use of a wander guard. R #89H. Record review of R #89's significant change Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 03/13/26, revealed the following:1. R #89 was admitted to the facility on [DATE].2. R #89 had the following diagnoses:- Pain in left knee,- Pain in right knee,3. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 06, severe impairment.4. Resident experienced pain in both knees. I. Record review of R #89's medical orders, dated 04/10/25, revealed an order for Voltaren gel (pain relief medication) to be applied to R #89's knees twice daily. J. Record review of R #89's Medication Administration Record (MAR), dated May 2026, revealed staff did not administer the Voltaren gel to R #89 as ordered on 05/01/26, 05/02/26, 05/03/26, 05/08/26, 05/09/26, 05/10/26, 05/15/26, 05/16/26, 05/23/26, 05/30/26, and 05/31/26. Further review revealed staff did not document a reason why the Voltaren was not administered. K. On 06/01/26 at 8:43am, during an observation and interview, R #89 lay in bed. The resident did not answer any questions. L. On 06/02/26 at 9:40 am, during an interview, R #89's daughter stated her mother had pain in both knees. She stated she knew from watching the camera in her mother's room that staff did not apply the Voltaren gel to her mother's knees every day as ordered. She stated she addressed this issue with nurses at the facility and with the Administrator in the past. M. On 06/04/26 at 2:00 pm, during an interview, the Market Resources Clinician (MRC; regional corporate staff sitting in for the DON) stated he expected the facility staff to administer all pain medications as ordered. The MRC stated the facility staff not administering R #89's Voltaren gel 11 times during May 2026 did not meet his expectations. The MRC stated it was expected if staff did not administer medications, then they should document in the MAR a reason for not administering the medication.

Based on observation, interviews, and record review, the facility failed to complete smoking evaluations for 2 (R #117 and R #122) of 6 (R #4, R #5, R #8, R #14, R #79, R #117 and R #122) residents reviewed. This deficient practice could likely result in residents getting injured in avoidable accidents and putting residents at risk of serious injury, serious harm, and possibly death. The findings are: R #117 A. Record review of R #117's Face Sheet revealed R #117 was admitted to the facility on [DATE] with the following diagnoses: 1. Paranoid personality disorder (includes conditions marked by odd or eccentric thinking and behavior), 2. Epilepsy (a seizure disorder), 3. Anxiety (feelings of fear or apprehension) disorder, 4. Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), 5. Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) with severe, psychotic features (refers to a loss of contact with reality). B. Record review of R #117's care plan, revised on 03/04/26, revealed R #117 could smoke with staff supervision. C. Record review of R #117's Electronic Health Record (EHR) revealed it did not contain a smoking evaluation. D. On 06/01/26 at 11:15 am, during an interview, R #117 stated she smoked cigarettes every day during the scheduled smoking times. E. On 06/04/26 at 1:45 pm, during an interview, the Market Resources Clinician (MRC; regional corporate staff sitting in for the DON) stated he expected facility staff to complete a smoking evaluation when a resident was admitted to the facility and quarterly. The MRC stated the facility failed to complete a smoking evaluation for R #117. R #122 F. Record review of R #122's Face Sheet revealed she was admitted to the facility on [DATE] with the following diagnoses: 1. Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), 2. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment). G. Record review of R #122's care plan, dated 08/12/25, revealed R #122 could smoke with staff supervision. H. Record review of R #122's EHR revealed it did not contain a smoking evaluation. I. On 06/01/26 at 12:00 pm, during an interview, R #122 stated she smoked cigarettes daily during the scheduled smoking times. J. On 06/04/26 at 1:45 pm, during an interview, the MRC stated the facility failed to complete a smoking evaluation for R #122. The MRC stated he expected facility staff to complete smoking evaluations quarterly for all residents.

Based on observation, record review, and interview, the facility failed to ensure supplemental oxygen orders were complete for 2 (R #6 and R #90) of 4 (R #4, R #6, R #7, and R #90) residents reviewed for respiratory care. These deficient practices are likely to result in residents receiving too much or not enough oxygen and can lead to worsening of conditions. The findings are:R #6 A. Record review of R #6's Face Sheet revealed he was admitted to the facility on [DATE] and re-admitted on [DATE] with the following diagnoses: 1. Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors, difficulty with walking, movement and coordination), 2. Congestive heart failure (CHF; impaired heart function), 3. Chronic obstructive pulmonary disease (COPD; lung disease). B. Record review of R #6's physician orders, dated 03/16/26, revealed an order for R #6 to receive supplemental oxygen. The order did not indicate flow rate, route of administration, frequency, and indication for use. C. On 06/01/26 at 9:30 am, during an observation and interview, R #6 lay in bed and wore a nasal cannula (flexible tube with two prongs inserted into the nostrils to deliver supplemental oxygen) connected to an oxygen concentrator (a medical device that concentrates oxygen and delivers it to someone that needs supplemental oxygen). R #6 stated he used supplemental oxygen continuously. D. On 06/04/26 at 1:37 pm, during an interview, the Market Resources Clinician (MRC; regional corporate staff sitting in for the DON) stated the order did not indicate the flow rate, route of delivery, frequency, and indication for use. He stated the order did not contain all the required elements for medication administration and did not meet his expectations. He stated his expectation was for the nurses, who received the order from the physician, to ensure all the necessary information was present. R #90 E. Record review of R #90's annual Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 02/25/26, revealed the following: 1. R #90 was admitted to the facility on [DATE]. 2. R #90 was rarely or never understood. 4. R #90 used oxygen therapy (a therapy treatment which provides supplemental oxygen). F. On 05/31/26 at 8:40 am, during an observation, R #90 lay in bed with a nasal cannula resting on her neck and chest. The nasal cannula was connected to an oxygen concentrator positioned on the floor near her bed. G. Record review of R #90's care plan revealed it did not contain interventions for R #90's oxygen use. H. Record review of R #90's electronic health record (EHR) revealed it did not contain an order for oxygen use. I. On 05/31/26 at 8:51 am, during an interview, Licensed Practical Nurse (LPN) #3 stated R #90 used supplemental oxygen. J. On 06/04/26 at 1:30 pm, during an interview, the MRC stated R #90's medical record did not contain an order for the use of oxygen. He stated it was expected for the nurse who requested oxygen for R #90 to ensure orders were completed.

Based on record review and interview, the facility failed to offer COVID-19 (an acute respiratory disease in humans characterized mainly by fever and cough, capable of progressing to severe symptoms and in some cases death) vaccinations to 3 (R #89, R #117, and R #122) of 5 (R #4, R #11, R #89, R #117, and R #122) residents reviewed for COVID-19 vaccinations. This deficient practice could likely result in residents having a higher likelihood of contracting COVID-19 and spreading the infection to other residents in the facility. The findings are: A. Record review of the facility's COVID-19 Vaccination policy, revised on 12/16/24, revealed the following:1. Facility staff to document the resident's vaccination history during the admission process.2. Facility staff to offer the COVID-19 vaccination following the manufacturer's recommended schedule.3. Facility staff to educate the resident and/or resident representative and obtain consent or document refusals in the resident's Patient Immunization Record. B. Record review of the Center for Disease Control and Prevention's website stated the following:1. CDC recommends an updated (2025-2026) COVID-19 vaccine for most adults ages 18 years and older.2. CDC recommends everyone ages 65 years and older, including people who live and work in Long Term Care settings, get two doses of an updated COVID-19 vaccine six months apart. R #89 C. Record review of R #89's significant change Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 03/13/26, revealed R #89 was admitted to the facility on [DATE]. D. Record review of R #89's Immunization Report, not dated, revealed R #89 received a COVID-19 vaccination on 02/10/23. The record did not contain documentation of any other COVID-19 vaccinations. E. Record review of R #89's Electronic Health Record revealed the record did not contain any COVID-19 vaccine forms indicating staff had offered or administered the COVID-19 vaccine to the resident. F. On 06/02/26 at 9:40 am, during an interview, R #89's daughter stated she did not remember the facility educating or offering the COVID-19 vaccination to R #89. R #117 G. Record review of R #117's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 03/20/26, revealed R #117 was admitted to the facility on [DATE]. H. Record review of R #117's Electronic Health Record revealed the following:1. R #117 did not have any immunization consent forms on file.2. Staff did not document whether R #117 was educated about or offered COVID-19 vaccine. I. Record review of R #117's Immunization Report, not dated, revealed the record did not contain documentation of R #117's last COVID-19 vaccination. R #122 J. Record review of R #122's annual Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 04/04/26, revealed R #122 was admitted to the facility on [DATE]. K. Record review of R #122's Electronic Health Record revealed the following:1. R #122 did not have any immunization consent forms on file.2. Staff did not document whether R #122 was educated about or offered COVID-19 vaccine. L. Record review of R #122's Immunization Report, not dated, revealed the record did not contain documentation of R #122's last COVID-19 vaccination. M. On 06/03/26 at 11:41 am, during an interview, the Unit Manager (Unit Mgr.) stated the following:1. Each resident's medical record should contain documentation of the resident or their representative being educated and offered the vaccination. The medical record should also contain evidence of the residents' or their representative's decision and the date of vaccination administration. 2. R #89's medical record did not contain any evidence R #89 was offered the COVID-19 vaccine.3. R #117's medical record did not contain any evidence R #117 was offered the COVID-19 vaccine.4. R #122's medical record did not contain any evidence R #122 was offered the COVID-19 vaccine.

Based on observation, record reviews, and interviews, the facility failed to completed a Preadmission Screening and Resident Review (PASARR; a Federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long-term care) prior to admission for 1 (R #59) of 3 (R #3, R #8, and R #59) residents reviewed for PASARR accuracy. This deficient practice is likely to result in the facility not providing the specialized services and support needed by residents. The findings are: A. Record review of R #59's face sheet revealed R #59 was admitted to the facility on [DATE] with the following diagnoses:1. Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs),2. Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest),3. Epilepsy (a seizure disorder). B. Record review of R #59's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 04/27/26, revealed the following:1. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 08, moderately impaired.2. R #59 had a seizure disorder or epilepsy.3. R #59 received anticonvulsant medication (used to prevent or control seizures). C. Record review of R #59's PASARR form, dated 06/12/24, revealed the following: 1. Staff documented the resident did not have a diagnosis or suspected mental illness, such as depression or mood disorder.2. Staff documented the resident did not have a history, diagnosis or evidence of a related condition, such as epilepsy, affecting their intellectual or adaptive functioning. D. On 06/01/26 at 9:19 am, during an observation and interview, R #59 sat on her bed in her room. R #59 stated the seizure medication she took must work, because shedid not have a seizure in a very long time. E. On 06/04/26 at 1:45 pm, during an interview, the Market Resources Clinician (MRC; regional corporate staff sitting in for the DON) stated R #59's PASARR was incorrect. The MRC stated this did not meet his expectations because the PASARRs should reflect all relevant diagnoses and aligned with the information in the medical orders.

Based on record review and interview, the facility failed complete performance reviews every 12 months for Certified Nursing Assistants (CNAs) for 1 (CNAs #4) of 5 (CNAs #4, #5, #6, #7, and #8) CNAs reviewed. If the facility is not completing a performance review of every CNA at least once every 12 months, then residents may not receive the appropriate care and services from the CNAs. The findings are: A. Record review of CNA #4's personnel file revealed the following:1. A start date of 12/10/24.2. An annual performance review was completed on 06/02/26.3. The record did not contain any other performance reviews for CNA #4. B. On 06/03/26 at 3:04 pm, during an interview, the Scheduler stated the only performance review for CNA #4 was completed on 06/02/26. The Scheduler stated it was her expectation that performance reviews were completed every 12 months for all CNAs. The Scheduler stated it was her responsibility to review CNA files to ensure performance reviews were completed timely. She stated she had been at the facility for a few months. She stated she was aware some performance reviews were not completed prior to her working at the facility, and she was in the process of reviewing all records to get them completed.

Based on observations and interviews, the facility failed to ensure staff properly stored and secured medications for all residents residing on the North Hall when staff left a medication storage cart unlocked and unattended. If the facility is not storing medications securely, then residents could experience injury or illness. The findings are: A. On 06/01/26 at 11:25 am, during an observation, a medication cart, located on the North Hall, contained insulin pens and was unlocked and unattended. B. On 06/01/26 at 11:28 am, during an interview, the Director of Nursing (DON) stated the medication cart should be locked when not in use.

Based on interviews and record reviews, the facility failed to properly complete consent forms for 4 (R #'s 1, 2, 5, and 6) of 6 (R #'s 1, 2, 3, 4, 5, and 6) residents, when:Psychotropic medication (medication used to treat mental health conditions) consent forms were not signed by residents or resident representatives. This deficient practice is likely to result in residents and/or their representatives not being consulted and informed of the risks and benefits of medications and treatments being provided to them. The findings are: R #1:A. Record review of R #1's face sheet revealed an admission date of 09/16/24, a discharge date of 02/24/26, and included the following diagnoses:Senile degeneration of brain (a range of neurological disorders characterized by a progressive decline in cognitive function, affecting memory, reasoning, and the ability to perform everyday activities and can severely impair the quality of a person's life),Severe vascular dementia with behavioral disturbance (caused by reduced or blocked blood flow to the brain leading to cognitive decline and impaired daily functioning),Sequelae of cerebral infarction (the long-term physical, cognitive, emotional, and sensory impairments that persist after a stroke),Adult failure to thrive (a syndrome that describes a decline characterized by weight loss, decreased appetite, poor nutrition, inactivity and often accompanied by dehydration, depressive symptoms, and impaired immune function, among others), Generalized muscle weakness (weakness throughout the body). B. Record review of R #1's physicians' orders revealed the following: Dated 02/01/26, Lorazepam (anti-anxiety medication) Oral Tablet 1 mg (milligram). Give 1 mg by mouth every 6 hours as needed for agitation. Dated 01/30/26, Lorazepam Tablet 0.5 mg. Give 1 tablet by mouth every 6 hours as needed for anxiety for 14 days, per hospice care provider. The medication was discontinued on 02/13/26. Dated 02/18/26, Seroquel (antipsychotic) oral tablet 25 mg. Give 1 tablet by mouth one time a day for anxiety.Dated 02/03/26, Seroquel oral tablet 25 mg. Give 1 tablet by mouth two times a day for anxiety. Dated 02/17/26, Seroquel oral tablet 50 mg. Give 1 tablet by mouth at bedtime for anxiety, per hospice order. Dated 02/23/26, Seroquel oral tablet 50 mg. Give 1 tablet by mouth two times a day for anxiety, per hospice order. C. Record review of R #1's Electronic Health Record (EHR), dated 04/27/26, revealed a Psychotherapeutic Medication Administration Disclosure/Consent form was not completed prior to R #1's Lorazepam and Seroquel use. R #2:D. Record review of R #2's face sheet revealed an admission date of 02/24/26, a discharge date of 03/14/26, and included the following diagnoses: Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment) with behavior disturbance,Anxiety (feelings of fear or apprehension) disorder, Moderate cognitive communication deficit (a condition where a person's ability to communicate effectively is impaired due to underlying cognitive dysfunction rather than a primary language or speech problem),Mild cognitive impairment (when you have problems remembering things, concentrating, making decisions and solving problems). E. Record review of R #2's physicians' orders revealed the following: Dated 03/03/26, Clonazepam (sedative) Oral Tablet 0.5 mg. Give 0.5 mg by mouth every 12 hours as needed for Anxiety/ Agitation.Dated 02/28/26, Clonazepam Oral Tablet 0.5 mg. Give 1 tablet by mouth every 12 hours as needed for anxiety, give 6 hours between routine doses. Dated 02/28/26, Clonazepam Oral Tablet 0.5 mg. Give 1 tablet by mouth two times a day for Anxiety. Dated 03/05/26, Clonazepam Tablet 0.125 mg. Give 1 tablet by mouth every 12 hours as needed for anxiety. Dated 02/27/26, Haldol Decanoate Intramuscular Solution (antipsychotic medication). Inject 2 mg intramuscularly (IM; administered in the muscle) every 6 hours as needed for agitation/combativeness. Dated 03/09/26, Haloperidol (antipsychotic medication) Tablet 0.5 mg. Give 1 tablet by mouth for agitation. The medication was discontinued on 3/9/26. Dated 02/25/26, Hydroxyzine (antihistamine) HCl Oral Tablet 25 mg. Give 1 tablet by mouth every 6 hours as needed for anxiety/agitation. Dated 03/12/26, Hydroxyzine HCl Tablet 25 mg. Give 1 tablet by mouth every 6 hours as needed for anxiety. Dated 02/28/26, Ramelteon (sedative) Oral Tablet 8 mg. Give 1 tablet by mouth at bedtime for insomnia (inability to sleep). Dated 03/09/26, Ramelteon Oral Tablet 8 mg. Give 1 tablet by mouth every 19 hours as needed for insomnia. Dated 03/23/26, Risperidone (antipsychotic) tablet 0.25 mg. Give 1 tablet by mouth every 8 hours as needed for agitation for 14 days. The medication was discontinued on 3/23/26. F. Record review of R #2's EHR, dated 04/27/26, revealed a Psychotherapeutic Medication Administration Disclosure/Consent form was not completed prior to the use of Clonazepam, Haldol, Hydroxyzine, Ramelteon, or Risperidone. R #5:G. Record review of R #5's face sheet revealed an admission date of 01/5/23 and included the following diagnoses: Parkinsonism (an umbrella term that refers to conditions with similar, movement-related effects),Dementia with behavioral disturbance,Cognitive communication deficit,Major Depressive Disorder (MDD; a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).Hallucinations (false perceptions, where you sense an object, person, or event even though it is not real). H. Record review of R #5's physicians' orders revealed the following:Dated 12/31/25, Caplyta Oral Capsule 10.5 mg. Give 1 capsule by mouth at bedtime for adjunctive treatment of MDD. The medication was discontinued on 04/23/26.Dated 12/31/25, Mirtazapine Tablet 15 mg. Give 1 tablet by mouth at bedtime for MDD. The medication was discontinued on 04/23/26.Dated 04/23/26, Mirtazapine (antidepressant) tablet 15 mg. Give 1 tablet by mouth at bedtime for Major Depressive Disorder. Dated 04/23/26, Caplyta (antipsychotic) Oral Capsule 10.5 mg. Give 1 capsule by mouth at bedtime for adjunctive treatment of MDD. I. Record review of R #5's EHR, dated 04/27/26, revealed a Psychotherapeutic Medication Administration Disclosure/Consent form was not completed prior to the use of Mirtazapine or Caplyta. R #6:J. Record review of R #6's face sheet revealed an admission date of 2/14/26 and included the following diagnoses:Depression,Panic disorder (type of anxiety disorder that causes repeated, unexpected episodes of intense fear and anxiety accompanied by physical symptoms that are similar to the body's normal response to danger). K. Record review of R #6's physicians' orders revealed the following: Dated 03/20/26, Clonazepam oral tablet 0.5 mg. Give 1 tablet by mouth two times a day for anxiety. Dated 04/13/26, Olanzapine (antipsychotic) oral tablet 10 mg. Give 1 tablet by mouth at bedtime for psychosis (a mental state in which a person loses touch with reality, experiencing symptoms such as hallucinations, delusions, and disorganized thinking). L. Record review of R #6's EHR, dated 04/27/26, revealed a Psychotherapeutic Medication Administration Disclosure/Consent form was not completed prior to the use of Clonazepam or Olanzapine. M. On 04/27/26 at 2:33 pm, during an interview, the Director of Nursing (DON) stated R #'s 1, 2, 5, and 6 should have completed and signed consent forms for the use of any psychotropic medications. She stated her expectation is that all residents or resident representatives receive information on all treatments and medications prior to using them, so they are aware of the risks and the benefits.

Based on observation and interviews, the facility failed to safeguard clinical record information by leaving Private Health Information (PHI) regarding residents of the 100-nursing unit, where unauthorized people had ability to access it. If the resident's clinical information is not sufficiently safe guarded, resident's PHI is likely to be viewed by unauthorized residents, visitors, and staff. The findings are: A. On 4/24/26 at 8:42 am, during an observation of the 100 unit, a cart was stationed in the unit between rooms #138 and #140 with a computer that contained 15 residents PHI including, their names and room numbers for anyone walking by to see. B. On 4/24/26 at 8:52 am, during an interview, the Director of Nursing (DON) stated the computer between rooms #138 and #140 should not be left unattended with resident PHI present, because unauthorized individuals could easily access the information. C. On 4/24/26 at 10:13 am, during an interview, the Administrator (ADM) stated the computer between rooms #138 and #140 should not have been left unattended with resident PHI present. She stated it is her expectation that nursing staff understand the importance of safeguarding resident records.

Based on observations and interviews, the facility failed to ensure the environment was free of accident hazards for residents residing on the 100-unit, when:An unattended computer cart with a cup of coffee, a chair, and a backpack was stationed in the doorway of room [ROOM NUMBER], blocking the entrance and without facility staff nearby. An unattended computer cart with a chair was blocking the hallway and handrails between rooms #138 and #140, without facility staff nearby. This deficient practice is likely to result in residents getting injured in avoidable accidents and putting residents at risk of serious injury and harm. The findings are: A. On 04/24/26 at 8:36 am, during an observation of the 100 unit, a computer cart with a cup of coffee and a chair with a backpack were stationed in the doorway of room [ROOM NUMBER], blocking the door entrance and without facility staff nearby. B. On 04/24/26 at 8:42 am, during an observation of the 100-unit, an unattended computer cart and chair with staff belongings was stationed in the hallway between resident rooms #138 and #140, blocking access to the unit handrails and without facility staff nearby. C. On 04/24/26 at 10:13 am, during an interview, the Administrator (ADM) stated it was not acceptable for staff to leave computer carts unattended in front of resident's doorways. She stated the facility staff should not leave drinks, purses, bags or other personal items in the hallways. She stated it is her expectation that staff put all personal belongings away in spaces provided for staff. The ADM stated this could potentially be a hazard if a resident picked up an item or tripped on the carts and chairs blocking the handrails and room access.

Based on record review and interview, the facility failed to ensure a comprehensive Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment was completed for 2 (R #1 and R #2) of 4 (R #1, #2, #5 and #6) residents, when:The facility did not change R #1 and R #2's discharge MDS status from return anticipated (returning to the facility) to return not anticipated (not returning to the facility). This deficient practice is likely to result in residents' needs not being met. The findings are: R #1:A. Record review of R #1's face sheet revealed an admission date of 09/16/24 and a discharge date of 02/24/26. B. Record review of R #1's discharge MDS, dated [DATE], revealed R #1 was discharged to the hospital with an anticipated return to the facility. C. Record review of R #1's Electronic Health Record (EHR), dated 04/27/26, revealed R #1 did not return to the facility and a final discharge MDS was not completed nor submitted as required. R #2:D. Record review of R #2's face sheet revealed an admission date of 02/24/26 and a discharge date of 03/14/26. E. Record review of R #2's discharge MDS, dated [DATE], revealed R #2 was discharged to the hospital with an anticipated return to the facility. F. Record review of R #2's EHR, dated 04/27/26, revealed R #2 did not return to the facility and a final discharge MDS was not completed nor submitted as required. G. On 04/27/26 at 2:33 pm, during an interview, the Director of Nursing (DON) stated her expectation was for the MDS assessments to accurately reflect the resident's current status in the facility, because an inaccurate status could affect billing for the resident and cause the facility census to be inaccurate. The DON stated the discharge MDS assessments for R #1 and R #2 were inaccurate and should have reflected a discharge-return not anticipated status.

Based on observations and interviews, the facility failed to store and serve food under sanitary condition when staff.Failed to ensure food and beverage items in the North and South nutrition room refrigerators were labeled and dated. Failed to ensure expired foods were not stored in the North and South nutrition room refrigerators. This deficient practice is likely to affect all 112 residents listed on the resident census list provided by the Administrator on 03/09/26, and is likely lead to foodborne illnesses in residents if food is not being stored properly. The findings are: A. Record review of the facility food and nutrition services policy dated 05/01/23 revealed the following: Food and nutrition employees prepare, label, and date evening snacks including the use by date, Labels are affixed to each item and include the name of the resident, current date, (use by) date, Use by date is either added to the tray card label or on an additional label is used to indicate the use by date. Food and nutrition services employees inventory nurses station pantries at least daily and stock pantries with enough covered, labeled, and dated with use by dates. B. On 03/09/26 at 2:53 PM, observation of the south nutrition room, revealed the following: One pitcher filled with a pink-colored beverage was not labeled or dated and stored in the refrigerator. One pitcher filled with a purple-colored beverage was not labeled or dated and stored in the refrigerator. Eight pre-packaged peanut butter and jelly sandwiches dated 02/07/26 were stored in the refrigerator. Four pre-packaged turkey sandwiches dated 02/08/26 were stored in the refrigerator. Three Vital Cuisine nutritional supplement shakes (ready-to-drink drinks providing extra calories, protein, and vitamins) were dated 03/03/26 and stored in the refrigerator. Three small, pre-packaged containers containing strawberries was dated 03/05/26 and stored in the refrigerator. C. On 03/09/26 at 3:01 PM, observation of the north nutrition room, revealed the following: Six pre-packaged peanut butter and jelly sandwiches dated 02/07/26 were stored in the refrigerator. Two pre-packaged turkey sandwiches dated 02/08/26 were stored in the refrigerator. Two Vital Cuisine nutritional supplement shakes were dated 03/03/26 and stored in the refrigerator. Three, 4-ounce (oz) pre-packaged containers of chocolate pudding were not labeled and stored in the refrigerator. D. On 03/10/26 at 11:31 AM, during an interview, the Dietary Manager (DM) stated it was the responsibility of the Dietary Aides to deliver and check for expired resident snacks located in both nutrition rooms, three times daily. The DM confirmed expired food should be thrown away, and all food and beverage items should be labeled and dated. E. On 03/10/26 at 2:55 PM, during an interview, the Administrator (AD) stated it was her expectation residents do not receive or consume expired foods. She stated if residents consume expired foods, they could become ill.

Based on record review and interview, the facility failed to ensure 1 (R #96) of 2 (R #11 and 96) residents reviewed for behavioral health concerns received necessary behavioral health care to meet the resident's needs when staff failed to: 1. Ensure R #96 received continued psychiatric services when facility staff observed symptoms of depression and when R #96 verbalized feelings of depression. These deficient practices likely resulted in R #96's depression worsening and not receiving the behavioral or mental health care needed to improve mood and reduce depression and anxiety. The findings are: A. Record review of R #96's face sheet revealed, R #96 was admitted into the facility on [DATE] with diagnosis of encephalopathy (a disease that affects brain structure or function. It causes altered mental state and confusion). B. Record review of R #96's psychiatric evaluation, dated 11/03/23, revealed a score of 5.0 (score used to measure the severity of depression), indicating R #96 experienced mild depression. C. Record review of R #96's care plan, dated 11/12/23, revealed, - Focus: R #96 has impaired/decline in cognitive function (multiple mental abilities) or impaired thought processes related to a condition other than delirium (a disturbed state of mind) encephalopathy. - Interventions: Evaluate need for Psychiatric/Behavioral Health consult if indicated. D. Record review of R #96's psychiatric progress notes, dated 11/16/23, revealed, Subjective: Confused and depressed. The [AGE] year old female sat in her wheelchair in her room. She was obviously depressed today. Plan: Follow up in 2 weeks. E. Record review of R #96's psychiatric progress notes, dated 02/08/24, revealed, Subjective: Having increased depression. Assessment: Loneliness and Sadness. Psychiatric progress note indicated this was the first time a psychiatric provider saw R #96 since 11/16/23. F. On 02/13/24, at 12:55 pm, during an interview with R #96, R #96 began to cry. R #96 stated she was very lonely and depressed, and she believed her psychiatric health needs were not being met at the facility. G. On 02/16/24, at 11:21 am, during an interview with the Psychiatric Physician Assistant (PPA), he stated he did not remember meeting with R #96 in November 2023; however, he stated R #96 should have been seen by a psychiatric provider sooner than 02/08/24 if she was continuing to show signs of depression. H. On 02/16/24 at 1:05 pm during an interview with Licensed Practical Nurse (LPN) #1, she stated R #96 had high anxiety and depression. LPN #1 stated R #96 had been depressed and showed signs of having depression since she was admitted . The LPN said the resident would not leave her room, refused activities, and R #96 stated she really wanted to go home. I. On 02/19/24 at 12:21 pm during an interview with the Social Services Director (SSD), she stated she was not aware R #96 did not receive continued psychiatric services. J. On 02/19/24 at 1:21 pm during an interview with the Director of Nursing (DON), he stated he expected R #96 to see a psychiatric provider a lot sooner than she did if she showed any signs of depression.

Based on record review and interview, the facility failed to notify the Providers (Physician's and Nurse Practitioner's) and resident representative of a change in condition that involved difficulty swallowing and not eating or drinking for multiple days for 1 (R #1) of 1 (R #1) resident reviewed. This deficient practice likely resulted in R #1 becoming severely dehydrated with poor health outcomes. The findings are: A. Record review of Care Plan dated 03/24/20 revealed R #1 is at nutritional risk r/t (related to) being underweight by his BMI (Body Mass Index) and weight loss. Interventions include: Encourage 100% consumption of all fluids provided, Weigh per protocol and alert dietitian and physician to any significant loss or gain, Monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/ gain, abnormal labs( lab values that are out of the normal range, high, low, or critical) and report to food and nutrition (dietary)/ physician as indicated. B. Record review of progress notes dated 08/30/22 reflected the following Nurses note Resident [R #1] resistive to take medication as he has difficulty swallowing; unable to swallow thin or thickened liquids. He coughs to clear his throat and spits out. He states it feels like something prevents him from swallowing. He refuses to lay down for the night stating in Spanish: Death will come. VS (vital signs) are normal except pulse at 110 (beats per minute) when coughing. C. Record review of progress notes dated 09/06/22 reflected the following Nurses note: Resident [R #1] residing in his bed this AM, unable to tolerate taking am (morning) medication, difficulty swallowing. Request HCP (health care provider) to evaluate resident for noted decline in his appetite and physical daily activity. During eval (evaluation) resident did state that he was having some abdominal discomfort. Denied constipation. D. Record review of progress notes dated 09/06/22 revealed Continued decline and change in VS (vital signs including blood pressure, temperature, pulse, oxygen). New order received to transport to ER (emergency room ) for evaluation and tx (treatment). Transport called; paramedics state they will transport to [name of medical center]. E. Record review of ED (Emergency Department) provider notes [History of Present Illness] dated 09/06/22 revealed: R #1 was initially sent to the ED for complaint of dental pain, Code status: full code. R #1's daughter stated she was called by the facility who informed her R #1 had not drank or eaten anything for several days. She states she was told it was due to ulcers in R #1's mouth. Provider note stated Call placed to the facility [place where R #1 resides], was able to speak with nurse [Registered Nurse (RN) #1] she confirms that the patient [R #1] has not eaten or drank anything for one week-he will put water into his mouth, but will not swallow it and will spit it into the trash. F. Record review of ED provider notes [Assessment & Plan] dated 09/06/22 revealed that upon ED assessment R #1 had severe skin tenting (Skin turgor is a sign of fluid loss (dehydration) and severe cracking of oral mucosa (the mucous membrane lining the inside of the mouth) and lips. He had RLQ (Right lower quadrant of the abdomen) tenderness on exam. Note stated Patient [R #1] was given 1L (litter) LR (lactated ringers) bolus (Intravenous fluid given rapidly in a short amount of time, administered in the emergency department to critically ill patients) in ED. He has clinical findings as well as labs (blood tests) consistent with severe dehydration(Dehydration occurs when you use or lose more fluid than you take in, and your body doesn't have enough water and other fluids to carry out its normal functions.) G. Record review of ED provider notes [Physical Exam] dated 09/07/22 revealed that upon physical exam Mouth Ulcers and Oral Candidiasis (thrush, fungal infection in the mouth) were present. R #1 appeared unkempt, very cachectic ( unintentional weight loss), dehydrated and moaning. Black eschar (dry, black tissue with a leathery texture) in buccal mucosa (inside of cheeks) patient [R #1] unable to fully open mouth, dentition is poor. H. On 06/01/23 at 2:55 PM during an interview with R #1's daughter/POA (Power of Attorney) stated, On 09/09/22 the facility called me to inform me that EMS (Emergency Medical Services) took my father [R #1] to [name of medical facility]. When I arrived at the ED I saw him [R #1] and he looked terrible, he had lost weight, his tongue was shriveled up, there was black stuff in his mouth, huge cracks on his tongue. The nurse in the ED asked me how long he [R #1] had been like this? I told her I had been informed by the facility that he had gone five (5) days without food or water. POA confirmed she was not notified by the facility prior to 09/09/22 that there were any concerns with her father. I. On 06/02/23 at 10:57 AM during interview with Registered Nurse (RN) #1, she stated, The aides (nurses aides) had reported to me that R #1's intake had decreased, his tongue and mucus membranes were dry. I remember questioning it and I knew that he hadn't eaten on my shift and the aide reported he hadn't drank fluids. He [R #1] could not swallow properly, he [R #1] would try to clear his throat by coughing and he was not swallowing, he was not eating his food or drinking water. J. On 06/05/23 at 10:21 AM during interview with License Practical Nurse (LPN) #1 she stated, He [R# 1] had some trouble swallowing, he was Spanish speaking, so we got an interpreter, he complained of a stomach ache, he wasn't interested in eating and would refuse. This interview is in reference to the progress note dated 08/30/22 at 9:55 pm that was written by LPN #1. K. On 06/05/23 at 2:30 PM during interview with Nurse Practitioner (NP) she stated, This resident [R #1] needed extensive assist with ADL's. I would expect it to be reported to me sooner, definitely, if someone is not eating or drinking for five (5) days or had significant weight loss. When asked if she was aware that R #1 had not eaten or drank fluids in five (5) days and that he had sores in his mouth? She stated No, I was not aware of this, nor had I been given this information at the time I gave an order for R #1 to be seen at the ED. I would have addressed it immediately had I known. He is not someone I see on a regular basis. L. On 06/05/23 at 3:30 PM during interview with Nurse Manager (NM) when asked what the expectation of the nurse would be if a resident had not ate or drank in five (5) days? When would it be reported to the provider. NM stated, Some residents choose not to eat or drink, the doctor should be notified so they could check the resident and see what's going on. The nurse should be doing an assessment. I would expect them to look in the mouth and see of there is something in their throat. M. On 06/06/23 at 12:03 PM during interview with Wound Care Nurse (WCRN) when asked what the protocol was for a nurse that has a patient that has not eaten or drank fluids in the last five (5) days? He stated, I would inform the unit manager, DON (Director of Nursing), and Dietitian, and also the NP or doctor. If someone stops eating for one (1) day, that should be reported immediately. N. On 06/06/23 at 2:47 pm during an interview with the Clinical Resource Nurse (CRN), she stated, A change of condition should have been completed [for R #1], the provider be notified, and the family be notified. CRN confirmed a provider should have been notified regarding R #1's change of condition and one was not. This deficient practice resulted in Immediate Jeopardy. The facility Administrator and Clinical Resource Nurse was first notified of the Immediate Jeopardy on 06/06/23 at 4:14 pm. Implementation of the Plan of Removal was validated on 06/07/23 onsite through observation and interview. The Plan of Removal Included: 1. Licensed nurses will complete head to toe assessments on current residents residing in the center to determine presence of a medical change in condition including oral cavity assessment. Identified issues will be reported to the provider [Physician's and Nurse Practitioner's] for further direction and medical orders. 2. An audit of all current residents progress notes/vital signs/ for the past 72 hours and monthly weights to determine presence of a medical change in condition with steps taken to provide care related to identified medical need. Identified changes in condition not reported to MD will be reported and medical orders will be followed, with monitoring. 3. An audit of all Tasks has been completed to make sure all tasks are scheduled correctly [and present in each resident's EHR for nursing staff to monitor] to trigger for staff to document care provided. 4. Meal and fluid intake will be reviewed for lunch on 6/7/2023. Intakes will be monitored for each resident after 06/07/23. 41988

Based on record review and interview, the facility failed to ensure that 3 (R #'s 1, 4 and 10) of 3 (R #'s 1, 4 and 10) residents received treatment and care in accordance with professional standards of practice by: 1. Failing to identify a change in condition when R #1 began to refuse medications due to having trouble swallowing and failing to monitor for signs of dehydration. 2. Failing to ensure that R #1, R #4 and R #10 were receiving assistance with various important ADL (Activities of Daily Living) and that these daily tasks were being completed for R #1, R #4, and R #10 as per facility protocol. This deficient likely resulted in R #1 being sent to the Emergency Department (ED) and receiving critical care required for severe dehydration. If the facility is not monitoring for residents' change in condition, residents are likely at risk of inadequate or delayed treatment. The findings are: Regarding R #1: A. R #1 was originally admitted to the facility on [DATE] with the following diagnoses: 1. Unspecified Atrial Fibrillation (a disease of the heart characterized by irregular and faster heartbeat). 2. Hypertensive Heart Disease (a long-term heart condition that develops over many years in people who have high blood pressure). 3. Unspecified Dementia (a group of symptoms that affects memory, thinking, and interferes with daily life.) 4. Hypertension (high pressure in the arteries/blood vessels that carry blood from the heart to the rest of the body). 5. Dysphagia (difficulty swallowing) 6. Cognitive communication deficit (result in difficulty with thinking and how someone uses language). B. Record review of Care Plan dated 03/24/20 revealed R #1 is at nutritional risk r/t (related to) being underweight by his BMI (Body Mass Index) and weight loss. Interventions include: Encourage 100% consumption of all fluids provided, Weigh per protocol and alert dietitian and physician to any significant loss or gain, Monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/ gain, abnormal labs( lab values that are out of the normal range, high, low, or critical) and report to food and nutrition/ physician as indicated. C. Record review of R #1's Care Plan dated 03/29/20 reveled that R #1 is at risk for decreased ability to perform ADL's in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer (from bed to chair), locomotion (walking), toileting related to dementia. D. Record review of Care Plan dated 09/17/20 noted that R #1 exhibits or is at risk for oral health or dental care problems. Interventions include: Assess for oral lesions (mouth sores), inflammation and bleeding and signs symptoms of pain during care and report to MD (Medical Doctor) as indicated, encourage resident to brush teeth twice a day and as needed, lubricate lips as needed, provide oral hygiene twice per day and as needed, use a mouth rinse as appropriate. E. Record review of MDS (Minimum Data Set is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes.) Section L: Dental Information dated 06/28/22, Sections A. and F. indicated that R #1 had no broken or loose teeth, no mouth or facial discomfort, no difficulty with chewing. F. Record review of MDS section K :Swallowing/Nutritional Status dated 06/28/22, Section C. indicated that R #1 did not cough or choke during meals or when swallowing medications. Section D. revealed R #1 did not have any complaints of difficulty swallowing. G. Record review of physicians orders dated 08/19/22 showed order for Regular diet, Dysphagia Advanced texture (The National Dysphagia Diet Level 3, also called Advanced textures, include foods that are almost regular textured (food minus hard, crunchy, and very sticky foods). This level is transitional, linking the mechanically altered foods and regular textured foods. This diet includes ground meats). H. Record review of physicians orders dated 08/31/22 showed R #1's diet was downgraded, new order for Regular diet, Dysphagia Puree texture (all food has been ground, pressed, and/or strained to a soft, smooth consistency, like a pudding), assist with all meal set-ups (ensuring proper utensils and dinnerware are available including any special adaptive equipment (special utensils) to aide R #1 with eating. I. Record review of R #1's Weights indicated upon admission R #1 weighed 114.4 lbs (pounds), on 08/01/22 R #1 weighed 108 lbs, and on 09/07/22 he weighed 94.2 lbs [weight loss of 14 lbs between 08/01/22 and 09/07/22]. J. Record review of progress notes dated 08/30/22 reflected the following Nurses note: Resident [R #1] resistive to take medication as he has difficulty swallowing; unable to swallow thin or thickened liquids. He coughs to clear his throat and spits out. He states it feels like something prevents him from swallowing. He refuses to lay down for the night stating in Spanish: Death will come. VS (vital signs) are normal except pulse at 110 (beats per minuet) when coughing. K. Record review of progress notes dated 09/06/22 reflected the following Nurses note: Resident [R #1] residing in his bed this AM, unable to tolerate taking am medication, difficulty swallowing. Request HCP (health care provider) to evaluate resident for noted decline in his appetite and physical daily activity. During eval (evaluation) resident did state that he was having some abdominal discomfort. Denied constipation. L. Record review of progress notes dated 09/06/22 revealed Continued decline and change in VS (vital signs including blood pressure, temperature, pulse, oxygen). New order received to transport to ER (emergency room ) for evaluation and tx (treatment). Transport called; paramedics state they will transport to [name of medical center]. M. Record review of ED (Emergency Department) provider notes [History of Present Illness] dated 09/06/22 revealed: R #1 was initially sent to the ED for complaint of dental pain, Code status: full code. R #1's daughter stated she was called by the facility who informed her R #1 had not drank or eaten anything for several days. She states she was told it was due to ulcers in R #1's mouth. Provider note stated Call placed to the facility [place where R #1 resides], was able to speak with nurse [Registered Nurse (RN) #1] she confirms that the patient [R #1] has not eaten or drank anything for one week-he will put water into his mouth, but will not swallow it and will spit it into the trash. N. Record review of ED provider notes [Assessment & Plan] dated 09/06/22 revealed that upon ED assessment R #1 had severe skin tenting (Skin turgor is a sign of fluid loss (dehydration) and severe cracking of oral mucosa (the mucous membrane lining the inside of the mouth) and lips. He had RLQ (Right lower quadrant of the abdomen) tenderness on exam. Note stated Patient [R #1] was given 1L (litter) LR (lactated ringers) bolus (Intravenuos fluid given rapidly in a short amount of time, administered in the emergency department to critically ill patients) in ED. He has clinical findings as well as labs (blood tests) consistent with severe dehydration(Dehydration occurs when you use or lose more fluid than you take in, and your body doesn't have enough water and other fluids to carry out its normal functions.) O. Record review of ED provider notes [Physical Exam] dated 09/07/22 revealed that upon physical exam Mouth Ulcers and Oral Candidiasis (thrush, fungal infection in the mouth) were present. R #1 appeared unkempt, very cachectic ( unintentional weight loss), dehydrated and moaning. Black eschar (dry, black tissue with a leathery texture) in buccal mucosa (inside of cheeks) patient [R #1] unable to fully open mouth, dentition is poor. P. Record review of R #1's Lab Results dated 09/08/22 revealed Sodium level of 170 [Critical High Value with normal range 136-145] and BUN (A common blood test, the blood urea nitrogen (BUN) test reveals important information about how well your kidneys are working) 140 [Critical High Value with normal range with normal range 6-25 used to assess kidney function]. Q. Record review of progress notes dated 09/09/22 confirmed that R #1's diet had been downgraded from Regular diet, Dysphagia Advanced texture to Regular diet, Dysphagia Puree texture on 08/31/22 r/t (related to) swallowing difficulties indicating a change of condition was present at this time. R. Record review of progress notes dated 09/14/22 revealed that R #1 was discharged from hospital on 09/14/22 with belongings. He was discharged on Hospice to [name of long term care facility] with code status being changed from Full code to DNR (Do not resuscitate or attempt to perform life saving measures in the event of a life threatening emergency). S. On 06/01/23 at 2:55 PM during an interview with R #1's daughter/POA (Power of Attorney) stated, On 09/06/22 the facility called me to inform me that EMS (Emergency Medical Services) took my father [R #1] to [name of medical facility]. When I arrived at the ED I saw him [R #1] and he looked terrible, he had lost weight, his tongue was shriveled up, there was black stuff in his mouth, huge cracks on his tongue. The nurse in the ED asked me how long he [R #1] had been like this? I told her I had been informed by the facility that he had gone five (5) days without food or water. POA confirmed that she was not aware of any issues related to R #1 prior to 09/06/22. T. On 06/02/23 at 10:57 AM during interview with Registered Nurse (RN) #1, she stated The aides (nurses aides) had reported to me that R #1's intake had decreased, his tongue and mucus membranes were dry. I remember questioning it and I knew that he hadn't eaten on my shift and the aide reported he hadn't drank fluids. He [R #1] could not swallow properly, he [R #1] would try to clear his throat by coughing and he was not swallowing, he was not eating his food or drinking water. U. On 06/05/23 at 10:21 AM during interview with License Practical Nurse (LPN) #1 she stated, He [R# 1] had some trouble swallowing, he was Spanish speaking, so we got an interpreter, he complained of a stomach ache, he wasn't interested in eating and would refuse. This interview is in reference to the progress note dated 08/30/22 at 9:55 pm that was written by LPN #1. V. On 06/05/23 at 2:30 PM during interview with Nurse Practitioner (NP) she stated, This resident [R #1] needed extensive assist with ADL's. I would expect it to be reported to me sooner, definitely, if someone is not eating or drinking for five (5) days or had significant weight loss. When asked if she was aware that R #1 had not eaten or drank fluids in five (5) days and that he had sores in his mouth? She stated No, I was not aware of this, nor had I been given this information at the time I gave an order for R #1 to be seen at the ED. I would have addressed it immediately had I known. He is not someone I see on a regular basis. W. On 06/05/23 at 3:30 PM during interview with Nurse Manager (NM) when asked what the expectation of the nurse would be if a resident had not ate or drank in five (5) days? When would it be reported to the provider. NM stated, Some residents choose not to eat or drink, the doctor should be notified so they could check the resident and see what's going on. The nurse should be doing an assessment. I would expect them to look in the mouth and see of there is something in their throat. X. On 06/06/23 at 12:03 PM during interview with Wound Care Nurse (WCRN) when asked what the protocol was for a nurse that has a patient that has not eaten or drank fluids in the last five (5) days? He stated, I would inform the unit manager, DON (Director of Nursing), and Dietitian, and also the NP or doctor. If someone stops eating for one (1) day, that should be reported immediately. Y. On 06/06/23 at 12:28 PM during interview with Certified Nurse Assistant (CNA) #3 when asked about providing care for R #1 she stated I remember him choking, it had to be not long before he left the facility. He would cough and choke a lot and it seemed like that is when his eating stopped. When asked how they keep track of a residents intake, she stated, we document it in the charting system and mark if they refuse drinks or what not. It should have been documented every day, three times a day. Z. R #1 was reported to have not eaten, nor drank, any fluids for five (5) days prior to being sent to the emergency room where critical care was required for severe dehydration 41988 Regarding R #4: Z. Record review of R #4's Face Sheet revealed R #4 was admitted into the facility on [DATE] with the following diagnoses: 1. BENIGN NEOPLASM OF CEREBRAL MENINGES (A condition in which a [usually] non-cancerous tumor develops from the membrane that surround the brain and spinal cord) 2. CARDIAC ARRHYTHMIA (abnormal heart rhythm), UNSPECIFIED 3. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough) UNSPECIFIED 4. POLYOSTEOARTHRITIS (joint pain and stiffness), UNSPECIFIED 5. MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED 6. ANXIETY DISORDER, UNSPECIFIED 7. UNSPECIFIED HEARING LOSS, BILATERAL (both sides) 8. VITAMIN B12 DEFICIENCY ANEMIA (Deficiency of healthy red blood cells),UNSPECIFIED 9. VITAMIN D DEFICIENCY, UNSPECIFIED 10. TOBACCO USE 11. TINEA UNGUIUM (common fungus infection of the nails) 12. DYSPHAGIA (difficulty in swallowing food or liquid), OROPHARYNGEAL (part of the pharynx- part of the throat) PHASE 13. COVID-19 (deadly respiratory virus) 14. UNSPECIFIED OSTEOARTHRITIS (Degenerative joint disease), UNSPECIFIED SITE AA. Record review of R #4's Care Plan dated 10/25/22 revealed, Focus: [Name of R #4] requires assistance for ADL care in bathing, grooming, personal hygiene, dressing, bed mobility, eating transfer, locomotion, toileting, related to: Dementia and COPD [Chronic Obstructive Pulmonary Disease], benign neoplasm of cerebral menages [three layers of membranes that cover and protect your brain and spinal cord], cardiac arrhythmia, osteoarthritis. Interventions: Monitor for decline in ADL function. Refer to rehabilitation therapy if decline in ADL's is noted. Monitor for SOB [shortness of breath], fatigue and/or change of condition, adjust ADL tasks accordingly, and encourage resident/patient to pace him/herself during ADL activity. Provide with limited assist of 1 for bed mobility, transfers and locomotion. Extensive assist of 1 [requires 1 staff member for assistance] for toileting, bathing, personal hygiene, grooming and dressing and eating as needed. BB. Record review of R #4's Documentation Survey Report (ADL Documentation Form-used by nursing staff to monitor resident's ADL's each day) dated 05/01/23-05/31/23 revealed the tasks: Walk in corridor (hallway) and Meal [eating self performance, eating support, percentage of meal eaten, and fluids accepted] were being documented by nursing staff. No other ADL tasks were being documented/tracked for R #4. CC. Record review of R #4's Documentation Survey Report (ADL Task Documentation Form) dated 06/01/23-06/06/23 revealed only the tasks- Walk in corridor (hallway) and Meal were being documented by nursing staff. No other ADL tasks were being documented/tracked for R #4. DD. On 06/06/23 at 2:09 pm during an interview with Certified Nursing Assistant (CNA) #1, she stated, Hydration, meals, and changing [of briefs- are all tasks documented by CNA's for each resident]. Every resident has it [ADL's] tracked [and monitored]. EE. On 06/06/23 at 2:21 pm during an interview with the Unit Manager (UM) #1, she stated, We're going to track everything [ADL related for each resident]. Like dressing, feeding herself, she's [R #4] normally a limited assist [required limited assistance for eating and meal set up]. She's [R #4] going to have a [meal intake] percentage [documented] and if she [R #4] accepts beverage at that time. It's [ADL tracking documentation] going to track bowel movements and incontinence. All residents should be tracked [with ADL care and performance]. It should have everything documented for each resident. She [R #4] has things [ADL's documentation] missing [and not being monitored]. UM #1 confirmed R #4 had ADL's that were not being tracked/documented by the CNA's. FF. On 06/06/23 at 2:44 pm during an interview with the Clinical Resource Nurse (CRN), she stated, Everything for the tasks [should be documented], such as bed mobility, transfer, locomotion, dressing, meals, drinks and snacks, and personal hygiene. You can add and take away, but those are the basic ones. It [residents ADL tracking/documentation] would be reviewed by the nurse on unit and reviewed by the clinical team in the morning meeting. The reason being, I don't know who did, but they changed the [shift] times on the [ADL] task part of [Name of Electronic Health Record (EHR)]. You can't change the [shift] times [for the ADL tasks (documentation and monitoring forms)] because the CNA's don't see the [ADL] tasks for documentation [and aren't able to document and monitor ADL's for each resident]. It's [EHR] not prompting them [CNA's] to document [certain ADL's for various residents]. We should be documenting all ADL care and if they're [residents] are refusing. CRN confirmed not all of R #4's ADL's were being tracked, documented, and monitored due to someone changing the shift times on the EHR, which prevented various ADL's from being visible to CNA's for tracking and monitoring. CRN also confirmed this would prevent CNA's from documenting ADL's for each resident in the facility. Findings for R #10: GG. Record review of R #10's face sheet revealed R #10 was admitted into the facility on [DATE] with the following diagnoses: 1. CHRONIC OBSTRUCTIVE PULMONARY DISEASE 2. ACUTE RESPIRATORY FAILURE WITH HYPOXIA (below-normal level of oxygen in the blood) 3. HEART FAILURE 4. PARKINSON'S DISEASE (chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement) 5. TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY (A group of diseases resulting from damaged or malfunctioning of nerves that causes weakness, numbness and pain in hands and feet) 6. ESSENTIAL (PRIMARY) HYPERTENSION (high blood pressure) 7. BENIGN PROSTATIC HYPERPLASIA ( flow of urine is blocked due to the enlargement of prostate gland- a gland surrounding the neck of the bladder) WITHOUT LOWER URINARY TRACT SYMPTOMS 8. PAROXYSMAL ATRIAL FIBRILLATION (AF) (episode of AF that ends spontaneously or with intervention in less than seven days) 9. OBSTRUCTIVE AND REFLUX UROPATHY (Any pathology-study of the causes and effects of disease or injury of the urinary tract) 10. EPILEPSY (neurological disorder that causes seizures or unusual sensations and behavior), UNSPECIFIED, NOT INTRACTABLE (hard to control or deal with), WITHOUT STATUS EPILEPTICUS (Seizure that occurs continuously for much longer than usual, or seizures that occur in quick succession with no time between the seizures for the person to recover) 11. REPEATED FALLS 12. PERSONAL HISTORY OF COVID-19 13. OTHER HYPERTROPHIC CARDIOMYOPATHY (disease in which the heart muscle becomes thickened) 14. CHRONIC SYSTOLIC (CONGESTIVE) HEART FAILURE (progressive heart disease that affects pumping action of the heart muscles) 15. MUSCLE WASTING AND ATROPHY (progressive and degeneration or shrinkage of muscles or nerve tissues), NOT ELSEWHERE CLASSIFIED, UNSPECIFIED SITE 16. MUSCLE WEAKNESS (GENERALIZED) 17. UNSTEADINESS ON FEET 18. OTHER ABNORMALITIES OF GAIT AND MOBILITY 19. PAIN, UNSPECIFIED 20. HYPOTHYROIDISM (condition resulting from decreased production of thyroid hormones), UNSPECIFIED 21. MAJOR DEPRESSIVE DISORDER, RECURRENT (happening or tending to happen again), UNSPECIFIED 22. ANXIETY DISORDER, UNSPECIFIED 23. INSOMNIA (trouble falling and/or staying asleep), UNSPECIFIED 24. UNSPECIFIED CONVULSIONS (sudden, violent, irregular movement of a limb or of the body) HH. Record review of R #10's Care Plan dated 05/12/23 revealed, Focus: [Name of R #10] requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting r/t [related to] Parkinson's disease and generalized weakness. Interventions: two person assist with bed mobility. Monitor for decline in ADL function. Refer to rehabilitation therapy if decline in ADL's is noted. Provide resident/patient with extensive assist for bathing. Provide resident/patient with extensive assist of two for toileting. Provide resident/patient with extensive assist for dressing. Provide resident/patient with extensive assist for personal hygiene (grooming). II. Record review of R #10's Documentation Survey Report (ADL Task Documentation Form) dated 05/01/23-05/31/23 revealed only the tasks- Meal [eating self performance, eating support, percentage of meal eaten, and fluids accepted] and Toilet / Bladder / Bowel [Toilet use: self performance, toilet uses support provided, Urinary continence, Device used for Bladder Continence, Bowel movement - Size, Consistency of stool, and Bowel continence] were being documented by nursing staff. No other ADL tasks were being documented/tracked for R #10. JJ. Record review of R #10's Documentation Survey Report (ADL Task Documentation Form) dated 06/01/23-06/06/23 revealed only the tasks- Walk in corridor (hallway) and Meal were being documented by nursing staff. No other ADL tasks were being documented/tracked for R #10. KK. On On 06/06/23 at 2:45 pm during an interview with the CRN, she confirmed that not all of R #10's ADL's were being tracked/documented by CNA's, and should have been. These deficient practices resulted in Immediate Jeopardy being identified on 06/06/23. The facility Administrator and Clinical Resource Nurse was first notified of the Immediate Jeopardy on 06/06/23 at 4:14 pm. Implementation of the Plan of Removal was validated on 06/07/23 onsite through observation and interview. The Plan of Removal Included: 1. Licensed nurses will complete head to toe assessments on current residents residing in the center to determine presence of a medical change in condition including oral cavity assessment. Identified issues will be reported to the provider [Physician's and Nurse Practitioner's] for further direction and medical orders. 2. An audit of all current residents progress notes/vital signs/ for the past 72 hours and monthly weights to determine presence of a medical change in condition with steps taken to provide care related to identified medical need. Identified changes in condition not reported to MD will be reported and medical orders will be followed, with monitoring. 3. An audit of all Tasks has been completed to make sure all tasks are scheduled correctly [and present in each resident's EHR for nursing staff to monitor] to trigger for staff to document care provided. 4. Meal and fluid intake will be reviewed for lunch on 6/7/2023. Intakes will be monitored for each resident after 06/07/23.

Based on observation, interview, and record review, the facility failed to: 1. Ensure that a resident with Pressure Ulcers (an injury to the skin and underlying tissue, caused by prolonged pressure on the skin) received the necessary treatment and services, consistent with professional standards of practice 2. Ensure wound care orders were initiated for R #1's pressure wound and leg amputation upon admission to the facility. 3. Ensure there was adequate communication with an offsite provider to begin wound care for R #2 resulting in delayed wound care for R #2. 4. Ensure there was documentation consistently in accordance with wound care orders for R #1's pressure wound, and R #3's new skin issue. This deficient practice resulted in R #1's right knee amputation becoming infected and requiring emergent medical attention, R #2's wound care orders and treatment to be delayed without proper communication, and R #3 to develop a new skin injury that was not reported or documented to facility staff and providers. If the facility is not ensuring that wound care orders are initiated, followed, provided and communicated, then residents wounds will worsen and are likely to acquire new skin issues and wounds to worsen. The findings are: Findings for R #1: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] 1. METABOLIC [CONDITION(S)] [problem in the brain caused by an imbalance in the blood] 2. [CONDITION(S)] [harmful microorganisms in the blood], UNSPECIFIED ORGANISM 3. URINARY TRACT INFECTION, SITE NOT SPECIFIED 4. ACUTE [CONDITION(S)] WITH [CONDITION(S)] [deficiency in the amount of oxygen reaching tissues] 5. [MEDICATION(S)] [inflammation of the urinary bladder], UNSPECIFIED WITHOUT HEMATURIA [blood in 6. ACQUIRED ABSENCE OF LIMB, UNSPECIFIED 7. PHANTOM LIMB SYNDROME WITH PAIN 8. UNSPECIFIED PROTEIN-CALORIE MALNUTRITION 9. MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED 10. CHRONIC PAIN SYNDROME 11. HEART FAILURE, UNSPECIFIED 12. [CONDITION(S)], UNSPECIFIED 13. [CONDITION(S)] [low blood pressure], UNSPECIFIED 14. PRESSURE ULCER OF SACRAL REGION, STAGE 3 15. PRESSURE ULCER OF OTHER SITE, UNSTAGEABLE 16. MUSCLE WEAKNESS (GENERALIZED) 17. DYSPHAGIA [difficulty or discomfort in swallowing], OROPHARYNGEAL PHASE 18. OTHER ABNORMALITIES OF GAIT AND MOBILITY 19. PAIN, UNSPECIFIED 20. WEAKNESS 21. OTHER NONSPECIFIC ABNORMAL FINDING OF LUNG FIELD R #1 was discharged on [DATE] to the hospital. B. Record review of R #1's History and Physical dated [DATE] revealed, Chief Complaint/ Nature of Presenting Problem: She (R #1) is being admitted for wound care therapy following complications of an above-the-knee amputation. Plan: Wound Care. C. Record review of R #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply medi honey and bordered gauze. Pressure injury knee right, distal (distance further from the center of the body)-unstageable Acquired [DATE] Present on arrival one time a day for wound care to knee. D. Record review of R #1's care plan dated [DATE] revealed, Focus: [Name of R #1] is at risk for skin breakdown related to________ and or has actual skin breakdown Type:___________ Location______ Pressure injury knee right, distal -unstageable Acquired [DATE] Present on arrival. Interventions: Provide wound treatment as ordered, Weekly skin check by license nurse, Weekly wound assessment to include measurements and description of wound status. E. Record review of R #1's Treatment Administration Record (TAR) dated [DATE] to [DATE] revealed wound care was not documented as completed to R #1's right knee pressure injury on [DATE], [DATE], and [DATE]. F. Record review of the facility Weekly Wound Report dated [DATE] to [DATE] revealed R #1 was on the wound report one time on [DATE]. The [DATE] report stated, SS Drainage (drainage containing blood). No other weekly wound reports were provided by facility that included R #1's wounds. G. Record review of R #1's progress notes dated [DATE] to [DATE] revealed no wound care progress noted for R #1's right knee amputation wound care. H. Record review of R #1's progress notes dated [DATE] at 9:17 am revealed, Resident was complaining of pain at the amputation site, right AKA [above-knee-amputation]. Wound is moist, with redness on the surrounding area. Doctor assessed the area and referred the resident to the ER [emergency room ]. Taken to [Name of local hospital] by [Name of local ambulance service]. I. Record review of R #1's Medical Doctor (MD) progress note dated [DATE] revealed, Chief Complaint/Nature of Presenting Problem: Worsening pain and exposed bone at stump site. History of Present Illness: They [facility staff] report that she [R #1] has increase exposed bone, stump breakdown, and a foul order. She [R #1] is having worsening pain. [ .] She does have some necrotic [death of cells or tissue through disease or injury] drainage. Plan: She [R #1] will be transferred to the Emergency Department, she [R #1] will need surgical attention, [ .] and her [R #1] prognosis is very poor. J. Record review of R #1's Emergency Department Provider Notes dated [DATE] at 1:48 pm revealed, Patient [R #1] discussed with [Name of ED physician]. He [ED physician] has reviewed the patient's [R #1] chart and he states the patient will likely need a revision of her amputation [a revision procedure may be necessary to address tissue breakdown, chronic pain, scarring, or other health issues] based on findings on CT [Computed Tomography] imaging. Discussed [MEDICATION(S)] and Zosin (antibiotics) for broad antibiotic coverage. Number of diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Above knee amputation of right lower extremity, Myositis [muscle inflammation] of right thigh, unspecified myositis type [CONDITION(S)] [inflammation of bone or bone marrow] of right femur, unspecified type Wound dehiscence [splitting or bursting open of a pod or wound]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . It is unclear when this wound dehiscence occurred but patient was evaluated in this emergency department on [DATE]. At that time [[DATE]], she [R #1] was found to have an intact wound with no evidence of dehiscence. She was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . [ .] It is possible that her [R #1's] findings on CT imaging are chronic in nature. However, given that she has exposed distal femur a wound site, she [R #1] will need operative management. I discussed the patient with orthopedics, [Name of ED physician] He is agreeable to consult and likely revise the amputation. Patient [R #1] will need infectious disease and possibly surgery as well. At this time she has no evidence of systemic infection. Patient was given [MEDICATION(S)] [antibiotic] and [MEDICATION(S)] [antibiotic] in consultation with orthopedics. Given relatively normal labs, normal vital signs, low suspicion for [CONDITION(S)] [a serious bacterial infection that destroys tissue under the skin], patient was not given [MEDICATION(S)] [antibiotic] in the emergency department. K. On [DATE] at 3:30 pm during an interview with R #1's son, he stated, My mother already had her leg amputated [prior to arriving in facility]. The wound specialist at [Name of facility] never saw my moms wound and she [R #1] said she went 10 days without anybody looking at it [wound on her right knee]. She [R #1] was sent to the hospital again and it [R #1's right knee amputation] was so infected that they [hospital] had to re-amputate it again. What they [facility] did to her [R #1] in that home (nursing facility), they took the little life she had left. I don't think she's [R #1] going to make it to be honest with you. I feel like they [facility] took her [R #1's] life away and I can't even bring her [R #1] home. L. On [DATE] at 2:47 pm during an interview with Registered Nurse (RN) #1, he stated, I usually get wound care, measure wounds, and document them weekly, on Saturday or Sunday. I usually do it [wound care] weekly. I'm not sure why that [R #1 not being on the weekly wound report until [DATE]] happened. The orders are there for them [nursing staff] to provide wound care and they [nursing staff] should document in the notes what they see, what they did, and if there's a photo they should document it. There is a policy that we are supposed to document [wound care]. M. On [DATE] at 2:23 pm during an interview with Licensed Practical Nurse (LPN) #1, she stated, Pressure ulcer injury care was on there [for R #1]. It does look like she [R #1] had wound care orders on the [DATE]. There is some nursing documents on ,d+[DATE] [2022], ,d+[DATE], and ,d+[DATE]. I don't know why [there aren't notes documented for R #1's wound care after [DATE] until [DATE]]. N. On [DATE] at 2:38 pm during an interview with RN #2, he stated, I think the orders [for R #1's right knee wound care] was every other day. I remember her [R #1] being sent out [to the ED] because she had signs of infection and when they [nursing staff] were doing wound care, they [nursing staff] noticed the wound was infected and the doctor decided to send her [R #1] out [to the ED]. It [R #1's right knee wound care] was every other day. Only the nurses who were assigned [to R #1] were the ones taking care of the wound. We [facility] didn't have a wound specialist. The time she [R #1] was sent out [to the ED], I was told the wound was infected. O. On [DATE] at 3:09 pm during an interview with Medical Doctor (MD) #1, he stated, I can't tell you how often they [facility nursing staff] would have communicated with me [about R #1's wounds]. I saw her [R #1] before they sent her out [to the ED] because she [R #1] had worse pain and what was stated there [in R #1's [DATE] MD Progress Note]. There was 100% [percent] wound dehiscence [partial or total separation of previously approximated wound edges, due to a failure of proper wound healing] and the [right knee] stump had fallen apart. P. On [DATE] at 3:30 pm during an interview with LPN #2, she stated, The admitting nurse will enter all the orders in and they [admitting nurse] are required to do a head to toe assessment and that's all documented. If there are wound care orders in the paperwork, that gets entered into the chart. When wound care is done, depending on if pain meds are administered, they [nursing staff] are to document how they [residents] tolerated it [wound care], what was done, and basically the interaction with the resident when they [nursing staff] were doing it [wound care]. So we have a kind of sort of wound care nurse [RN #1] and when he's [RN #1] not being utilized on the floor. When that [RN #1 conducting wound care] doesn't happen, we have the floor nurses do their own wounds. LPN #2 confirmed R #1's wound care should have been documented in R #1's progress notes and was not. Q. On [DATE] at 4:07 pm during an interview with the Director of Nursing (DON), he stated. The expectations are they [nursing staff] should be documenting when they are doing wound care, letting skin lead know [any wound changes], and any complications [with wound care]. We tried to have some sort of documentation [for resident wound care]. We [facility] document that it [wound care] was done and any exceptions within it. There should have been something documented [for R #1's wound care between [DATE] to [DATE]]. There should have been a documentation of that [R #1's right knee wound] change. Our typical [wound] measurement period is every 7 days, that would be the expectation. R. On [DATE] at 9:44 am during an interview with the Nurse Practioner (NP) #1, she stated, They [facility nursing staff] tell me [Name of RN #1] is doing the wound care. When you talk to [Name of RN #1], he says he only fills in [for wound care]. There's no wound care person onsite. I was getting wound reports at one time, but I haven't seen one [wound report] in a bit. If I'm only here two days a week, it's hard to keep up with that [resident wound care]. There's supposed to be an area in [Name of Electronic Health Record (EHR) with wounds, I don't have access to it and I don't know why. That [R #1's wound worsening] would be something the nursing staff would notify us and they [R #1] would need to be sent back to the surgeon. I don't get [wound] measurements or what the wound looks like. They [facility] don't have a wound care specialist. I can take a look at it and give suggestions, but it is not my position to be a wound care provider here. He's [RN #1] not wound care certified and he's [RN #1] not a wound care nurse. If there is a wound infection, they [resident] need to be seen by the surgeon immediately. Findings for R #2: S. Record review of R #2's face sheet revealed R #2 was admitted on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] 1. UNSPECIFIED OPEN WOUND OF SCROTUM AND TESTES, SUBSEQUENT ENCOUNTER 2. [CONDITION(S)] DISORDERS OF SCROTUM 3. ANAL ABSCESS [swollen area within body tissue] 4. DISRUPTION OF EXTERNAL OPERATION (SURGICAL) WOUND, NOT ELSEWHERE CLASSIFIED, SEQUELA (an aftereffect of a disease, condition, or injury) 5. [CONDITION(S)] [prostate gland enlargement] WITH LOWER URINARY TRACT SYMPTOMS 6.DISRUPTION OF EXTERNAL OPERATION (SURGICAL) WOUND, NOT ELSEWHERE CLASSIFIED, SUBSEQUENT ENCOUNTER 7. COVID-19 [deadly respiratory virus] 8. URINARY TRACT INFECTION, SITE NOT SPECIFIED 9. [CONDITION(S)] [deficiency of red blood cells], UNSPECIFIED 10. [CONDITION(S)] [high concentration of fats or lipids in the blood], UNSPECIFIED 11. [NAME] SYNDROME [condition which the liver doesn't properly process bilirubin] 12. UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE 13. UNSPECIFIED HEARING LOSS, BILATERAL 14. UNSPECIFIED SYSTOLIC (CONGESTIVE) HEART FAILURE 15. UNSPECIFIED ASTHMA, UNCOMPLICATED 16. MUSCLE WEAKNESS (GENERALIZED) 17. OTHER ABNORMALITIES OF GAIT AND MOBILITY 18. REPEATED FALLS R #2 expired on [DATE] and was discharged to a local funeral home. T. Record review of R #2's offsite provider physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . U. Record review of R #2's progress notes dated [DATE] at 11:39 pm revealed, Patient was admitted /readmitted for the following reason(s): Wound Care perineal abscess (a collection of pus in the tissue around the anus and rectum), [CONDITION(S)] [Urinary Tract Infection] Additional details about this note: multiple wounds. V. Record review of R #2's progress notes dated [DATE] at 1:08 am revealed, assessment complete, rsd [resident] does have multiple severe wounds that will require wound care and monitoring. No wound care orders were sent with resident on admission. will refer to wound care nurse for appropriate orders. W. Record review of R #2's progress notes dated [DATE] at 11:15 pm revealed, Remains alert and HOH [hard of hearing]. Able to communicate. No specific c/o [complaint of] pain or discomfort. Packing remains in place to perineal wound (the area of skin and muscle between the vaginal opening and the anus). RN [Registered Nurse] from [offsite provider] called and stated that she would be in ,d+[DATE] [pm on] ,d+[DATE] to assess the wound(s) and would do a telehealth call with the DR [doctor] to determine tx [treatment] and clarify orders in question. X. Record review of R #2's progress notes dated [DATE] at 12:18 pm revealed, RESIDENT AWAKE AND ALERT IN HIS BED THIS SHIFT. DENIES PAIN/DISCOMFORT. THIS NURSE CONTACTED SOCIAL WORKER WITH [Name of offsite provider] THIS AM TO SEEK DIRECTION ON HAVING [Name of offsite provider] PROVIDER ADVISED OF NEEDED ASSESSMENT OF RESIDENT'S AS NEW ADMISSION AND NUMEROUS WOUNDS. SOCIAL WORKER WITH [Name of offsite provider] REFERS THIS NURSE CONTACT CLINIC OFFICE. OFFICE NUMBER CALLED AND NO ANSWER. WILL CONTINUE TO ATTEMPT REACHING [Name of offsite provider] FOR ORDER CLARIFICATIONS, INCLUDING WOUND CARES. CURRENTLY WOUNDS ARE TO BE MONITORED Q [every] SHIFT AND NEW CHANGES REPORTED. Y. Record review of R #2's progress notes dated [DATE] at 1:28 pm revealed, NURSE CASE MANAGER FROM [Name of offsite provider] HERE THIS SHIFT AND RESIDENT'S ORDERS WERE CLARIFIED AND CONFIRMED. WOUND TREATMENTS OBTAINED AFTER ALL WOUNDS WERE ASSESSED BY CASE MANAGER RN. RESIDENT HAS RESTED WITHOUT C/O THIS SHIFT. WOUND CARE WAS PROVIDED TO ALL WOUNDS. RESIDENT CONTINUES TO HAVE PENDING ORTHO (correction of deformities of bone and muscle) AND UROLOGY (branch of medicine concerned with the function and disorder of the urinary system) CONSULT. Z. Record review of R #2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R #2's wound care began in facility on [DATE]. AA. Record review of R #2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] SOILAGE. BB. Record review of R #2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . CC. Record review of R #2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DO NOT GET DEVICE WET. APPLY ABDOMINAL PAD TO COVER SITE, WRAP WITH KERLIX. DD. Record review of R #2's progress notes dated [DATE] revealed, THERAPY HAS BEEN NOTIFIED THAT RESIDENT IS NOW PALLIATIVE CARE AND COMFORT MEASURES. EE. On [DATE] at 11:49 am during an interview with LPN #3, she stated, He [R #2] was a [Name of offsite provider] resident and was on the north unit. When he [R #2] came [to the facility], he had a stage 2 [pressure ulcer] on his bottom, unstageable on his left or right heel, and he had a surgical procedure done on the knee and metal prosthesis (an artificial device that replaces a missing body part) exposed. I'm not sure, but I know [Name of offsite provider] will come and make orders to continue the care for him [R #2]. It took a little while [to get wound care orders for R #2 from the offsite provider] and a [Name of offsite provider] manager came out and she had the doctor on the zoom and the doctor saw his [R #2's] wounds. I need orders from the [Name of offsite provider] physicians for wounds or medicine. I need orders from [Name of offsite provider] and sometimes it [physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He [R #2] came with orders for medications and things, but for the wounds he had, there was no clear cut orders for that and his prosthesis. For me, they [offsite providers] needed to see him [R #2] and provide orders. LPN #3 confirmed R #2's wound care was delayed when he was admitted to the facility because of a lack of communication between the facility and offsite provider. FF. On [DATE] at 2:53 pm during an interview with RN #1, he stated, He [R #2] had exposed prosthesis [implant] underneath. There was some talk about that [R #2's delayed wound care treatment due to communication issues with offsite provider]. I had difficulty getting an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #2] had a prosthesis so we left it alone on the prosthesis side. Generally, we [facility] talk to our doctor, and with [Name of offsite provider], there is a little communications issue with [Name of offsite provider] and us [facility]. Our [facility] doctors don't want to handle [Name of offsite provider] patients for some reason and when [Name of offsite provider] is involved, they [Name of offsite provider] call the shots on [Name of offsite provider] orders. [Facility] Staff made attempts to get orders [for R #2's wound care] because we were concerned about not doing nothing. RN #1 confirmed R #2's wound care was delayed when he was admitted to the facility because of a lack of communication between the facility and offsite provider. GG. On [DATE] at 3:42 pm during an interview with LPN #2, she stated, The communication [between the facility and offsite provider] is definitely delayed. We [facility] just do what they [Name of offsite provider] tell us. I talk to the [facility] staff, but I do let [Name of offsite provider] know I need further instructions [for wound care]. Our in house physician won't tell us [staff] what to do with that [residents who use offsite provider]. LPN #2 confirmed R #2's wound care was delayed when he was admitted to the facility because of a lack of communication between the facility and offsite provider. HH. On [DATE] at 4:25 pm during an interview with the DON, he stated, If [physician] orders are sent with the patient, we try to get those orders in. We do have difficulties with getting things from [Name of offsite provider]. I have my unit managers communicate with them [Name of offsite provider]. DON confirmed communication issues between the facility and the offsite provider. All orders are entered into the medical chart by the facility staff and any communication that is done is entered into the nurses progress notes by facility staff. Findings for R #3: II. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [CONDITION(S)] [abnormally low activity of the [CONDITION(S)] gland] UNSPECIFIED 2. SPONDYLOSIS [painful condition of the spine resulting from degeneration of the intervertebral disks], UNSPECIFIED 3. PRIMARY [CONDITION(S)] [type of arthritis that occurs when flexible tissue at the ends of bones wears down], UNSPECIFIED SITE 4. ADULT FAILURE TO THRIVE 5. OTHER ABNORMALITIES OF GAIT AND MOBILITY 6. MUSCLE WEAKNESS (GENERALIZED) 7. [CONDITION(S)], UNSPECIFIED 8. PERSONAL HISTORY OF COVID-19 9. ANOREXIA [lack or loss of appetite for food] 10. PRESSURE ULCER OF SACRAL (coccyx) REGION, STAGE 4 11.ESSENTIAL (PRIMARY) HYPERTENSION [high blood pressure] 12. UNSPECIFIED [CONDITION(S)], UNSPECIFIED SITE JJ. Record review of R #3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Change dressing twice daily. KK. Record review of R #3's skin integrity report dated [DATE] revealed R #3 had a healing stage 2 pressure ulcer located on her coccyx. No other skin issues/wounds were documented. LL. On [DATE] at 2:06 pm during a wound care observation, a bandage was discovered on R #3's right lower extremity (RLE). R #3's RLE bandage was dated [DATE]. R #3's RLE abrasion (an area damaged) was observed to be red. MM. Record review of R #3's progress notes date ,d+[DATE]-[DATE] revealed no progress note indicating abrasion to R #3's RLE prior to wound care observation with surveyor. NN. On [DATE] at 2:08 pm during an interview with LPN #3, she confirmed R #3's RLE bandage dated [DATE] was not reported or documented, and LPN #3 was unaware of R #3's new skin issue. OO. On [DATE] at 2:09 pm during an interview with R #3, she stated her RLE abrasion was burning. PP. On [DATE] at 4:14 pm during an interview with the DON, he stated, A change of condition would be indicated and something should be documented. I [recently] found out about the one [R #3's new skin issue on [DATE]] and I need to review. DON confirmed he was unaware of R #3's new skin abrasion prior to ,d+[DATE], and R #3's RLE abrasion dated [DATE] should have been documented and reported, but it was not. This resulted in an Immediate Jeopardy (IJ) at a scope and severity of K (a pattern of jeopardy to resident health and safety) being identified on [DATE] at 1:51 pm with the facility Administrator (ADM). A Plan of Removal was received and accepted on [DATE] at 8:28 am. Based on this Plan of Removal, the interventions included: 1. On [DATE] the Nursing team initiated a whole house resident skin sweep to identify any not previously documented skin integrity issues. Any identified issues will be corrected immediately, any new wounds will have a full assessment by the wound nurse and a treatment initiated per facility DIMES (consistent and evidence based approach to wound healing) and treatments will be accessed for appropriateness. 2. Center Nurses will be re-educated by the Skin Health Team Lead beginning [DATE] regarding their responsibility regarding wound basics, wound evaluation, wound treatments, and documentation. 3. The Skin Health Team Lead/UM (Unit Manager)/designee will ensure center staff that have not completed (training)/re-education will receive the training described above prior to the next work shift. The Skin Health Team Lead/UM/designee will ensure licensed nursing staff that have not completed re-education will receive the training and competency described above prior to beginning of next work shift. 4. The DON and or designees will review progress notes during morning clinical for appropriate documentation and provide education to the nurses as identified. 5. The DON/UM/or designee will audit the TAR for completion of wound care daily and perform a random spot check of wounds documented as completed for appropriate dating of dressing related to said wound care. This shall be done daily for 7 days, then 3 times per week for 3 weeks, then weekly for 2 months. 6. The Skin Team Health Lead/DON will be responsible for the skin integrity process in the center and to make sure assessments, communications and treatments are documented. 7. An Ad Hoc [as needed] QAPI [Quality Assurance Performance Improvement] Meeting will be held on [DATE] to approve the above plan. 8. The DON [Director of Nursing]/designee and the Administrator/designee will bring the results of the audits to the QAPI committee for tracking, trending and further recommendations to ensure compliance with plan. The audits will be brought to the QAPI committee for 3 months. The Administrator will oversee the QAPI committee

On [DATE], R #281 was found unresponsive in the dining room. Resident was transferred from the dining room to the resident's room before CPR was initiated. R #281 later died . On [DATE], R #283 was found unresponsive in his room following the lunch meal service. Before CPR was initiated, Nurse went to the Nurse's station to look up resident's code status and call 911. CPR was not immediately initiated until full code status was confirmed in the electronic medical record. R #283 was not able to be revived and pronounced deceased . On [DATE] and [DATE] Nursing staff (licensed nurses and certified aides) were interviewed and found to be unaware of resident's advance directives (a resident's code status which describes their wish to either accept or reject emergency intervention such as Cardiopulmonary Resuscitation). Nursing staff stated they must have access to resident's electronic health record (EHR) (a medical resident found on an electronic device such as a computer) to access and identify resident's code status. Nursing Staff stated that EHR's can be found at the computers located at the two facility nurses stations (an area in which staff maintain resident records and computers) or at the front desk. Nursing staff stated that in the event of a resident found non-responsive (unconscious and unable to respond) they would go to the nearest nurses station, review the resident's EHR then return to the residents location with that information to be provided to others on scene or begin treatment according to resident wishes. Nursing staff further stated that if they were to find a non-responsive resident they would begin CPR until the resident's code status was confirmed. Nursing Staff further stated that if they started CPR for a resident found unresponsive they would stop CPR if the resident's codes status was found to be DNR (Do Not Resuscitate: a person's request to not receive emergency intervention). This is process is reported as being the facility policy. This resulted in an Immediate Jeopardy (IJ) at a scope and severity of K (a pattern of jeopardy to resident health and safety) being identified on [DATE] at 1:47 pm. A Plan of Removal was received and rejected on [DATE] at 11:15 am. A Plan of Removal was received and rejected on [DATE] at 12:18 pm. A Plan of Removal was received and accepted on [DATE] at 12:56 pm. Based on this Plan of Removal, the interventions included: 1. An audit of all residents was completed on [DATE] to verify that resident code status orders are congruent (equivalent and the same) with the MOST (Medical Orders for Scope of Treatment) form (a standardized form signed by each resident indicating their wishes to be followed in the event of a medical emergency such as a [CONDITION(S)] ). This was completed by the Center Nurse Executive (CNE). Corrective action was taken as necessary to ensure accuracy of resident code status. 2. A printed list of each resident's code status will be carried by each licensed nurse and Certified Medication Aide (CMA) beginning [DATE]. 3. Licensed nursing staff will be educated on Code Status Orders and Cardiac and/or Respiratory Arrest policies and procedures, as well as maintaining an updated printed document which identifies each resident's code status. The document will be carried on their person at all times while on duty beginning [DATE] or before their next scheduled shift. 4. All facility staff will be educated on procedures related to finding a resident unresponsive. 5. A random audit will be completed 5 times per week for 4 weeks then monthly for 2 months to verify that licensed nurses and CMA's have the printed list of current code status on their person. Based on the Plan of Removal, the Scope and Severity was reduced from the Level of K to H (actual harm). Based on record review and interview, the facility failed to ensure that personnel would be able to provide basic life support to residents requiring emergency care without delay for those residents that have been identified as wanting intervention, and not initiate basic life support for residents' whose wish is to not have intervention. This deficient practice is likely to result in residents who desire emergency intervention to have treatment delayed which is likely to result in death; or residents who do not desire emergency intervention to have unwanted emergency interventions started, resulting in resident receiving severe injuries and unwanted results (Broken bones, punctured lungs, undesired revival). The findings are: Findings for R #281: A. Record review of the complaint allegation received by the State Agency identified While unattended during meal she [R #281] choked and was found dead. Report states she was not a DNR but no one attempted any life saving measures. B. Record review of R #281's progress notes dated [DATE] revealed, This nurse responded to resident in the dining room noted by CNA (Certified nursing assistant) to have her head down and face 'blue'. This nurse assessed resident and noted resident non responsive, eyes open with pupils dilated, resident immediately transported per geri chair [a large padded chair designed to help seniors with limited mobility] to her room and her noted code status is full code, resident placed on floor when CPR [cardiopulmonary resuscitation- an emergency procedure that involves chest compressions] initiated and 911 contacted and responded. Resident transferred out via stretcher with apparent rhythm (had a heartbeat) to [name of local hospital]. C. On [DATE] at 11:11 am during interview with Licensed Practical Nurse (LPN) #1 regarding R #281, she stated A CNA came to the desk and she informed me there was a patient she wanted me to see that wasn't eating, her [R #281] face was blue and her pupils were small. She was taken to her room. LPN #1 described that R #281 was leaning over the table when found and was wheeled in the geri-chair back to her room while being unresponsive. LPN #1 reported that she requested another nurse to call code blue. LPN #1 confirmed she responded to the unresponsive resident in the dining hall and did not begin CPR until the resident was brought to her room due to privacy issues. LPN #1 stated that it was easier to move the resident to her room, than to clear all the residents from the dining room to start CPR. LPN #1 confirmed that she did not immediately know R #281's code status until she was informed by another nurse. Findings for R #283 D. Record review of R #283's progress notes dated [DATE] revealed, The CNA stated that around 12:00 p.m. the residents food tray was placed in his room, and then between 12:15 p.m. and 12:20 p.m. the resident was observed unresponsive when the residents meal tray was being picked up from his room. The attending nurse was immediately notified, and CPR was initiated as the resident has a Full Code Status. In addition to CPR the AED [Automated External Defibrillator- portable electronic device used to help those experiencing sudden cardiac arrest] defibrillator was also implemented, Crash Cart was brought to the room, suctioning of mouth was started to suction out food particles observed in the mouth and throat. Paramedics (911) were called and dispatched and they arrived at around 12:40 p.m. RN (Registered Nurse) contacted Emergency Contact #1 at 12:45 p.m. to inform him of the residents change In condition. Paramedic arrived and they implemented CPR and other measures but were unsuccessful in their attempt to stabilize the resident, and he passed on. I was called into the room by paramedic prior to them leaving to show me a medium size piece of meat that was laying next to the resident. At 12:50 p.m. RN informed the on-call clinical supervisor again to inform him of the residents passing away, he stated he will contact [Name of local medical investigator]. RN contacted [Name of Emergency Contact #1] to inform him of the residents passed away .RN did the pronunciation and time of death was 1:16 p.m. E. Record review of R #283's face sheet with a print date of [DATE] revealed R #283 was a Full Code. F. On [DATE] at 10:56 am during an interview, the Director of Nursing (DON) stated The CNA found him [R #283] when she went to collect a tray. She [CNA] called the two nurses. Everybody [residents] had metal utensils except for the fork. The piece [of food in R #283's mouth] we found wasn't that tough and we were able to pull it out and I gave that to [Name of local medical investigator]. G. On [DATE] at 11:10 am during an interview with LPN #5, she stated, I didn't go into the room [R #283's room]. I prepared paperwork for him [R #283] and called 911. As soon as we knew there was something going on [R #283 unresponsive], I went to the desk [nursing station] and looked at his [R #283] code status and called 911. It just seems like everyone [staff] went automatically [to R #283's room] when we knew [R #283's code status]. As far as I know, CPR didn't begin [on R #283] until everyone was notified [of R #283's code status]. LPN #5 confirmed she had to go the nurses station to find out R #283's code status and relay that information to the staff in R #283's room before CPR could begin. Findings related to code status: H. Record review of resident census dated [DATE] revealed a census of 107 residents I. Record review of Advance Directive Order Listing Report provided on [DATE] by facility Infection Preventionist revealed that 60 residents requested they be considered as full code (a person's request to receive full emergency intervention should they become unresponsive) should they require emergency intervention. The remaining 47 residents requested they be considered as Do Not Resuscitate and directing that no emergency interventions be provided should they become unresponsive. J. On [DATE] at 2:42 pm during interview with the DON she stated that all licensed nursing staff (Registered Nurses and Licensed Practical Nurses) have completed a hands on CPR class in compliance with the American Heart Association in which all were trained in the standard procedure to respond to a resident who is found to be unresponsive. K. On [DATE] at 3:21 pm during interview with LPN #4, she stated that if a resident were found unresponsive she would assess the resident, place the resident in a position and begin doing CPR, she would call somebody to go and look at the medical record [to confirm their code status] before I go and do something, but of course you want to save someone's life. I would start CPR. I have 30 residents, some I've had for more of a long time but for the newer ones I'd have to look (their code status in the medical records) . My people in the front (unit front hallway) I'd automatically assume they are a full code except for the hospice .It's a judgment call. LPN #4 confirmed she would ask staff to clear a room and check a residents code status before beginning CPR. LPN #4 also confirmed she would consider moving an unresponsive resident if possible. L. On [DATE] at 4:11 pm during an interview with LPN #3, she stated, I would approach them [resident] and ask if it would be ok to help them. I would call for help. I would move them [choking resident] to a safer place and I would make sure it was Ok to administer CPR and I would ask someone to check [resident code status]. If I knew they were a full code, I'd start CPR. M. On [DATE] at 9:23 am during interview with Certified Medication Aide (CMA) #3, when asked what she would do if she found a resident unresponsive, she stated I would report it to the nurse. I would have to check the resident's code status. Yeah, of course it would take time. I would try to get them to their room or somewhere with no other residents around [before starting CPR]. N. On [DATE] at 9:30 am during interview with CMA #4, she confirmed that she is CPR certified but that she does not know residents code statuses. CMA #4 confirmed that if she found a resident unresponsive, she would try to arouse them and if not she would get the nurse. Regarding code statuses, CMA #4 stated It's on the computer. It would cause a little delay cause I would have to check the computer or call out for some else to check [code status] if we [staff] weren't by a computer. O. On [DATE] at 9:57 am during interview with Physical Therapist (PT) #1, he confirmed that he is CPR certified however he only knows the code statuses of the residents he works with. If he found a resident unresponsive, he stated that he would call the nurse. P. On [DATE] at 10:01 pm during interview with RN #2 he stated, As an RN, I would try to find out what's going on .I would call the doctor and do CPR and call 911 regardless of their code status. I would get them on a hard surface as quickly as possible. Usually we don't know off the bat (what their code status is) but it's on the screen [at the Nurse's Station computer] and usually we keep a list of code statuses, but I don't see it here right now. Q. On [DATE] at 11:11 am during interview with LPN #1 she stated We should know everyone's code status, but unfortunately, we would have to send someone to check the code status [of an unresponsive resident]. This happened with a patient a long time ago [referring to R #281] .I'd do everything I could to take care of it (resident's needs) and send someone for help to check their code status. I don't know their (residents) code status. I would start (CPR) immediately, I would start CPR even if I didn't know their code status. LPN #1 stated that it would be reasonable to take up to one minute to locate a resident's code status in the medical record however anything longer than a minute would be considered wasting time to start CPR. R. On [DATE] at 3:08 pm during interview with Regional Nurse Leader (RNL), she stated that Staff should start CPR until the resident's code status can be confirmed. If the resident is DNR, we stop CPR. That is the facility policy. By the time we get the crash cart we know the code status. It's [a resident's code status] on the MAR and TAR [Treatment Administration Record], and iPads for aides on [name of electronic health record]. The nurses station is centrally located. We should keep a printed copy of code statuses.

On 09/29/21 during observation of wound care for R #23, R #23 was grimacing and expressing pain during movement and wound care. Interview with staff confirmed that R #23 receives wound care daily and is repositioned every 2 hours, each time expressing pain during repositioning and wound care. Record review for R #23 revealed order for resident to receive pain medication 30 minutes prior to wound care and movement, however this was not being administered to R #23 as intended despite staff awareness of R #23's pain. In addition, record review and interview also revealed that R #42 was expressing an increase in agitation due to pain of a pressure wound, however was not provided pain medication despite an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . These deficient practices resulted in an Immediate Jeopardy (IJ) at a scope and severity of K [pattern of jeopardy to resident health and safety] being identified on 09/29/21 at 6:25 pm. A Plan of Removal was approved and verified on 09/30/21 at 1:55 pm. Based on the Plan of Removal, the interventions included: 1. A comprehensive pain assessments of R's #23 and 42 were conducted by a licensed nurse, results were communicated to the attending physician and new orders received. Both residents were medicated per attending physician orders. 2. The identified Certified Nursing Aide (CNA) and nurse were educated by the Center Nurse Executive (CNE) regarding pain management. 3. Current residents received comprehensive pain assessments on 09/29/21 to assess resident pain with wound care or any residual pain associated with wound care. Any assessed pain that was identified as not addressed will be reviewed with residents attending physician and/or designee for any needed order changes and/or medical treatment plan. Orders and/or changes to treatment plans will be implemented upon receipt from attending physician. 4. Licensed nurses will be educated by the Nurse Practice Educator/Infection Preventionist (NPE/IP) on pain management, including but not limited to offering pain medication as ordered prior to wound care, ceasing wound care for residents with associated pain until pain can be controlled, assessing for pain, implementation of interventions and pain re-evaluation beginning 09/29/21 or before their next scheduled shift. 5. CNA or designee reviewed pain monitoring orders for current residents on 09/29/21 to ensure pain is monitored and documented every shift with corrective action taken as necessary. 6. The Interdisciplinary Team (IDT) will review identified concerns related to pain or ineffective pain management interventions are in place. 7. A random sample audit of residents that receive wound care will be completed 5 times a week to evaluate effective pain management by the CNE with corrective action taken as necessary. Based on the Plan of Removal, the Scope and Severity was reduced from the level K to a level H. Based on observation, record review, and interview, the facility failed to ensure that pain management was provided for 2 (R #23 and 42) of 4 (R #23, 42, 113, and 122) residents reviewed for wound care. This deficient practice likely resulted in R #23 and #42 experiencing unrelieved pain. The findings are: Findings related to R #23 A. Record review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . B. Record review of R #23's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . C. Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . D. On 09/29/21 at 2:30 pm during observation and interview, CNA #10, Licensed Practical Nurse (LPN) #3 and LPN #4 were observed as they provided wound care to several wounds at different locations on R #23's body. All three staff members worked to move R #23 from his right side to his left side so they could complete dressing changes of each wound. They then changed R #23's brief and replaced his bedding. R #23 was observed to grunt and grimace (a facial expression of pain) and speak up saying watch it as he was moved. R #23 is unable to engage in a conversation does use facial expressions and some words to express pain/emotion. During interview all three staff stated that R #23 frequently complained of pain, that he often yelled out anytime he was moved from side to side. E On 09/29/21 at 2:30 pm during interview with LPNs #3 & 4 both stated that R #23 is provided dressing changes daily as ordered and occasionally as needed. F. On 09/29/21 at 2:30 pm during interview with CNA #10, she stated that R #23 is moved and repositioned from side to side at least every two hours or more often if needed. CNA #10 confirmed that R #23 frequently expressed pain during repositioning. G. On 09/29/21 at 2:30 pm during interview with LPNs #3 and 4, both stated R #23 is very contracted (a condition in which muscles are constantly tense) and cannot extend his arms and legs without pain. H. On 09/29/22 at 3:22 pm during interview LPN #3 confirmed that R #23's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #3 confirmed that R #23 was not provided pain medication prior to wound care despite demonstrating pain during movement and wound care. I. On 09/29/21 at 4:10 pm during interview with LPN #4, she stated that she thought R #23 was always in pain. Findings related to R #42 J. Record review of R #42's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . K. Record review of daily progress note dated 09/28/21 at 1:22 pm revealed resident struck and hit left side torso (Upper body/Chest) of CNA during incontinence care (care provided to change brief and/or clean the lower body of feces and urine). Resident with residual agitation (pain or discomfort as the result of care provided) associated with wound care provision. Progress note did not identify any interventions to relieve R #42's pain. L. Record review of progress note dated 09/29/21 at 3:14 pm resident has been moved to room [ROOM NUMBER] A associated with poor roommate compatibility. Resident has exhibited increased verbal behaviors possible due to wound discomfort to left sacral area (tail bone). Progress note did not identify any interventions to relieve R #42's pain. M. Record review of R #42's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . N. On 09/29/21 at 4:54 pm interview with nurse she stated R #42 has been in pain since yesterday- 09/28/21- after wound care was provided by nurse practitioner. Nurse confirmed that no pain medication had been administered to R #42 since 09/13/21, despite staff awareness that R #42 was exhibiting pain related to her wound.

Based on observation, record review and interview, the following was discovered: 1. Residents who had tested positive for COVID 19 (a potentially deadly infectious [MEDICAL CONDITION] disease that is easily transmitted from person to person) and who required isolation and separation from other residents and staff were being housed in the same rooms with residents who had unknown COVID 19 status. 2. A resident who was on isolation precautions due to unknown COVID 19 status was observed to exit her room, pass through hallways and enter into common areas. 3. A resident who was on isolation precautions due to possible COVID 19 exposure during appointments outside of the facility was observed to exit his room pass through several open areas, enter a courtyard and move to a smoking area where he sat within three feet of other resident smokers. This resulted in Immediate Jeopardy being called on 07/15/20 at 7:23 pm. The Administrator (ADM) and Director of Nursing (DON) were both notified at this time. A first plan of removal was received on 07/16/20 at 9:44 am and rejected on 07/16/20 at 1:26 pm. A third plan of removal was approved and verified on 07/17/20 at 5:58 pm. The facility Administrator was notified. The scope and severity was reduced from Level 4, K to Level 2, E. The plan of removal included: 1. On July 15, 2020, Resident #1 and Resident #2 were separated, and each resident was placed into private rooms. Resident #2 is being assessed three times a day for specific indicators of COVID 19 and will be retested per physician orders. Resident #2 was re-educated by the Administrator on quarantine precautions and infection control practices to include hand hygiene, mask use, and social distancing. 2. Resident #2, beginning on 7/16/20, was placed on 1:1 staff observations from 06:00 am -10:00 pm to ensure compliance with quarantine precautions and supervise resident activities when the resident leaves her room and escorted to and from smoking area to ensure compliance on infection control practices to include hand hygiene, mask use, and social distancing. 3. Staff re-education was initiated on 7/15/20 by the Unit Manager and provided to licensed nursing staff that when a resident in the Admission Quarantine Unit (AQU-an area of the facility dedicated to residents who are on quarantine and observation for COVID 19 symptoms) is leaving their room and when going outside to smoke that resident will be supervised to observe and adhere to proper infection control practices to include wear of mask, hand hygiene, and social distancing. Nursing staff will be re-educated on Resident #2's current plan of care related to 1:1 staff supervision to ensure the resident is compliant with quarantine precautions and infection control practices to include hand hygiene and social distancing. 4. An audit will be conducted by designated staff beginning 7/16/20, to identify other residents who could potentially be affected by not being compliant with quarantine precautions, as not adhering to proper infection control practices while leaving the unit and going out to smoke to include use of appropriate PPE (Personal Protective Equipment-Items used to protect self and others from the spread of infectious diseases), social distancing and proper supervision is provided while on quarantine. Current residents who smoke will be evaluated by designated staff to validate safe smoking assessment, and the care plan is current with smoking and supervision needs. 5. An observation audit was conducted by staff on 7/15/20 to identify other resident's compliance with social distancing in the smoking area. No areas of noncompliance were observed. 6. Smoking area/process: The concrete was painted to provide visual cues for residents and staff to maintain a safe social distance. Smoking schedules will be developed that will provide different smoking times for Asymptomatic residents on the AQU; Quarantine Unit and non- quarantine residents in order to segregate the residents and maintain infection control precautions. Staff members will be scheduled to escort residents to and from the smoking area and ensure that residents have a mask on. The current residents who smoke will be observed to ensure social distancing is maintained. The facility staff will be re-educated by designated staff beginning on 7/16/20 related to segregation of targeted residents/units by following smoking schedules and infection control precautions. 7. Beginning July 16, 2020, staff will be re-educated on supervising the smoking area to ensure that residents who smoke will be escorted to and from the smoking area with a mask on, social distancing is observed, supplies for hand sanitizer for residents hand hygiene are in the smoking box, and disinfection of the tables and chairs used by residents are available and is performed post smoking activities. 8. On July 15, 2020, staff validated that residents in the facility are tested weekly for COVID, the facility assesses the residents three times a day and prn (as needed) for changes in resident's condition and indicators of COVID. The facility will monitor for compliance daily. 9. Current Guidance on Cohorting (housing residents of like situation in semi-private rooms together) residents will be followed. When tested positive or clinically diagnosed as presumed positive, will include the following: a. A confirmed positive roommate should be separated from his test-negative or test-pending roommate as soon as it is practicable. b. Symptomatic (SUSPECTED) Resident with Test Pending: c. Roommates of symptomatic residents who are being tested for COVID-19 should be tested and screened at the same time. d. Residents who are symptomatic (SUSPECTED) should be separated from their Asymptomatic roommate as soon as it is practicable, even if test results are still pending. e. Residents who are symptomatic (SUSPECTED) should be moved to a private room or a private space created by using other multi-purpose areas: f. On the same unit, preferably, g. On a different unit only if there are other diagnosed cases on the destination unit. h. The facility will assign dedicated staff to work with confirmed COVID residents, admission quarantine units, and residents on non- quarantine units. 10. On July 16, 2020, an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting with the Performance Improvement Team to review Infection Control Process and the Performance Improvement measures outlined in this document. The Committee reviewed the results of the audits in which compliance is achieved, and appropriate corrective measures were put in place. Certified Nurse Executive (CNE) designee will report findings of audits in the monthly QAPI meeting. Committee will continue with the performance improvement audits for monitoring of compliance and report on the next meeting monthly for three months or until compliance is achieved as determined by the Committee. The plan will be updated, reviewed, and revised as needed monthly in the QAPI meeting. Based on observation, record review and interview, the facility failed to maintain infection prevention measures by not properly isolating 7 (R #1, R#2, R#3, R#4, R#5, R#6 and R#8) of 7 (R #1, R#2, R#3, R#4, R#5, R#6 and R#8) residents reviewed for isolation and quarantine practices during random observation. This deficient practice is likely to result in the spread of potentially deadly infectious diseases to other residents and staff. The findings are: Regarding R#2 A. Record review of facility census dated 07/15/20 revealed that R #1 and R #2 are currently roommates in the same room, and both living in facility room [ROOM NUMBER]. B. Record review of R #1 testing results for COVID 19 dated 07/13/20 revealed that R #1 had tested positive for the COVID 19 disease. C. On 07/15/20 at 2:42 pm during observation, R #2 was observed leaving her room [ROOM NUMBER] and wheeling down the hallway, passing through two closed doors and entering into an open common area where other residents passed and where a nursing station was located. She was observed to be wearing a surgical mask and no other protective equipment. As R #2 passed the nursing station she stated to Registered Nurse (RN) #1 that she was going out to the courtyard to smoke. R #2 then passed through another set of open doors and entered another common area where she received assistance from Activities Aide (AA) #1 to open a locked refrigerator and retrieve a snack from the refrigerator. D. On 07/15/20 at 2:56 pm during observation, RN #1 was observed walking up to R#2. RN#1 stated that R #2 was not to be out of her room. RN #1 then escorted R #2 back to her room. Neither R#2, nor RN #1, was wearing full PPE at the time of contact. E. On 07/15/20 at 3:23 pm during interview with the facility Administrator (ADM) and Director of Nursing (DON), they both confirmed that R#2 was still pending the results of her COVID 19 test and her current status was unknown. Both confirmed that R #2's roommate had tested positive for COVID 19. Both confirmed that R #1 and R #2 were currently in the same Room # 105, and that both were considered to be on isolation. They both stated that R #2 was often out of her room and wandering through the hallways to go smoke. Regarding R #3, R #4, R #5 and R #6 F. Record review of testing results for COVID 19 dated 07/13/20 revealed that R#3 and R#4 had both tested positive for COVID 19. G. Record review of facility census dated 07/15/20 revealed that R#3 shared room [ROOM NUMBER] with R#6 and that R #4 shared room [ROOM NUMBER] with R #5. H. On 07/15/20 3:23 pm during interview with ADM and DON, both confirmed that R #3 and R #4 had tested positive for COVID 19 and that results were still pending for R #5 and R #6. Both ADM and DON confirmed that residents R #3 and 4 were positive and were sharing their respective rooms with R #5 and R #6 who were unknown if they were positive or negative for COVID 19. Regarding R #8 I. Record review of R#8 face sheet dated 07/15/20 reveals that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. J Record review of R#8 physician orders [REDACTED]. 05/18/20 R #8 is to be transported to a local hospital every two weeks for paracentesis (a medical procedure in which a needle is inserted into the abdomen and excess fluids are allowed to drain) 07/02/20 R#8 to be transported to local physician office for surgical consult. K. On 07/15/20 at 1:00 pm during observation of the admission quarantine unit (area of the facility in which residents reside while on COVID 19 separation for 14 day observation following exit from and return to the facility building) R #8 was observed exiting the unit and entering the nursing station area wearing a loose fitting surgical mask on his face and no other PPE. He then went passed the nursing station through a common area and into a courtyard. There he went to a designated smoking area and took up a place within three feet proximity to several other residents. He sat in this location without a mask or other PPE and smoked a cigarette. L. On 07/15/20 at 3:23 pm during interview with ADM he confirmed that R #8 had recently left the facility for an outside appointment and that he had returned. He stated that R #8 made occasional trips out of the building and for this reason he was residing in a private room with no roommates. This room was located in a wing that had been set aside for such residents who had appointments outside of the facility. ADM stated that residents in this wing were on quarantine but that R #8 was a smoker who was allowed to exit the quarantine area and pass through to the smoking area located in the central courtyard.

Based on record review, observation and interview, the facility failed to ensure that 1 (R #s 4) of 3 (R #s 4, 5 and 6) residents reviewed for pressure ulcer (also called, bedsore or decubitus (act of lying down) ulcers are injuries to skin and underlying tissue resulting from prolonged pressure, friction and/or shear forces on the skin) care in facility received the needed assessments and care. This deficient practice resulted in a reopened ischial tuberosity (also referred to as, ischium at times in wound assessment documentation, it is part of bone that forms the lower and back portion of the hip bone and comes to a narrow tip on each side ) and a new sacral ( large heavy bone at the base of the spine), a new coccyx and new right leg wounds developing which were unrecognized by the facility. This deficient practice can result in existing ulcers failing to heal, new ulcers developing and causing the affected resident increased time to reach maximal wellness. The findings are: [NAME] Record review of notes from the Long term acute care facility R #4 was admitted from revealed: 1. On 11/04/19 (R #4) now status [REDACTED]. Patient is now postoperative day 9 with his flaps healing well and incisions intact. 2. On 11/04/19 (R #4) he does have an area in the middle of the 3 intersecting incisions that is open .it now has 2 cm (centimeters) of tunneling (a defect in tissue that channels extending from the central injury into the surrounding tissue). 3. On 11/01/19 the following wounds are documented: a. Left ischial tuberosity: 2.00 X 2.00 X 0.00 (length times width times depth, in centimeters (cm)). b. Right ischial tuberosity 6.8 X 3.20 X 3.80 cm. B. Record review, of Long term care facility census sheet for R #4 revealed, he was admitted on [DATE] and discharged on [DATE]. C. Record review, of face sheet revealed that R #4, [DIAGNOSES REDACTED]. D. Record review of admission progress note from provider dated 11/11/19 revealed, This is a 32 y/o (year old) male with PMH (past medical history) of T-12 (level of damage at the 12th [MEDICATION NAME] vertebrae) [MEDICAL CONDITION] (paralysis of legs) from MVA (motor vehicle accident), [MEDICAL CONDITION] (less red blood cells than normal) .and chronic bilateral (right and left sides) ischial tuberosity stage 3-4 ulcers. He was admitted to (acronym for name of local acute care hospital) for wound debridement (removal of dead tissue) and bone biopsy .the left wound was closed .He still as a deep open area on the right IT (ischial tuberosity, the bones in pelvis that absorb weight when a human sits straight up) .He has been transferred here for OT (Occupational Therapy) and wound care. E. Record review of EHR (electronic health record) for nursing skin checks revealed one documented on 11/18/19 at 3:45 pm. It noted, Bilateral stage 3-4 tuberosity pressure ulcer. (No other skin checks were found in the resident record). F. On 12/31/19 at 10:40 am wound documentation for this resident was requested as it was not found in the electronic health record (EHR) and the following was provided: Skin Integrity Report (where facility documents wound assessment) on review these revealed: 1. On 11/16/19 a right gluteal area wound measuring, 3.0 X 3.0 X 2.0 cm. (Length X Width X Depth) 2. On 11/16/19 a left gluteal area wound measuring, 0.2 X 2.0 X < 0.1 cm 3. On 11/23/19 a right gluteal area wound measuring, 2.0 X 1.0 X 2.0 cm. 4. On 11/23/19 a left gluteal area wound noted as, resolved. 5. On 11/30/19 a right gluteal area wound measuring 2.0 X 1.0 X 1.5 cm. No other wounds were identified. [NAME] On 12/31/19 at 11:50 am, during interview the nurse unit manager confirms that the wound documentation will be found on paper and she has provided what is available for R #1. Wound assessment documentation for R #1's admission was again requested as the documentation previously provided started on 11/16/19, the resident was admitted on [DATE]. The following was provided on a Skin Integrity Report dated, 11/08/19 .R (right) ischial pressure wound .stage 4 .measuring, 6.8 X 3.2 X 3.8 cm. H. Record review of provider orders revealed no order for a pressure relief surface (a mattress or bed reduces the pressure exerted at the interface between the patient and the supporting surface). I. Record review of care plan for R #4 revealed, pressure redistribution surface to bed as per guideline. No individualized schedule for positioning/ repositioning or daily skin observations interventions documented. [NAME] Record review of nursing notes for documentation of pressure relief or redistribution mattress or bed revealed on 11/08/19 at 3:45 pm, Device(s) in use: low air loss mattress No (There was no other documentation found in the remainder of the nursing progress notes that a pressure redistribution or relief mattress or bed was placed). K. On 12/31/19 at 2:15 pm, during interview the Facility Center Nurse Executive (CNE), regarding any proof that R #4 was placed on a or pressure redistribution surface, as per the policy and noted in Care Plan she revealed, (First name of person who works at the facility) would have put it on a work order but he is not here today. (No work orders were forwarded). L. Record review of policy, Pressure Injury/Ulcer Prevention Guideline .Basic Prevention Interventions for all Patients at Risk, revealed, .Perform daily observation of skin .Risk Factor .Impaired/Decreased mobility/function .Pressure reduction/relief mattress and chair cushion .Individualized positioning and repositioning schedule. M. Record review of nursing progress notes in electronic health record (EHR) from 11/26/19 through 12/06/19, for other wound skin assessment/documentation revealed repetitive assessments documented that did not address the residents entire skin status: 1. On 11/27/19 at 5:31 pm,12/04/19 at 2:20 pm and 12/05/19 at 6:44 pm: Integumentary (skin) System reviewed Resident is not experiencing foot pain. Heels appear free from redness, maceration or breakdown. between toes appear free from redness, maceration (moisture damaged skin) or breakdown. Bony prominence appear free from redness, maceration or breakdown. No signs of ingrown toenails (redness, swelling of nail fold) observed. stage 4 to right buttocks. 2. On 12/01/19 at 7:04 pm, 12/02/19 at 1:08 am and 12/03/19 at 1:08 am: Integumentary System reviewed Resident is not experiencing foot pain. Heels appear free from redness, maceration or breakdown between toes appear free from redness, maceration or breakdown. Bony prominence appear free from redness, maceration or breakdown. No signs of ingrown toenails (redness, swelling of nail fold) observed Summary of any additional findings: (none were noted). 3. On 11/26/19 at 1:02 am: Integumentary System reviewed Resident is not experiencing foot pain. Heels appear free from redness, maceration or breakdown. between toes appear free from redness, maceration or breakdown. Bony prominence appear free from redness, maceration or breakdown. No signs of ingrown toenails (redness, swelling of nail fold) observed. Summary of any additional findings: (none were noted). N. Record review of nursing notes for information on resident transfer to acute care on 12/06/19 revealed, at 1:52 pm, unplanned transfer. O. Record review of wound care documentation from acute care hospital for R #4 revealed: 1. On 12/06/19 at 6:08 pm, the following note from acute care hospital Physical Therapist (PT), Patient seen in the ED (Emergency Department) before admitting to the floors. Presents with multiple pressure injuries to R (right) and L (left) ischium, posterior legs and coccyx and left sacrum. Stage 4 to right ischium ., 2. Pressure injury, ischium right posterior lateral; date/time first assessed: 12/06/19 at 1649 (4:49 pm) .stage 4 . 2 X 2 X 4 ( L X W X D in cm) Deepest undermining (undermining extends under the skin, the actual amount of damaged tissue is much bigger than it appears by just looking at the surface of the wound), 6 cm. 3. Pressure injury, ischium medial; date/time first assessed: 12/06/19 at 1649 .stage 4, .2 X 0.5 X 4 cm communicate to lateral (right lateral ischium). 4. Pressure injury, coccyx, date/time first assessed; 12/06/19 at 1650 (4:59 pm) .stage 2 .1 X 1 X 0.01 cm. 5. Pressure injury, ischium left posterior, date/time first assessed; 12/06/19 at 1700 (5 :00 pm) .partial thickness draining. (no measurements found). 6. Pressure injury, sacrum left, no date/time assessed . stage 3 .Present on hospital admission: Yes. 7. Pressure injury, leg, right posterior upper lateral, date/time first assessed: 12/06/19 at 1653 (4:53 pm) .stage 3 .7 X 1 X 0.1 cm. 8. Pressure injury, leg right, posterior upper medial, date/time first assessed 12/06/19 at 1656 (4:56 pm) .stage 3 .3 X 1 X 0.1 cm.

Based on observation, record review and interview, the facility failed to follow the resident's written plan of care requiring two person extensive to total assistance for transferring from one position to another for 1 (R #43) of 1 (R #43) residents. R #43 was transferred multiple times by staff using only one person. This deficient practice is likely to have caused the resident to experience an adverse outcome in which the resident sustained [REDACTED]. A. On 12/15/11 at 4:30 pm, observation of Resident #43 revealed her to be laying in bed and saying "Mi Duele" (meaning I hurt, or it hurts in Spanish). She could be heard in the hallway. At this time, a CNA (certified nursing assist) Staff #1 was walking by and also heard the resident crying from her room. She spoke to the resident in Spanish. When asked what was said, she stated that she asked the resident in Spanish what happened and the resident told her "I fell ". The resident continued to say "Mi Duele" and was pointing towards her leg. At this time, the CNA rolled back the top sheet and observation revealed the residents left leg from the knee down was very bright purple and bruised. The resident continued to say "Mi Duele". B. Review of the medical record for Resident #43 revealed the following: 1. Face Sheet, dated 06/16/11 indicated [DIAGNOSES REDACTED]. 2. Comprehensive Care Plan dated 03/31/09 and revised 01/29/10 indicated that the resident "Requires extensive to total assistance for transferring from one position to another related to physical limitations and lack of strength. Staff are to provide two persons for transfers and physical assist with mechanical device or transfer belt." The Care plan further indicated "the resident has a chronic/progressive decline characterized by deficit in memory, judgement, thought process related to long term memory loss." 3. August Quarterly Nursing Assessment (no date indicated) revealed the resident does not ambulate and transfers with assistance of two people. 4. Certified Nursing Assistant Care Card indicated the residents mode of transfer is by "two persons only." 5. Resident Functional Performance Record dated December 2011 revealed fifteen documented times from December 1-15 in which the resident was being transferred by the use of only one person on day, evening, and/or night shifts. 6. Interdisciplinary Progress Notes dated 12/15/11 indicated at 10:00 am, "Resident c/o (complained of) left leg hurting. Checked resident leg. No injuries noted. Awaiting shower." At 11:30 am the progress notes indicated, "Resident complained of pain to left leg to shower aide. Shower aide stated she noticed bruise after resident showered." At 9:00 pm the progress notes indicated, "X-ray report shows left proximal tibia-fibula fracture." 7. physician progress notes [REDACTED]. (patient) found to have painful bruising to left shin...Extensive bruising...Positive proximal tib (tibia) fib (fibula) nondisplaced fracture...Frail [AGE] year old with acute nondisplaced fracture. She has severe [MEDICAL CONDITION] she could have had a fracture with minimal trauma." C. On 12/16/11 at 7:45 am, during interview, the Director of Nursing (DON) stated that the x-rays did show a tibia/fibula fracture. He stated that the Doctor said it could have been a spontaneous fracture or her foot could have been caught under the foot rests during a transfer. The DON also stated that he saw the residents leg when she was in the shower room and saw bruising. He then stated, "It did look displaced to me because her knee was a little bit out." D. On 12/16/11 at 7:55 am, during interview, CNA Staff #2 stated she came to work after 6:00 am on the morning of Thursday 12/15/11. She stated the resident was already up, was dressed, and sitting up in her wheelchair. "There was no information how the night went. We just took her to breakfast. We didn't put her back to bed. After that I took her to the shower room. I just checked her brief by myself. She was saying she was hurting but then she was saying her eyes were hurting. I just took her in the shower room. After her shower, the nurse told me to put her to bed. (Name of CNA Staff #3) and I put her to bed. We put the gait belt on her. We don't use any other device to lift her. After her shower was when I noticed the bruising. When we transferred her she was already saying she was in pain. She was saying her knee was hurting. She was bruised on the left leg. That was something I didn't notice before. The shower aide didn't say anything to me about a bruise. She is a total assist for transfers." E. On 12/16/11 at 8:45 am, during interview, CNA Staff #3 stated "Before lunch, around 11:00 am she complained her leg was hurting. She was saying 'my leg hurt.' After her shower, the nurse told us 'you guys need to lay her down because her leg was swollen.' The other girl and I used a gait belt to transfer her in bed. We did a total lift with a gait belt. She doesn't bear any weight on her legs. She was saying 'Mi Duele my pierna' (meaning I hurt on my legs). She is not a Hoyer or Sara lift. She was saying her legs were hurting. Her leg was already swollen and bruised." F. On 12/16/11 at 9:40 am, during interview, CNA Staff #4 stated, "When the resident was brought to the shower room she was complaining of pain. She was crying saying she was dying and her leg was hurting. She was saying she was in pain and she kept saying that to me. I noticed she was pretty pale. I was looking for the nurse to see if it was going to be ok to shower her because she was crying and was pale before her shower. I transferred her by myself from the wheelchair to the shower chair. I pulled her up and put her in the shower chair. Then I showered her. Since I started I was always told she was a one person transfer. After the shower, I transferred her from the shower chair to the wheelchair. I transferred her myself. I didn't see any bruising until after the shower. As I was drying her off her left leg felt really swollen to me and I looked at it more closely. I saw the bruising to start. At that time she was already in so much pain she kept saying 'my leg hurts I'm going to die.' I have always used one person to transfer her." G. On 12/16/11 at 10:14 am, during interview, the DON stated when he went in the shower room and assessed the residents leg it was bruised from the left lower leg to the ankle. To me her leg looked displaced. It did not look in alignment to me. All I was told was this was new and they didn't know how it happened. From what I hear she is a one person assist." H. On 12/16/11 at 10:30 am, during interview, the Assistant Director of Nursing stated, "When I looked at her leg, it was swollen below the knee. It was blue and starting to bruise up. She is a one person assist." I. On 12/16/11 at 10:55 am, during interview, the Administrator stated, "She has a severe osteopathic condition. It (referring to the fractured leg) was identified when she received a bath." J. On 12/16/11 at 12:55 pm, during interview, CNA Staff #5 stated, "I can transfer her by myself with my gait belt. I pick her up and transfer her to the wheelchair. She is not a stand pivot transfer. She can't move her legs by herself. She is not able to bear any weight for me. She can't stand. We lift her with one person." K. On 12/16/11 at 3:00 pm, during interview, CNA Staff #1 stated, "When I came on my shift, she was complaining about pain. When I pulled back her sheet I saw the bruises and swelling. I work with her by myself. You have to pick her up when transferring. Everything has to be done for her." L. On 12/16/11 at 4:00 pm, during interview, Registered Nurse (RN) Staff #6 stated, "She would not let me touch her leg. She was in so much pain she wouldn't let me near it." M. On 12/19/11 at 8:25 am, during interview, Licensed Practical Nurse (LPN) Staff #7 stated, "I didn't see anything before the shower. After she finished showering was when the shower aide told me she noticed bruising on her leg." O. On 12/19/11 at 2:13 pm, during interview, the DON stated, "She would not be able to sustain any balance or bear weight without physical help. She would not be able to pivot at all including rising, pivoting or seating herself. With the care plan, it says there should have been two people to transfer her. The CNA's are required to follow what the nursing assistant care card says for each resident. With her, it says she is a two person transfer." P. On 12/19/11 at 2:30 pm, during interview, CNA Staff #8 stated, "We use a gait belt to transfer her. Usually she is a one person transfer. She can stand up and twist herself and we just use the gait belt. She was able to bear weight on her legs and able to stand pivot for me. She can be a one person transfer with a gait belt." Q. On 12/19/11 at 2:35 pm, during interview, the Director of Therapy stated, "She is not able to bear any weight on her legs at this time. She has contractures in her knees and hands. She shouldn't have been a stand pivot transfer at all." R. On 12/19/11 at 2:55 pm, during interview, CNA Staff #9 stated, "I got her up in the mornings. When I transfer her she holds on to my neck, and I gently put her down. She was not able to bear weight. No-one ever said anything to me about a two person transfer. She has never been a two person assist that I know of." S. On 12/19/11 at 3:30 pm, during interview, CNA Staff #10 stated, "I would have gotten her up by myself between 4:50-5:00am. I sat her on the edge of the bed I put the gait belt around her waist and I gently supported her. I would have stand pivoted her and put her in her chair." T. On 12/20/11 at 7:41 am, during interview, RN Staff #11 stated "I think they use one person to transfer her unless the resident is heavy, but I really don't know. She cannot bear weight on her lower legs." U. On 12/20/11 at 8:30 am, during interview, CNA Staff #12 stated, "I get her up for dinner by myself. Then I lay her back to bed. I transfer her by myself." V. On 12/20/11 at 10:30 am, during interview, the Medical director stated "Any type of manipulation could have caused this. She does have severe [MEDICAL CONDITION] and it was a mild trauma. She does have poor mobility and I've never known her to be able to bear weight." W. On 12/20/11 at 12:35 pm, during interview, the Staff Development Coordinator stated, "If she could not bear any weight, it would not be acceptable to do a stand pivot transfer. We would go by what the care plan says." .

Based on observation, record review and interview, the facility failed to ensure 1 (R #43) of 1 (R #43) residents who was identified as needing a two person extensive to total assist for transferring was being done to prevent accidents. R #43 was transferred multiple times by staff using only one person. This deficient practice is likely to have caused the resident to experience an adverse outcome in which the resident sustained [REDACTED]. A. On 12/15/11 at 4:30 pm, observation of Resident #43 revealed her to be laying in bed and saying "Mi Duele" (meaning I hurt, or it hurts in Spanish). She could be heard in the hallway. At this time, a Certified Nursing Assistant (CNA) Staff #1 was walking by and also heard the resident crying from her room. She spoke to the resident in Spanish. When asked what was said, she stated that she asked the resident in Spanish what happened and the resident told her "I fell ". The resident continued to say "Mi Duele" and was pointing towards her leg. At this time, the CNA rolled back the top sheet and observation revealed the residents left leg from the knee down was very bright purple and bruised. The resident continued to say "Mi Duele". B. Review of the medical record for Resident #43 revealed the following: 1. Face Sheet, dated 06/16/11 indicated [DIAGNOSES REDACTED]. 2. Comprehensive Care Plan dated 03/31/09 and revised 01/29/10 indicated that the resident "Requires extensive to total assistance for transferring from one position to another related to physical limitations and lack of strength. Staff are to provide two persons for transfers and physical assist with mechanical device or transfer belt." The Care plan further indicated "the resident has a chronic/progressive decline characterized by deficit in memory, judgement, thought process related to long term memory loss." 3. August Quarterly Nursing Assessment (no date indicated) revealed the resident does not ambulate and transfers with assistance of two people. 4. Certified Nursing Assistant Care Card indicated the residents mode of transfer is by "two persons only." 5. Resident Functional Performance Record dated December 2011 revealed fifteen documented times from December 1-15 in which the resident was being transferred by the use of only one person on day, evening, and/or night shifts. 6. Interdisciplinary Progress Notes dated 12/15/11 indicated at 10:00 am, "Resident c/o (complained of) left leg hurting. Checked resident leg. No injuries noted. Awaiting shower." At 11:30 am the progress notes indicated, "Resident complained of pain to left leg to shower aide. Shower aide stated she noticed bruise after resident showered." At 9:00 pm the progress notes indicated, "X-ray report shows left proximal tibia-fibula fracture." 7. physician progress notes [REDACTED]. (patient) found to have painful bruising to left shin...Extensive bruising...Positive proximal tib (tibia) fib (fibula) nondisplaced fracture...Frail [AGE] year old with acute nondisplaced fracture. She has severe osteoporosis she could have had a fracture with minimal trauma." C. On 12/16/11 at 7:45 am, during interview, the Director of Nursing (DON) stated "The x-rays did show a tibia/fibula fracture. The Doctor said it could have been a spontaneous fracture or her foot could have been caught under the foot rests during a transfer. I saw the residents leg when she was in the shower room and saw bruising. It did look displaced to me because her knee was a little bit out." D. On 12/16/11 at 7:55 am, during interview, CNA Staff #2 stated she came to work after 6:00 am on the morning of Thursday 12/15/11. "The resident was already up, was dressed, and sitting up in her wheelchair. There was no information how the night went. We just took her to breakfast. We didn't put her back to bed. After that I took her to the shower room. I just checked her brief by myself. She (the resident) was saying she was hurting but then she was saying her eyes were hurting. I just took her in the shower room. After her shower, the nurse told me to put her to bed. (Name of Staff #3) and I put her to bed. We put the gait belt on her. We don't use any other device to lift her. After her shower was when I noticed the bruising. When we transferred her she was already saying she was in pain. She was saying her knee was hurting. She was bruised on the left leg. That was something I didn't notice before. The shower aide didn't say anything to me about a bruise. She is a total assist for transfers." E. On 12/16/11 at 8:45 am, during interview, CNA Staff #3 stated "Before lunch, around 11:00 am she complained her leg was hurting. She was saying 'My leg hurt.' After her shower, the nurse told us 'You guys need to lay her down because her leg was swollen.' The other girl and I used a gait belt to transfer her in bed. We did a total lift with a gait belt. She doesn't bear any weight on her legs. She was saying 'Mi Duele my pierna' (meaning I hurt on my legs). She is not a Hoyer or Sara lift. She was saying her legs were hurting. Her leg was already swollen and bruised." F. On 12/16/11 at 9:40 am, during interview, CNA Staff #4 stated, "When she (the resident) was brought to the shower room she was complaining of pain. She was crying saying she was dying and her leg was hurting. She was saying she was in pain and she kept saying that to me. I noticed she was pretty pale. I was looking for the nurse to see if it was going to be ok to shower her because she was crying and was pale before her shower. I transferred her by myself from the wheelchair to the shower chair. I pulled her up and put her in the shower chair. Then I showered her. Since I started I was always told she was a one person transfer. After the shower, I transferred her from the shower chair to the wheelchair. I transferred her myself. I didn't see any bruising until after the shower. As I was drying her off her left leg felt really swollen to me and I looked at it more closely. I saw the bruising to start. At that time she was already in so much pain she kept saying 'My leg hurts I'm going to die.' I have always used one person to transfer her." G. On 12/16/11 at 10:14 am, during interview, the DON stated when he went in the shower room and assessed the residents leg it was bruised from the left lower leg to the ankle. To me her leg looked displaced. It did not look in alignment to me. All I was told was this was new and they didn't know how it happened. From what I hear she is a one person assist." H. On 12/16/11 at 10:30 am, during interview, the Assistant Director of Nursing stated, "When I looked at her leg, it was swollen below the knee. It was blue and starting to bruise up. She is a one person assist." I. On 12/16/11 at 10:55 am, during interview, the Administrator stated, "She has a severe osteopathic condition. It (referring to the fractured leg) was identified when she received a bath." J. On 12/16/11 at 12:55 pm, during interview, CNA Staff #5 stated, "I can transfer her by myself with my gait belt. I pick her up and transfer her to the wheelchair. She is not a stand pivot transfer. She can't move her legs by herself. She is not able to bear any weight for me. She can't stand. We lift her with one person." K. On 12/16/11 at 3:00 pm, during interview, CNA Staff #1 stated, "When I came on my shift, she was complaining about pain. When I pulled back her sheet I saw the bruises and swelling. I work with her by myself. You have to pick her up when transferring. Everything has to be done for her." L. On 12/16/11 at 4:00 pm, during interview, Registered Nurse (RN) Staff #6 stated, "She would not let me touch her leg. She was in so much pain she wouldn't let me near it." M. On 12/19/11 at 8:25 am, during interview, Licensed Practical Nurse (LPN) Staff #7 stated, "I didn't see anything before the shower. After she finished showering was when the shower aide told me she noticed bruising on her leg." O. On 12/19/11 at 2:13 pm, during interview, the DON stated, "She would not be able to sustain any balance or bear weight without physical help. She would not be able to pivot at all including rising, pivoting or seating herself. With the care plan, it says there should have been two people to transfer her. The CNA's are required to follow what the nursing assistant care card says for each resident. With her, it says she is a two person transfer." P. On 12/19/11 at 2:30 pm, during interview, CNA Staff #8 stated, "We use a gait belt to transfer her. Usually she is a one person transfer. She can stand up and twist herself and we just use the gait belt. She was able to bear weight on her legs and able to stand pivot for me. She can be a one person transfer with a gait belt." Q. On 12/19/11 at 2:35 pm, during interview, the Director of Therapy stated, "She is not able to bear any weight on her legs at this time. She has contractures in her knees and hands. She shouldn't have been a stand pivot transfer at all." R. On 12/19/11 at 2:55 pm, during interview, CNA Staff #9 stated, "I got her up in the mornings. When I transfer her she holds on to my neck, and I gently put her down. She was not able to bear weight. No-one ever said anything to me about a two person transfer. She has never been a two person assist that I know of." S. On 12/19/11 at 3:30 pm, during interview, CNA Staff #10 stated, "I would have gotten her up by myself between 4:50-5:00am. I sat her on the edge of the bed I put the gait belt around her waist and I gently supported her. I would have stand pivoted her and put her in her chair." T. On 12/20/11 at 7:41 am, during interview, RN Staff #11 stated "I think they use one person to transfer her unless the resident is heavy, but I really don't know. She cannot bear weight on her lower legs." U. On 12/20/11 at 8:30 am, during interview, CNA Staff #12 stated, "I get her up for dinner by myself. Then I lay her back to bed. I transfer her by myself." V. On 12/20/11 at 10:30 am, during interview, the Medical director stated "Any type of manipulation could have caused this. She does have severe osteoporosis and it was a mild trauma. She does have poor mobility and I've never known her to be able to bear weight." W. On 12/20/11 at 12:35 pm, during interview, the Staff Development Coordinator stated, "If she could not bear any weight, it would not be acceptable to do a stand pivot transfer. We would go by what the care plan says." .